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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 [email protected] 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
519.482.3416 ext. 2259
Huron County Health Unit 77722B London Road RR#5 Clinton ON N0M 1L0 | www.huronhealthunit.com
