THE DANGERS OF DIETING Evidence, Alternatives & Benefits of a HAES Approach

Transcription

1 THE DANGERS OF DIETING Evidence, Alternatives & Benefits of a HAES Approach Presented by: Glenys Oyston, RDN of Dare to Not Diet and co-producer of Dietitians Unplugged podcast EDRDpro

2 ABOUT ME Glenys Oyston, RDN Clinical dietitian in both inpatient and outpatient settings Private practice: Dare To Not Diet Podcast: Dietitians Unplugged Former long-time dieter 2

3 OBJECTIVES Describe the history of diets and how it informs current diet culture Describe the potential harmful consequences of dieting based on the evidence Describe the relationship between weight stigma and dieting and it s impact on health Articulate the differences between the diet and non-diet approaches Describe the Health at Every Size philosophy Describe the health benefits of a non-diet approach 3

4 4 A BRIEF HISTORY OF DIETING

5 A BRIEF HISTORY OF DIETING People have long manipulated food intake: religious diets, to differentiate themselves from other groups, perceived health value, weight/shape Example: Grain free monks of China teleportation! 5

6 A BRIEF HISTORY OF DIETING Ancient Greece: Hippocrates (c BCE) Ideas about the ideal body form The word diet derives from diaita : a word that describes lifestyle that included what they ate Hippocrates extolled the virtues of exercise to burn off excess food Fat bodies seen as undesirable for health; but then again, so was sex Distrust of body and its processes 6

7 A BRIEF HISTORY OF DIETING 16th - 17 th Centuries Hunger from poor harvests >>> hunger suppressing foods At the same time, access to new and foreign foods broadens Sugar arrives and replaces honey as sweetener Female beauty ideals grow >>> corsets are invented! Fat is seen as weak and feminine Connection between behavior, health, medicine and diet deepens The Art of Living Long the first diet book? 7

8 A BRIEF HISTORY OF DIETING 18 th -19 th Centuries Connection between body size and diet now grows French Revolution >>> hungry lower classes vs perceived gluttony of the upper classes Diet and spiritual purity Sylvester Graham Desire to control the body, especially corpulence Lord Byron: famous poet-dieter! Brillat-Savarin: famous French gourmet/gourmand who wrote The Physiology of Taste or Meditations on Transcendental Gastronomy 8

9 A BRIEF HISTORY OF DIETING 19 th Century Medical profession starts to see fatness as a symptom of disease Other diet gurus emerge and begin to see opportunity for profit >>> especially from wealthy overweight clients Diet fads proliferate at the end of the 19 th century Insurance companies look for way to reduce their liability >>> begin to use weight as risk indicator despite no statistical evidence Medieval times on: some fatness in women acceptable, but not excessive fatness 9

10 A BRIEF HISTORY OF DIETING 20 th Century Horace Fletcher >>> Fletcherism By 1920s, slimness was the ideal for women Home scales for weighing became popular As feminism rises, women internalize control over their bodies Miss America pageant originates in 1921, one year after women get the vote: reinforcement of the importance of beauty for women despite increasing political and economic power 1930s: everyone is dieting! 1960s: Jean Nidetch creates Weight Watchers: mass commercialization of diet industry 10

11 DIETING WITHIN A HISTORICAL CONTEXT Fat has long been culturally demonized even when there was little evidence for its affect on health Nutrition was based on body distrust Restriction was encouraged despite complete lack of evidence for its efficacy The problem has never been solved: Fatness still exists! Now: obesity epidemic moral panic 11

12 DIETING IS THE NEW(ISH) NORMAL Everyone diets 46% women, 33% of men attempt weight loss each year; 64.9% and 62.9% overweight/obese women and men Frequently an intervention given by medical professionals for anyone over a certain BMI BMI used as a health indicator What s the problem with all this? 12

13 DIETING DOESN T WORK! Doesn t work long term high rate (90-95%) of regain within 3-5 years of initial weight loss Most people regain some, all or even more weight No data to suggest long-term weight loss can be sustained for all but a tiny percentage of people Calories in/calories out does not work in practice 13

14 DIETS DON T WORK! Weight loss studies: Weight is lost at first The longer the study, the more weight regained Key = < 20% drop out = >20% drop out Size of circle represents sample size 14 Tomiyama, Ahlstrom & Mann, 2012

15 DIETING DOESN T WORK No data to suggest that weight loss actually makes people healthier in the long run or improves longevity LOOK AHEAD study: cancelled due to futility weight loss did not decrease cardiovascular risk in diabetics Studies now showing greater longevity in overweight and first obese classes Only see larger number of significant weight-related health problems at the extreme ends of the weight spectrum Health risks associated with obesity largely exaggerated and may be related to behaviors rather than weight 15

16 HEALTH RISKS OF DIETING & DIET CULTURE Disease Data suggests weight cycling is associated with higher risk of cardiovascular disease and type two diabetes; may be associated with higher mortality Calorie restriction dieting may increase inflammation; weight cycling increases this effect Epidemiological evidence: correlation only, not causation Often behavior changes are not considered, eg. diet quality, exercise levels 16

17 HEALTH RISKS OF DIETING & DIET CULTURE Eating Disorders Food restriction is a key factor in the development in Binge Eating Disorder; weight loss goals in BED treatment can undermine recovery Individuals who try to achieve and maintain a weight-suppressed state are at risk for binge eating disorder and bulimia nervosa Binge behaviors can be recreated in lab mice with restriction of highly palatable rat chow 17

18 HEALTH RISKS OF DIETING & DIET CULTURE Eating Disorders According to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), a person must have a "significantly low body weight" to be diagnosed as having anorexia nervosa. How many people who diet but are not underweight actually have an eating disorder? 18

19 HEALTH RISKS OF DIETING & DIET CULTURE Weight gain Weight cycling highly associated with higher weights Decreases leptin (fullness signal), increases grehlin (hunger) >>>over-eating Decreases lean body mass, slows metabolism Biggest Loser Study: 14 show contestants, normal metabolism for weight before show; after, some burned up to 800 calories less, even 6 years later; all but one regained most or all of the weight lost during the show 19

20 HEALTH RISKS OF DIETING & DIET CULTURE Psychological Impact Study: women who felt bad about their weights had worse health than women who didn t feel bad about their weights Study of 170,000 adults: Body dissatisfaction ( feeling fat ) has stronger negative health effect than actually being fat People who diet score higher on measurements of stress and depression compared to non-dieters Dieting increases stress hormone cortisol (which is associated with belly fat) Preoccupation with food 20

21 HEALTH RISKS OF DIETING & DIET CULTURE Sociological Impact Diet culture reinforces the idea that we can change our weight if we try hard enough, and therefore reinforces weight stigma Study out of Yale showed 50% of doctors find fat patients awkward, ugly, weak-willed and unlikely to comply with treatment and 28% of nurses said that they were repulsed by their obese patients Higher weight people receive a lower quality of medical care because of weight bias 21

22 HEALTH RISKS OF DIETING & DIET CULTURE Sociological Impact Weight discrimination was reported by 7% of US adults in , and almost doubled to 12% by 2006 Rudd Center research: discrimination based on weight is now on par with discrimination based on race or gender Higher weight people make less money; weight discrimination in hiring is legal in all but a few municipalities 22

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24 COMMON PROBLEMS OF CHRONIC DIETERS Overeating Superfluous eating Unable to sense hunger or fullness Compulsive eating Guilt when eating Body shame Weight gain 24

25 DIETING SUCKS! Bottom line: we diet for cultural, not health, reasons, nobody is happy on a diet, and they don t work anyway. 25

26 THE DIET DOUBLE STANDARD If a person with a BMI of 18.5 told you she frequently went hungry on purpose, avoided pleasurable foods to avoid weight gain, refused to eat more than 1000 calories a day, exercised 2 hours a day, and worried about weight gain all the time you might recommend eating disorder screening. 26

27 THE DIET DOUBLE STANDARD If a person with a BMI of 31 told you she did the same things does the exact same things, that person is usually congratulated and told to keep it up. In this case, it s not called an eating disorder, it s called a diet. We recommend for larger people what we would treat in thinner people. 27

28 WHAT S THE ALTERNATIVE? Health at Every Size Weight neutral/weight inclusive approach that focuses on behaviors and other contributors to health Weight neutral = weight may be lost or gained, but this is viewed, neither positively nor negatively, and it is not the focus of the intervention 28

29 HEALTH AT EVERY SIZE PRINCIPLES Weight Inclusivity: Accept and respect the inherent diversity of body shapes and sizes and reject the idealizing or pathologizing of specific weights. Health Enhancement: Support health policies that improve and equalize access to information and services, and personal practices that improve human well-being, including attention to individual physical, economic, social, spiritual, emotional, and other needs. Respectful Care: Acknowledge our biases, and work to end weight discrimination, weight stigma, and weight bias. Provide information and services from an understanding that socio-economic status, race, gender, sexual orientation, age, and other identities impact weight stigma, and support environments that address these inequities. 29

30 HEALTH AT EVERY SIZE PRINCIPLES Eating for Well-being: Promote flexible, individualized eating based on hunger, satiety, nutritional needs, and pleasure, rather than any externally regulated eating plan focused on weight control. Life-Enhancing Movement: Support physical activities that allow people of all sizes, abilities, and interests to engage in enjoyable movement, to the degree that they choose. 30

31 NON-DIET APPROACHES These eating models fit within the HAES philosophy Intuitive Eating (Tribole and Resch) Eating Competence (Satter) Mindful Eating 31

32 NON-DIET APPROACHES The Research Intuitive Eating Over 60 studies done to date Shown to improve well-being, lower risk of eating disorders, improved biomarkers (blood sugar and cholesterol) Intuitive eaters enjoy eating a variety of foods and have better interoceptive awareness and psychological hardiness Feel better about their bodies 32

33 NON-DIET APPROACHES The Research Eating Competence Have better diets Have stable or lower BMIs Have better physical self acceptance Are more active Sleep better Have better medical and lab tests Do better with feeding their children 33

34 NON-DIET APPROACHES Both models focus on Using internal signals of hunger and fullness to drive eating Rejecting a restrictive, prescriptive style of eating Focusing on pleasure and satisfaction Respecting size diversity Unconditional permission to eat any foods 34

35 NON-DIET APPROACHES Some Differences Honoring feelings without using food, experimenting with demand feeding (IE) Discipline and permission: providing regular, reliable meals and snacks (discipline) with complete permission to eat as much of it as is wanted (EC) 35

36 BENEFITS OF USING A HAES APPROACH Improved weight satisfaction >>>better health regardless of BMI A more sustainable approach Clients learn skills around honoring body cues which is a more holistic approach Addresses the role weight stigma plays in health Recognizes that health is more than just eating, exercise and weight, and can address the true needs of the client Client is not blamed for failure of a poor product Behaviors more important than weight for health and longevity 36

37 BENEFITS OF USING A HAES APPROACH HAES in the clinical setting Not just for dieters Works well even with MNT HAES does not mean Just eat whatever you want health concerns, medical conditions, intolerances, allergies can all be considered Lab results become body cues, eg. blood sugars Providing diet education without focusing on a weight-based outcome is key 37

38 HOW DO I WORK WITH DIETERS? Health at Every Size focus on health, not weight Focus initially on complete permission Reject diet and restriction mentality Emphasize that fitness matters more than fatness Intuitive Eating, Eating Competence models, mindfulness, making small, positive changes to diet, focus on adding foods in, not taking away 38

39 HOW DO I WORK WITH DIETERS? Work on building body acceptance Acknowledge society s role in oppression of fat bodies Focus on what the client wants her body to do, not look like Acknowledge cognitive dissonance of gaining weight while healing relationship to food 39

40 HAES AND INTENTIONAL WEIGHT LOSS? No, please HAES and a goal of intentional weight loss are not compatible A focus on weight loss will undermine healthy eating and selfcare behaviors in favor of the weight loss goal There is no evidence to show that this is appropriate for weight loss 40

41 AVOID PARADIGM STRADDLING Straddling the diet and HAES paradigms will most likely cause confusion and trust issues for your clients Those who are fleeing the diet paradigm will want to feel that you also firmly believe as they now do: that weight loss doesn t work and there is another path to health 41

42 RECOMMENDATIONS FOR FURTHER STUDY Body Respect by Linda Bacon and Lucy Aphramor Health at Every Size by Linda Bacon Intuitive Eating by Evelyn Tribole and Elyse Resch Secrets from the Eating Lab by Traci Mann Calories & Corsets: A History of Dieting Over 2000 Years by Louise Foxcroft Secrets of Feeding a Healthy Family by Ellyn Satter Wellness Not Weight: Health at Every Size and Motivational Interviewing edited by Ellen Glovsky(CEUs through Skelly Skills) 42

43 REFERENCES History of Dieting Foxcroft, Louse. Calories & Corsets: A History of Dieting over 2000 Years. Profile Books Limited, Dieting Stats Bish CL1, Blanck HM, Serdula MK, Marcus M, Kohl HW 3rd, Khan LK. Diet and physical activity behaviors among Americans trying to lose weight: 2000 Behavioral Risk Factor Surveillance System. Obes Res Mar;13(3):

44 REFERENCES Lack of Diet Efficacy Mann, Traci. Secrets from the Eating Lab: The Science of Weight Loss, the Myth of Willpower, and Why You Should Never Diet Again. HarperCollins, Medscape: Look AHEAD halted: Lifestyle management fails to reduce hard CV outcomes in diabetics Mann T, Tomiyama AJ, Westling E, Lew AM, Samuels B, Chatman J. Medicare's search for effective obesity treatments: diets are not the answer. Am Psychol Apr;62(3):

45 REFERENCES Lack of Diet Efficacy Mann, Traci. Secrets from the Eating Lab: The Science of Weight Loss, the Myth of Willpower, and Why You Should Never Diet Again. HarperCollins, Medscape: Look AHEAD halted: Lifestyle management fails to reduce hard CV outcomes in diabetics Mann T, Tomiyama AJ, Westling E, Lew AM, Samuels B, Chatman J. Medicare's search for effective obesity treatments: diets are not the answer. Am Psychol Apr;62(3):

46 REFERENCES Mann, Traci. Secrets from the Eating Lab: The Science of Weight Loss, the Myth of Willpower, and Why You Should Never Diet Again. HarperCollins, Medscape: Look AHEAD halted: Lifestyle management fails to reduce hard CV outcomes in diabetics Mann T, Tomiyama AJ, Westling E, Lew AM, Samuels B, Chatman J. Medicare's search for effective obesity treatments: diets are not the answer. Am Psychol Apr;62(3): Tomiyama, A. J., Ahlstrom, B., & Mann, T. (2013). Long-term effects of dieting: Is weight loss related to health? Social and Personality Psychology Compass, 7(12), doi: /spc term_effects_of_dieting_is_weight_loss_related_to_health_social_and_personality_psychology_compass_7_12_ _doi_ _spc

47 REFERENCES Miller WC. How effective are traditional dietary and exercise interventions for weight loss? Med Sci Sports Exerc Aug;31(8): NIH. Methods for voluntary weight loss and control. NIH Technology Assessment Conference Panel. Ann Intern Med Jun 1;116(11): Field a E, Manson JE, Taylor CB, Willett WC, Colditz G a. Association of weight change, weight control practices, and weight cycling among women in the Nurses Health Study II. International Journal of Obesity and Related Metabolic Disorders : Journal of the International Association for the Study of Obesity. 2004;28(9): Available at: Accessed February 10,

48 REFERENCES Diet Damage Glovsky, Ellen, PhD, RD, LDN (Ed.). Wellness, not weight: Health at every size and motivational interviewing. Cognella Academic Publishing, N. John Bosomworth. The downside of weight loss: Realistic intervention in body-weight trajectory. Canadian Family Physician May 2012, 58 (5) ; Rasmus Køster-Rasmussen, Mette Kildevæld Simonsen, Volkert Siersma, Jan Erik Henriksen, Berit Lilienthal Heitmann, Niels de Fine Olivarius. Intentional Weight Loss and Longevity in Overweight Patients with Type 2 Diabetes: A Population-Based Cohort Study. PLoS One Jan 25;11(1):e doi: /journal.pone ecollection Field AE1, Manson JE, Taylor CB, Willett WC, Colditz GA. Association of weight change, weight control practices, and weight cycling among women in the Nurses' Health Study II. Int J Obes Relat Metab Disord Sep;28(9):

49 REFERENCES Mathes WF, Brownley K a, Mo X, Bulik CM. The biology of binge eating. Appetite. 2009;52(3): Available at: Accessed November 5, Corwin RL, Buda-Levin A. Behavioral models of binge-type eating. Physiology & Behavior. 2004;82(1): Available at: Accessed February 10, Muennig P. The body politic: the relationship between stigma and obesity-associated disease. BMC Public Health Apr 21;8:128. doi: / Muennig P, Jia H, Lee R, Lubetkin E. I think therefore I am: perceived ideal weight as a determinant of health. Am J Public Health Mar;98(3): doi: /AJPH Epub 2008 Jan 30 Judith Matz, Ellen Frankel. Beyond a Shadow of a Diet: The Comprehensive Guide to Treating Binge Eating Disorder, Compulsive Eating, and Emotional Overeating. (2nd Ed.) Routledge,

50 REFERENCES Sharon Kirkey. Bias against obese people increasing, study says. SM Phelan, DJ Burgess, MW Yeazel, WL Hellerstedt, JM Griffin, and M van Ryn. Impact of weight bias and stigma on quality of care and outcomes for patients with obesity. Obes Rev Apr; 16(4): Published online 2015 Mar 5. doi: /obr Support for HAES Bacon, Linda. Health at Every Size. Benbella Books, Inc., Flegal, Katherine, et al. Association of All-Cause Mortality with Overweight and Obesity Using Standard Body Mass Index Categories: A Systematic Review and Meta-Analysis. JAMA 309, no. 1 (January 2, 2013): 71-82, doi: /jama Size Acceptance and Intuitive Eating Improve Health for Obese, Female Chronic Dieters Bacon, Linda et al. Journal of the Academy of Nutrition and Dietetic, Volume 105, Issue 6,

51 REFERENCES Health-At-Every-Size and Eating Behaviors: 1-Year Follow-Up Results of a Size Acceptance Intervention Provencher, Véronique et al. Journal of the Academy of Nutrition and Dietetics, Volume 109, Issue 11, Eric M. Matheson, MS, MD, Dana E. King, MS, MD and Charles J. Everett, PhD. Healthy Lifestyle Habits and Mortality in Overweight and Obese Individuals. J Am Board Fam Med January-February 2012 vol. 25 no doi: /jabfm Blake CE, Hébert JR, Lee D, et al. Adults with Greater Weight Satisfaction Report More Positive Health Behaviors and Have Better Health Status Regardless of BMI. Journal of Obesity. 2013;2013: doi: /2013/ Tracy L. Tylka, Rachel A. Annunziato, Deb Burgard, et al., The Weight-Inclusive versus Weight-Normative Approach to Health: Evaluating the Evidence for Prioritizing Well-Being over Weight Loss, Journal of Obesity, vol. 2014, Article ID , 18 pages, doi: /2014/

52 REFERENCES Studies supporting EC Lohse B, Bailey RL, Krall JS, Wall DE, Mitchell DC. Diet quality is related to eating competence in cross-sectional sample of low-income females surveyed in Pennsylvania. Appetite. 2012;58: Lohse B, Psota T, Estruch R, et al. Eating competence of elderly Spanish adults is associated with a healthy diet and a favorable cardiovascular disease risk profile. J Nutr. Jul 2010;140: Lohse B, Satter E, Horacek T, Gebreselassie T, Oakland MJ. Measuring Eating Competence: psychometric properties and validity of the ecsatter Inventory. J Nutr Educ Behav. 2007;39 (suppl):s154-s166. Quick V, Byrd-Bredbenner C, White AA, et al. Eat, Sleep, Work, Play: Associations of Weight Status and Health-Related Behaviors Among Young Adult College Students. Am J Health Promot. Dec Krall JS, Lohse B. Cognitive testing with female nutrition and education assistance program participants informs validity of the satter eating competence inventory. J Nutr Educ Behav. Jul-Aug 2010;42(4):

53 REFERENCES Lohse BL, Arnold K, Wamboldt P. Evaluation of About Being Active, an online lesson about physical activity shows that perception of being physically active is higher in eating competent low-income women. Women's Health :12-. Psota T, Lohse B, West S. Associations between eating competence and cardiovascular disease biomarkers. J Nutr Educ Behav. 2007;39:S171-S178. Tylka TL, Eneli IU, Kroon Van Diest AM, Lumeng JC. Which adaptive maternal eating behaviors predict child feeding practices? An examination with mothers of 2- to 5-year-old children. Eat Behav. Jan 2013;14: Lohse B, Satter E, Arnold K. Development of a tool to assess adherence to a model of the division of responsibility in feeding young children: using response mapping to capacitate validation measures. Child Obes. 2014;10:

54 REFERENCES Studies Supporting Intuitive Eating Bruce LJ, Ricciardelli LA. (2016). A systematic review of the psychosocial correlates of intuitive eating among adult women. Appetite.96: Anderson LM, Reilly EE, Schaumberg K, Dmochowski S, Anderson DA. (2015). Contributions of mindful eating, intuitive eating, and restraint to BMI, disordered eating, and meal consumption in college students. Eat Weight Disord. Aug 5. Tylka, T.L., Calogero, R.M., & Danielsdottir S. (2015). Is intuitive eating the same as flexible dietary control? Their links to each other and well-being could provide an answer. Appetite 95: Wheeler BJ, Lawrence J, Chae M, Paterson H, Gray AR, Healey D, Reith DM, Taylor BJ. (2015). Intuitive eating is associated with glycaemic control in adolescents with type I diabetes mellitus. Appetite. Sep 25;96: Bush H, Rossy L, Mintz L, & Schopp (2014). Eat for Life: A Worksite Feasibility Study of a Novel Mindfulness-based Intuitive Eating Intervention. Am J Health Promotion (July/Aug): Gast J, et al (2014). Intuitive Eating:Associations with Physical Activity Motivation and BMI Am J Health Promotion.Jan 24. [Epub ahead of print] 54

55 REFERENCES Schoenefeld SJ, & Webb JB. (2013). Self-compassion and intuitive eating in college women: Examining the contributions of distress tolerance and body image acceptance and action. Eat Behav Dec;14(4): Madden C.E., Leong, S.L., Gray A., and Horwath C.C. ( 2012). Eating in response to hunger and satiety signals is related to BMI in a nationwide sample of 1601 mid-age New Zealand women. Public Health Nutrition. Mar 23:1-8. [Epub ahead of print]. 55