Christy Harrison ANCE Slides PPT v2 ANCE Speakers... · • “The social devaluation and denigration of people perceived to carry excess weight, [which] leads to prejudice, negative

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Debate: Health At Every Size®Christy Harrison, MPH, RD, CDN

Food Psych Programs, Inc.

© 2019 Food Psych Programs, Inc.christyharrison.com

About Me• Founder & CEO, Food Psych Programs, Inc.

• Registered dietitian and certified intuitive eating counselor based in Brooklyn, NY

• Creator & host of Food Psych®, a podcast about intuitive eating, Health at Every Size, eating-disorder recovery, and body acceptance

• One of iTunes' top 100 health podcasts

• Launched in 2013

• Food & nutrition journalist with 16+ years of experience writing and editing for major media outlets, including award-winning books, magazines, and websites

• Forthcoming book Anti-Diet -- January 2020 by Little, Brown Spark (Hachette)


Disclosures

• Employee of Food Psych Programs, Inc.

• Past board member of the Association of Size Diversity and Health (ASDAH)


Our Shared Vision• As RDs, we all want to help people and do no harm

• Code of Ethics: beneficence

• Code of Ethics: non-maleficence

• We are committed to justice

• Code of Ethics: reduce health disparities and protect human rights

• We don’t just want people to be healthy for its own sake; we want to help them support their health so that they can live better lives

• We use an evidence-based approach as a means of supporting people’s health and improving lives


The Problem: A Flawed Paradigm

• The conventional view of weight and health—both in the culture at large and in the medical field—does harm and creates injustice

• Detracts from both physical and mental health

• Interferes with people’s access to healthcare

• Creates and reinforces health disparities

• Undermines human rights

• Beyond debating biological effects of weight or medical necessity or non-necessity of weight loss, this is a matter of social justice.


Weight Stigma: Definitions• Aka weight bias or weight-based discrimination

• “The social devaluation and denigration of people perceived to carry excess weight, [which] leads to prejudice, negative stereotyping and discrimination toward those people.” (Tomiyama 2014)

• “A broad range of experiences from minor, everyday instances of differential treatment, or ‘microaggressions’ (e.g., being treated with less respect than others in subtle ways), to being treated unjustly in specific contexts (e.g., being denied employment).” (Pearl 2018)

• Note parallels to other forms of discrimination (racism, sexism, etc.)

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Weight Stigma: Examples• People having low expectations of you because of your weight

• Getting negative comments about your weight from doctors

• Encountering physical barriers and obstacles (e.g. public accommodations being too small)

• Having loved ones be embarrassed by your size

• Being treated poorly by coworkers/employees and denied jobs and promotions

• Being pressured to lose weight or be thin

• Being complimented on weight loss

Sources: Puhl & Brownell 2006; Tylka et al. 2014© 2019 Food Psych Programs, Inc.christyharrison.com

Weight Stigma: Examples“The emotional costs are incalculable. I have never written a story where so many of my sources cried during interviews, where they double- and triple-checked that I would not reveal their names, where they shook with anger describing their interactions with doctors and strangers and their own families. One remembered kids singing ‘Baby Beluga’ as she boarded the school bus, another said she has tried diets so extreme she has passed out, and yet another described the elaborate measures he takes to keep his spouse from seeing him naked in the light. A medical technician I’ll call Sam (he asked me to change his name so his wife wouldn’t find out he spoke to me) said that one glimpse of himself in a mirror can destroy his mood for days. ‘I have this sense I’m fat and I shouldn’t be,’ he says. ‘It feels like the worst kind of weakness.’”

Source: Hobbes 2018


Weight Stigma: Health FX• Independent health risk factor (not due to BMI):

• Higher levels of weight stigma = more than 2x risk of high allostatic load

• Metabolic and lipid dysregulation

• Impaired glucose metabolism

• ↑ Inflammation

• ↑ risk for type 2 diabetes, hypertension, cardiovascular disease, and mortality

• WS is greater risk factor than diet

• Equivalent to risk of physical inactivity

• Raises cortisol (stress hormone) in experimental settings

Sources: Vadiveloo & Mattei 2017; Himmelstein et al. 2015; Wu & Berry 2018© 2019 Food Psych Programs, Inc.christyharrison.com

Weight Stigma: Health FX• Weight stigma in medical settings → avoidance of medical care

• Implicit and explicit weight bias from healthcare providers (including dietitians)

• Misdiagnosis and misattribution of symptoms based on weight

• Greater likelihood of being prescribed weight management instead of necessary interventions for actual health conditions

• Lower likelihood of patient following provider recommendations

• Delaying care → worse health outcomes and more advanced disease states

• Doctors = most frequent source of weight stigma reported by women & 2nd most frequent source reported by men

Sources: Phelan et al. 2015; Puhl & Brownell 2006; Tylka et al. 2014


Weight Stigma: Health FX• Greater body dissatisfaction

• Increased risk of disordered eating

• Increased risk of depression, anxiety, and low self-esteem

• Lower rates of physical activity

• Even people in “normal” BMI range w/high internalized WS experience more frequent illness

Sources: Wu & Berry 2018; Jackson & Steptoe 2017; Muennig et al. 2008© 2019 Food Psych Programs, Inc.christyharrison.com

Weight Cycling & IWL• Weight cycling = repeated weight loss and regain

• Intentional weight-loss interventions (diets, “lifestyle changes,” etc.) are ineffective in the long run

• Large body of evidence showing that it’s very rare for people to “lose weight and keep it off”

• Average amount of weight loss maintained is only 2.4 lbs., still “obese” BMI

• 1/3 to 2/3 of people regain more weight than they lost

• Published results are optimistic; failure rates of WL interventions likely much higher

• “It is only the rate of weight regain, not the fact of weight regain, that appears open to debate.”

Source: Mann et al. 2007

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Weight Cycling & IWL• Typical WL trajectory:

• Weight reaches lowest point ~6 months of IWL intervention

• Starts increasing at about 1 year

• Rate of weight regain speeds up over time

• People trying to lose weight are more likely to weight cycle than not.

Source: Dansinger et al. 2007© 2019 Food Psych Programs, Inc.christyharrison.com

Weight Cycling: Health FX• WC increases likelihood of binge eating

• WC has wide range of physical health risks

• Higher mortality risk

• Higher risk of osteoporotic fractures and gallstone attacks

• Loss of muscle tissue

• Chronic inflammation

• Some forms of cancer

• Hypertension

• Heart disease risk

• WC may explain all excess heart risk seen in people in higher BMI categories

Sources: Field et al. 2004; Tylka et al. 2014; Bacon & Aphramor 2011; 1. Nam et al. 2018; Cho et al. 2017


Weight Management => Weight Stigma

• Framing “obesity” as unhealthy and a matter of personal responsibility leads to:

• Greater anti-fat prejudice

• Greater willingness to discriminate against people w/“obese” BMIs in the workplace

• Greater support for charging people w/“obese” BMIs higher rates for health insurance

• Thus, WM can increase weight stigma

Source: Frederick et al. 2016© 2019 Food Psych Programs, Inc.christyharrison.com

WM => Weight Cycling & Disordered Eating

• Belief underlying weight-management paradigm: With enough effort, people can lose weight and keep it off permanently

• But decades of research show that IWL is not effective in long run

• Therefore, efforts at weight management almost inevitably lead to cycles of loss and regain

• Efforts not to weight cycle → disordered eating

• Trying to achieve and maintain a weight-suppressed state increases risk of binge eating disorder and bulimia nervosa

• Likely because maintaining a weight-suppressed state requires rigid dietary control and often leads to rebound binge eating

Sources: Mann et al. 2007; Tylka et al. 2014


The System Is Broken

• Weight stigma & cycling are harming people

• Weight management has iatrogenic effects

• We need a different approach to weight & health that does no harm


Enter Health At Every Size®

(HAES®)• Developed by group of dietitians & other health

professionals in 1990s, roots to 1970s

• Response to concern w/growing weight stigma in society & medicine

• Designed to help combat disordered eating, chronic dieting, weight-based discrimination, & health disparities

• Interdisciplinary model that includes nutrition, mental health, sociological factors, physical health

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HAES Principles• Weight Inclusivity: Accept and respect the inherent diversity of

body shapes and sizes and reject the idealizing or pathologizing of specific weights.

• Health Enhancement: Support health policies that improve and equalize access to information and services, and personal practices that improve human well-being, including attention to individual physical, economic, social, spiritual, emotional, and other needs.

• Respectful Care: Acknowledge our biases, and work to end weight discrimination, weight stigma, and weight bias. Provide information and services from an understanding that socio-economic status, race, gender, sexual orientation, age, and other identities impact weight stigma, and support environments that address these inequities.

Source: ASDAH© 2019 Food Psych Programs, Inc.christyharrison.com

HAES Principles (cont’d)• Eating for Well-being: Promote flexible,

individualized eating based on hunger, satiety, nutritional needs, and pleasure, rather than any externally regulated eating plan focused on weight control. [aka Intuitive Eating, Attuned Eating, Eating Competence]

• Life-Enhancing Movement: Support physical activities that allow people of all sizes, abilities, and interests to engage in enjoyable movement, to the degree that they choose.

Source: ASDAH


Underlying Beliefs: HAES vs. Weight Management

HAES Weight Management

Higher BMI may be correlated with, but doesn’t cause, poor health outcomes.

Higher BMI is a cause of poor health outcomes.

People have very little long-term control over their body size.

People’s food & activity choices determine their size.

Weight loss is NOT considered a health-promoting intervention.

Weight loss IS considered a health-promoting intervention.

Nutrition and physical activity are engaged in for the sake of well-being.

Nutrition and physical activity are engaged in for the sake of weight loss.


Health Outcomes of HAES Approach

• Better long-term outcomes:

• Lower blood pressure

• More favorable lipid profile

• Increased physical activity

• Lower levels of disordered eating

• Better mood

• Increased self-esteem

• Better body image

• Significantly higher retention rates than conventional weight management

• No weight cycling

• Greater resilience to weight stigma

Source: Bacon & Aphramor 2011


HAES: Measures Used to Assess Health Outcomes

• Everything except weight, BMI, or other body-size / body-composition measurements

• LDL and HDL

• Triglycerides

• Hemoglobin A1C

• Blood pressure

• Dietary recall

• Self-reported physical activity

• Disordered-eating measures

• Body image

• Self-esteem


HAES ≠ Healthism• HAES doesn’t mean “it’s OK to be larger-bodied only as

long as you’re healthy”

• People aren’t required to pursue health in order to prove worthiness or deserve respect

• Health isn’t entirely within our control

• “Pursuing health is neither a moral imperative nor an individual obligation, and health status should never be used to judge, oppress, or determine the value of an individual” —Tylka et al. 2014

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HAES ≠ Healthism

• Social determinants of health, including weight stigma, play a major role in our health outcomes—often more so than behaviors

• HAES does mean it’s OK to be larger-bodied, and we have ways to help you take care of yourself if you so desire—without weight stigma or cycling.

Sources: Vadiveloo & Mattei 2017; ASDAH© 2019 Food Psych Programs, Inc.christyharrison.com

Role of the RDN: Food & Nutrition

• Use intuitive/attuned eating approach to help clients:

• Recover from disordered eating and dieting behaviors

• Let go of internalized diet rules and restrictions

• Re-attune to internal hunger, fullness, and satisfaction cues (NOT for weight loss, but for self-care)

• Develop full, unconditional permission to eat and make peace with all foods

• Learn gentle, evidence-based nutrition principles when client is ready (e.g. adding fruits and vegetables, creating balanced meals, managing chronic conditions)

• Help clients heal their relationship with food and their bodies; don’t just focus on what they eat


Role of the RDN: Support the Whole Person

• Be an advocate and ally to help clients recover from weight stigma

• Support clients in caring for their health in a truly holistic way:

• Finding doctors and other providers willing to use a HAES approach

• Referring to mental-health professionals as needed to recover from disordered eating and weight stigma

• Finding styles of physical activity they enjoy and can sustain (NOT for weight loss but for heart health, blood-sugar management, mental health, etc.)

• Getting enough sleep

• Navigating barriers to health, e.g. insurance, financial access to care, etc.

• Not treating food, exercise, or body size as the be-all-end-all of health


Role of the RDN: Build Body Acceptance & Trust

• A peaceful, health-promoting relationship with food & body is based on self-care, not self-control

• Weight does NOT need to be managed

• Help clients engage in health-promoting behaviors (to the extent available to each individual) & let weight fall where it may

• Help clients accept their body size & make any necessary accommodations

• Trust people’s bodies to figure it out.

“Body trust is your birthright.” —Dana Sturtevant, MS, RD, and Hilary Kinavey, MS, LPC, benourished.org


Practice Applications

• Start exploring the research on HAES, intuitive eating, weight stigma, and weight cycling for yourself

• Understand the impacts of weight stigma and weight cycling

• Offer an ethical alternative to weight management

• Truly support your clients’ well-being


References1. Academ y of Nutrition and Dietetics, Com m ission on Dietetic Registration. Code of Ethics for the Nutrition and Dietetics Profession.; 2018.

2. Tom iyam a AJ. W eight Stigm a Is Stressful. A Review of Evidence for the Cyclic Obesity/W eight-Based Stigm a M odel. Appetite. 2014;82:8-15.

3. Pearl RL. W eight Bias and Stigm a: Public Health Im plications and Structural Solutions. Soc Issues Policy Rev. 2018.

4. Puhl RM , Brownell KD. Confronting and Coping with W eight Stigm a: An Investigation of Overweight and Obese Adults*. Obesity. 2006;14(10):1802-1815.

5. Tylka TL, Annunziato RA, Burgard D, et al. The weight-inclusive versus weight-norm ative approach to health: evaluating the evidence for prioritizing well-being over weight loss. J Obes. 2014;2014:983495.

6. Hobbes M . Everything You Know About Obesity Is W rong. Huffington Post. Septem ber 19, 2018.

7. Vadiveloo M , M attei J. Perceived W eight Discrim ination and 10-Year Risk of Allostatic Load Am ong US Adults. Ann Behav M ed. 2017;51(1):94-104.

8. Him m elstein M S, Incollingo Belsky AC, Tom iyam a AJ. The W eight of Stigm a: Cortisol Reactivity to M anipulated W eight Stigm a. Obesity. 2015;23(2):368-374.

9. W u Y-K, Berry DC. Im pact of weight stigm a on physiological and psychological health outcom es for overweight and obese adults: A system atic review. J Adv Nurs. 2018;74(5):1030-1042.

10.Phelan SM , Burgess DJ, Yeazel M W , Hellerstedt W L, Griffin JM , van Ryn M . Im pact of W eight Bias and Stigm a on Quality of Care and Outcom es for Patients with Obesity. Obes Rev. 2015;16(4):319-326.

11.Jackson SE, Steptoe A. Association between perceived weight discrim ination and physical activity: a population-based study am ong English m iddle-aged and older adults. BM J Open. 2017;7(3):e014592.

12.M uennig P, Jia H, Lee R, Lubetkin E. I Think Therefore I Am : Perceived Ideal W eight as a Determ inant of Health. Am J Public Health. 2008;98(3):501-506.

13.M ann T, Tom iyam a AJ, W estling E, Lew A-M , Sam uels B, Chatm an J. M edicare’s search for effective obesity treatm ents: Diets are not the answer. Am Psychol. 2007;62(3):220-233.

14.Dansinger M L, Tatsioni A, W ong JB, Chung M , Balk EM . M eta-analysis: the effect of dietary counseling for weight loss. Ann Intern M ed. 2007;147(1):41-50.

15.Field AE, M anson JE, Taylor CB, W illett W C, Colditz GA. Association of weight change, weight control practices and weight cycling am ong wom en in the Nurses’ Health Study II. Int J Obes. 2004;28(9):1134-1142.

16.Bacon L, Aphram or L. W eight Science: Evaluating the Evidence for a Paradigm Shift. Nutr J. 2011;10(1):9.

17. Nam GE, Cho KH, Han K, et al. Im pact of body m ass index and body weight variabilities on m ortality: a nationwide cohort study. Int J Obes. M ay 2018:1.

18.Cho I-J, Chang H-J, Sung JM , Yun YM , Kim HC, Chung N. Associations of changes in body m ass index with all-cause and cardiovascular m ortality in healthy m iddle-aged adults. Berglund L, ed. PLoS One. 2017;12(12):e0189180.

19.Frederick DA, Saguy AC, Sandhu G, M ann T. Effects of com peting news m edia fram es of weight on antifat stigm a, beliefs about weight and support for obesity-related public policies. Int J Obes. 2016;40(3):543-549.

20.ASDAH: HAES® Principles. https://www.sizediversityandhealth.org/content.asp?id=152. Accessed August 17, 2018.

http://benourished.org/


References1. Academy of Nutrition and Dietetics, Commission on Dietetic Registration. Code of Ethics for the Nutrition and Dietetics Profession.; 2018.

2. Tomiyama AJ. Weight Stigma Is Stressful. A Review of Evidence for the Cyclic Obesity/Weight-Based Stigma Model. Appetite. 2014;82:8-15.

3. Pearl RL. Weight Bias and Stigma: Public Health Implications and Structural Solutions. Soc Issues Policy Rev. 2018.

4. Puhl RM, Brownell KD. Confronting and Coping with Weight Stigma: An Investigation of Overweight and Obese Adults*. Obesity. 2006;14(10):1802-1815.

5. Tylka TL, Annunziato RA, Burgard D, et al. The weight-inclusive versus weight-normative approach to health: evaluating the evidence for prioritizing well-being over weight loss. J Obes. 2014;2014:983495.

6. Hobbes M. Everything You Know About Obesity Is Wrong. Huffington Post. September 19, 2018.

7. Vadiveloo M, Mattei J. Perceived Weight Discrimination and 10-Year Risk of Allostatic Load Among US Adults. Ann Behav Med. 2017;51(1):94-104.

8. Himmelstein MS, Incollingo Belsky AC, Tomiyama AJ. The Weight of Stigma: Cortisol Reactivity to Manipulated Weight Stigma. Obesity. 2015;23(2):368-374.

9. Wu Y-K, Berry DC. Impact of weight stigma on physiological and psychological health outcomes for overweight and obese adults: A systematic review. J Adv Nurs. 2018;74(5):1030-1042.

10.Phelan SM, Burgess DJ, Yeazel MW, Hellerstedt WL, Griffin JM, van Ryn M. Impact of Weight Bias and Stigma on Quality of Care and Outcomes for Patients with Obesity. Obes Rev. 2015;16(4):319-326.

11.Jackson SE, Steptoe A. Association between perceived weight discrimination and physical activity: a population-based study among English middle-aged and older adults. BMJ Open. 2017;7(3):e014592.

12.Muennig P, Jia H, Lee R, Lubetkin E. I Think Therefore I Am: Perceived Ideal Weight as a Determinant of Health. Am J Public Health. 2008;98(3):501-506.

13.Mann T, Tomiyama AJ, Westling E, Lew A-M, Samuels B, Chatman J. Medicare’s search for effective obesity treatments: Diets are not the answer. Am Psychol. 2007;62(3):220-233.

14.Dansinger ML, Tatsioni A, Wong JB, Chung M, Balk EM. Meta-analysis: the effect of dietary counseling for weight loss. Ann Intern Med. 2007;147(1):41-50.

15.Field AE, Manson JE, Taylor CB, Willett WC, Colditz GA. Association of weight change, weight control practices and weight cycling among women in the Nurses’ Health Study II. Int J Obes. 2004;28(9):1134-1142.

16.Bacon L, Aphramor L. Weight Science: Evaluating the Evidence for a Paradigm Shift. Nutr J. 2011;10(1):9.

17. Nam GE, Cho KH, Han K, et al. Impact of body mass index and body weight variabilities on mortality: a nationwide cohort study. Int J Obes. May 2018:1.

18.Cho I-J, Chang H-J, Sung JM, Yun YM, Kim HC, Chung N. Associations of changes in body mass index with all-cause and cardiovascular mortality in healthy middle-aged adults. Berglund L, ed. PLoS One. 2017;12(12):e0189180.

19.Frederick DA, Saguy AC, Sandhu G, Mann T. Effects of competing news media frames of weight on antifat stigma, beliefs about weight and support for obesity-related public policies. Int J Obes. 2016;40(3):543-549.

20.ASDAH: HAES® Principles. https://www.sizediversityandhealth.org/content.asp?id=152. Accessed August 17, 2018.

Documents

Christy Harrison ANCE Slides PPT v2 ANCE Speakers... · • “The social devaluation and denigration of people perceived to carry excess weight, [which] leads to prejudice, negative