Moving Toward a Weight-Inclusive Practice

Home , Obesity paradox

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

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

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

Kerns, J.C., Guo, J., Fothergill, E., Howard, L., Knuth, N.D., et al. Increased physical activity associated with less weight regain six years after “The Biggest Loser” Competition. (2017) Obesity, 25(11), November 2017, 1838-1843. Retrieved from: https://www.ncbi.nlm.nih.gov/pubmed/29086499

Lyons, P., Husen, L., Martin, T., Tealer, L. M., Howell, P. and Warr, P. Guidelines for Healthcare Providers Who Treat Fat Clients. (2011). Retrieved from The National Association to Advance Fat Acceptance website: https://www.naafaonline.com/dev2/about/Brochures/NAAFA_Guidelines_for_Healthcare_ Providers.pdf

MacLean, P.S., Bergouignan, A., Cornier, M., and Jackman, M. (2011) Biology’s Response to Dieting: The Impetus for Weight Gain. American Journal of Physiology: Regulatory, Integrative and Comparative Physiology Sep: 301(3): R581-R600. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3174765/

Mann, T., Tomiyama, A.J., Westling, E., Lew, A.M., Samuels, B., and Chatman, J. (2007) Medicare’s Search for Effective Obesity Treatments, diets are not the answer. American Psychologist 62(3) 220-233. Retrieved from: https://www.ncbi.nlm.nih.gov/pubmed/17469900

Matheson, E.M., King, D.E., and Everett, C.J. (2012) Healthy Lifestyle Habits and Mortality in Overweight and Obese Individuals. Journal of American Board of Family Medicine 2012.

3 25(1): 9-15. Retrived from: https://www.researchgate.net/publication/51983342_Healthy_Lifestyle_Habits_and_Morta lity_in_Overweight_and_Obese_Individuals

Mensigner, J.L. and Meadows, A. Internalization weight stigma mediates and moderates physical activity outcomes during a healthy living program for women with high body mass index. Psychology of Sport and Exercise, 30(2017) 64-72. Retrieved from: https://www.sciencedirect.com/science/article/pii/S1469029217300730

Mensinger, J. L., Calogero, R. M., Stranges, S., & Tylka, T. L. (2016). A weight-neutral versus weight-loss approach for health promotion in women with high BMI: A randomized-controlled trial. Appetite, 105, 364–374. doi:10.1016/j.appet.2016.06.006

Mensinger, J.L., Tylka, T.L. and Calamari, M.E. (2018). Mechanisms underlying weight status and healthcare avoidance in women: A study of weight stigma, body-related shame and guilt, and healthcare stress. Body Image 25(2018) 139-147. Retrived from: https://www.sciencedirect.com/science/article/abs/pii/S1740144517303790

Pantell, M., Rehkopf, D., Jutte, D., Syme, S. L., Balmes, J., & Adler, N. (2013). Social Isolation: A Predictor of Mortality Comparable to Traditional Clinical Risk Factors. American Journal of Public Health, 103(11), 2056–2062. doi:10.2105/ajph.2013.301261

Pearl, R.L. and Puhl, R.M. (2018) Weight Bias internalization and health: a systematic review. Obesity Reviews, 19(8), 1141–1163. Retrieved from: http://www.uconnruddcenter.org/files/Pdfs/Pearl_et_al-2018-Obesity_Reviews.pdf

Pont, S. J., Puhl, R., Cook, S. R., and Slusser, W. Stigma Experiences by Children and Adolescents With Obesity. Pediatrics 2017; 140(6): e20173034. Retrieved from: http://pediatrics.aappublications.org/content/pediatrics/early/2017/11/16/peds.2017- 3034.full.pdf

Puhl, R. M., & Heuer, C. A. (2009). The Stigma of Obesity: A Review and Update. Obesity, 17(5), 941–964. doi:10.1038/oby.2008.636

Puhl, R., and Suh, Y. Health Consequences of Weight Stigma: Implications for Obesity Prevention and Treatment, Current Obestiy Report, (2015) June: 4(2): 182-90. Doi: 10.1007/s13679-015-0153-z. Retrieved from: https://www.researchgate.net/publication/277615705_Health_Consequences_of_Weight_S tigma_Implications_for_Obesity_Prevention_and_Treatment

Rothblum, E. D. Slim Chance for Permanent Weight Loss. Archives of Scientific Psychology 2018; 6, 63-69. Retrieved from: http://psycnet.apa.org/record/2018-40989-001

Sturgiss, E., Jay, M., Campbell-Scherer, D., and van Weel, C. Challenging Assumptions in Obesity Research. BMJ 2017:359:j5303. Doi: 10.1136/bmj.j5303. Retrieved from: https://www.bmj.com/content/359/bmj.j5303

Tomiyama, A.J. Stress and Obesity. Annual Review of Psychology 2018. Retrieved from: https://www.annualreviews.org/doi/abs/10.1146/annurev-psych-010418-102936

4 Tomiyama, A. J. Weight Stigma Is Stressful. A Review Of Evidence for the Cyclic Obesity/Weight-Based Stigma Model. Appetite, July 2, 2014. Retrieved from: https://www.sciencedirect.com/science/article/pii/S0195666314003560

Tomiyama, A. J., Hunger, J. M., Nguyen-Cuu, J., & Wells, C. (2016). Misclassification of cardiometabolic health when using body mass index categories in NHANES 2005–2012. International Journal of Obesity, 40(5), 883–886. doi:10.1038/ijo.2016.17

Tomiyama, A. J., Carr, D., Granberg, E. M., Major, B., Robinson, E., Sutin, A. R., and Brewis, A. (2018). How And Why Weight Stigma Drives The Obesity ‘Epidemic’ And Harms Health. BioMed Central, 16:123, 1-6. https://bmcmedicine.biomedcentral.com/track/pdf/10.1186/s12916-018-1116-5

Tylka, T. L., Annunziato, R. A., Burgard, D., Daníelsdóttir, S., Shuman, E., Davis, C., & Calogero, R. M. (2014). The Weight-Inclusive versus Weight-Normative Approach to Health: Evaluating the Evidence for Prioritizing Well-Being over Weight Loss. Journal of Obesity, 2014, 1–18. doi:10.1155/2014/983495

Vaughn, W. B., Baruth, M., Beets, M.W., Durstine, L., Liu, J., and Blair, S.N. (2014) Fitness vs. Fatness on All-Cause Mortality: A Meta-Analysis. Progress in Cardiovascular Diseases 56(2014) 382-390. Retrieved from: https://www.sciencedirect.com/science/article/pii/S0033062013001552

Wellman, J.D., Araiza A.M., Newell E.E., and McCoy S.K. Weight Stigma facilitates unhealthy eating and weight gain via fear of fat. (2018) Stigma and Health, August 2018: 3(3); 186-194. Retrieved from: https://psycnet.apa.org/doiLanding?doi=10.1037%2Fsah0000088

World Health Organization Europe Weight bias and obesity stigma: considerations for the WHO European Region http://www.euro.who.int/__data/assets/pdf_file/0017/351026/WeightBias.pdf?ua=1

Journal articles specific to orthopedics:

Inacio, M. C. S., Kritz-Silverstein, D., Raman, R., Macera, C. A., Nichols, J. F., Shaffer, R. A., & Fithian, D. C. (2014). The risk of surgical site infection and re-admission in obese patients undergoing total joint replacement who lose weight before surgery and keep it off post- operatively. The Bone & Joint Journal, 96-B(5), 629–635. doi:10.1302/0301- 620x.96b5.33136

Lui, M., Jones, C. A., & Westby, M. D. (2015). Effect of non-surgical, non-pharmacological weight loss interventions in patients who are obese prior to hip and knee arthroplasty surgery: a rapid review. Systematic Reviews, 4(1). doi:10.1186/s13643-015-0107-2

Vaishya, R., Vijay, V., WAMAE, D., & Agarwal, A. K. (2016). Is Total Knee Replacement Justified in the Morbidly Obese? A Systematic Review. Cureus. doi:10.7759/cureus.804

Hale, I. (2018). Is it weight loss or exercise that matters in osteoarthritis? Canadian Medical Association Journal, 190(43), E1289–E1289. doi:10.1503/cmaj.70597

5 Zhang, J. C., Matelski, J., Gandhi, R., Jackson, T., Urbach, D., & Cram, P. (2018). Can Patient Selection Explain the Obesity Paradox in Orthopaedic Hip Surgery? An Analysis of the ACS- NSQIP Registry. Clinical Orthopaedics and Related Research, 476(5), 964–973. doi:10.1007/s11999.0000000000000218

Frisch, N., Wessell, N. M., Charters, M., Peterson, E., Cann, B., Greenstein, A., & Silverton, C. D. (2016). Effect of Body Mass Index on Blood Transfusion in Total Hip and Knee Arthroplasty. Orthopedics, 39(5), e844–e849. doi:10.3928/01477447-20160509-04

Gurunathan, U., & Myles, P. S. (2016). Limitations of body mass index as an obesity measure of perioperative risk. British Journal of Anaesthesia, 116(3), 319–321. doi:10.1093/bja/aev541