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Health At Every Size An Alternative Approach. Julie Rochefort , MHSc , RD Jacqui Gingras, PhD, RD Canadian Obesity Summit May 1, 2013. “Opening oneself to the possibility for transformation is a profound act of courage .” - Maureen Walker. Outline . Overview
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Health At Every Size An Alternative Approach Julie Rochefort, MHSc, RD Jacqui Gingras, PhD, RD Canadian Obesity Summit May 1, 2013
“Opening oneself to the possibility for transformation is a profound act of courage.” - Maureen Walker
Outline • Overview • Learning Objectives • Introductions • HAES 101 • Activity 1: Shift the focus in Clinical Practice • Break
Outline • Summary • Activity 2: Barriers and enablers to practicing from a HAES perspective • Closing
Learning Objectives At the end of this workshop, participants will be able to: • Clarify the tenets of HAES • Engage with case-based learning activities • Identify challenges and opportunities
Julie & Jacqui
Promoting weight loss • 95% of those who lose weight regain it (Bray, 2005;Mann et al, 2007;Wing et al, 2001). • Nutritional inadequacy. • Difficulty sustaining low calorie intake. • Frustration • Weight cycling: “yo-yo” effect. This strategy ISN’T working.
REPEAT • DIET RETURN TO OLD HABITS THE DIET TRAP CYCLE Weight Regain Decrease in calories FEAST RESPONSE Increase in calories FAMINE RESPONSE • Reduced metabolic rate • Loss of muscle • Regain weight from fat • Lose weight from lean muscle and fat • Reduced metabolic rate • Increase in fat storage
“There’s 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 O’Dea
Non-Compliant Self-indulgent Unmotivated Repulsing Awkward Unattractive Brownless et al., (2006) Puhl RM and Latner JD (2007/2009))
Your kids are listening campaign Peel Public Health & Toronto Public Health (2013)
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).
Obesity Paradox Assumption: • “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).
Obesity Paradox Assumption: • “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).
What Else is going on? Psychological Status Endocrine System Menopause Sleep Apnea/Sleep Deprivation Availability/Quality of Food Stress Environment Chemicals/ Toxins Lack of Exercise Genetics SES Medication Co-morbidities Quitting Smoking Cultural Norms/Beliefs
Evidence of HAES • HAES approach associated with statistical & clinical improvements: • physiologicalmeasures (e.g. blood pressure, blood lipids), • healthbehaviors(e.g. physical activity, reduced eating disorder pathology), and • psychosocialoutcomes(e.g. mood, self-esteem, body image).
Bacon et al, 2005 • Study participants: • 78 white, obese, female chronic dieters • Age: 30-45 years • BMI: 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
Bacon et al., JADA. 2005 – 2 year Follow Up Diet group: • Weight lost was regained. • Psychological measures worsened. HAES group: • Maintained weight • Sustained improvement: • metabolic health indicators, activity levels, eating behaviours & psychological measures.
Arianna, 25 Case Study
Arianna, 25 • Self-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. • Wthx: BMI 33kg/m2 • Labs-unremarkable
Recommendations • Providing not depriving • Explore diet history, relationship with food and body • Sources of stress and coping strategies • “Do you feel like you can manage your stress?” • How much time, energy and resources she is spending dedicated to diet.
Frank, 44 Case Study
44 y.o Frank • Reveals 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 Assistance • Medical hx: Lactose intolerance • Osteoarthritis in both knees • Scheduled R-knee replacement in 6 months • Wthx: He reports that he has gained over 40 lbs in the last 5years. • Lab data: Triglycerides, LDL and normal HDL
Recommendations • Normalize his eating • Is he eating for reasons other than hunger? • How does his pain impact his hunger/fullness • How does he cope with pain • Explore pleasurable and appropriate physical activity • Explore social supports (isolated?) • Medications • How does this influence his hunger
Normalizing Eating • 1) AWARENESS – INITIAL APPOINTMENT • Pay attention to hunger cues – NO changes • “When do you feel hunger’ • “when do you start eating, when do you stop” • Could 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 appetite”
Frank states: “My doctor said I can feel less pain if I lose weight.”
Elisa, 8 Case Study
8 year old Elisa Mom very concerned about weight Child is not active in sports Wthx: Growth chart indicates weight for height moved from 90th 93rd percentile Mother has been finding hidden food wrappers and finds a ‘dyiet’ note in her school agenda.
Recommendations (HAES) • Division of Responsibility • Reassure around eating competence • Reduce pressure to eat • Avoid food restriction • Promote self-regulation • “What 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 Satter
Mom’s asks if she could take her daughter’s weight while at clinic
“Although 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.551