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Moving Toward a Weight-Inclusive Practice 2/1/2019 Moving Toward a Weight-Inclusive MARGARINE Practice Nicole Eikenberry, MS,RD Mindful Food & Motion *The presenter declares no conflict of interest . Assumption 1: BMI is a useful proxy for health and longevity. http://www.shiftn.com/obesity/zoom-map.html 1 2/1/2019 Hazard ratio for all-cause mortality by BMI and number of healthy habits (fruit BMI 25-35= lowest incidence of early death. and vegetable intake, exercise, tobacco, alcohol). Adjusted for age, gender, smoking, and alcohol consumption. Hotchkiss JW, Leyland AH. The relationship between body size and mortality in the linked Scottish Health Surveys: cross-sectional surveys with follow-up. Intl Journal of Obesity 2011;35:838-851. Matheson EM, King DE, Everett CJ. Healthy Lifestyle Habits and Mortality in Overweight and Obese See also: Flegal KM, et al. Excess Deaths Associated with Underweight, Overweight, and Obesity. JAMA Individuals. J Am Board Fam Med 2012;25:9-15. 2005;15:1861-1867. Assumption 2: The pursuit of weight loss is a practical and positive goal • 1/3 – 2/3 of dieters regain more weight than they lost. • Methodological problems bias studies toward showing successful weight loss maintenance. • No consistent evidence that dieting results in significant health improvements, regardless of weight change. • “In sum, there is little support for the notion that diets lead to lasting weight loss or health benefits.” . Mann T, et al. Medicare’s Search for Effective Obesity Treatments: Diets Are Not the Answer. American Psychologist. 2007;62:220-232 Assumption 2: Minnesota Starvation Study, Ancel Keys, 1950 The pursuit of weight loss is a practical and positive goal “Most obese persons will not stay in treatment of obesity. Of those who stay in treatment most will not lose weight and of those who do lose weight, most will regain it.” -Albert Stunkard • incessant hunger • irritability • exhaustion • loss of libido Stunkard AJ. The management of obesity. New York State • obsessive thoughts about food • social withdrawal Journal of Medicine. 1958 ;58:79-87. • emotional distress • isolation 2 2/1/2019 Assumption 2: Assumption 3: Not addressing obesity at The pursuit of weight loss is a practical and positive goal every patient encounter is lazy medicine. • Level A evidence • Weight loss behaviors – desperate to do anything • We prescribe and praise for larger bodies what we diagnose as disordered in smaller bodies. • When exercise or healthy eating is tied to weight loss, people often give them up when the diet ultimately fails. • Pediatrics and adolescents – establish healthy relationship • Weight cycling is more detrimental than steady weight • Malnourished vs. optimized Another look at Bias and Stigma Assumptions • BMI is a useful proxy for health and longevity. • The pursuit of weight loss is a practical and positive goal • Not addressing weight at every encounter is lazy medicine. Phelan SM, et al. Impact of weight bias and stigma on quality of care and outcomes for patients with obesity. Obesity Reviews 2015;16:319-326. The Weight-Inclusive Paradigm Health at Every Size ® (HAES ®) • Emphasizes that bodies naturally come in a variety of Health exists on a continuum for each individual, shapes and sizes. varying with time, circumstance, condition, and care . • Assumes everybody can achieve greater health and well- being regardless of current body weight. • Weight Inclusivity • Health Enhancement • Believes weight is not a behavior, and there are • Respectful Care countless self-care behaviors that can improve health • Eating for Well-being measures and day-to-day life. • Life-Enhancing Movement This requires non-stigmatizing health care. 3 2/1/2019 The Active and Athletic Female Weight-Inclusive Practice • Use BMI as a single data-point or non-modifiable risk factor • To optimize a patient, prescribe health behavior change not weight loss • Clinic/office/exam room space • Elevate patient interest and your expertise over systematic policy • To weigh or not to weigh • Add higher-weight patient/athlete care to your specialty • Facilities welcoming and equipment fitting all sizes • Trainers who focus on increments in strength, flexibility, endurance, and pleasure or play • Language • Would you give similar advice to a thin person? Image from: In conclusion: • Create awareness around bias. • Be a critical examiner of the evidence. • Move toward a focus on healthy behavior and increasing physical activity. • Accommodate the needs of all bodies with compassion and skill. Thank you! Nicole Eikenberry, MS,RD Mindful Food & Motion [email protected] mfmnutrition.com 4 Nicole Eikenberry, MS,RD,LN [email protected] 651-383-5997 Mindful Food & Motion: http://mfmnutrition.com Weight-Inclusive Resource List Websites: Association for Size Diversity and Health (ASDAH) : https://www.sizediversityandhealth.org Harvard Implicit Bias Test: https://implicit.harvard.edu/implicit/takeatest.html CDC Social Determinants of Health: https://www.cdc.gov/nchhstp/socialdeterminants/faq.html National Eating Disorders Association (NEDA): https://www.nationaleatingdisorders.org Binge Eating Disorder Association (BEDA): https://bedaonline.com National Association to Advance Fat Acceptance (NAAFA): https://naafaonline.com/dev2/ Unpacking Weight Science https://www.unpackingweightscience.com Shift’n Obesity System Influencer Diagram: http://www.shiftn.com/obesity/Full-Map.html 1 University of Minnesota Orthopedic Grand Rounds webex, Dr. Patrick Horst: https://umn.webex.com/ec3300/eventcenter/recording/recordAction.do?theAction=poprecord&siteurl=umn&e ntappname=url3300&internalRecordTicket=4832534b0000000489ac99a96eb0be3129254e19a69a664c004 3f326506541cac34bb4d5504d4878&renewticket=0&isurlact=true&format=short&rnd=9799939727&RCID=1 5b1624131e84621ac3b8f3df150e768&rID=118358247&needFilter=false&recordID=118358247&apiname=ls r.php&AT=pb&actappname=ec3300&&SP=EC&entactname=/nbrRecordingURL.do&actname=/eventcenter/f rame/g.do What Obese Patients Should Say to Doctors, by Gina Kolata, September 25, 2016, The New York Times: https://www.nytimes.com/2016/09/26/health/doctor-advice-for-obese- patients.html Journal Articles: Aphramor, L. (2010) Validity of Claims Made in Weight Management Research: A Narrative Review of Dietetic Articles. Nutrition Journal BioMed Central, 9:30. Retrieved from: https://nutritionj.biomedcentral.com/articles/10.1186/1475-2891-9-30 Bacon, L, and Aphramor, L. (2011). Weight Science: Evaluating the Evidence for a Paradigm Shift. Nutrition Journal, 10. https://nutritionj.biomedcentral.com/articles/10.1186/1475- 2891-10-9 Carbonneau, E, et al. A Health at Every Size Intervention Improves Intuitive Eating and Diet Quality in Canadian Women, Clinical Nutrition (2016), https://www.researchgate.net/publication/304531563_A_Health_at_Every_Size_interventi on_improves_intuitive_eating_and_diet_quality_in_Canadian_women Chang, S., Beason, T. S., Hunleth, J. M, and Colditz, G. A. (2012). A Systematic Review of Body Fat Distribution and Mortality in Older People. Maturitas, July 72(3): 175-191. doi: 10.1016/j.maturitas.2012.04.004 or https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3367099/ Do, K., Brown, R.E., Wharton, S., Ardern, C.I., and Kuk, J.L. (2018) Association between cardiorespiratory fitness and metabolic risk factors in a population with mild to severe obesity. Obesity, (2018) 5:5 Retrieved from: https://www.ncbi.nlm.nih.gov/pubmed/29435350 Dolezal, L, and Lyons, B. Health-Related Shame: An Affective Determinant Of Health? Medical Humanities BMJ (2017). 43: 257-263. https://www.researchgate.net/publication/317432413_Health- related_shame_An_affective_determinant_of_health Alegria Drury, C. A., & Louis, M. (2002). Exploring the Association Between Body Weight, Stigma of Obesity, and Health Care Avoidance. Journal of the American Academy of Nurse Practitioners, 14(12), 554–561. doi:10.1111/j.1745-7599.2002.tb00089.x Clifford, D., Ozier, A., Bundros, J., Moore, J., Kreiser, A., & Morris, M. N. (2015). Impact of Non- Diet Approaches on Attitudes, Behaviors, and Health Outcomes: A Systematic Review. 2 Journal of Nutrition Education and Behavior, 47(2), 143–155.e1. doi:10.1016/j.jneb.2014.12.002 Fildes, A., Charlton, J., Rudisill, C.., Littlejohns, P, Prevost, A. T., and Guilliford, M. C.. (2015) Probability of an Obese Person Attaining Normal Body Weight: Cohort Study Using Electronic Health Records. American Journal of Public Health, Research and Practice. Retrieved from: https://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2015.302773 Flegal, K. M. (2005). Excess Deaths Associated With Underweight, Overweight, and Obesity. JAMA, 293(15), 1861. doi:10.1001/jama.293.15.1861 Fothergill, E., Guo, J., Howard, L., Kerns, J. C., Knuth, N. D., Brychta, R., … Hall, K. D. (2016). Persistent metabolic adaptation 6 years after “The Biggest Loser” competition. Obesity, 24(8), 1612–1619. doi:10.1002/oby.21538 Golden, N. H., Schneider, M., & Wood, C. (2016). Preventing Obesity and Eating Disorders in Adolescents. PEDIATRICS, 138(3), e20161649–e20161649. doi:10.1542/peds.2016-1649 http://pediatrics.aappublications.org/content/138/3/e20161649 Hotchkiss, J. W., & Leyland, A. H. (2010). The relationship between body size and mortality in the linked Scottish Health Surveys: cross-sectional surveys with follow-up. International Journal of Obesity, 35(6), 838–851. doi:10.1038/ijo.2010.207 Kalm, L. M. and Semba, R.D. (2005). They Starved So That Others Be Better Fed: Remembering Ancel Keys and the Minnesota Experiment. History of Nutrition. Retrieved from: https://academic.oup.com/jn/article/135/6/1347/4663828
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