Taking a health-gain (salutogenic) approach to public health: advancing body respect to deliver dietary improvement

Dr Lucy Aphramor RD AMRSPH Honorary Research Fellow Chester University

The Well Now way: embodied, relational, intentionally political

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Practice concerns: weight loss

• high failure rate

• wider determinants of health

• size stigma, body shame, troubled eating

• commitment to patient welfare

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Iatrogenic impact

• “You end up feeling crap about yourself... because you then just get that public label about how you are a problem.”

• “I’ve had it said to me that fat people are just a drain on the health service.”

Iatrogenic impact

• “I retreat into myself and I feel that I am worthless”

• “How do you challenge a society that’s having a drip effect constantly .. that it’s OK to have a go at people..”

Iatrogenic Impact

www.teenweightwise.com

Ethical Considerations

• Is it free of harm?

nonmaleficence

• Does it promote health?

beneficence

• Are we acting with integrity?

fidelity, justice, veracity, caring response

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Switching the focus

• Changing health behaviours and attitudes (self-care and self-worth) can impact health outcomes whether or not someone loses weight

The Well Now Table: Untangling Health Behaviours, Respect, Weight and Wellbeing (Aphramor, 2015)

Health

condition

Could these have any impact?

Eating Well

Being Active

Mindful- ness

SDH* Respect

Does it harm?

Diabetes

NO

Heart disease

NO

Joint problems

NO

Depression

NO

Switching the focus

•Switching the focus off weight supports people in behaviours and attitudes that enhance wellbeing

Size acceptance and intuitive eating • 6 RCTs - associated with statistically and clinically

relevant improvements

• Physiological measures (e.g. blood pressure, blood lipids)

• Health behaviours (e.g. physical activity, eating disorder symptomology)

• Psychosocial outcomes (e.g. mood, self-esteem, and body image)

• No decrement in any variable http://www.nutritionj.com/content/10/1/9 2011

Switching the focus

• Focusing on health behaviours and body respect for all helps people establish self-care and stabilise at their set-point

•Whereas the focus on weight is likely to lead to weight fluctuation

SIGN (2011) ( p. 18) • “ Weight cycling is a common condition as only a

minority of people who lose weight through weight management interventions are able to maintain their weight loss.115,116 . . . Weight cycling is a risk factor for all-cause mortality and cardiovascular mortality (hazard ratio (HR) approximately 1.8 for both).118,119

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The British Nutrition Foundation (1999):

‘‘ a positive association has consistently been observed between body weight fluctuation and all-cause mortality and usually… with coronary mortality in particular. This finding is very robust, further confirmation is found in the British Regional Heart Study (Wannamethee & Shaper, 1990), in the Seven Nations Study (Peters et al., 1995) and in the Iowa Women’s Health Study (French et al., 1997) (p 137).’’

Women’s Health Initiative

• high quality dietary intervention (RCT)

• 20,000 women followed for over 7 years of “healthy eating”

• 360 kcal daily deficit and increased activity level no match for set-point

Howard, JAMA, 2006, 295(1), p 969.

Body or Machine?

Energy deficit leads to weight loss:

BUT we are not machines, and energy deficit also leads to adjustments to mitigate weight loss.

RCT Evidence on Weight Control Mann et al 2007 Am Psyc Vol. 62, No. 3, 220–233

“one third to two thirds of dieters regain more weight than they lost on their diets, and these studies likely underestimate the extent to which dieting is counterproductive because of several methodological problems, all of which bias the studies toward showing successful weight loss maintenance. In addition, the studies do not provide consistent evidence that dieting results in significant

health improvements, regardless of weight change...The benefits of dieting are simply too small and the potential harms of dieting are too large for it to be recommended as a safe and effective treatment for obesity.

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Switching the focus

• The small % of people who do lose weight will still lose it

• The majority of people who yo-yo diet won’t be sacrificed in the process

• And our services will be non-stigmatising and inclusive

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The beneficial effects of modest weight loss on cardiovascular risk factors Van Gaal et al 1997

• n=9

• “data on the effects of weight loss on Lp(a) are scarce and contradictory”

• “possible effects of exercise were difficult to determine”

• “it cannot be proven that weight loss per se is the most important trigger of the reduced mortality”

The Well Now way promotes body respect and self-care

•Compassion

•Connection

•Criticality

with goals and outcomes around:

fair society

health equity

accurate science and ethical practice

compassionate self-care

self-acceptance : own our worth, value our experiences

courage and opportunity to live vulnerably

How? Connected Eating

What am I hungry for? •food

•emotional sustenance

… fresh air, a pick-me-up chat, a hug…

Hunger-o-meter

Compassion and acceptance

acceptance:

speak kindly to

myself

compassion:

self-care, different options

rough day

cakes

judgement - guilt, anger,

hopelessness

compensatory behaviours

distress

Health Equity

Or

Why do thin people have heart attacks and get type 2 diabetes?

Conventional risk factors

• Smoking

• Diet

• Exercise

• Alcohol

In the Whitehall II study lifestyle factors account for ¼ of socioeconomic gradient (Marmot et al 1997)

My risk of heart problems

0.9%

In a crowd of 100 people with the same risk factors as me 1 are likely to have a heart attack or stroke within the next 10 years.

My weight doubles

1.1%

In a crowd of 100 people with the same risk factors as me 1 are likely to have a heart attack or stroke within the next 10 years.

Moved house

1.7%

In a crowd of 100 people with the same risk factors as me 2 are likely to have a heart attack or stroke within the next 10 years.

The Well Now way offers us a harm-free approach to ethical, effective, inclusive health promotion. Participants on Well Now courses have said:

• I think you made me look at lots of things. . .how I think about everything, my emotions and what’s in my heart really. You made me think about what’s in my heart and what’s in my soul. And who am I really? And why am I just worried about my weight? There is more to me than how much I weigh.

Well Now in Coventry

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I used to stay in bed til 11 because I couldn't face the

day but now I get up in the morning. It's really helped

my mood. I noticed I was getting sugar highs like when

I drank orange juice and stuff and then feeling really

tired, I had no energy. The course has really made a

difference. It’s changed my life.

Thank you for listening

For more details of my work and the Well Now course see see www.well-founded.org.uk

How would have heard me differently if I was fat?

http://www.disruptivewomen.net/2015/08/27/body-respect-disrupts-business-as-usual-to-advance-nutritional-wellbeing-for-all/

© Lucy Aphramor 2015. Please contact for enquiries about

reproduction or distribution. hello@well-founded.org.uk

Copyright

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You’ll also find links on my website to you tube clips explaining several of the concepts I’ve covered here in more detail.

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