Health At Every Size An Alternative ApproachJulie Rochefort, MHSc, RD Jacqui Gingras, PhD, RD Canadian Obesity Summit May 1, 20131Opening oneself to the possibility for transformation is a profound act of courage. - Maureen Walker

Accepting wider range of healthy weights and body sizes while discouraging social pressures for extreme slimness is not an easy task whether you are a parent, teacher or health care professional. Promote healthy eating (not dieting) and regular physical activity (not exercise).

This is not going to be easy- theres a lot of resistance from various disciplines. But by opening oneself to the possible of transformation we are one step closer to making a real change in our world.

2Outline OverviewLearning ObjectivesIntroductionsHAES 101Activity 1: Shift the focus in Clinical PracticeBreak3Outline SummaryActivity 2: Barriers and enablers to practicing from a HAES perspectiveClosing4Learning ObjectivesAt the end of this workshop, participants will be able to:

Clarify the tenets of HAES Engage with case-based learning activities Identify challenges and opportunities5Facilitator Introductions

6

Julie & Jacqui7HistoryFailure rate of dietWeight stigma and resulting health consequencesResponding to the incidence of ED/DEHealth promotion practice with low side-effects

8

HAES AS SOCIAL JUSTICE JG9Promoting weight loss95% of those who lose weight regain it (Bray, 2005;Mann et al, 2007;Wing et al, 2001).Nutritional inadequacy.Difficulty sustaining low calorie intake.FrustrationWeight cycling: yo-yo effect.

This strategy ISNT working.JG

What do we know about people who lose weight? Refer to first bullet on slide.In fact, a panel of experts convened by the NIH stated that: One third to two thirds of the weight is regained within one year [after weight loss], and almost all is regained within 5 years (NIH, 1992) (NHLBI, 1998) no prospective trials to show changes in mortality with weight loss in obese pts. Executive summary of the clinical guidelines on the identification, evaluation and treatment of overweight and obesity in adults. (October 1998). JADA. Vol. 98 No.10. pp. 1178-1191.

We are encouraging a treatment that we know doesnt work.

10REPEATFEAST RESPONSE

RETURN TO OLD HABITSFAMINE RESPONSE

DIET

Lose weight from lean muscle and fat Reduced metabolic rate Increase in fat storage Reduced metabolic rate Loss of muscle Regain weight from fatDecrease in caloriesIncrease in caloriesTHE DIET TRAP CYCLEWeight Regain11Theres 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 ODea

JG

12

OBESITY PANIC:This is some examples of the fearful language used to treat and inform the public about obesity. I took these words from Canadian government weights, obesity practice guidelines. During my masters, I became aware that this language listed behind me is perpetuating more harm than positive health outcomes.

Campaigns: Obesity Campaigns: The Fine Line Between Educating and Shaming

13Why now?Obesity panic Show obesity campaigns and emerging productsBMI Report CardsCommercials/BillboardsAspire AssistMaggie Goes on a diet14

Non-CompliantSelf-indulgentUnmotivatedRepulsingAwkwardUnattractiveBrownless et al., (2006) Puhl RM and Latner JD (2007/2009))Trained RN/MD/RD and also students training within these professions.

Recent study: Journal: Obesity- a research journal: Physicians build less rapport with obese patientsThere is evidence to show that after visits with more empathy, patients have improved clinical outcomes e.g. DM- BG, TG15

Consequences of weight stigma- NOT WEIGHT.Our efforts to help people to lose weight can unintentionally caused harm. 16

USA Anti-Obesity Campaign 17Disney World: The "Bad Habits"

[UPDATE: 48 hours after this blog was posted, and after intense uproar in social media circles and in the press, Disney did the right thing and closed the exhibit for retooling. Kudos to them for responding quickly - I'm sure their intent wasn't to vilify children with obesity and am hopeful that Habit Heroes' next iteration will be a helpful ally in good health]18Food Labelling: OMA

Your kids are listening campaignPeel Public Health & Toronto Public Health (2013)Obesity Campaigns: The Fine Line Between Educating and Shaming20Shift the focus

HAES 101

22

Listening to bodys hunger/fullness cuesMoving for pleasureAccepting and respecting current state of well being Speaking outPromoting belonging

23

Evidence

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).

Dr. Ross is a researcher in exercise physiology from Queens University. He is quoted as saying . (refer to slide)

26Wildman et al. Arch Intern Med. 2008;168(15):If weight was the ultimate indicator of health, we shouldnt be seeing one third of normal weight individuals having metabolic abnormalities. While we cant ignore that abnormalities are occurring in high proportions in those overweight, weight may be more of an symptom of a larger underlying factor.Also, strong research has demonstrated that individuals whether normal weight or obese can improve their metabolic profile without loosing weight.

27Obesity ParadoxAssumption: 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).

Lucy Aphramor and Linda Bacon are 2 dietitians and researchers who wrote an extensive review paper of the obesity literature. They highlight some assumptions made about weight and fat:28Obesity ParadoxAssumption: 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).

Association does not equal causation.29What Else is going on?Sleep Apnea/Sleep DeprivationEnvironmentAvailability/Quality of FoodMedicationEndocrine System Psychological Status Co-morbiditiesCultural Norms/BeliefsChemicals/Toxins Lack of ExerciseQuitting SmokingGeneticsSESMenopauseStressMedication: not just prednisone or SSRIs used to treat depression, but beta-blockers, prednisone, OHA like glyburide, diamicron and then of course theres insulin.

Smoking: wt gain of 1-2 KG occurs in the first few weeks and often followed by additional 2-3kg weight gain over the next 4-6 months: average weight gain 4-5kg (9-11 lbs) or more (Bray & Champagne, 2005).

Sleep deprivation: releases peptides that produce hunger (pS20).

Its widely known that the primary determinant of health is related to the social and economic environment in which people live.

SES is something that is largely out of the control of our patients. So to hear pts blame themselves for not being able to lose weight or keep it off, is only going to further perpetuate the problem.

Unfortunately, HCPs make assumptions and inflict this blame on them as well.

So what can we do? We can lobby those who have the power to better equalize the current situation.

30Evidence of HAESHAES approach associated with statistical & clinical improvements:physiological measures (e.g. blood pressure, blood lipids), health behaviors (e.g. physical activity, reduced eating disorder pathology), and psychosocial outcomes (e.g. mood, self-esteem, body image). To date, there have been seven randomized controlled trials using a non-diet approach to lifestyle change.

participants in the programs have experienced statistically significant improvements in mental health, self-esteem and body image vs. controls .

HAES approach associated with improvements physiological measures (e.g. blood pressure, blood lipids), health behaviors (e.g. physical activity, reduced eating disorder pathology), and psychosocial outcomes (e.g. mood, self-esteem, body image). (11-20)

Improvements in self-esteem and eating behaviors (11-14,16,17,19,20). 31Bacon et al, 2005Study participants:78 white, obese, female chronic dietersAge: 30-45 yearsBMI: 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

weekly visits x 6 months; then, monthly visits x 6 months32

Bacon et al., JADA. 2005 2 year Follow UpDiet group: Weight lost was regained.Psychological measures worsened.

HAES group:Maintained weightSustained improvement:metabolic health indicators, activity levels, eating behaviours & psychological measures.

34Case StudiesArianna, 25Case StudyArianna, 25Self-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. Wt hx: BMI 33kg/m2Labs-unremarkable

37RecommendationsProviding not depriving Explore diet history, relationship with food and bodySources of stress and coping strategiesDo you feel like you can manage your stress?How much time, energy and resources she is spending dedicated to diet. Frank, 44Case StudyThe 300 lb+ man with osteoarthritis who would benefit from weight loss would be done a disservice if he didnt get feedback whether he was getting closer to a self-set wt goal to reduce his joint pain because we were worried about hurting his feelings.4044 y.o FrankReveals 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 AssistanceMedical hx: Lactose intoleranceOsteoarthritis in both kneesScheduled R-knee replacement in 6 monthsWt hx: He reports that he has gained over 40 lbs in the last 5 years. Lab data: Triglycerides, LDL and normal HDL

As an orthopedic surgeon my concerns are more with increased wear on weight -bearing joints and joint replacements. How does this affect your recommendations? I dont really enjoy trying to force weight loss on prospective TJR candidates but the ortho literature enforces that approach. Any thoughts for me?-David Heller, M.D., South Weymouth, Massachusetts

41RecommendationsNormalize his eatingIs he eating for reasons other than hunger?How does his pain impact his hunger/fullnessHow does he cope with painExplore pleasurable and appropriate physical activity Explore social supports (isolated?)MedicationsHow does this influence his hunger

Normalizing Eating 1) AWARENESS INITIAL APPOINTMENTPay attention to hunger cues NO changesWhen do you feel hungerwhen do you start eating, when do you stopCould 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 appetiteFrank states: My doctor said I can feel less pain if I lose weight. WHAT CAN YOU DO NOW, FRANK? That may or may not be trueOur concern if for your health and comfort right nowWe know that prescribing a weight loss diet can lead you to gain more weight + feeling worst and deterring yourself from healthy behaviours 44Elisa, 8Case StudyEvidence: Food-Related Parenting Practices and Adolescent Weight Status: A Population-Based StudyKatie A. Loth, RD, MPHa, Richard F. MacLehose, PhDa, Jayne A. Fulkerson, PhDb, Scott Crow, MDc, and Dianne Neumark-Sztainer, RD, MPH, PhDa+ Author AffiliationsaDivision of Epidemiology and Community Health, School of Public Health, bSchool of Nursing, and cDepartment of Psychiatry, University of Minnesota, Minneapolis, Minnesota AbstractOBJECTIVE: To examine food-related parenting practices (pressure-to-eat and food restriction) among mothers and fathers of adolescents and associations with adolescent weight status within a large population-based sample of racially/ethnically and socioeconomically diverse parent-adolescent pairs. METHODS: Adolescents (N = 2231; 14.4 years old [SD = 2.0]) and their parents (N = 3431) participated in 2 coordinated population-based studies designed to examine factors associated with weight status and weight-related behaviors in adolescents. Adolescents completed anthropometric measurements and surveys at school. Parents (or other caregivers) completed questionnaires via mail or phone. RESULTS: Findings suggest that the use of controlling food-related parenting practices, including pressure-to-eat and restriction, is common among parents of adolescents. Mean restriction levels were significantly higher among parents of overweight and obese adolescents compared with nonoverweight adolescents. However, levels of pressure-to-eat were significantly higher among nonoverweight adolescents. Results indicate that fathers are more likely than mothers to engage in pressure-to-eat behaviors and boys are more likely than girls to be on the receiving end of parental pressure-to-eat. Parental report of restriction did not differ significantly by parent or adolescent gender. No significant interactions by race/ethnicity or socioeconomic status were seen in the relationship between restriction or pressure-to-eat and adolescent weight status. CONCLUSIONS: Given that there is accumulating evidence for the detrimental effects of controlling feeding practices on childrens ability to self-regulate energy intake, these findings suggest that parents should be educated and empowered through anticipatory guidance to encourage moderation rather than overconsumption and emphasize healthful food choices rather than restrictive eating patterns.

458 year old Elisa Mom very concerned about weightChild is not active in sportsWt hx: Growth chart indicates weight for height moved from 90th 93rd percentileMother has been finding hidden food wrappers and finds a dyiet note in her school agenda.

By a show of hands, how many of you had an encounter with Elisa?

Evidence: Food-Related Parenting Practices and Adolescent Weight Status: A Population-Based StudyKatie A. Loth, RD, MPHa, Richard F. MacLehose, PhDa, Jayne A. Fulkerson, PhDb, Scott Crow, MDc, and Dianne Neumark-Sztainer, RD, MPH, PhDa+ Author AffiliationsaDivision of Epidemiology and Community Health, School of Public Health, bSchool of Nursing, and cDepartment of Psychiatry, University of Minnesota, Minneapolis, Minnesota AbstractOBJECTIVE: To examine food-related parenting practices (pressure-to-eat and food restriction) among mothers and fathers of adolescents and associations with adolescent weight status within a large population-based sample of racially/ethnically and socioeconomically diverse parent-adolescent pairs. METHODS: Adolescents (N = 2231; 14.4 years old [SD = 2.0]) and their parents (N = 3431) participated in 2 coordinated population-based studies designed to examine factors associated with weight status and weight-related behaviors in adolescents. Adolescents completed anthropometric measurements and surveys at school. Parents (or other caregivers) completed questionnaires via mail or phone. RESULTS: Findings suggest that the use of controlling food-related parenting practices, including pressure-to-eat and restriction, is common among parents of adolescents. Mean restriction levels were significantly higher among parents of overweight and obese adolescents compared with nonoverweight adolescents. However, levels of pressure-to-eat were significantly higher among nonoverweight adolescents. Results indicate that fathers are more likely than mothers to engage in pressure-to-eat behaviors and boys are more likely than girls to be on the receiving end of parental pressure-to-eat. Parental report of restriction did not differ significantly by parent or adolescent gender. No significant interactions by race/ethnicity or socioeconomic status were seen in the relationship between restriction or pressure-to-eat and adolescent weight status. CONCLUSIONS: Given that there is accumulating evidence for the detrimental effects of controlling feeding practices on childrens ability to self-regulate energy intake, these findings suggest that parents should be educated and empowered through anticipatory guidance to encourage moderation rather than overconsumption and emphasize healthful food choices rather than restrictive eating patterns.

46

Recommendations (HAES)Division of ResponsibilityReassure around eating competenceReduce pressure to eatAvoid food restrictionPromote self-regulationWhat 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 SatterMoms asks if she could take her daughters weight while at clinicI hear that you are concerned about body weight. But from my perspective this is not the most productive way to proceed- provided that weight doesnt capture your daughters health and well being. We hear your concern.We understand where its coming from.Based on our research and years of practice- that concern is making matters worst. Ask Alissa to wait outside to finish discussing We have an amazing opportunity to set her on a course to happy and healthy. Shift the focus from her well being to her happiness. 49Although 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.55150We recommend an energy-reduced diet and regular physical activity as the first treatment option for overweight and obese children to achieve clinically important weight loss and reduce obesity-related symptoms. CMAJ (2007), Vol 176 (8)pp-88Following the clinical practice guidelines is always a choice. However, we have an alternative approach we should like to share with you?Lets meet Elisa. 51Derick/Danielle, 17Case Study17 y.o Derick (Danielle) Transgendered youth, no sibs , live at home with both parents.Med hx: Diagnosed with EDNOS following a healthy weights promotion at school.Dietary recall demonstrates extreme hunger, binge eating, excessive exercise Wt hx/Labs: BMI=27, blood work unremarkable

53RecommendationsIs the stress attached to the social-cultural context?Normalize eating and exercise Hunger/fullness hunger metreModerating exercise/Readiness Are you happy with the current amount of exercise you are doing?What is the benefit to you right now for exercising? Is there anything you wish you could do that you cant due to the amount of exercise you are committed to?Validate her food/exercise behaviour as coping strategy however discuss this does not sustain LT. Emphasis on providing not taking away (Ellyn Satter)Dignity54Biochemistry of DiscriminationActivation of SNS and HPA axis cortisol + inhibition of sex steroids + GH abdominal adiposity + insulin resistance cortisol = hyperphagic, antithermogenic? disrupt balance of leptin & NPYHT from parallel activation of SNS/insulin(Sumithran et al., 2011).Butler, et al., (2002). Internalised racism, body fat distribution, and abnormal fasting glucose among African-Caribbean women in Dominica, West Indies. J Natl Med Assoc, 94(3), 143-148.55*need to create Smart Art + animations ***Recommendation (Advocacy)Unlearning what she learned at the healthy weights initiative at the schoolWith permission from D, ask to share with parents and discuss the initiative with principal. Offer teachings to staff on next Professional Development day.

Mary, 5757 y.o MaryDiagnosed with T2DM 7 yrs ago and afraid that doctor will put her on needles. States not being a big eater and stays away from sugars. Generally grazes most of the day and eats full meal at supper time with family. Social hx: lives with husband and fosters 2 children (4 and 10). Participates in walking group 3x per week when 4 y.o is at daycare.Family hx: T2DM (mother), CVD (uncle)Labs: A1c= 10.2%, TG Her FBS at clinic was 10 mmol/LMedication: Metformin (BID), Calcium and Vitamin D

Recommendations Examine source and coping of stress in her life (could be related to TG/FBS).Discuss how she feels (emotionally, mentally, physically) when her blood sugars are high/low.What are your energy level like throughout the day?How does this relate to your activity and food intake?Normalize eating-Identifying hunger/satiety cues (hunger-scale)Reduce any anxiety and guilt about eating.May require re-distribution of meal throughout day; however important that it is not prescriptive

Important that changes are personally meaningful and freely chosen.

Discuss how she feels (emotionally, mentally, physically) when her blood sugars are high/low to enhance intuitiveness/biofeedback--physiological consequences. Normalize eating Diabetes can feel like a betrayal by their bodys which can make it difficult to trust body signals (tool box). So if someone percieves that their body has betrayed them, how can this affect their self-care?e.G Diagnosis of diabetes often means that food and eating can no longer be enjoyed.

Redistribution of meals: this will be informed by our discussion around her energy levels experienced during the day when she grazes. We use the information she provides to suggest changes that are meaningful to her aka patient centered care.

59When discussing her goals, Mary states that she would like to lose 10-20 lbs.Situation is: you are employing the HAES view of de-focusing on weight; however her goal and focus has gone towards weight, despite your discussion about food relationships/hunger cues.

60Sharon, 40Sharon, 40Referral received from MD re: eating and PA. MD reports Sharon was interested in bariatric surgery. She states she would like to have more energy to play with her children. Employment: Human Resource CoordinatorLab values: TGs, HDL, WC >88cm, A1C 6.2%Wt hx: reports struggling with her wt since she was a teenager.

MetS based on AdultTreatment PanelIII criteria62

Hunger MeterExternalizing Inner Cues of Hunger, Satiety, and FullnessHungry0Full10Satisfied563RecommendationsEstablish a rapport important for her to rely on you for help if she decided to have B/SAssess readiness of change provided that the negative consequences of bariatric sgx are magnified if intake isnt controlled. Promote eating competence using Hunger Metre do you feel reliably confident that you could provide yourself with predictable (timing) meals and snacks?Sources of stress and coping strategies

64What else is going on?School-based Obesity Prevention ProgramPublic HealthBefore the case study- heres a little insight about the stated of weight-related bullying in canadian schools66 Eisenberg et al ; Puhl RM and Latner JD (2007))

2x higher Fat-so

Tub of lardPigLazyWorthlessIn a canadian study on over 1500 youth living in the ottawa area weight-based teasing was significantly higher among overweight and obese youth than among normal weight youth (45% versus 22%; P a cdn study showed that overweight/obese school children attributed their weight as the primary reason for Cyber bullying

This What gives kids permission to tease someone about their weight and why does this particular type of teasing/bullying affect kids so severely compared to lets say, being the only red head kid in the class? While my professional scope isnt in child psychology, my experience observing obesity messaging and seeing body dissatisfaction in the client I see back in my practice, I have a philosophical hunch, or as my fellow colleagues and I like to say spidy sense are pointing to the way in which professionals and non-professionals speak about obese individuals. [ I would go into the shaming public health campaigns].

67Eisenberg et al

body dissatisfactionlow self-esteem depressive symptomssuicidal ideation avoidance strategiesPoorer school performance

Puhl RM and Latner JD (2007; Pulh, 2012, NEDIC)Research has shown that some overweight youth attribute social rejection to their weight, and believe weight loss would increase their friends.

Body dissatisfaction/poor body image; Body-image refers to ones feelings, attitudes, and perceptions towards ones body and physical appearance. It is an important consideration in the development of eating disorders because it has been shown that disturbances in body-image increase the risk of dieting and bulimia (NEDIC,)

Suicide: Those who are teased about their weight report more suicidal thoughts than peers who are not teased.Puhl RM and Latner JD (2007)

Importantly, findings show that the more that adolescents reported negative health behaviours in response to weight-based victimization, the more they reported coping with avoidance strategies (e.g., avoiding physical activity), and using maladaptive coping strategies (Pulh, 2012)

TransitionAnd while the school environment is supposed to foster a safe learning environment and protect children from bulling, the ongoing pressure put on schools to become one of the nations most effective weapons in the fight against obesity. And while food policies in the schools are a step forward to promoting a an environment that is surrounded by healthier foods, a growing trend in school-based weight prevention programs is growing.

68You receive an email from the principal and guidance counsellor from the local high school regarding an interest in initiating a health report card. Currently , 20% of the schools students are overweight or obese. Components of the report card would include:Waist Circumference, BMI and Body Fat %Blood PressureBlood SugarScreen TimeAs the school nurse they are asking you to be part of the implementation process and data collection. The goal of this initiative is to ensure the health and well being of their students are maintained and to reduce obesity prevalence in the school by half in the next 5 years.

Kalich et al., 200810%Diet pills Herbal supplements

20%RestrictingSkipping mealsStudies have also investigated the level of comfort and acceptability of school-based weight screening assessment. These studies demonstrated that students report being uncomfortable with being weighed at school (Kalich et al., 2008). Consequently, when these students were asked about their intentions to engage in weight management activities after receiving information regarding weight, close to 20% of students stated restricting food (diet) and skip meals or snacks with an additional 10% stating they would take diet pills/herbal supplements and visit a weight loss clinic (Kalich et al., 2008).

Moreover a recent article published in the Canadian Medical Association Journal states that school-based programs that collect weight measures may lead increase the prevalence of stigmatization and bullying (CMAJ, 2011).

Long lasting research both from the ED realm and public health has been sounding the alarm at these unintended consequences but for some reason or antoher, weve continuously ignored them, letting the public health message and interventions become more and more shaming and blaming.

70RecommendationsCritiquesAssumption: Anyone who is determined can lose weight and keep it off through appropriate diet and exerciseAssumption: The pursuit of weight loss is a practical and positive goalAssumption: The only way for overweight and obese people to improve health is to lose weightAssumption: Obesity-related costs place a large burden on the economy, and this can be corrected by focused attention to obesity treatment and preventionConsider ThatAs evidence-based competencies are more firmly embedded into standard practice, more attention given to the ethical implications of recommending treatment that may be ineffective or damaging. (5, 9)

Shifting ParadigmsInterventions will focus only on modifiable behaviors where there is evidence that such modification will improve health. Weight is not a behavior and therefore not an appropriate target for behavior modification.Lay experience will inform practice, and the political dimensions of health research and policy will be articulated.Bacon, Aphramor, 2011Interventions will be careful to avoid weight-biased stigma, such as not using language like "overweight" and "obesity.

Interventions will seek to change major determinants of health that reside in inequitable social, economic and environmental factors, including all forms of stigma and oppression.

Support each other by focusing on health and well-being, NOT weight. Show compassion & understanding for the difficulties that arise from living in non-relational society.Provide a non-judgmental environment. Help develop sustainable behavioural changes that easily fit into peoples busy lives.Continually and rigourously evaluate effectivenessGet active and involved in re-shaping attitudes, not bodies.

75Body positive

HAES Practice Resourceswww.shiftthefocus.wordpress.comDiscussionWhat barriers and enablers do you predict as you transition from HAES theory to practice?In what contexts can you advocate for HAES?What resources are needed moving forward?What research is required to explore HAES further, especially in your practice context?

Jacqui78Weight=HealthCultural value of thinness & individualismWorkplaceLobby GroupsResearchBARRIERSDemand for weight lossBarriersTalk about the International HAES group79AcknowledgementsCurrent and previous Ryerson students

Colleagues & Clients Noojmowin Teg Health Centre

Conference delegates! Thats YOU!

Rare opportuniyt and crisi 80ReferencesBacon L. (2005). Size Acceptance and Intuitive Eating Improve Health in Obese Female Chronic Dieters.J Am Dietetic Association, 105, 929-936. Bacon, L., & Aphramor, L. (2011). Weight science: evaluating the evidence for a paradigm shift. Nutrition Journal, 24(10), 9.Bacon, L, Keim, NL, Van Loan, MD, Derricote,M, Gale, B, Kazaks, A and Stern, JS. (2002). Evaluating a non-diet wellness intervention for improvement of metabolic fitness, psychological well-being and eating and activity behaviors. International Journal of Obesity, 26, 854865.ReferencesBray & Champagne. (May 2005) Beyond energy balance: there is more to obesity than kilocalories. JADA. Vol 105 No. 5, Suppl. 1. PP S17-23. Cohen, D., de la Vega, R., & Watson, G. (2001). Advocacy for social justice: A global action and reflection guide. Bloomfield, CT: Kumarian Press Inc.Berke, D. L., Boyd-Soisson, E. F., Voorhees, A. N., & Reininga, E. W. (2011). Advocacy as Service-Learning. Family Science Review, 15(1), 13-30.ReferencesBrown, I. (2004). Nurses attitudes towards adult patients who are obese: literature review. Journal of Advanced Nursing, 53(2), 221232.Puhl R and Heuer C. 2009. The Stigma of Obesity: A Review and Update. Obesity, 17(5), 941-964.Puhl R; Warton C, Heuer.2009. Weight Bias among Dietetics Students: Implications for Treatment Practices. Journal of the American Dietetic Association, 109, 438-444.Rengasamy, S. (2009, June 26). Advocacy and lobbying. Retrieved August 12, 2009, from http://www.wepapers.com/Papers/39072/Advocacy_&_Lobbying ReferencesScherbakov et al., (2011). Body weight after stroke: lessons from the obesity paradox. J Am Heart Assoc. 42, 1-5. Schwartz, M. (2001). Brain pathways controlling food intake and body weight. Experimental Biology & Medicine, 226(11), 978-81.Schwartz MB. 2003. Weight Bias among Health Professionals Specializing in Obesity. Obesity Research, 11(9), 1033-1039.Sumithran et al. (2011). New Eng J Med, 365(17), 1597-1604.

Recommended ReadingAphramor L. (2009). Weight management as a cardioprotective intervention raises issues for nutritional scientists regarding clinical ethics. Proc Nut Soc, 67, E401.Aphramor L. (2005). Is A Weight-Centred Health Framework Salutogenic? Some Thoughts on Unhinging Certain Dietary Ideologies. Social Theory and Health, 3, 315340.Aphramor L, Gingras J. (2009). That remains to be seen: Disappeared feminist discourses on fat in dietetic theory and practice. (pp. 97105). In: The Fat Studies Reader. E. Rothblum & S. Solovay (Eds.). NY: NY University Press.Bacon L. (2010). Health at Every Size: The Surprising Truth About Your Weight. Second. Dallas: BenBella Books.Recommended ReadingBrownell, K., Puhl, R., Schwartz, M., & Rudd, L. E. (2005). Weight bias: Nature, consequences, and remedies. NY: Guilford.Campos, P., Saguy, A., Ernsberger, P., Oliver, E., & Gaesser, G. (2005). The epidemiology of overweight and obesity: public health crisis or moral panic? Int J Epidemiol, 35, 5560.Gaesser, G. (2002). Big Fat Lies: The Truth About Your Weight and Your Health. Carlsbad, CA: Gurze Books.Gard, M., & Wright, J. (2005). The Obesity Epidemic. NY: Routledge. Gingras, J. (2006). Throwing their weight around: Canadians take on Health at Every Size. HAES, 19(4), 195-206.Holm, S. (2007). Obesity interventions and ethics. Obesity Reviews, 8(Suppl 1):207210.Recommended ReadingNeumark-Sztainer, D. (2005). Can We Simultaneously Work Toward the Prevention of Obesity and Eating Disorders in Children and Adolescents? International Journal of Eating Disorders, 38, 220 - 227.Puhl RM, Andreyeva T, Brownell KD. (2008). Perceptions of weight discrimination: Prevalence and comparison to race and gender discrimination in America. Int J Obes, 32, 9921000. Puhl R, Heuer C. (2010). Obesity Stigma: Important Considerations for Public Health. Am J Public Health, 100, 10191028.Tribole E, & Resch E.(2010). Intuitive eating: a revolutionary program that works. New York: St. Martin's Griffin.

Save the datesMay 6th 2013- International No Diet DayMay 6-12, 2013- Mental Health Awareness WeekSeptember 2013- Weight Stigma Awareness Week

Conferences/GatheringsMay 9th-10th Body-Image and Self-Esteem Conference-Toronto, ON www.nedic.caAugust 15th-17th 2013 Critical Dietetics Conference, Wolfville, NS www.criticaldietetics.org

Did we miss anything? Let us know!

Microsoft Engineering ExcellenceMicrosoft Confidential88Is your presentation as crisp as possible? Consider moving extra content to the appendix.Use appendix slides to store content that you might want to refer to during the Question slide or that may be useful for attendees to investigate deeper in the future.