Lucy AphramorDietetic Theorist

OverviewDoubts – updated reviewTowards a weight-neutral modelEthical perplexityMeeting resistanceMaking waves

Frameworks Evidence based medicineClinical ethicsPublic health ethicsSocial justice

Critical pedagogyOrganisational knowledge creationSociology of emotionArts based inquiry

Clinical DieteticsCase 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)

Dietetics Today

Patients > BMI 25 should be helped to lose weight

Science is value free

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

NIH Evidence Review: Obesity

" recent evidence suggests that intentional weight loss is not associated with increased morbidity and mortality”

Fat acceptance

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

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

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

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 Epid Comm Hlth, 1996

Another study of almost 50,000 Finns followed for an average of 17 years by Hu 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

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

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

Lightening the LoadIn 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%.

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++

Outcomes of Weight Loss Behaviour (WLB)

Effective Ineffective and harmful

Foresight uses Avenell et al which has 12 months follow-up ?ethics

Mann et al (2007) A systematic review of RCTs with weight gain at 2 years

DOMUK (2007) Discredited by Ikeda et al (2005) ?ethics

Jain (2006) Systematic review -research to date shows what does not work

Your Weight, Your Health – 3 refs not fit for purpose ? ethics

Bacon et al (2005)

The deleterious effect of 9 months energy restriction on bone remodelling rate appears to persist during weight maintenance/NIH.

Recognising the Diet Mentality Counting calories

Buying diet foods instead of regular foods

Feeling guilty or fearful about eating

Weighing yourself frequently

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

BDA Code of Conduct - ethicsDo the risks outweigh the benefits? nonmaleficence

Does it promote health? beneficence

Are we acting with integrity? fidelity, justice, veracity, caring response

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

Childhood WeightSingapore reduced fat children’s weight

Uzbekistan, Kiribati, Algeria and Egypt fattest children - Fast foods are relatively rare

Limits and dangers of energy balance model

Obesity as Anti-ScienceBody 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    

‘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

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

“… 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)

Experiencing ResistanceAbsolute 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

Types of interpretive biasConfirmation 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

Message biasEvaluating 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

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”

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.

“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

JP Poulain, 2009

Social JusticeEqual worth of each person

Equal outcomes

Responsibility and sustainability

Process matters

Bywaters 2004

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

Wellness

8% attrition

Weight stability

Sustained improvements in BP, depression, LDL, eating disorder symptomology

X4 increase moderate activity

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

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 acceptancetrust in your self and your body

“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

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

‘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

Food for Thought - McKibbin

“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

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).

Tackling the Thinness PrivilegeEquality Impact Assessment

Disability Advocacy

User groups

Hate crime

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

Path Model for Chronic Stress and CHD

CHD

Poor health habits

Metabolicsyndrome

Socialresources

Distress

Chronicstress

Personal resources

vulnerability

Vitaliano et al 2002

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

SilencesDiabetes – Canada 2010; insecure work;

marginalization

Racism, ethnocentrism & violence underlie much of poor nutrition

Pro reform or pro status quo?

silence’s permissivenessmakes us all tightlipped with truthslack jawed on fibswe laugh indecently at gags

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

Beyond NutritionismHealth 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).

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

Response to inequality. . . compassion. I offer this not as a superficial

panacea but as an active stance which recognises the lived realities of patients and their contextualised embodied narratives of distress. It is a position which prohibits unrealistic expectations and demands of patients and does not diminish the dignity of individual lives. The second is a re-awakening of [practitioners’] role as advocates for social justice

Roberts, J. (2009) Structural violence and emotional health: a message from Easington, a former mining community in northern England, Anthropology & Medicine, 16, 1, pp 37 – 48.

“Unlearning has been described as the ‘process of reducing or eliminating preexisiting knowledge or habits that would otherwise represent formidable barriers to new learning.”

Newstrom 1983 p36 in McDonald 2002

“All art begins in the location where certainty ends. Poetry begins here, deeply rooted in the ambiguities, blood rememberings, human obsessions and desires that cannot embody ethics but may be capable of measures of truth..”

Dunlop 2002

Tacking PositivismEven restricting ourselves to the growing body of

research that illustrates the relationship between our diet and our feelings and behaviours, it becomes obvious that what we eat is affected by why and how we eat, both of which may also have an impact on our mental health. For example, if we see food purely as a means of ‘re-fuelling’, our meal times will affect us differently than if we see food as a vital source of nourishment for our body and mind. Similarly, if we eat alone, the psychosocial benefits of food may be different than if we eat with others (Feeding Minds, 2006, p. 17).

The decision to feed the worldis the real decision. No revolution has chosen it for that choice requires that women shall be free

Adrienne Rich

Critical Pedagogy “It is a grave responsibility not to settle for

the convenient, the shoddy, the conventionally expected, nor the merely safe” Audre Lorde

It would have to contain losses, resiliencies, histories faced; it would have to contain a face. Rich 1999

Professional socialisation“The relationships dietitians have with their

own bodies and the bodies of those who seek their services are constituted and constrained by a control discourse, which marginalizes bodily difference.

Control discourse constitutes individuals’ eating patterns as a series of reasoned, discrete, and quantifiable choices (i. e. weigh, measure, limit, and avoid) in direct contrast to views that eating is determined by emotion, hunger, appetite, and sociality.

This “discourse inherently delimits possibilities for authenticity and connection in dietitians’ relationships with theirs and Others’ bodies.

It is an ethical imperative to make visible this route to bodily difference that has dramatic potential to exacerbate feelings of body shame and hatred. “

Gingras & Brady, 2010

Ethical survival “Name the seriousness of the situation. Do

not pretend that what is happening, or not happening, is acceptable and that it will go away. It is not and will not.”

“Take the opportunity to nurture and be nurtured by essential sources of support.”

Purtilo

“Information and insight are created in the hearts and minds of individuals , and … information seeking and use are a dynamic disorderly social process that is enfolded in layers of cognitive, affective and situational contingencies.”

Choo 1998 p29

“There is both sadness and adventure ahead, and there is pain to pay for the somnambulant beliefs in our own dominion”

Jardine 1998 in Gingras, 2009

“it’s the layers of historywe have to choose, alongwith our own practice: what must be tried againover and over and what must not be repeatedand at what depth which layerwill we meet others”

the words barely begin to match the desire

Adrienne Rich, 1999