Legalizing Eating with Diabetes. An Intuitive Approach The Harm Associated with Weight Bias, Weight Stigma, and Weight Focused Interventions

Alison St. Germain MS, RD, LD Iowa Academy of Nutrition and Dietetics Representative Assistant Clinical Professor at Iowa State University

I have no conflict(s) with commercial interest companies to disclose.

Why am I here today?

• RD 24 years • Iowa State University Food Science & Human Nutrition Clinical Professor • Iowa Academy Representative • St. Germain Consulting: Redefining Health—Nutrition for ALL Bodies • Advanced areas of expertise – Certified Intuitive Eating® Counselor – Certified Craving Change™ Facilitator (Cognitive Behavior Therapy) – Health at Every Size® (HAES®) & Health For Every Body Facilitator – Eating Disorders—awareness, prevention and treatment – Non‐diet Weight Neutral Registered Dietitian – Body Respect & Size Acceptance • Finding my passion Objectives

• Deconstruct weight stigma and learn how it hinders clinician‐ patient communication; learn how it increases the likelihood of poor health outcomes. • Explore non‐diet weight neutral approaches to well‐being as an alternative to weight centered interventions with specific application to diabetes. • Learn from examples shown and handouts provided for practitioners to use with patients.

Jot it Down

Weight Stigma

• Definition – Weight bias or weight discrimination – Shame, judgement, inequalities and stereotypes placed on individuals based on weight and body size.

Adapted from BEDA National Weight Stigma Awareness Week materials Weight Stigma

• Origins – Media portrayal – Societal pressure regarding obesity/diet culture • Healthcare • Wellness/Fitness Industry • Culture blaming the individual • General belief: lazy, lack of willpower & discipline

Adapted from BEDA National Weight Stigma Awareness Week materials

The Harm Associated with Weight Stigma

• Hinders communication • Increases likelihood of poorer health behaviors – Increased kcal consumption – Weight gain – Decreased motivation to exercise – Increased risk for chronic disease – Avoidance of seeking medical care

Pearl et al 2018 Weight Bias Internalization and Health: a Systematic Review O’Hara et al What’s Wrong with the War on Obesity? Harm of Weight Focused Paradigms

• Weight stigma & discrimination – Culture obsessed with weight and food – Diet industry and diet mindset for the “obesity epidemic” – “Fat” phobia – Dislike/Fear of becoming “fat”

Harm of Weight Focused Paradigms

• Dysfunctional Eating & Eating Disorders – Delay in diagnoses/treatment of those in a larger body – Disordered eating affects up to 40% of patients with diabetes (Garcia‐Mayor et al 2017) • Psychological and emotional damage • Dangers of Yo Yo dieting • Body composition changes • Slow metabolism Examples of Weight Stigma in the Media

• Headless people • Eating large amounts of food sloppily • Engaging in sedentary activity

Examples of Weight Stigma in Healthcare

• Chairs • Artwork • Reading material • Gowns • Blood pressure cuff • Language

Language of Change

Weight Stigmatizing Weight Neutral • Overweight/Underweight • Higher/Lower Weight • Obesity • Living in a larger body • Skinny • Person of size • Fat • Middle of the road • Combatting Obesity • Fat • War on Obesity • Obesity Epidemic Weight Stigma in Your Facility

• Take 1 minute to write down examples from your facility that lends to weight stigma • At Your Table – Share your examples with each other – Come up with a plan to resolve – Choose a reporter and be ready to report out

Can You Really Control Your Weight?

• We aren’t supposed to live our lives scared of food and weight • We have less control of our weight than we think we do – Genetics – Biology – Indiv w/diabetes have increased difficulty losing weight • Starvation occurs even in a larger body – Body will do everything it can to stop starvation • Slow metabolism • Increase cravings and thoughts about food

Diets Don’t Work

• Weight loss usually can’t be maintained long‐term – Biggest Loser Study (Fothergill et al 2016) • Loss of lean muscle • Lower levels of Leptin (satiety hormone) – Some weight loss research is usually flawed • Publication bias Diets Don’t Work

• “But being fat is unhealthy”‐‐‐ is it? – Weight and chronic disease is association – Health is not a moral value – Health is not a prerequisite to be treated well – Disrespecting or shaming someone with a higher weight under the guise of concern IS NOT MAKING THEM HEALTHIER – Traditional weight loss education and counseling is ineffective long term‐‐‐why??

Peer Reviewed Research to Support Weight Neutral Approach

• www.IntuitiveEating.org – Handout with 40+ research articles with summaries updated 2015 – Handout with research articles but not summaries updated 2018 – Certification • https://lindabacon.org/_resources Health at Every Size

Diabetes & Weight Neutral Approach From Updated Professional Guide to Embracing Weight Neutral Approach for Type 2 DM • Limited evidence to support weight loss improves outcomes long‐term • Beneficial outcomes on A1c, lipids and blood pressure irrespective of weight (Franz et al 2015 JAND). • Why A Weight‐Neutral Approach is Essential in Diabetes Care – https://wn4dcsymposium.com/ – Also one of your handouts – Many peer reviewed references Diabetes & Weight Neutral Approach

• Remember someone WITHOUT diabetes has high rate of weight re‐gain, now add in factors of hyperinsulinemia, meds, insulin promoting weight gain in individuals with Type 2.

“Food for Thought”…

What would happen if we thought of weight gain as a sign or symptom and NOT the problem, etiology or the goal? How would our intervention change? What do we know about symptom based treatment?

What would happen if we gave same recommendations to a person of size as a thin or middle of the road person?

How to incorporate non diet weight neutral approaches into your practice Poodle Science Video

Health At Every Size HAES® Framework Acceptance of: • Natural diversity in body shape and size • Ineffectiveness and dangers of dieting for weight loss • Health centered/weight neutral paradigm • Importance of relaxed eating in response to internal body cues – Intuitive and mindful eating • Critical contribution of social, emotional, spiritual and physical factors to health and happiness

Resources Principles of Intuitive Eating Evelyn Tribole & Elyse Resch

• Reject the Diet Mentality • Honor Your Hunger • Make Peace With Food • Challenge the Food Police • Feel Your Fullness • Discover the Satisfaction Factor • Coping with Emotions without using food • Respect Your Body • Exercise—Feel the Difference • Honor Your Health with Gentle Nutrition

Paradigm Change

Diet Mentality Intuitive Eating

Intense Desire to be Dieting/Food Restrictions Desire to feel Intuitive Eating thin/lose weight Cravings/Reduced self control Good/Healthy All Foods w/Balance Body Respect

Overeating Binging Healthy Relationship Weight Gain Disordered Eating Food/Mind/Body Low Self Esteem Eating Disorder Weight Changes Gast et al 2014 Tribole et al 2012 Anderson et al, 2015 Madden et al 2012 Hawks et al 2005 Denny et al 2013

Created by Alison St. Germain, MS, RD, LD Adapted from concepts of Intuitive Eating Tribole 2012

Diets Don’t Work

• Traditional weight loss counseling ineffective long‐term • Sustainable framework – Honor genetic diversity – Non‐diet weight neutral approach – Bring focus on eating and moving/exercising • To feel healthy strong, empowered vs to burn energy • Remember all aspects of health not just physical – Highly individual Reject the Diet Mentality

Health & Weight • Fitness surpasses fatness (Barry et al 2013) • BMI is an awful indicator of health & not evidenced based • Behaviors that have more impact on health than weight – Food Choice – Physical Activity – Drinking or Smoking – Social Determinants of Health

Reject the Diet Mentality

Health & Weight continued… • Social Determinants of health – Socioeconomic status – Race – Education level – Access to health care – Stigma – Social support – Public safety – Literacy

Activity From: The Non-Diet Approach Guidebook for Dietitians (Fiona Willner 2013) page 62

• Debunking Diets • Pinpointing Diet Dreams • Key point for clients after doing the activity – The diet promises more than it delivers – Diets don’t work and lead to binging and obsessing about food and weight. Honor Your Hunger

• Keep body fed to prevent ravenous hunger – excessive hunger ravenous eating – bingeing is a result of restriction • Not lack of willpower • Body is working correctly to prevent starvation • The more true hunger is denied… – the more intense food cravings & obsessions • Denying true hunger bingeing & deafness to internal cues

Clues You May Have Had Enough Food

• Food doesn’t taste as good as first bite • Stomach sensation of fullness • Starting to numb feelings and eating unconsciously

Activity From: The Non-Diet Approach Guidebook for Dietitians (Fiona Willner 2013) page 45, 48 • Hunger and Fullness • Investigate how your body responds to hunger and fullness • Investigate when it is hungry, full • Goal – Gain information not judgement – Revive lost innate cues of hunger and satiety Respect Your Body

• Fear of Acceptance of Current Body Size – Giving up, getting bigger – Complacency

Respect Your Body

Respect/accepting your body doesn’t mean disregard it – It means taking care of your health – Feeding well + physical activity = respect – Treat it with dignity and meet its basic needs – Don’t have to like every part to accept/respect it – You don’t have to eat perfectly to feed it well

Respect Your Body

Hard to reject the diet mentality if: – Unrealistic about body shape – Overly Critical about body – Hard to escape the body torture when the whole country is playing. – STOP body negativity talk Winnie the Pooh on Body Image

Winnie the Pooh wore crop tops with no pants, ate his favorite food AND loved himself too!

Honor Your Health With Gentle Nutrition

• Closing the loop between “eating what you want” and honoring your body with nutrition and health. • Deciding on what to eat goes beyond what your taste buds crave – Interoceptive awareness Interoceptive Awareness

• Represents how a particular food choice feels in your body • This internal awareness causes a shift in how you decide what to eat • Goes beyond what your taste buds may crave – Tongue is not the only part of the body that is honored – This does not mean that the tongue should be ignored – Takes practice to be able to figure out what tastes good yet honors your health and body functioning

Summary of Gentle Nutrition Principle

Primarily making food choices based on:

• Health to support diabetes diagnosis – Carb counting? Consistent carb? Moderate fat? High fiber?

• Interoceptive Awareness ie Body functioning – Link high blood glucose to how body feels and possible food choice – Link low blood glucose to how body feels – Checking blood sugar when feeling hungry/full can provide valuable information • If low—likely physical hunger • Taste

Playtime vs “Nutritious Food”

• Play food definition – Food that you crave whose main nutritional value is an energy source (aka Calories). – Lacks in vitamins, minerals, protein, fiber • ie Devils Food Cake for breakfast • Teach how to incorporate into their life without harm – VERY individual – Discussion of “give and take” Playtime vs “Nutritious Food”

• Play time and rest are needed in our lives for balance – Same is true for eating

• What would happen if all you ate was rigidly health food?

Tips with Gentle Nutrition Principle

• Checking in before/during/after eating to develop interoceptive awareness • Viewing foods as Emotionally Equivalent – Devils Food Cake for Breakfast example  • Was this choice based on interoceptive awareness?

Changing the Language

Push Language Pull Language You must You might You should Why might you consider.. It is important because In what way is this important to you Here is what you need to do How might you possibly go about making these changes Specific Application to Diabetes

Weight Neutral Approaches Intuitive Eating

Diabetes & Intuitive Eating From Diabetes Self-Management November/December 2010 • Changing the Diet Mentality – Review of weight controlled studies • Initial improvements in glucose control • Return to starting levels 6‐18 months later even if weight loss maintained – Remember someone WITHOUT diabetes has high rate of weight re‐ gain, now add in factors of hyperinsulinemia, meds, insulin promoting weight gain in individuals with Type 2.

Mindful Eating For Diabetes

• https://amihungry.com/pdf/Mindful‐Eating‐Cycle‐for‐ Diabetes.pdf Mindful Meal Planning Using Diabetes Plate

• https://amihungry.com/pdf/Eat‐What‐You‐Love‐with‐Diabetes‐ Plate‐and‐Tips.pdf

• https://amihungry.com/pdf/7‐Day‐Fearless‐Glucose‐Log.pdf

Gentle Nutrition For Diabetes

• https://drive.google.com/open?id=15dSypccNhGNyir7a642UZv fgKkHnI196 Resources for Weight Neutral Diabetes Counseling • www.megrette.com offers free resources (ebook, handouts) – Sign up for newsletter • Weight‐Neutral Diabetes Counseling and Education Activities book is available at www.megrette.com – 16 CPEUs available www.skellyskills.com • Weight‐Neutral 4 Diabetes Care www.wn4dc.com • Take the weight‐neutral self assessment (end of assessment has many free resources) https://wn4dc.com/weight‐neutral‐self‐assessment/

Barriers

• What barriers exist in your practice to effectively use non‐diet weight neutral approaches to nutrition? – Discuss at your table – Chose a reporter and be ready to share to large group

Key Points

• Shame and scare tactics do not work • Restrictive diets do not work • BMI is not a good indicator of health • Complexity of obesity – Not just eating well and exercising and willpower – Biology and hormones • Weight stigma hinders change and increases likelihood of poorer health outcomes Key Points continued…

• Healthy behaviors are important regardless of size. • Fitness & social determinants of health are key factors in health, not weight. • Change focus from weight loss to healthy behaviors that are sustainable. • Language of Change is sooo important to establish

Contact me St.Germain Consulting Redefining Health—Nutrition for ALL Bodies

[email protected]

References

Bacon L. Health at Every Size: The Surprising Truth about Your Weight; TX: BenBella Books; 2010.

Barry V, Baruth M, Beets M, Durstine J, Jihong L, Blair S. Fitness vs Fatness on All‐Cause Mortality: A Meta‐analysis. 2014 https://doi.org/10.1016/j.pcad.2013.09.002

Clifford Dawn, Curtis Laura. Motivational Interviewing in Nutrition and Fitness; NY: The Guilford Press 2016.

Garcia‐Mayor RV, Garcia‐Soidan FJ. Eating Disorders in Type 2 Diabetic People: Brief Review. Diabetes & Metabolic Syndrome. Clinical Research & Reviews; 2017; 11(3), 221‐224. doi: 10.1016/j.dsx. 2016.08.004

Mann T, Tomiyama AJ, Westling E, Lew AM, Samuels B, Chatman J. Medicare’s search for effective obesity treatments: Diets are not the answer. American Psychologist; 2007 62, 220‐233.

O’Hara L, Taylor J. What’s Wrong With the ‘War on Obesity?’ A Narrative Review of the Weight‐Centered Health Paradigm and Development of the 3C Framework to Build Critical Competency for a Paradigm Shift; Sage April‐June 2018 1‐28.

Pearl RL, Puhl RM; Weight Bias Internalization and Health: a Systematic Review. Obesity Reviews 2018.

Ellyn Satter Institute http://ellynsatterinstitute.org References continued…

Scritchfield R. Body Kindness; NY: Workman Publishing; 2016.

Sobczak C. Embody; CA: Gurz Books; 2014.

Tribole E, Resch E. Intuitive Eating; NY: St. Martin’s Griffin; 2012.

Tribole E, Resch E. The Intuitive Eating Workbook. 10 Principles for Nourishing a Healthy Relationship with Food; CA: New Harbinger Productions, Inc; 2017.

Willer F. The Non‐Diet Approach Guidebook for Dietitians; NC: Lulu Publishing; 2013.

Don’t forget about all the links in the presentation and your handouts!!