Health At Every Size An Alternative Approach

1. Health At Every Size An Alternative Approach Julie Rochefort, MHSc, RD Jacqui Gingras, PhD, RD Canadian Obesity Summit May 1, 2013

2. “Opening oneself to the possibility for transformation is a profound act of courage.” - Maureen Walker

3. Outline • Overview • Learning Objectives • Introductions • HAES 101 • Activity 1: Shift the focus in Clinical Practice • Break

4. Outline • Summary • Activity 2: Barriers and enablers to practicing from a HAES perspective • Closing

5. Learning Objectives At the end of this workshop, participants will be able to: • Clarify the tenets of HAES • Engage with case-based learning activities • Identify challenges and opportunities

6. Facilitator Introductions

7. Julie & Jacqui

8. History

10. Promoting weight loss • 95% of those who lose weight regain it (Bray, 2005;Mann et al, 2007;Wing et al, 2001). • Nutritional inadequacy. • Difficulty sustaining low calorie intake. • Frustration • Weight cycling: “yo-yo” effect. This strategy ISN’T working.

11. REPEAT • DIET RETURN TO OLD HABITS THE DIET TRAP CYCLE Weight Regain Decrease in calories FEAST RESPONSE Increase in calories FAMINE RESPONSE • Reduced metabolic rate • Loss of muscle • Regain weight from fat • Lose weight from lean muscle and fat • Reduced metabolic rate • Increase in fat storage

12. “There’s a lot of money to be made out of the idea that every Australian man, woman, child and dog could lose some weight.” -Associate Professor Jenny O’Dea

14. Why now?

15. Non-Compliant Self-indulgent Unmotivated Repulsing Awkward Unattractive Brownless et al., (2006) Puhl RM and Latner JD (2007/2009))

17. USA Anti-Obesity Campaign

18. Disney World: The "Bad Habits"

19. Food Labelling: OMA

20. Your kids are listening campaign Peel Public Health & Toronto Public Health (2013)

21. Shift the focus

22. HAES 101

25. Evidence

26. Fat and Healthy? Reducing cardiometabolic risk: • “A healthy diet and exercise without (minimal) weight loss is NOT failure” (Ross & Janiszewski, 2007). • Health improvements can be achieved through changing health behaviours, even in the absence of weight loss (Bacon et al., 2005; Appel et al., 1997; Gaesser,2007).

27. Wildman et al. Arch Intern Med. 2008;168(15):

28. Obesity Paradox Assumption: • “Weight loss will prolong life.” Evidence: • Mortality increased among those who lost weight & who were over 50 yrs. (NHANES Review, 2010). • Obesity associated with longer survival in heart disease, kidney disease, and stroke (Morse et al., 2010; Scherbakov et al., 2011).

29. Obesity Paradox Assumption: • “Adiposity poses significant morbidity risk.” Evidence: • Obesity associated with increased disease risk. • When fitness level, activity, nutrient intake, weight cycling or SES is controlled, increased risk of disease due to obesity disappears or is significantly reduced (Campos et al., 2005; Strohacker et al., 2010; Montani., 2006; Rzehak et al., 2007; Raphael et al., 2010).

30. What Else is going on? Psychological Status Endocrine System Menopause Sleep Apnea/Sleep Deprivation Availability/Quality of Food Stress Environment Chemicals/ Toxins Lack of Exercise Genetics SES Medication Co-morbidities Quitting Smoking Cultural Norms/Beliefs

31. Evidence of HAES • HAES approach associated with statistical & clinical improvements: • physiologicalmeasures (e.g. blood pressure, blood lipids), • healthbehaviors(e.g. physical activity, reduced eating disorder pathology), and • psychosocialoutcomes(e.g. mood, self-esteem, body image).

32. Bacon et al, 2005 • Study participants: • 78 white, obese, female chronic dieters • Age: 30-45 years • BMI: 30-45 • Randomly assigned: HAES or Conventional Diet Program • DESIGN: weekly visits x 6 mo.; monthly visits x 6 mo.; follow-up 1 year later – no intervention

34. Bacon et al., JADA. 2005 – 2 year Follow Up Diet group: • Weight lost was regained. • Psychological measures worsened. HAES group: • Maintained weight • Sustained improvement: • metabolic health indicators, activity levels, eating behaviours & psychological measures.

35. Case Studies

36. Arianna, 25 Case Study

37. Arianna, 25 • Self-referred to your care for annual check-up. • Mentions she needs to make changes in her diet because she dislikes vegetables. • Currently completing last year of her university degree. • Wthx: BMI 33kg/m2 • Labs-unremarkable

38. Recommendations • Providing not depriving • Explore diet history, relationship with food and body • Sources of stress and coping strategies • “Do you feel like you can manage your stress?” • How much time, energy and resources she is spending dedicated to diet.

40. Frank, 44 Case Study

41. 44 y.o Frank • Reveals that he is unable to do more than 5 minute on his recumbent bike without knee pain • Takes the bus to the nearest grocery store. • Income: Social Assistance • Medical hx: Lactose intolerance • Osteoarthritis in both knees • Scheduled R-knee replacement in 6 months • Wthx: He reports that he has gained over 40 lbs in the last 5years. • Lab data: Triglycerides, LDL and normal HDL

42. Recommendations • Normalize his eating • Is he eating for reasons other than hunger? • How does his pain impact his hunger/fullness • How does he cope with pain • Explore pleasurable and appropriate physical activity • Explore social supports (isolated?) • Medications • How does this influence his hunger

43. Normalizing Eating • 1) AWARENESS – INITIAL APPOINTMENT • Pay attention to hunger cues – NO changes • “When do you feel hunger’ • “when do you start eating, when do you stop” • Could other substances (pop, coffee, cigarette, alcohol) mask hunger? • 2) INTERVENTION- FOLLOW-UP • When you notice hunger, then ask yourself: • “what do I want to eat”, • “what will fulfill my appetite”

44. Frank states: “My doctor said I can feel less pain if I lose weight.”

45. Elisa, 8 Case Study

46. 8 year old Elisa Mom very concerned about weight Child is not active in sports Wthx: Growth chart indicates weight for height moved from 90th 93rd percentile Mother has been finding hidden food wrappers and finds a ‘dyiet’ note in her school agenda.

48. Recommendations (HAES) • Division of Responsibility • Reassure around eating competence • Reduce pressure to eat • Avoid food restriction • Promote self-regulation • “What makes you decide to stop eating?” • Asking, “How do you know when you need to eat?” Striving for a particular weight outcome undermines eating competence.- Ellyn Satter

49. Mom’s asks if she could take her daughter’s weight while at clinic

50. “Although weight loss strategies may seem desirable for overweight [youth], they are often ineffective and may actually result in weight gain and eating disturbances.” Jones, JM et al. p.551