A Weight-Inclusive Approach – Webinar

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New York Gastroenterology Associates

March Webinar Transcription

Suzie Finkel: 

Alright, good evening everyone and welcome to this month’s installment of the webinar series here at New York Gastroenterology Associates (NYGA).

Susie Finkel i’m one of the dietitians here at NYGA i’m so excited to introduce tonight’s talk to you.

This month is actually national nutrition month and, if you didn’t know we’ve expanded the nutrition services at New York Castro and now we have the largest nutrition team of.

Any independent gastroenterology group in the city so it’s very fitting that we also have part of the GI nutrition team here tonight to present on a really important topic in health care and in gastroenterology.

Which is the health at every size movement and we’re an inclusive city and our presenters are going to tell us about what that is.

So tonight you’re going to get two for the price of one because we have to have my amazing colleagues here Shira Hirshberg and Faith Aronowitz it’s

Shira is a registered dietician who works, both on the NYGA nutrition team and runs a Rhode Island based private practice, she has an extensive background in nutrition research, community nutrition, clinical nutrition and higher education.

She earned her master’s in nutrition from the University of Rhode Island and completed her clinical training at Brigham and Women’s Hospital in Boston a Harvard Medical

School teaching hospital; she also taught online courses at university of Rhode Island and as planned and presented numerous workshops specifically focused on

Medical weight stigma, both for medical residents and working health care providers and has tremendous insight to share with us all tonight.

Faith is also a registered dietitian here in New York at New York Gastro and has a special interest in the convergence of GI disorders and eating disorders.

She earned her master’s in nutrition from Columbia University and completed her clinical training there as well.

She’s worked, both in inpatient and outpatient behavioral health settings and she employs a weight inclusive approach in her nutrition practice and she’s going to talk to us about what that means tonight.

So just a few housekeeping pieces this webinar is going to be recorded.

So if you can’t stay for the whole thing or you, you want to you know dip out early or you couldn’t even make it this evening you’ll be watching this later on repeat.

And you’ll also be able to share it with others, we’re going to have a Q and A portion at the end to a time where you can

Ask any questions that you can actually put in the Q and A box you’ll see at the bottom of the screen.

That’s where you can put any questions for the presenters that I will be looking through as they’re talking, please don’t use the chat box, that will be

Just left left alone there if you have anything that you want to to ask put it in the Q and A.

And just a reminder, we can’t answer any personal health questions, anything that pertains to you very specifically, but we’re happy to answer more general questions that you have so without further ado, we can begin, Shira and Faith.

Faith Aronowitz: 

Hey, Thank you Suzie.

So Shira, and I are very excited to be here tonight, presenting this talk entitled Health at Every Size & GI Care, A Weight Inclusive Approach to Gastroenterology & Nutrition.

It’s a topic because you can probably see from our bios that we’re both extremely passionate about so let’s go ahead and dive in.

Okay, so we’ll start with the overview for tonight we’ll start off talking about some misconceptions involving weight and health weight stigma, in general, and what weird stigma might look like in healthcare.

And then we’ll discuss the weight inclusive approach, including the health at every size or HAES movement and will unlock some examples of how a weight inclusive dietitian might practice and provide some suggestions as to how to deal with weight stigma and healthcare.

But first misconception, we want to highlight tonight is that your body size determines your health.

The chart here shows how the relationship between the number of healthy lifestyle habits you engage in and your risk of all cause mortality.

At different body sizes on the right hand side of the slide you’ll notice the four different healthy lifestyle habits represented in this chart.

Which are, one not currently smoking, two eating five servings of fruits and vegetables per day, three doing something physically active more than 12 times per month, such as walking gardening or yard work.

And, four drinking moderately or less than moderately, meaning one or fewer drinks per day for women and two or fewer drinks per day for men.

So you can see that the latest bar and the chart represents the smallest bodies, as measured by BMI.

Body mass index and the darkest bar represents the largest bodies will actually get back to BMI in a few slides so hold that thought for now.

But this chart tells us that if you have a BMI over 30 and don’t engage in any healthy lifestyle habits, then yes you’re at higher risk of death, compared to people in smaller bodies.

But if you engage in even one of these healthy lifestyle habits, the risk drops dramatically.

If you look across the groupings from zero healthy lifestyle habits to four healthy lifestyle habits you’ll notice the risk continues to drop as each additional healthy lifestyle habit is added.

So we look at the four healthy habits grouping over there on the right.

You can see that the three bars are just about the same height indicating that people who engage in these four different healthy lifestyle habits, independent of their body size, have just about the same risk of all cause mortality.

Another common misconception, is that many people believe that you can tell whether someone is healthy by simply looking at them.

As we demonstrated in the last slide someone’s health status is determined much more by their behaviors than by their size.

We know that there are people of all body sizes, who are very healthy and likewise people of all body sizes, who are very unhealthy.

Sometimes their choices impact this, but often they don’t.

I’m sure you might all be able to think of somebody who you know might make many health healthy lifestyle choices, but who might you know, unfortunately, have a major health condition like cancer or an autoimmune disease.

That misconception can also have a significant negative impact on diagnosing eating disorders and people in larger bodies.

Eating disorders are often missed by health care providers who don’t realize that the reason for drastic weight loss, maybe due to eating disorder behaviors such as restriction.

If you’re someone in a larger body, you know that this misconception comes up with friends, family and in the workplace, through…

Discriminatory practices like higher health care costs for people, based on a variety of measurements, one of which is body mass index.

You also know this comes off in the offices of health care providers who made you extra tests on you that they wouldn’t necessarily do on someone of the same agent sex, who was in a smaller body.

This may also negatively affect people in smaller bodies as they may not get testing that would identify health issues they may have had earlier on, for example, hemoglobin E1C to check average blood sugar or an EKG to check for any heart issues.

Another common misconception is that you can tell what someone eats by looking at them.

Many people assume that someone in a smaller body has a healthy diet and that someone in a larger body has an unhealthy diet.

When working as a dietitian and asking people about what they eat all day, every day, you learn very quickly, that this is not the case at all and that there’s a large variety of diets and people of all sizes, truly, the only way to tell if someone eats is to ask them.

The last common misconception will discuss tonight is that one’s behaviors are the only thing that determine health status.

Help focused culture that we live in, now sometimes make it seem like if you do you know quote unquote all the right things you’ll have total control over your health.

There are of course many things about our health that are completely outside of our control.

This image here on the left hand side represents the social determinants of health, which are the conditions in the environments where people are born, live, learn, work,

Play, and age that affect a wide range of health functioning and quality of life outcomes and risks.

So these include things like the school environment, such as access to safe homes water, clean air, safe schools, and workplaces, and parks, and playgrounds, it also includes education, research has shown that lower education levels are associated with poor health status.

Socioeconomic status is another social determinant of health, higher income and social status have been associated with better health status.

To give a little bit more detail here one nationally representative study examined socioeconomic status and mortality.

And found that those in the most disadvantaged quarter of the study population had almost triple the risk of death, compared to those with the highest socioeconomic status.

Also includes social support which includes close bonds with family, friends and communities as well as religious and cultural customs and traditions.

And, as well as access to quality health care services such as physical therapy, mental health services and dentistry.

So while personal behaviors and coping skills such as balanced eating, physical activity, stress management and other behaviors such as alcohol use or tobacco use certainly impact our health status.

These social determinants have a major impact on people’s health, well being and quality of life.

Of course, these determinants are not distinct entities in themselves, but rather they relate to each other in many ways.

For example, people who don’t have access to grocery stores with healthy foods are less likely to have good nutrition.

And that raises their risk of health conditions like heart disease and diabetes and even lower life expectancy relative to people who do have access to healthy foods.

So the social determinants of health, often drive an individual’s ability to engage and health behaviors.

Just promoting healthy choices won’t eliminate these and other health disparities.

So, instead, public health, organizations and their partners in sectors like education, transportation and housing need to take action to improve the conditions and people’s environments, but that is another topic for another evening.

So the result of all of these misconceptions is that people are discriminated against in a variety of ways, because of their body size, this is called weight stigma, also known as weight based discrimination, but we will use the term weight stigma for tonight.

Weight stigma has been shown to have negative consequences for both physiological and psychological health.

In this review WHO and others examine the effects of weight stigma on adults and larger bodies and found that those who experienced more weight stigma also experienced work physiological health.

Experiencing more weight stigma was shown to be related to increased difficulty taking medications as prescribed, higher blood sugar, increased risk for type two diabetes.

Elevated C reactive protein levels, which is a marker of inflammation and higher cortisol levels, which is a stress hormone.

Now, as you all know, especially if you have experienced it discrimination is stressful and many people might turn to food and eating as coping mechanisms to manage trust.

So it follows that people who experienced more weight stigma are also more likely to have eating disturbances, such as over eating more symptoms of depression, anxiety body dissatisfaction and lower self esteem.

They were also more likely to experience more social isolation and social phobia as well as panic post traumatic stress syndrome and antisocial behavior.

So wait stigma has been documented in healthcare professionals, including physicians nurses psychologists and dietitians and therefore many patients have stigmatizing experiences in these settings.

However, it is important to point out that healthcare experience can increase or decrease weight stigma depending upon a variety of factors.

Some practices that can increase weight stigma are, one getting weight advice when unrelated to the reason for the visit, for example, somebody coming in, with a sore throat. I’ll dig a bit more into this example on the next slide.

So, while some medical guidelines recommend that those with a BMI of 30 are automatically provided with weight loss and nutritional advice.

Regardless of the reason for their visit, this is a significant stressor for patients and leads them to avoid medical care entirely which may also lead to worse outcomes.

Being weighed every medical visit also increases weight stigma. For many people getting weighed at the beginning of every medical visit is extremely stressful and makes them worried that they will again have to have a conversation with their health care provider about the weight.

It’s also true that sometimes people in different size bodies receive different recommendations, based on their body size.

For example, someone in a smaller body with prediabetes is told to eat a low glycemic diet or referred to a dietitian.

But someone in a larger body with prediabetes is told to lose weight and not given any specific dietary recommendations at all, even though those same recommendations would help them as well.

Some health care providers may not have the appropriate medical equipment to accurately assess those folks in larger bodies.

For example, blood pressure is a very important measure of health, but people in larger bodies may receive falsely high readings, due to a blood pressure cuff that doesn’t fit them.

And finally, patients with larger bodies may experience weight stigma due to stigmatizing language used by healthcare providers which may include complimenting patients on weight loss.

People can lose weight for all sorts of reasons including chronic physical illness, eating disorders and depression as a side effect of grief.

So the assumption that weight loss is always intentional and a desirable outcome can often be upheld by weight stigma and healthcare, however, someone may simply be really struggling mentally, physically or emotionally.

So I don’t know if anyone is familiar with this memoir Hunger by Roxane Gay.

But if you’re not, Roxane Gay is an American author and academic who wrote an Internet memoir in 2017 called Hunger, in which she recalls a brutal sexual assault in childhood.

After which time she began to gain significant amounts of weight, she writes vividly about her experiences as a person living in a larger body.

Specifically related to how others treat her in a professional medical and even mundane community encounters.

In one anecdote she recalls going to a doctor for a sore throat, which turned out to be strep the doctor talked to her about weight loss which clearly does not address the reason that she came in.

And then the doctor coded obesity, as her primary diagnosis, for that visit, this is an example of weight stigma and seemingly small gesture or an interaction by healthcare professional that prevents a person in a larger body

Feeling respected in a healthcare setting often dissuades them from seeking health care until they are extremely sick and have no other choice.

And i’d like to read this quotation, you see, on the slide from an interview that Gay gave about her memoir to a Canadian publication, The National Post.

“I definitely hope that people gain a different empathy for different bodies, I would love for doctors to read it, and remember their oath and treat fat bodies better…

…As I say, in the book, you can talk to me about my weight as a medical professional, but when I come into the office because of a sore throat you can’t write on my chart obese that’s not why i’m there i’m really there for some penicillin give me the penicillin.

I mentioned earlier in the top that we would come back to BMI So here we are.

This topic could fill an entire presentation itself. So here we will highlight some key points.

First it’s important to understand that BMI, also known as body mass index is not a diagnosis it’s simply a way to describe your body size, the equation for BMI is your weight in kilograms divided by your height in meters squared.

And it’s used clinically because it’s cheap and easy, it can be done in a doctor’s office very quickly.

However, the BMI equation is overly simplified and does not account for differences in age, body frame or body composition.

There are many examples that show us how poorly and often works, for example, weight weight lifters are often classified as quote unquote obese, because they are heavy duty high muscle mass.

This classification certainly doesn’t give their health care providers any useful information it works, especially poorly on both the very short and very tall ends of the spectrum so, for example, a man who is six foot four and is 153 pounds is within a quote unquote healthy BMI at 18.6.

But I bet many of you can see that this weight would be somewhat worryingly thin for most men of that height.

To give you a little bit of historical context BMI was invented by a Belgian academic named Adolphe Quetelet who focused on statistics and astronomy back in 1842.

And he specifically said that it shouldn’t be used to measure individuals but was instead just to get an idea of the population as a whole, based on the quote unquote average man.

Shortly after this it started to be more widely used and in the 1970s BMI category cut offs were created based on percentiles.

Like they do for children if that’s something you you’re familiar with so anyone in the 85th percentile of the BMI and up with considered overweight.

This wasn’t based on any health risks associated with these categories just how you compared to other people in terms of weight and height.

In fact, before 1995 the overweight BMI cut off, according to the national institutes of health was 27.8 for men and 27.3 for women.

But three years later, in 1998 the US national institutes of health and the centers for Disease Control and Prevention brought the US definitions in line with that of the World Health Organization.

Which lowered the normal BMI overweight BMI cut off from 27.8 to 25 which resulted in 30 million people becoming quote unquote overweight literally overnight.

One of those strange things about this overweight category is that the average westerner has a BMI between 24 and 27 so around half the population is considered overweight and has been for decades.

You can see Based on this information, that BMI categories are largely arbitrary.

Finally, the last point I wanted to bring up today is BMI thresholds which created the obesity paradox. So what does that mean?

So research has shown that, paradoxically, people who fit in the overweight BMI category live the longest.

And that people who fit in the obese BMI category are at no higher risk of death than those who fit in the normal weight category when controlling for other variables.

So, in other words a healthy normal weight person has the same mortality risk as a healthy obese person and so why is this considered a paradox? It’s a paradox, because of the expectation that weight is synonymous with health and that thin is, you know, thin equals healthy.

Our society wouldn’t expect somebody in a larger body to be healthy and this expectation has been filled in part by medical weight stigma.

In fact, in 2013 the American Medical Association officially defined obesity as a disease as measured by BMI.

This ruling actually went against the recommendation of their own committee, who identified that BMI was too flawed and measure and that there were no specific symptoms to obesity alone.

The decision did benefit pharmaceutical companies who were previously struggling to get insurance to cover their newly released weight loss drugs.

And finally, one of the many issues with BMI that I want to highlight tonight is that it was built only around measurements for white people.

And while it works poorly in this population it works even more poorly in populations of color and contributes to already established disparities and weight stigma and medical care for people of color.

And now I will hand things over to share up who will discuss the week inclusive approach.

Shira Hirshberg: 

Hi everybody.

Okay, so.

We are going to get started, and speak a little more specifically now about what healthcare can look like when a weight-inclusive approach is used.

And as you can see from all those things listed on this slide this approach really focuses on health and well being, and so we think about things like reduced LDL levels.

And we think of these things as separate from weight so we’re going to be talking about a lot of the details around what goes into that but we really want to focus on specifically health instead of complete markers and so next we’re going to transition to.

Looking at a little more detail around that so as you can see, this is some of these are some of the benefits of a weight-inclusive approach.

So when this type of approach to health care has been studied the benefits include physiological benefits so things like.

Improvements in markers in addition to the ldl I talked about also things like blood pressure, blood sugar.

As well as lifestyle behaviors like increased physical activity reduced disordered eating and psychological benefits improvements in depression and mood and self esteem and body image.

One of the main foundations of a weight inclusive approach comes from the health at every size movement, this is a social justice movement with the three listed principles, you can see here of respect, critical awareness and compassionate self care.

Here’s a bit more of a detailed look at the three principles and, as you can see they’re really relevant to health care, because…

These focus on behaviors that are specifically within an individual’s of control and when you apply that to healthcare it actually changes the approach that many health care providers have traditionally taken.

To issues related to weight, so these principles, you can see here come directly from the HAES community website.

They’re an excerpt from the Body Respect book, this is by Bacon enough for more and if you’re interested in learning more about this topic I highly recommend the book.

You can see that, if you look at the third principle compassionate self care, this starts to get into how nutrition and physical activity are approached from a health and every size perspective that these principles really keep the focus on honoring the individual and their body signals.

Often HAES providers hail that every size providers are misconstrued as being anti weight loss, and you know, as you can see here there’s really just no mention of weight at all.

You can see that the section that focuses on self care focuses on how to eat and move and not what happens to your body, as a result of those choices, because…

When you ascribe to the HAES philosophy body size isn’t an outcome that’s relevant to care, we’re going to spend some more time talking about weight loss goals within a weight inclusive approach in a few minutes, but I just want to give you this foundation before we spend more time there.

So before we get to that I want to talk a little bit about what it’s like to work with a registered dietitian in general you’re hearing from three of us tonight, so I want to…

Explain what it looks like if you’ve never met with one, so if you meet with a dietitian you can expect us to ask you about physical health, your energy your hunger and, of course, what you eat.

People often come in thinking that we will be the food police and we’re going to tell you all the things not to eat.

But I want to assure you that, here at New York Gastroenterology Associates, this is not how our nutrition team operates.

When we ask you about your current eating habits we’re not judging your choices we’re just trying to understand your day to day life and your day to day eating.

Our goal is always to help you meet your own personal goals, whether that’s simply to eat more healthfully to improve our manager disease, develop a better relationship with food.

You know our dietitians can work with you on dietary management of high blood pressure, cholesterol, kidney disease, diabetes…

As well as dietitians work on other goals, improving quality of diet prevent chronic disease before it starts recover from disordered eating.

So dietitians do a really wide variety of things and here at New York Gastro the dietitians are also specifically trained in the management of gastrointestinal disorders.

So we can provide you with evidence and clinical experience based recommendations for those in terms of logistics our nutrition team meets with patients, both in person and through video appointments right now.

Next, I want to highlight what makes working with a week inclusive dietitian a little different and, since you know…

We’re dietitians. I’m going to start there, but then I’m going to expand and talk a little more about other health care providers as well, and what that looks like.

So, health and every size aligned, or we inclusive providers work with patients to set goals that are focused on compassionate self care so we really work with things that are within your control as an individual.

Of course we do work with people who would like to change their body, but we think that when we’re setting goals of treatment, we really want to focus on behavior change instead of a body change goal.

And I think this is important for a few reasons, the first Is it actually doesn’t change what we do together it changes, how you measure your success on me so i’m going to give you an example.

I often work with people who find they eat beyond their physical comfort level they leave the dinner table and feel full uncomfortable.

And people do that for a variety of reasons, right and i’m sure you know, some of these sometimes people may eat too little during the day, and they go into dinner incredibly hungry.

And so, of course, then it’s hard to manage the amount that you’re eating at dinner.

Maybe you’re eating a meal that’s not well balanced and so then later on in the day, you don’t stay satisfied between meals and maybe you feel like…

You also have to finish everything on your plate, a lot of people were trained that way as children, so they find it very hard to not finish everything, even if they’ve…

You know their body has said, you’re full, you know, they just feel like they need to finish that plate.

So let’s say you’re working hard to change his behavior and now you’re typically eating balanced meals regularly throughout the day and a pattern that works for you.

And you’re leaving the dinner table feeling satisfied but not overfull, not uncomfortable.

I think that everyone who accomplishes a goal like that should feel successful and then a weight inclusive model of care they do, they set a goal, they achieve the goal success.

Unfortunately, in a weight centric model of care if you work hard to do this and you accomplish it and that results in weight loss then you’re successful.

But if you work hard to do this you’ll accomplish it and you don’t lose weight as a result you feel like a failure and then just doesn’t seem fair or reasonable to me.

Now, sometimes people wonder about how they fit into this model because they do want to lose weight, and so I want to directly address how we talk about weight loss in a weight inclusive bottle of care.

We inclusive providers are not anti wait loss, we just don’t focus on weight as the measure of success, because we want to focus on behaviors you can control.

And well often weight loss goes along with behavior change being 120 pounds exactly is not something you can do behavior wise.

If you set goals around healthy eating, you may indeed lose weight and many people do, but all bodies are different and all histories are different and we can’t promise that.

So if you do lose weight, the amount also is not always something you can micromanage if you make helpful dietary changes, you will improve your health.

Even if you don’t see the number, you want to see on the scale and so we really like to focus on that health improvement, instead of the number.

So let’s take an even more detailed example, so you want to lose 20 pounds and at least one to two pounds a week, so this is the goal you come into new if the dietitian with.

Now you don’t eat a lot of vegetables, currently, and so you start working with a dietitian you together decide to add them into dinners you come up with ideas of how to do that.

You do it you’re eating sizable portions of vegetables five nights a week your energy is good, you don’t feel bloated and refluxy the every night at bedtime you are pooping like a champ.

But you only lose two pounds after doing this for a month weight inclusive approach success what changed, should we work on next to improve your diet and health.

You continue to make healthy changes it’s a process.

That weight centric approach failure you didn’t lose enough weight you feel frustrated you stop eating vegetables, you might as well go back to eating burgers and take out since it’s just not worth it, to make the effort to eat well it doesn’t work, so you know.

This is really the reason why we love this model of care we just think it’s a much more workable one to keep going and be successful over time.

Another reason that a weight centric approach can be problematic for people around dietary change is that you know if you make those…

Specific changes let’s say you go to the gym and you exercise 40 minutes a day, five days a week, you end up with this reasonable plan.

And you like it and you don’t achieve the weight loss you wanted that can actually stop you from engaging those helpful behaviors.

Sometimes people in order to meet their weight loss goals have to engage in unhelpful behaviors.

Like disordered eating or things that aren’t sustainable like avoiding all social occasions, so that you don’t eat any fun foods.

And those things are usually not sustainable, on the long run, and if they were they wouldn’t be a good idea for you, and so you would also likely regain any weight you’ve lost using those approaches.

So while weight loss, you know we inclusive dieticians are not anti weight loss, we are against people engaging in unhealthy behavior and we don’t want to set you up to do that.

Now I want to talk a little bit about what it would look like to work with other types of weight inclusive health care providers beyond dietitians.

Now, if you are meeting with a week inclusive provider a doctor or a nurse practitioner, you know, a PA.

The physical environment would be comfortable for people of all bodies there would always be a variety of blood pressure cuffs and gowns and that would fit people have different sizes.

chairs wouldn’t all have arms so that bodies of all sizes could fit comfortably in them and recommendations given by your provider would be the same, regardless of the size of your body.

People wouldn’t automatically be weighed at the beginning of the visit instead you would actually only be weighed if that we was going to be used to drive your medical care, BMI wouldn’t be discussed.

And as weight stigma gets more and more attention, and more medical societies put out recommendations that ask doctors and other providers to be careful about weight stigma, we have seen a shift in some healthcare providers discussing these topics.

Now, when patients tell us what their provider said about the recent weight gain they say things like they were as kind as possible about it, or they were really very nice about it.

And well That certainly is good that they were kind about it, the problem with the shift is that weight loss is still often the recommendation that people are given.

And, as a general public health message provided without detailed knowledge of what you eat how you exercise your history, whether that includes disordered eating.

The message to lose weight is still often not helpful and can be harmful.

And it’s not helpful for a few reasons, the one is that we’ve talked about a lot and so you’re familiar with that that we lost itself is not something you can do, so, you don’t really walk away with any specific recommendation that you can go and implement.

The second problem is because we know that most people who lose weight will regain it within two years.

Unless things change and we have an evidence based treatment that really does help you lose weight and keep it off in the long term it’s a recommendation that a person is just unlikely to be successful in implementing over time.

And finally, this recommendation, can do harm, because it can trigger disordered eating crash diets or lead the person to avoid future needed medical treatment.

Because they don’t like to have those conversations and they get less medical care in general, which of course isn’t good for anybody’s health to avoid medical care.

Also in a ideal visit with a weight inclusive provider, you would not leave a doctor’s office feeling like you caused your own medical condition, because your body is too large.

And we hear from patients all the time, this is how they leave feeling it’s my weight, you know it’s my fault, i’m too heavy.

And we don’t feel like that’s the way people should leave so that would be, you know, ideally, what you would experience and what you would not experience at these visits.

I want to take a couple minutes to share a couple of case studies for a couple of common conditions that we discussed with patients and highlight the differences in treatment between a weight centric and a weight inclusive approach.

So first we’ll talk about non alcoholic fatty liver disease and a common weight centric approach to this condition we often see healthcare providers telling patients to lose weight to improve their liver function.

In a weight inclusive approach the provider would say something like…

There are a lot of data showing diet changes the primary treatment to manage your fatty liver disease would you like to meet with a dietitian to talk about therapeutic dietary treatments for fatty liver disease.

All people would receive the same advice, regardless of the size of their body.

Now i’ve noted before often weight loss does a company helpful dietary change, even if it doesn’t, we know that there’s a set of dietary changes that can improve your liver function, regardless of whether your weight changes or it doesn’t.

So one example of that is to change your dietary pattern it’s not great, for your liver to eat very little during the day and get most of your energy at night.

So changing your pattern so that it’s more evenly distributed throughout the day or we eat more earlier in the day, compared to at night, can be helpful, even if you’re eating the same amount in total throughout the day.

A Mediterranean style dietary pattern can also improve your liver function so dietary changes might focus on eating more fiber rich carbohydrates, like legumes and beans.

Fruits, whole grains, eating less bread white rice, potatoes, chips and things higher in sugar and sweeteners.

You can also focus on including things high in saturated fats like fish, avocado, nuts, olive oil.

And eating less of the saturated fats from animal products like red meat and higher fat dairy foods so as you can see, there are really wide variety things that we can work on that can improve fatty liver disease.

And we’d love to focus to shift to that and that’s what a weight inclusive approach would look like.

And then, secondly, I want to talk a little bit about gastro esophageal reflux disease, chronic acid reflux…

And weight loss is often also recommended to manage GERD and so in a weight centric approach the doctor diagnoses you with GERD and tells you to lose weight.

And while weight loss does help reduce GERD for some people it’s not always the cause and it’s also not the only way to manage it.

A weight inclusive approach would be where your health care provider instead says something like there are lots of triggers for GERD, and we can talk about managing some of the triggers today.

Having more fat around your abdominal area can also trigger GERD. Would you like to meet with a dietitian to discuss behavioral changes that might impact your weight and focus on other dietary patterns that can also help manage your GERD.

When you would meet with a dietitian we then spend time focusing on each of the areas that can help you manage your GERD.

And tailor our recommendations to you as a person, taking into account what’s important to you what life looks like day to day and what things seem to be problematic for your specific gastrointestinal tract.

Now we have spent some time discussing what we think is the kind of ideal way to provide weight inclusive care, but, as you all know, unfortunately, this is not what most people get right now.

But we hope that will be changing in the future, and so we want to end our presentation today by providing some ideas of ways, you can advocate for yourself if you’re experiencing weight stigma in a medical setting.

It can be difficult to know how to handle medical weight stigma in the moment, so the cards you see here were created by Jenny Jones she’s a parent coach who helps parents handle their kids food and body issues.

And these can be a helpful tool to share with your health care provider at your appointment, there a polite way to initiate a conversation.

About whether the provider really needs your weight, and if they do really need your weight, then you as a patient can make an informed choice about that. It’s a little bit of a different mindset and that being weighed at your appointment can be a conversation rather than an assumption.

Now, if you feel comfortable engaging further in a conversation about these topics, you might try some of the following strategies so let’s say your doctor or other healthcare provider recommends weight loss, as you know, part of your treatment or, as the only treatment.

For whatever you’re struggling with so you could say something like.

Let’s pretend for a minute that weight loss is not an option for me what other treatment options would you recommend for if I were in a smaller body would you have some different ideas for me.

Now, of course, not everyone wants to have this conversation or is able to have this conversation, however, from what we’ve seen, especially over the last.

Couple of years, with respect to other isms things like racism is that, in order to create change, we have to have uncomfortable conversations and so, if you’re willing and able, this is something I really encourage you to do.

Finally, always keeping in mind that you have the option to seek a second opinion and find another health care provider.

If your current one doesn’t seem open to having this conversation with you and it’s, something that would be really important and helpful for your medical care.

Again, we understand that that’s not always easy, sometimes access is difficult, logistics insurance reasons get in the way, but to the extent that you’re able you don’t have to continue to receive care from any one specific provider.

So on this slide we’ve provided some resources to help you learn more about this topic, if you want to.

Of course, the handouts on these websites you’ll see both the HAES health sheets and the creating peace with food i’m not substitute for medical advice and we recommend anyone with a nutrition related health concerns see a registered dietitian.

But sometimes it’s helpful to get some idea of the options out there, and so we wanted to give you a starting point, you can see, there are books, their websites, podcasts, an article and a blog so a variety of ways to to get started getting more of this information.

And now we’re going to… thank you for listening, we really appreciate your time and now we have a little bit of time to answer any questions that you might have.

Yeah thank you both that was so great, you know, I just want to emphasize that I think that this is really the future of healthcare and so.

For anyone listening tonight that feels like this is like a new concept new way of thinking about weight in healthcare, this is really how we’re going to see.

Healthcare transform in the future, and so all of these really tangible, you know kind of tips, and you know ways to advocate for your health are super important.

And we have a few really interesting questions here, some of them, I think you guys kind of covered, but I feel like it would be really helpful to recap, some of these points because they’re so important.

So one question is if someone’s receiving stigmatizing language or actions from their health care provider, how can you talk to that professional without getting too confrontational are ending up in a conflict..

That’s a great question, I think I will say, before I kind of give a more useful answer to this question that is always hard to say how people will react so it may be that, no matter how friendly you are no matter how kindly you say something people will still get offended.

There’s just no way to guarantee that they won’t take offense especially sometimes if…

If somebody realizes they’ve done something yucky because of what you say, they may get defensive about that, and so I think there’s no guaranteed way to do that.

I think the best way to get started, though, is to just speak about your feelings and be honest and say.

Dr. I really appreciate your time and your advice and I wanted to let you know that when you said X.

I felt really hurt and or you know, whatever actually came up for you, I would be honest about that feeling or I felt, you know really triggered when he said that it made me want to do xyz.

And I think that’s important feedback for them to get and so that’s what I would advise is really kind of just talk about specifically what they said, and then how it made you feel.

And then you know if you want to say in the future i’d really rather we not talk about my weight, or we focus on other options, or whatever you would like to see them do differently if you feel ready to give them a next step.

Yeah I would just echo that with kind of the idea that you as a patient, you have the right to have you know meaningful and open conversations with your healthcare providers and…

To the extent that you’re able to do so, I really you know, encourage you to to initiate those conversations when you feel comfortable.

Suzie Finkel: 

Oh, you know one thing I know we hear a lot we see our patients and and after they’ve maybe met with their physician…

What, what do you think a patient should do if the doctor says, you know you should lose weight that’s kind of the main recommendation when they leave a visit what what is an appropriate response.

Shira Hirshberg:

I think it depends on how brave you’re feeling that day, I think the kind of gentlest place to start is.

To say Oh, I hear I hear that that would be a good option, but what other options do you have what other things might help you know I think is like the…

The gentlest way to get started with expanding that and hopefully they’ll recognize that, then they should be providing you different options, I think if if.

They don’t, then the kind of poke ear and way to say it is, if I were a smaller person would you have any other ideas for me, you know, to really make it clear that you wonder is it your size that is changing the recommendation they’re giving.

Suzie Finkel: 

What do you guys think about, you know, being sort of an advocate, if you are a caregiver for someone else or you’re involved in someone else’s health care, so one question is like I’m sure there’s other parents.

Here tonight, listening to but one question is, you know going to a visit, for your child and the doctor making a comment about your child’s weight.

You know how can you prevent that from happening in the future, and you know in another visit you still you know, like that physician you think they’re providing really good care, but.

Maybe don’t want to have that, as part of your person’s health care experience, whether it’s a child or you know, a parent a spouse, whatever it is.

Faith Aronowitz: 

Yeah I think it can be even more difficult, sometimes when the care, when we’re not talking about your own personal care, but that of some of the loved one.

You know, with respect to if it’s your child they’re actually similar don’t weigh me cards specific to a child made by the same.

Person, so you know if you’re a caregiver of a minor you might you know ask.

Their health care provider, you know, please don’t have any conversations regarding weight or body size, without me present in the space, so that you might better be able to sort of modify the conversation as needed or be able to be there.

For them.

Shira Hirshberg: 

I think it would also be very fair to say and it’s depends on the age of your child.

If you have a way to get the doctor alone with you know the kid going to the waiting room a few minutes at the end of the conversation when this first comes up.

A way that you could speak to the doctor without the child listening, you could say listen.

I have a lot of experience with people eating disorders, I really don’t want my kid to develop one, and I know that talking about weight can be one of the risk factors.

So I am happy to engage in conversations about healthy lifestyle choices and what we can do as a family to stay healthy, but can you please avoid specifically mentioning weight or body size going forward i’d really appreciate it.

I think they would you know understand that that worry and that choice.

Suzie Finkel: 

You have another question that’s a little unrelated but it might be just a good way to round out this whole toxins were all dietitians here, one of our favorite questions, what’s the difference between a dietitian and nutritionist.

Faith Aronowitz: 

And a great question.

So essentially.

Dietitian is the the license terms, so we have a whole host of different qualifications and certifications necessary to practice so that as of 2024 that includes master’s degree that includes.

A dietetic internship which is typically a year long kind of clinical practice fellowship type of experience, and then we have a National Board exam that we have to pass.

And based upon you know the State or States that you’re practicing in certifications that are state based, and then we have continuing education credits that we’re responsible for so that’s kind of the difference there anything you want to add here that I left out.

Shira Hirshberg: 

Or i’ll just say that it can be confusing because you can call yourself one of two things now, you can call yourself a registered dietitian or a registered dietitian nutritionist.

I would say nutritionist is a more commonly understood phrase, and so I use that on quite a lot, so I would say that all dieticians are nutritionists but not all nutritionist or dietitians.

And so the way you can tell the difference if you look for the credential somebody has to have an RD or an RDN after their name to have that list of things that Faith mentioned.

And if they do not have those letters after their name, then they may be somebody who was trained in like a weekend type program or just have a lot less.

A lot less training, and so there are people who call themselves nutritionist with a much more minimal level of training.

Suzie Finkel: 

Great so you know just a reminder this webinar will be recorded, so you can share it with others, or you know catch the replay if you were doing some multitasking.

And you know reach out to any of us if you want to set up a telehealth appointment if you’re interested in nutrition services or you want to talk more about these topics and how they pertain to you.

We’re all really interested in talking further, and thank you all for attending, this is great.

Shira Hirshberg: 

Thanks everybody for coming.

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