Never mind the ethics, feel the resistance: challenges to HAES in the UK

1. Never mind the ethics, feel the resistance: challenges to HAES in the UK Lucy Aphramor Dietetic Theorist

2. Overview • Doubts – updated review • Towards a weight-neutral model • Ethical perplexity • Meeting resistance • Making waves

3. Frameworks • Evidence based medicine • Clinical ethics • Public health ethics • Social justice • Critical pedagogy • Organisational knowledge creation • Sociology of emotion • Arts based inquiry

4. Clinical Dietetics Case 6 Jon: Obesity “Explain the concept of ‘gluttony’ and how this might affect construction of an intervention diet, dietary compliance and hence clinical outcome.” (Pender, 2008, p 23)

5. Dietetics Today Patients > BMI 25 should be helped to lose weight Science is value free

6. NIH Evidence Reviews: Obesity Three studies - relationship between intentional weight loss and mortality. • “We cannot determine whether the favorable survival effect of bariatric surgery is explained by weight loss or by other beneficial effects of the surgical procedures.”SOS 2007 • 1-year RCT of a cardioprotective diet in East Indian patients post-MI Singh et al BMJ. 1992;304:1015-1019 • “. . . loss of < 20 lb (< 9.1 kg) or loss that occurred over an interval of ≥1 year was generally associated with small to modest increases in mortality.” Williamson, D.F., et al., Am J Epid, 1995. 141: p. 1128-1141

7. NIH Evidence Review: Obesity " recent evidence suggests that intentional weight loss is not associated with increased morbidity and mortality” Fat acceptance

8. Mortality risk not increased in overweight: NHLBI Clinical Guidelines report “Recently, a 20-year prospective study of a nationally representative sample of U.S. adults aged 55 to 74 years suggested that lowest mortality occurs in the BMI range of 25 to 30. After adjusting for smoking status and pre-existing illness, lowest mortality occurred at a BMI of 24.5 in white men, 26.5 in white women, 27.0 in black men, and 29.8 in black women” Clinical Guidelines on the Identification, Evaluation and Treatment of Overweight and Obesity in Adults, NHLBI, 1998, p. 24

9. Studies finding no excess mortality risk among the overweight, BMI 25-<30 • In the Black Pooling Project, Abell et al found that “overweight (BMI 25–29.9) was not associated with increased risk in black or white women “Pub Hlth Reports, 2007 • Al Snih et al found the lowest mortality among the overweight and modestly obese groups among over 8,000 adults over age 65 from the Established Populations for the Epidemiologic Studies of the Elderly cohort Arch Int Med,2007 • Corrada et al found that “being overweight (RR = 1.01) was not associated with excess mortality” among more than 13,000 participants in the Leisure World Cohort Study with on average 23 years of follow-up. AJE, 2006 • Among over 8,000 women ages 65 from the Study of Osteoporotic Fractures Dolan et al found the lowest mortality rates among the modestly overweight; they reported that these findings were not attributable to smoking or measures of preexisting illness. AJPH , 2007 • For almost 5,000 older adults from the Cardiovascular Health Study followed for up to 9 years Janssen found that mortality in the overweight group was 11% lower than in those of normal weight. Obesity, 2007

10. Studies finding no excess mortality risk among the overweight, BMI 25-<30 • In a 7-year follow-up of more than 90,000 women who participated in the Womens Health Initiative Observational Study, McTigue et al found no association between overweight and mortality. JAMA, 2006 • Farrell et al. studied over 9,000 women followed for 11 years and found no increased mortality in the overweight. Obesity Res, 2002 • In a study of older men from the Physicians Health Study, Yates et al found that overweight (BMI 25-<30) had no detrimental effect on the probability of surviving to age 90 (relative risk = 0.97) . Arch Int Med, 2008 • In a large national sample in China of almost 170,000 adults who were followed for up to 9 years, Gu et al found lower mortality in the overweight category than in the normal weight category; their results were not affected by extensive exclusions for smoking and pre-existing illness. JAMA, 2006 • In Finland, Haapenen-Niemi et al followed over 2,000 men and women ages 35-63 for 16 years and found the lowest all-cause mortality rates among the overweight men and women. Int J Obesity, 2000

11. Studies finding no excess mortality risk among the overweight, BMI 25-<30 • Laara’s study of 12,000 Finnish women followed for 22 years found that “… moderately overweight women (BMI of 25 to < 29) had a consistently lower mortality than women of normal weight.” J EpidCommHlth, 1996 • Another study of almost 50,000 Finns followed for an average of 17 years byHu et al also found no increased mortality among overweight men and women. Int J Obes, 2005 • In the Malmo Diet and Cancer Study Lahmann et al (18) reported that “In both sexes, there was no evidence of any excess mortality in the BMI 25.0 to 29.9 category when compared with the normal-range BMI 18.5 to 24.9 category “ and “the removal of early death or self-reported preexisting illness from the analytical cohort, did not materially change the main findings.” Obesity Res, 2002 • Arndt et al followed almost 20,000 German construction workers for 10 years and found the lowest mortality in the overweight category. JOEM, 2007 • Among almost 5,000 middle-aged European men from the Seven Countries Study followed for 25 years Visscher et al found that “a BMI of 25-30 was not related to increased mortality.” AJE, 2000

12. Other studies finding no excess mortality risk among the overweight, BMI 25-<30 • Locher et al found that in their study of a cohort of older adults participating in the UAB Study of Aging “There was no association with being overweight or obese on mortality” J Gerontol, 2007 • In a study of adults ages 40 and above in a rural community in Sweden, Nyholm et al reported that “no indication of overweight being negative for longevity was found in this population” Scand J Pub Hlth, 2005 • In a study of over 45,000 adults ages 60 and above from the National Health Interview Survey, Kreuger found that overweight was associated with significantly reduced mortality relative to normal weight (RR=0.89, p < .0001). Res Aging, 2004 • Engeland et al analyzed prospective data for over 2 million Norwegians ages 20-74 years with measured heights and weights who were followed up for 22 years. They suggested that the normal range of BMI should be shifted upwards because higher mortality rates were observed in the lower part of the normal range than in the lower part of the overweight range. Epidemiology, 2003

13. Other studies finding no excess mortality risk among the overweight, BMI 25-<30 • Menotti et al followed elderly men in Finland, Italy and the Netherlands for ten years and reported that “The results of the present study suggest that in healthy elderly men, body mass index is probably not related to all-cause mortality.” Eur Heart J, 2001 • McGee combined data for over 350,000 people from 26 studies and found slightly lower mortality among the overweight than among those of normal weight. Ann Epidemiol, 2005. • Heiat et al evaluated the published literature on weight and mortality in the elderly and concluded that “studies do not support overweight, as opposed to obesity, as conferring an excess mortality risk.” Arch Int Med , 2001 • Janssen analyzed data from 26 published studies and found no evidence of excess mortality associated with overweight among the elderly. Obesity Rev, 2007

14. Lightening the Load In relation to reduction in co-morbidities, the Diabetes Prevention Program in the US has shown that, among individuals with impaired glucose tolerance, a 5-7% decrease in initial weight reduces the risk of developing type 2 diabetes by 58%.

15. Obesity & Disease Management: Effects of Weight Loss on Comorbid ConditionsAnderson & Konz 2001 Ob Res 9(4) 326S-334S • EuroAction • British Association of Cardiac Rehabilitation • Department of Health 1++

16. Outcomes of Weight Loss Behaviour (WLB)

17. Recognising the Diet Mentality • Counting calories • Buying diet foods instead of regular foods • Feeling guilty or fearful about eating • Weighing yourself frequently

18. Treating your body like a machine that can tightly regulated • Skipping meals • Avoiding certain types of foods • Trying to go for long periods without food • Feeling preoccupied with food, weight and eating

19. BDA Code of Conduct - ethics • Do the risks outweigh the benefits? nonmaleficence • Does it promote health? beneficence • Are we acting with integrity? fidelity, justice, veracity, caring response

20. BDA Code of Professional Conduct (2008) • Not to wrongly raise expectations, waste time and resources treating service users for whom the treatment will not be or has ceased to be beneficial • It is morally and ethically wrong to give unnecessary or harmful treatment • Request for a treatment that would be of dubious benefit should be taken up with referrer or more formally

21. Childhood Weight • Singapore reduced fat children’s weight • Uzbekistan, Kiribati, Algeria and Egypt fattest children - Fast foods are relatively rare • Limits and dangers of energy balance model

22. Obesity as Anti-Science • Body weight cannot be evaluated in a vacuum. It is not a reliable proxy for eating behaviours and physical activity. Although statistical associations exist between body weight and risk for morbidity and mortality, being heavy or slender is not by definition pathological. Correlation does not imply causation and the middle of the weight spectrum can cloak a panoply of unhealthy practices. Since healthy living is important for children of all sizes, interventions should focus on lifestyle rather than weight.       • AED Danielsdottir et al, 2010  

23. ‘We do have some elephants in our room’ • ‘To me professional integrity includes not being swayed by current fashion and ideology’ • Reform requires more than ‘a nice debate and continued papers whose titles include polite question marks.’ • Public censure for professionals who make misleading claims Margrett, 2006

24. Science and pseudo-science • “. . . one of the central conditions of scientific reasoning is that theories must be supported by facts . . . scientists have thick skins. They do not abandon a theory only because facts contradict it. . . .the problem of demarcation between science and pseudoscience is not a pseudo-problem of armchair philosophy, it has grave ethical and political implications” Lakatos, 1973

25. “… attempts to coherently examine the truth, to break through the veil of lies, are powerfully suppressed by ridicule, expert obfuscation, or just plain silence.” (Edwards, 2000: 113) • "The impulse to obscure dark facts . . . comes from the need to preserve the integrity of the self, whether individual or shared. A group may implicitly demand of its members that they sacrifice the truth to preserve an illusion. ... For if that truth is of the sort that undermines shared illusions, that to speak it is to betray the group". (Goleman, 1997)

26. Experiencing Resistance • Absolute need for cognitive control / intuitive eating = ‘eating with abandonment’ • Continued belief in body as calorie burning machine • Failure to recognise food panic as legacy of WLB • Silences – students/ethics WLB/harm/ KSF • Likened to pro smoking lobbyists • “Evidence on knife edge about to tip over” None of your colleagues agree

27. Types of interpretive bias • Confirmation bias: evaluating evidence that supports one’s preconceptions differently from evidence that challenges these convictions • Rescue bias: discounting data by finding selective faults in the experiment • Alternative hypothesis bias - introducing ad hoc modifications to imply that an unanticipated finding would have been otherwise had the experimental conditions been different • Mechanism bias: being less skeptical when underlying science furnishes credibility for the data • “Time will tell” bias: the phenomenon that different scientists need different amounts of confirmatory evidence • Orientation bias: the possibility that the hypothesis itself introduces prejudices and errors and becomes a determinate of experimental outcomes Kaptchuk 2003 BMJ

28. Message bias Evaluating studies on the basis of the message that other people might receive from them. “Public health guidance from national and international policy makers … is .. being undermined by publications that question whether being overweight or obese is associated with important levels of increased mortality or health risks” • ‘Need consistent messages’ eg causes of diabetes

29. Did CDC recant the Flegal et al findings? • An article by Bleich et al “Scientific trust in experts on obesity” published in Obesity in 2007 stated • [CDC] recently received widespread media attention by publishing a study suggesting that people who are slightly overweight live longer than people of normal weight (Flegal et al, 2005), and later recanted the findings • The authors provided no reference for this statement. Apparently, the reviewers, the editor and the journal did not request any verification of the statement • Follow-up erratum, Obesity 2007 “The statement on p. 2154 is inaccurate. The CDC did not recant the findings of the Flegal et al paper”

30. Continuing criticism in the media … • Washington Post (11-7-07): • “It's just rubbish," said Walter Willett, professor of epidemiology and nutrition at the Harvard School of Public Health. "It's just ludicrous to say there is no increased risk of mortality from being overweight “ • Oprah magazine (Feb 2008) • "This research should be completely disregarded," says Walter Willett, MD, professor of ... • Scientific American (Sept 2007) • “It’s complete nonsense, and it’s obviously complete nonsense, and it’s very easy to explain why some people have gone astray,” says Meir Stampfer, a professor of nutrition and epidemiology at the Harvard School of Public Health. …Stampfer cites the Flegal study as a prime example of the errors the critics make. The reason being overweight seemed to reduce mortality is because Flegal used the wrong comparison group, he says.

31. “Time will tell” • 'obesity is increasing at such a rapid rate that the evidence demonstrating how serious the health consequences are likely to be can't keep pace.' (Pett: p:6) • Pett C, Why should obese women listen to obese midwives? The Practising Midwife March 2010,13 (3): 6). Foresight – cl change

32. JP Poulain, 2009

33. Social Justice • Equal worth of each person • Equal outcomes • Responsibility and sustainability • Process matters Bywaters 2004

34. Wellness Bacon, L., Stern, J.S., Van Loan, M.D. & Keim, N. L. (2005). Size acceptance and intuitive eating improve health for obese, female chronic dieters. JADA,105 (6), 929–936. Weight loss 41 % attrition Weight lost then regain Change in health measures not sustained Decrease in self-esteem • 8% attrition • Weight stability • Sustained improvements in BP, depression, LDL, eating disorder symptomology • X4 increase moderate activity

35. Diet vs Wellness Evaluation • my involvement with the HLP has helped me to feel better about myself 47% 100% • hopeful that the HLP would have a positive life-long impact 37% 100% • I currently implement some of the tools that I learned regularly/often 11% 89% • I feel like I have failed in the program 53% agree 95% disagree

36. Health at Every Size, or HAES, promotes: • Healthy and pleasurable eating • Enjoyable physical activity • Self- and societal-acceptance for every body • Scientific and ethical healthcare practice Goals and outcomes include: • weight stability • realistic fitness • healthy relationship with food • good self-esteem and body acceptance • trust in your self and your body

37. “The course that will change your life” What’s different about this approach is that it helps you to tune in. It gives you the tools and techniques to tune in to how you feel about, when you’ve eaten certain foods, how does it make you feel and tune in to yourself and learn how to control your emotions that lead you to eat the wrong things

38. The D Word Worrying weighing plating starving hurting hating counting sinning winning losing piling purging fitting joining chatting meeting shaming bingeing fearing swallowing measuring yearning hoping hungering balancing pinching failing numbing dumbing despair-ing believing restraining Dieting Hurting linking loving reaching doubting learning moving fearing querying feeling flailing caring eating sharing talking laughing tasting weeping wondering grieving leaving thinking swaying stepping asking nurturing noticing risking savouring teaching feasting trying healing Dignity

39. ‘The moment a feeling enters the body is political ‘ Adrienne Rich • Compassionate/ articulate guilt • Embodied knowledge/autonomy • Diet mentality impact on thinking patterns • Discrimination and privilege • Determinants of health

40. Food for Thought - McKibbin

41. “Nothing about us without us” • “It is time to replace the medical model of obesity with a human rights model and ensure that discriminatory social and cultural norms not be institutionalised by law.” • “Have legislators considered asking fat children how they will feel returning to school. . . during ‘Childhood Obesity Awareness’ month?” Deb Lemire, President ASDAH 2010

42. HAES Beyond the Clinic Paying attention to the extent that people are ‘stereotyped, rendered voiceless, silenced, not taken seriously, peripheralized, homogenised, ignored, dehumanized and ordered around’ (Meleis & Im, 1999, p. 96).

43. Tackling the Thinness Privilege • Equality Impact Assessment • Disability Advocacy • User groups • Hate crime

44. Pathways Linking Stress/Status and Metabolic Syndrome • Raikkonen K et al (2002) The relationship between psychological risk attributes and the metabolic syndrome in healthy women: antecedent or consequence? Metabolism 51(12):1573-7 • Butler C 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):143-8 • Vitaliano PP, Scanlan JM, Zhang J, Savage MV, Hirsch IB, Siegler IC. A path model of chronic stress, the metabolic syndrome, and coronary heart disease. Psychosom. Med. May-Jun 2002;64(3):418-435. • Marmot, M. (2004) The status syndrome: how social standing affects our health and longevity. Times Books/Henry Holt:UK • Marmot, M. & Wilkinson, R. (2001) Psychosocial and material pathways in the relation between income and health: a response to Lynch et al. Br. Med. J. 322, p. 1235

45. Path Model for Chronic Stress and CHD Social resources vulnerability Personal resources Metabolic syndrome Distress CHD Chronic stress Vitaliano et al 2002 Poor health habits

46. What’s trust got to do with it? ‘lower levels of social trust were associated with higher rates of most major causes of death, including coronary heart disease, malignant neoplasms, strokes … and infant mortality’ Kawachi 1997

47. Silences • Diabetes – Canada 2010; insecure work; marginalization • Racism, ethnocentrism & violence underlie much of poor nutrition • Pro reform or pro status quo? silence’s permissiveness makes us all tightlipped with truth slack jawed on fibs we laugh indecently at gags

48. Effective health promotion: “actively seeking to eliminate the kind of misleading, mechanistic thinking that turns our bodies into engines and our health into a commodity to be bought and sold.” Scott-Samuel, 2006

49. Beyond Nutritionism • Health in Every Respect reaffirms the need for uncertainty, asking us to be careful, to be: • "wary of our own presumptions, in the understanding that what we thought were the limits of the relevant, of the useful, and of the possible, may indeed turn out to be simply the (subtly imposed) limits of the permissible” (p 3) (Edwards, 2000).

50. I had been told that darkness and water were a threat Instead darkness and water helped me to arrive here I had no special training and my own training was against me Adrienne Rich