Transcript Slide 1

Lucy Aphramor
Dietetic Theorist
Overview
 Doubts – updated review
 Towards a weight-neutral model
 Ethical perplexity
 Meeting resistance
 Making waves
Frameworks
 Evidence based medicine
 Clinical ethics
 Public health ethics
 Social justice
 Critical pedagogy
 Organisational knowledge creation
 Sociology of emotion
 Arts based inquiry
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)
Dietetics Today
• High BMI
linked with
morbidity
and mortality
1
Patients > BMI
25 should be
helped to lose
weight
2
3
Science is value free
• WLB reliably
reduces BMI
& is risk free
• WLB is
proven to
reduce
mortality
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
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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
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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
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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 selfreported 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 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%.
Obesity & Disease Management: Effects of
Weight Loss on Comorbid Conditions
Anderson & 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 - ethics
 Do 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 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
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
‘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 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
Types of interpretive bias
 Confirmation bias: evaluating evidence that supports
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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 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
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 Justice
 Equal 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
Wellness
 8% attrition
 41 % attrition
 Weight stability
 Weight lost then regain
 Sustained improvements in BP,
 Change in health measures
not sustained
 Decrease in self-esteem
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
 I feel like I have failed in the program
11%
89%
53% agree
95% disagree
Health at Every Size, or HAES, promotes:
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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
“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 despairing 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
Public
health
ethics
Health
multifactorial
Eating
for
nurture
Active
living
“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 Privilege
 Equality 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
Social
resources
vulnerability
Personal
resources
Chronic
stress
Distress
Metabolic
syndrome
Poor health
habits
CHD
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
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
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 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).
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 Positivism
 Even 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 world
is 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 history
we have to choose, along
with our own practice: what must be tried again
over and over and
what must not be repeated
and at what depth which layer
will we meet others”
the words barely begin
to match the desire
Adrienne Rich, 1999