Addressing Weight Bias: What is the role of public health?

PANEL CONVERSATION

March 27, 2019

The Ontario Public Health Convention (TOPHC) 2019

DISCLOSURE OF COMMERCIAL SUPPORT

• None of the presenters at this session have

received financial support or in-kind support

from a commercial sponsor.

• None of the presenters have potential

conflicts of interest to declare.

Panelists

Vincent Ng, THUNDER BAY & DISTRICT

HEALTH UNIT (moderator)

Jessica Hambleton & Kimberly McColl,

TORONTO PUBLIC HEALTH

Lesley Andrade, UNIVERSITY OF WATERLOO

Claire Bilik, PUBLIC HEALTH SUDBURY &

DISTRICT

Danielle Labonte, LEEDS, GRENVILLE,

LANARK & DISTRICT HEALTH UNIT

Amy MacDonald, HURON COUNTY

HEALTH UNIT

Bias & Stigma: Why is it an Issue?

Weight bias = negative prejudicial attitudes

toward persons in larger bodies

Widely held, socially acceptable

Can be implicit (unconscious) and explicit (conscious)

Stigmatizing others and self (internalized weight bias)

Leading to unfair and unjust treatment of people with

obesity at a systemic level

Weight stigma actively contributes to and

exacerbates the mental and physical health

problems associated with obesity

Negative relationships with our bodies, food,

exercise and self-care

Promoting Health Without Doing Harm

A R a p i d R e v i e w o n We i g h t B i a s a n d t h e R o l e o f P u b l i c H e a l t h

Jessica Hambleton, MPH, RD and Kimberly McColl, MHSc, RD

2

Acknowledgements

Other members of the Rapid Review Team:

Ella Manowiec and Sielen Raoufi

Toronto Public Health Librarian: Minakshi Sharma

NCCMT Consultant: Donna Ciliska

3

Why did we do this?

• The field of public health has been criticized for contributing to weight bias

• Some health promotion strategies have placed a greater emphasis on individual behavior change

• To update our evidence and develop recommendations that would reduce the potential for weight bias in public health practice

4

Research Question

“How does public health promote health without increasing weight bias?”

Population: General Population

Exposure: Exposure to Health Promotion Strategies

Comparison: No Exposure

Outcome: Weight Bias

5

Search Strategy

3-Concept Search: body weight + bias + health promotion strategies

Database Search: Ovid MEDLINE, SocINDEX, Psychology and Behavioral Sciences Collection

Timeline: 1990 – June 2018

6

Exclusion CriteriaAnimal studies

Eating disorder, Disordered Eating

Weight-control/management, Dieting

Obesity prevention

1:1 setting

Clinical setting

Counselling setting

Medical setting

Pregnancy &/or breastfeeding

Other language than English or French

Editorials, review, Summaries

Case studies, Policy Statements

No exposure or not related to health promotion

Outcome is not weight bias

Prevalence of weight bias

Validation of tools to measure weight bias

Interventions to reduce weight bias

Public support for policies

7

Search Results• Search yielded 3914 articles

• 82 Duplicates removed

• 3832 Titles and abstracts screened

• 162 Full-text articles were reviewed producing 31 eligible articles

• 4 additional articles identified through a reference list search

• Secondary exclusion criteria applied

• 22 Random Control Trial articles appraised for quality

• 17 articles were included in the analysis

8

Emerging Themes

Images

Messaging

Complex Causes of Obesity

9

Findings: Images

10

Findings: Images

11

Findings: Messaging

12

Findings: Messaging

Findings: Complex Causes of Obesity

Findings: Complex Causes of Obesity

15

LimitationsInconsistent use of measurement tools

Studies were conducted on mostly women

University students were often used as the sample pool

Studies were not entirely representative of the population of Toronto

Some small sample sizes

16

RecommendationsAll messaging or images used in resources and communications should:

• Continue to focus on health and wellbeing, instead of weight

• Acknowledge the role of individual and social determinants of health

• Be inclusive of all shapes and sizes and not exacerbate negative stereotypes of individuals with obesity

Programs and campaigns should not frame obesity as a public health crisis.

Public Health should support efforts to develop and implement alternate indicators of health other than weight and BMI.

17

Next StepsA Model for Evidence-Informed Decision Making, NCCMT

18

Next Steps

A TPH-wide policy on weight bias and health that will inform practice

Internal staff training

Knowledge exchange

Advocacy

19

Thank You

CREATING A CULTURE OF WEIGHT-SENSITIVE EDUCATION:3

Development of an online learning module

Lesley Andrade, MHSc., RD, PhD CandidateSchool of Public Health and Health SystemsUniversity of Waterloo

March 27, 2019

Acknowledgements

University of Waterloo’s OC-SNPWeight Bias Working Group

Amanda Raffoul, MSc., PhD CandidateRachel Acton, PhD CandidateKirsten Lee, PhD CandidateKatie Burns, MSc., PhD CandidateDr. Katelyn Godin, PhDDr. Rhona Hanning, RD, PhD

PAGE 2Creating a culture of weight-sensitive education:

Development of an online learning module

Learning Innovation and Teaching

Enhancement (LITE) Grants

Education sector plays a key role in shaping weight-related attitudes

Creating a culture of weight-sensitive education:

Development of an online learning modulePAGE 3

▪ Belief that obesity is a simple issue and within an

individual’s full control contributes to weight bias and

stigma

▪ Weight bias is common in the population and among

health professionals and pre-service health students

▪ There is a lack of weight bias information in the formal

curriculum

Brief educational intervention

PAGE 4

Lecture

Creating a culture of weight-sensitive education:

Development of an online learning module

Documentary Discussions

Image source: flaticon.com

Evaluation

Advisory Committee Planning

Online weight bias course: Development, implementation and evaluation timeline

PAGE 5Creating a culture of weight-sensitive education:

Development of an online learning module

Research Ethics

LITE Funding

Implementation

Image source: flaticon.com

Developing capacity for weight-sensitive

instruction among educators and learners at

the University of Waterloo

TACKLING WEIGHT BIAS AND STIGMA IN THE CLASSROOM:

PAGE 6Creating a culture of weight-sensitive education:

Development of an online learning module

Tackling weight bias and stigma in the classroom: Student online module

PAGE 9Creating a culture of weight-sensitive education:

Development of an online learning module

Interactive 3-Part Module

1. Weight bias and its unintended

consequences

2. Complexities of obesity1. environment

3. Creating a positive and non-

stigmatizing learning

environment

Recap and next steps:

PAGE 12Creating a culture of weight-sensitive education:

Development of an online learning module

Weight-sensitive

learning

environment

Evaluate &

revise

Scale out to

other courses &

other Faculties

Image source: flaticon.com

PAGE 13landrade@uwaterloo.caCreating a culture of weight-sensitive education:

Development of an online learning module

Public Health Sudbury & Districts’ Approach

to Weight

Claire Bilik, RD

Public Health Dietitian, Public Health Sudbury & Districts

March 2019

Disclosure of commercial support

• None of the presenters at this session have received financial support or in-kind support from a commercial sponsor.

• None of the presenters have potential conflicts of interest to declare.

Presentation outline

• Initial stages of obesity prevention and the promotion of healthy weights

• Introduction of the Balanced Approach

• The evolution of the Balanced Approach

• Reach for your best (R4YB) and present day health and well-being approach to weight

How it all began

72-03 OBESITY PREVENTION AND THE PROMOTION OF HEALTHY WEIGHT IN SUDBURY AND DISTRICT

Therefore be it resolved that the Sudbury & District Board of Health endorse the City of Toronto, Board of Health “Healthy Weights Concept” which supports prevention of unhealthy weights; and

Further that (…) take necessary actions to achieve the goal of the Sudbury & District Health Unit healthy weights initiative; and

Further that the Board of Health urge the Ministry of Health and Long-Term Care to (…) call for national and provincial public responses including population based prevention strategies (…)

The Balanced Approach

The Balanced Approach

Evolution of the Balanced Approach

• BOH motion: Obesity prevention and promotion of healthy weights

• Balanced Approach position statement developed, supported by local eating disorders clinic

• Healthy Weights Action Team formed

• Healthy measures community sessions

• Wide spread Balanced Approach resources and messaging delivered to community, schools, and health care providers

2003 2010

• Professional development sessions for community members

• Training sessions related to promoting healthy weights: integrating mental health into daily practice

• Balanced Approach visioning day

• Development of the Pathways to Healthy Kids

• Collaboration on It Takes A Village module

Evolution of the Balanced Approach

2010 2015

• Adopted internal definition for a healthy weight

Evolution of the Balanced Approach

2015 to present

A healthy weight is the weight your body is naturally when you regularly enjoy a healthy lifestyle which includes eating well, moving well, sleeping well and feeling well. Weight is only one marker of health and a healthy weight is different for every individual1. Supporting a healthy weight requires an integrated and comprehensive approach that includes supportive environments, health and social services, and policies that address inequities which facilitate healthy behaviours and well-being where people live, learn, work and play2.1. Adapted from Freedhoff, Y. and Sharma, A. M. (2010). Best Weight: A Practical Guide to Office-Based Obesity Management. 2. Province of British Columbia (2013). The Meaning of Healthy Weights in British Columbia

• Make connections• Accept self/others• Be critical of media

images/messagesSleep

Feel well

Eat well

• Live actively

• Limit screen time

• Choose energetic activities

• Eat regularly

• Trust and follow hunger cues

• Choose nutritious and wholesome foods everyday

Be active

• Get enough sleep• Good sleep

habits• Reduce screen

use before sleep

Where does healthy weights and weight bias fit into the current OPHS?

This presentation was prepared by Public Health Sudbury & Districts.

This resource may be reproduced, for educational purposes, on the condition that full credit is given to Public Health Sudbury & Districts.

This resource may not be reproduced or used for revenue generation purposes.

© 2019, Public Health Sudbury & Districts

Using a Healthy Bodies and Healthy Minds Approach in Public Health

Danielle Labonté, MAN, RD

Public Health Nutritionist

Re-framing our approach at LGLDHU

LGLDHU approach:

• Strength-based approaches

• The Population Health Approach, considering the Determinants of Health and upstream prevention

• Promotes mental health and well-being

• Supports us in our work on the following topics:

– Physical Activity

– Healthy Eating

– Body Image/Self-Esteem

– Mental Well-being

Position Statement

• Support a strength-based, population health

approach to promote ‘Healthy Bodies, Healthy

Minds’ through:

healthy balanced eating

regular physical activity

positive mental well-being

for everyone

Infographic & Fact Sheets

A Tool For Every Educator

• Self-Esteem & Body Image

• Weight

• Physical Activity

• Healthy Eating

• Eating Disorders

• Media Literacy

• Healthy School Environments

What is included:

How it has been used

• Provide teacher training with schools,

families of schools, or through local

teacher education training days

• Identify their strengths

and build on them

What’s Next

• We will be developing a

new training for

Educators and exploring

the best format for this

• Creating a resource for

youth that includes

activities

Set the HBHM foundation

• Offer training to parents and other

community leaders

• Help ensure a “do no harm” approach

Tool for Working with Children & Teens

• Coaches

• Mentors

• Youth centre staff

• Volunteers

• Camp counsellors

• Employers

Any Influencers of

Youth or adult allies!

Tool for Parenting

• A Tool for Parenting Children

• A Tool for Parenting Teens

Contact usContact Us!

Questions?

Thank you so much for your

time and attention!

Amy MacDonald, RD, MScFN,

Public Health Dietitian

Huron County Health Unit

March 2019

Addressing Weight Bias: What is the role of public health?

Everyone has biases

Conscious and unconscious bias results in stigma, prejudice, and discrimination.

Key Questions:

• How to identify and address weight bias?

• How to shift staff, partners’, and community’s understanding of the issue?

• What are the major barriers?

• What are the next steps for the Huron County Health Unit?

What did we find?

Documented across a wide range of health

care professionals, educators, media, public

Inaccessible spaces and equipment

Weight/BMI based practices, policies,

care guidelines

Literature showing varying preferences for

language & approaches

Society treats weight as if it’s a behaviour

that’s easily modifiable and without risk

Effects of Weight Bias, Stigma, and Discrimination

Afraid to travel7

Anxiety8-12

Avoiding physical activity1,2,6, 8-16

Changes in eating pathology1

Decreased academic performance1,11,13

Decreased functional capacity9,14

Delays in seeking healthcare2,8,10

Depression6,8,10-12,15,17,18

Identity threat9

Impaired psychological well-being11

Increased pain14

Increased risk of psychiatric diagnosis12,14

Increased substance use1,12

Increased blood pressure (and stress)1,6,9,10,12,19

Lower SES11,13

Low self-esteem1,6-

8,10,11,15,17,18

Patient non-adherence8,12

Poor quality of relationships13

Poor body/self-image1,8,11,15,17

Psychological stress1

Reduced quality of life14,19

Social isolation11-13

Suicidal thoughts8,17

Uneasy in crowds7

Unhealthy eating practices1,2,6-8,10-13,15,16,20

What else did we find?

Evidence of limitations of BMI and unrealistic

weight loss expectations

Increasing public attention and support for

body positivity, Health At Every Size®

Evolving language and marketing

Even diet companies are changing their message

(but they are still diet companies)

++ Opportunities to shift our approach

What drives weight bias?

Lack of appreciation of the drivers of health

outside of our control

Emphasis on personal responsibility

Drive for control of health outcomes

Media perpetuation of the thin ideal and

portraying larger bodies negatively

Lack of positive representation of diverse

bodies in media

Weight bias is ingrained in healthcare provider

education and systems

Weight bias causes harm

Long-term sustainable weight loss is difficult

Unrealistic expectations are

common

“Best weight” does not equal “normal BMI”

Weight normative approach

Focus on increasing research, treatment

and resources

Supportive of lifestyle interventions, meal

replacements, pharmacological

management, bariatric surgery

Weight neutral and inclusive approaches

Critiques ‘disease model’ as patho-logizing normal body diversity

Addressing eating, activity, mental

health, self-care, etc. may improve health, but can’t predict impact on weight

Health At Every Size® (HAES)

Obesity as a Disease

How do we address weight bias?

What Influences Health?

So why are we putting so

much emphasis on weight?

Being Active

Eating Well

Feeling Good about

Oneself

Self-Care

Adequate Sleep

Stress Management

Not smoking or

drinking too much…

1. Income and Social Status

2. Social Support Networks

3. Education

4. Employment/Working

Conditions

5. Social Environment

6. Physical Environment

7. Personal Health Practices

and Coping Skills

8. Healthy Child

Development

9. Biology and Genetic

Endowment

10.Health Services

11.Gender

12.Culture

How do we define health?

Physical, mental, and social well-being

Must include the presence of quality of life

Health is not based on weight or body size!

What can we do?

1. Stop contributing to weight bias and

start contributing to a more weight-

inclusive culture.

2. Support eating for wellbeing, enjoyable

activity, positive self-care, mental well-

being, and other health protective factors,

while rejecting weight-focused

interventions.

3. Recognize the role of inequities in the

distribution of and access to the social

determinants of health.

What can we do? (cont.)

4. Reviewing and improving health messaging,

creating communications plans, paid and

earned media, and online social messaging.

5. Actively reach out to partner agencies

(health providers and organizations, school

boards, staff and parents, childcare and

early learning professionals, and local

media) and seek opportunities to support

their needs.

6. Advocating for change at the local,

regional, provincial and federal level.

Effective and Ethical Strategies

“Aim to address the behaviours and

attitudes of individuals and institutions

that do the stigmatizing, rather than those

of the targets of mistreatment!”

Multi-pronged strategy both within

healthcare settings and at higher levels

of government and society

Healthcare provider education

Public health approaches

Provider Education

It’s complex!

Evidence that eating habits and caloric intake

don’t vary significantly by BMI at the

population level

Weight-inclusive atmospheres that focus on

well-being rather than weight loss

Compassion, empathy, respect, humanity

Promoting Health

How might we

inadvertently reinforce

cultural preoccupations

with individual weight

“control”?

How are we detracting from

policy strategies to address

inequities?

How do we shift social

attitudes?

Changing Our Ways

Talk to parents/other providers

How do we support and reassure?

How to we address parent’s body image

and food and weight preoccupations?

How do we promote health without

causing fear?

We work with schools/teachers

What language are we using?

How does it translate to students?

2010

• Starting the conversation

• Engaging colleagues

2014

• Crafting and adopting a policy and procedure

• Focusing internally

2016

• Completing a situational assessment

• Making recommendations for external initiatives

2018

• Building partnerships

• Endorsement of ODPH Position Statement

2019

• Ever-evolving

• Integrating within other strategies

It’s a process!

Health Equity

Community

Partners

Social

Marketing

Policy &

Position

Statement

Chronic

Disease &

Wellbeing

Internal

Strategies

External

Strategies

Mental

Health

Promotion

Healthy

Growth &

Development

Ontario Public

Health Standards

Health & Wellbeing Philosophy:

Approach to Weight

POSITION STATEMENT

1. Do No Harm

2. Overall Health

3. Body Diversity

4. Health for All

www.odph.ca/advocacy

5. Being Active

6. Eating Well

7. Feeling Good about Oneself

8. Self-Care

Guiding Principles:

Amy MacDonald, MScFN, RD

Public Health Dietitian

amacdonald@huroncounty.ca

519.482.3416 ext. 2259

Huron County Health Unit 77722B London Road RR#5 Clinton ON N0M 1L0 | www.huronhealthunit.com