Jacqui Gingras
“Adiposity emerges as a relational condition that may or may not be associated with poor health. As individuals, clinicians, researchers and policy makers we are pro-status quo or pro-reform; we can throw our weight around or we can swallow things whole.” (Aphramor, 2005, p. 334)
Introduction
In Canada, the Health at Every Size (HAES) philosophy seems to have been taken up most enthusiastically in the health care setting by a small faction of dietitians and nutritionists. Perhaps dietitians are willing to consider and embrace the HAES philosophy since our professional identity is organized around being food and weight experts. More than that, however, dietetics represents a site of multiple and complex subjectivities—mostly thin, non-disabled, heterosexual, white female bodies positioned subordinately in medical hierarchies, sustained by corporeal/cultural expressions, and complicated by infinite food politics. In this article, I will explore further how the HAES philosophy has played out in Canada considering the forces acting on and within individuals who consider their main professional activities to be those structured around food and weight. By considering professional identity in relation to HAES philosophy, those advocating for size acceptance might glean a new perspective in moving our cause forward among all health professions including dietetics.
Who’s Who in the Canadian HAES Movement?
In Canada, the HAES movement can be traced within two groups: health professionals/governments, and the grassroots organizations/university scholars. I will provide a brief history of each, apologizing in advance for any omissions.
When people think of HAES and the non-diet movement in Canada, one name that might come immediately to mind is Linda Omichinski. Omichinski, a Registered Dietitian started the HUGS program in 1987 when she realized that promoting weight loss was not actually helping her “patients” become healthier. In 1992, Omichinski published the first edition of You Count, Calories Don’t, which has gone on to sell 20,000 copies in ries Canada alone. Now, HUGS is an International company promoting a non-diet lifestyle and supporting HUGS program facilitators in Canada, USA, UK, New Zealand, and South Africa (http://www.hugs.com). HUGS is truly a Canadian success story and Omichinski’s efforts were recently acknowledged in the 2004 edition of the Current Biography International Yearbook; one of only six Canadians recognized that year (Cavin, et al, 2004).
In 1988–1989, Health Canada introduced the Vitality program, which continues to “promote healthy eating (not dieting), regular physical activity (not necessarily intense exercise), and social acceptance of a wider range of healthy weights and body sizes.” Vitality is considered by many in the HAES movement to be a noteworthy program, ahead of its time in acknowledging that weight loss is not necessarily a precondition of improved health and longevity (Health Canada, 2000). One pro-dieting website claims that the “anti-diet movement seems to be stronger and has originated via national health policy in Canada” (http://www.bestdietforme.com). Such a claim will likely elicit a feeling of pride among Canadians who support HAES. Of interest, the Vitality message encourages participants to achieve and maintain a healthy weight through the adoption of a healthy lifestyle. Is weight loss more likely if one adopts a healthy lifestyle? Some people might argue that efforts towards weight loss would be redundant if one were to adopt a healthy lifestyle since metabolic fitness can be achieved at a wide variety of body weights. From a critical perspective, the Vitality approach could be considered a “size acceptance diet,” which tends to promise people that if they work diligently to accept who they are and at the same time make healthy food and activity choices, weight loss will follow. The diet industry, always looking for new marketing angles has co-opted and commodified size acceptance language as a means for increasing their bottom line. Slogans such as “Eat all the foods you love without counting” reinforce the size acceptance premise, but still continue to promote weight loss. Recent research indicates that even some dietitians who indicate they are working from a size acceptance/non-dieting philosophy still use body weight as an indicator of health and actively promote weight loss for their “clients” (Barr, et al, 2004). This remains not only an issue of semantics, but a highly contentious debate among those endorsing health at every size.
Predating both HUGS and Vitality was a very popular program called ParticipACTION. In 1971, ParticipACTION, chaired by then Prime Minister, Lester B. Pearson aimed to raise awareness among Canadians of their inactivity and the health implications (a 30-year old Canadian was compared to a 60-year old Swede and the results were not favourable… for the Canadian). The message dramatized the poor fitness level of Canadians so effectively that it became the cornerstone of a new physical activity movement. In fact, ParticipACTION was contracted by Health Canada in 1991 to develop the Vitality/Vitalité name, logo, and media campaign. Another spin-off from ParticipACTION was Body Break with Hal Johnson and Joanne McLeod. They promoted the Vitality message on television for three years (1989–1991) before adopting Body Break as a commercial venture. The final ParticipACTION campaign targeted a wide variety of health and social issues, but lack of funding plagued the program in its later years. With government funding becoming scarce, ParticipACTION resorted to accepting funds from pharmaceutical companies such as Hoffman La Roche (producer of Xenical) to sponsor “obesity education programs.” After thirty years of health promotion, ParticipACTION closed its doors. “A Mouse That Roared” (Edwards, 2004) is a comprehensive review of ParticipACTION’s compelling history and its legacy as an early contributor to the HAES movement.
The second historical stream is delineated along grassroots organizations that often work collaboratively with individual scholars/authors determined to take up size acceptance from a theoretical perspective. Helena Spring, founder of the Canadian Association for Size Acceptance (CASA) is also the NAAFA Eastern Canada facilitator. She has been active in the size acceptance movement for 25 years (.(JavaScript must be enabled to view this email address)). Spring is an author, activist, magazine publisher of Canada Wyde, and public speaker. In a recent conversation with Spring, she noted that “fifteen years ago, the [size acceptance] movement was more positive, but now fat people have become vilified to even greater extents.” Spring has recently partnered with Dr. Janet Polivy, University of Toronto Professor of Psychology and co-author of Breaking the Diet Habit (1983) to educate first and second year medical students about the issue of size discrimination. Polivy has written numerous articles on the negative consequences of dieting, making her one of the founding Canadian theorists of HAES. Other significant contributions to HAES were Nursing Professor Dr. Donna Ciliska’s Beyond Dieting, (1990), and Dr. Gail Marchessault, who was instrumental in nurturing the size acceptance movement into what’s now known as HAES. Marchessault, a nutrition professor at the University of Manitoba worked as an associate editor for the Healthy Weight Journal (currently HAES) and encouraged critical examination of native issues, global perspectives on health, and urged us toward social change. She likened the HAES movement to a “revolution,” saying that HAES “has the potential to revolutionize research, prevention, and treatment of health and weight.”
More recently Jennifer Ellison, a History doctoral student at York University has proposed for her research an exploration of the historical roots of size acceptance in Canada. Ellison intends to “document an emergent fat acceptance movement in Canada by tracing the history of [fat acceptance] groups” such as Hersize: A Weight Prejudice Action Group (founded by Carla Rice and others in Toronto in 1988) and Large as Life (founded by Kate Partridge in Vancouver in 1981). Ellison is seeking input from members of size acceptance groups, so if you have an experience to share visit Ellison’s blog (http://thejennyellison.blogspot.com), which also affords visitors an opportunity to follow and comment on her dissertation in progress.
In association with Large as Life, Vancouver therapist Sandra Friedman offered Facing Your Fat workshops for fat women, which eventually turned into groups for individuals struggling with disordered eating. Friedman remains active in the fat liberation movement through her wildly popular writing on female development and eating disorder prevention. She is the author two manuals, Nurturing Girlpower (2003) and Just for Girls (2003), and two books, When Girls Feel Fat (1997) and Body Thieves (2002), which addresses how we can become “size acceptance warriors” and fight fat prejudice while being fat with dignity (http://www.salal.com). Finally, Jennifer Branson is the President of the Canadian chapter of the International Size Acceptance Association, another grassroots organization originating as an off-shoot of NAAFA. ISAA’s mission “is to promote size acceptance and to help end weight-based discrimination throughout the world by means of advocacy and visible, lawful actions.” Branson is beginning her second year as President this January (http://www.size-acceptance.org/Canada).
Our Challenges
Canadians, especially children and youth, are gaining weight at faster rates than ever before (Tremblay & Willms, 2000). As our population gains weight, so grows our fascination with weight loss, dieting, and nutrition information. Canadians are preoccupied with food and are learning that the pursuit of even more nutrition knowledge is not necessarily helping them achieve health. As a nation, we are also overly focused on eating the “right” foods for weight loss (Statistics Canada, 1999). Those in the HAES movement understand that focusing on low-fat, low-calorie, low-carb food is not entirely a precursor to health (Taubes, 2000), yet that doesn’t stop some dietitians’ from offering heart health workshops titled, “Diets Do Work!”
What social, political, and cultural factors may be contributing to this trend of unremitting weight gain, increased incidence of chronic disease (diabetes, CVD), and growing unease with food? Along with decreasing levels of physical activity, consider the dietitian’s role in “bridging the knowledge gap between producers and consumers” by teaching Canadians to “possess a highly specific knowledge about fat, calories, cholesterol, and fiber,” which coincidentally enhances the diet industry’s bottom line (Austin, 1999, p. 162). Perhaps the dietitian as nutrition expert can assume some responsibility for manufacturing “food ambivalence” among Canadians living in a high stress lifestyle with perceived little or no time for attending to innate cues of hunger and satisfaction. The biochemistry of stress and fat discrimination also contributes to elevated cortisol levels that lead to increased abdominal adiposity. If dietitians and others can encourage and support a shift among Canadians towards mindfulness, peacefulness, and attentiveness in body and food matters, they will have accomplished significant advances in health promotion without once talking about nutrition or BMI.
The Canadian medical establishment’s unrelenting “war on obesity” is spearheaded in part by Obesity Canada, which “aims to improve Canadians’ health through research and education about obesity and its clear health consequences.” Members of Obesity Canada include dietitians, nurse educators, researchers,physicians, and representatives from Health Canada. Interestingly, a recent Medical Post report revealed that Obesity Canada’s president receives funding as the spokesperson for Slim Fast and Meridia (Manzer, 2002). In 2001, a National Dialogue on Healthy Body Weights was sponsored by no fewer than seven pharmaceutical companies including Abbott Laboratories, Hoffmann La Roche, AstraZeneca Canada, Eli Lilly Canada, plus Slim Fast (http://www.cihr-irsc.gc.ca). The relationship between health professionals and weight loss pharmaceutical multinationals creates obvious conflict of interest and drastically undermines public trust in the care that dietitians, nurses, and physicians offer. If health professionals are to continue to be trusted during times of skepticism in ‘‘expert’’ knowledge, “reflexivity, active contestation, and moral testing… need be employed so that we may respond to people in respectful, authentic, meaningful ways; practices worthy of our trust” (Gingras, 2005, p. 57).
Given our training and the highly specialized nutrition language we are taught to use, nutrition experts are partly responsible for creating an environment that reinforces a weight-centered philosophy. One of our challenges is to critically examine the power of “ideological nutrition discourse” and even acknowledge our feelings of shame in perpetuating such discourse. Both can be accomplished in pedagogical contexts in the university classrooms across Canada where health care students are being professionalized. Nutrition discourse is the very specialized language shaped by nutritional science that determines what “counts” as valid nutrition knowledge within the discipline. When nutrition discourse becomes ideological there exists a failure to recognize some knowledge that exists outside of the accepted discourse so that such knowledge is marginalized and marked as irrelevant (Travers, 1995). When nutrition discourse becomes ideological, a partial, misinformed view is constructed.
Consider the power of nutrition discourse to sell a diet product, to permeate food policy, and to reinforce individualism, which only works to accentuate inequities in nutritional health. Travers (1995) contends that “ideological [nutrition] discourse is dangerous when it is used to exert the power of the state over individuals who are struggling to work within an inequitable system” (p. 233). In such a context, health professionals continue to adjust their “patients” or “clients” deficiencies while ignoring the broader social context within which these individuals exist. Ideological nutrition discourse contributes to size discrimination by not acknowledging the social and relational context of fatness. When we reinforce size discrimination, we actually contribute to raising fat people’s experience of body shame, which then elevates their cortisol levels, and well, you know the rest of the story.
Consider a recent example of the power of nutrition discourse in the field of dietetics. Recently, Flegal and colleagues (2005) published an article reevaluating the number of deaths associated with fatness. Dietitians of Canada (DC) Director of Policy Communications sent an e-mail to all members (approximately 5000 dietitians) providing information on how to interpret the Flegal study. The broadcast message included hyperlinks to documents from The Canadian Institute of Health (Overweight and Obesity in Canada: A Population Health Perspective) and two articles from the Canadian Medical Association Journal (The Cost of Obesity in Canada and The Skinny on Obesity in Canada). Following these “obesity statistics” were the following statements:
1. Obesity remains an important cause of death in the United States, with 75% of deaths from obesity occurring in people age 70 or younger. Scientists continue to work on developing better ways to estimate the number of obesity-related deaths and at present there is not a consensus.
2. There is strong scientific consensus that obesity significantly increases the risk of serious chronic diseases like diabetes, heart disease, and some cancers.
3. Overweight among children and teenagers has risen dramatically in recent years, contributing to the development of Type 2 diabetes and risk factors for heart disease. Sixty-one percent of overweight 5-to 10-year-olds already have risk factors for heart disease, and 26% have two or more risk factors. Several decades may lapse for the effects of this epidemic to show up as health problems in adults.
4. Obesity-related deaths do not adequately represent deaths related to poor nutrition and physical inactivity. For example, people with a normal weight can die of heart disease caused, at least in part, by poor diet and/or lack of physical activity.
5. Eating better diets and being more active are important in helping to reduce chronic disease and the high medical costs of treating them.
Clearly, these statements do not represent an HAES perspective and what’s more they foreclose on other ideological perspectives. Consider the following information provided at the end of the same e-mail message to Canadian dietitians:
1. Does this study mean that obesity is less important than CDC once thought?
Not at all. Obesity also increases health care costs, causes pain and suffering, and has negative effects on disability, mobility, and other quality-of-life measures. These measures are very important, since medical science continually improves and does a better job of reducing deaths once you have a disease. For example, suffering a heart attack related to obesity may not be as deadly as it once was, but may reduce quality of life substantially.
2. I was thinking of losing a few pounds to get to my “desired” weight. Should I forget about that for now?
No, keep with your plans to eat a healthier diet and become more physically active. Achieving and maintaining a normal weight is best for your overall health. In fact, practicing healthy lifestyle behaviors will help prevent overweight and obesity as well as improve other risk factors.
3. Isn’t it better to be overweight than normal weight, since the research shows that overweight is not associated with excess mortality?
No, it is not better to be overweight. Overweight increases your chances of getting Type 2 diabetes. Overweight also carries risks for osteoarthritis, low-back pain, and other health problems. In addition, being overweight is a warning sign that a person may be on the path to becoming obese.
4. Does CDC still consider obesity in America to be an important problem?
Yes. Despite the evolving science estimating the number of deaths that obesity causes, we must not lose sight of the fact that overweight and obesity are urgent public health concerns of this country. This epidemic has devastating impacts on health, quality of life, and health care costs.
This information was provided without references and when requested, none were forthcoming since the information was shared via verbal communication by Center for Disease Control spokespersons. The DC Director of Policy Communications assured me that this message was not intended to be “Dietitians of Canada’s voice” on the issue. Not surprisingly, I was not assured. I remain uneasy with how dietitians are left with the message that this is the only voice on the issue of weight and health. When I asked that an HAES perspective on the study be shared with Canadian dietitians, I was refused. The sweeping statements made in the message to Canadian dietitians are highly contentious and some completely without merit. This example demonstrates how the use of weight-centered nutrition discourse leads to a partial, misinformed view since a vast body of evidence is missing. What happens when practitioners come to realize this gap exists? How are we to reconcile our practice in the face of such an abyss?
Where Can We Go From Here?
When we come to understand that evidence exists to demonstrate we are likely doing harm when we promote weight loss in the name of health, we may encounter our shame at the mundane violence we have enacted. When health care professionals commit to HAES, they embrace anti-oppressive practices in general. As Aphramor states, such shifting “would conceivably require a period of shame-work by organizations as they realize the extent to which they have unintentionally been complicit in perpetuating bias” (Aphramor, 2005, p. 332). Acknowledging shame is important in the healing process necessary to move more fully towards size acceptance, social justice, and nutrition equity. Such a healing process continues in other social contexts where discrimination such as racism, sexism, and homophobia has done harm to all involved. We can borrow from social theory to educate ourselves and work towards a world free from sizeism and size discriminating attitudes and behaviours.
A climate of fat phobia, size prejudice, and weight discrimination breeds a culture of shame, uncertainty, and silence. If our professional success is largely determined by our ability to persuade individuals of proper eating and maintenance of healthy weights (Parham, 1999), then it makes sense that we continue to maintain an iron grip on traditional, weight-centered paradigms. Generous use of dichotomous language describing foods as good or bad also implies a moral code of eating conduct that can be punished or rewarded based on resulting changes in body weight. These changes in weight can be carefully monitored against commonly held values of acceptability. When body weights fall out of the “healthy range,” the dietitian can internalize the resulting indication of failure. Thus, the stakes are high for dietitians who continue to measure their identity and worth on the same bathroom scale as their “clients.”
In Canada, we have taken great strides towards an HAES perspective, yet there is more work necessary to bring size acceptance into full view. What will it take for the HAES philosophy to move into mainstream consciousness? As health care professionals and those who seek their support, we might consider how to relinquish our grip on established modes of thought and practice.
It has been sufficiently determined that a new approach to weight issues is not only warranted but ethically necessary (Hawks & Gast, 2000). Despite the scientific rigors of our training, some health care professionals have shifted their approach towards a relational, feminist, health-centred model of weight (Neumark-Sztainer, 1999). Often this change is precipitated by what our “clients” are demanding of us. We read their frustration in their tears, grief, and sorrow at not being able to lose weight despite being told that is what they must do in order to be healthy. In addition to expanding nutrition discourse beyond ideology, there is often a need for health professionals to consider the human dimension of their work and to some extent, ignore the traditional philosophies of their professions (Kalucy, et al, 1984). How can we support each other to integrate an HAES perspective? One way to start is to create multidisciplinary learning environments for health profession students, including in the curricula knowledges from the domains of sociology, feminism, aboriginal studies, education, and anthropology. Currently, dietetic students are educated by those possessing a terminal degree in nutritional science; the scientific method is well represented, but humanism is not (Buchanan, 2004). We might also consider the natural partnership offered by the slow food movement, in particular the recent work by Canadian authors Menzies (2005) and Honoré (2004). There is hope. A great deal of support, dialogue, and encouragement is needed among those espousing HAES in order to maintain their philosophical beliefs amidst the preponderance of those that oppose the health-centered philosophy. Despite the risks there exists an imperative to open a space for diversity in perspectives, not yet another ideology. Look how far we’ve come and consider our capacity for future change. Together it is possible. This issue of the Heath At Every Size Journal clearly emphasizes the passion, commitment, and resources we possess as a global community. And, in Canada there is certainly much at stake for those intrepid HAES practitioners intending to “throw their weight around.”
Jacqui Gingras is a Registered Dietitian and founder of Deliciosa! Nutrition Counselling (http://www.jacquigingras.com). She has been an active member of the size acceptance movement since 1997 when she coordinated the first of many scale smashings to celebrate International No Diet Day. She continues to support those who seek an alternative to dieting by encouraging self and social awareness as a means to size acceptance. Currently, Jacqui is a PhD Candidate in the Centre for the Study of Curriculum and Instruction, Faculty of Education at University of British Columbia, Vancouver, BC where she is using poetry, image, and evocative autoethnographic narrative to understand how dietitians experience their education. She can be contacted at .(JavaScript must be enabled to view this email address).
Author Contact:
Jacqui Gingras, MSc, RD, PhD (Candidate)
Faculty of Education, Scarfe 309 - 2125 Main Mall
University Of British Columbia
Vancouver, BC, CANADA V6V 1Z4
E-mail: .(JavaScript must be enabled to view this email address)
Tel: 604-729-8885 (cell)
References
Aprhamor, L. (2005). Is a weight-centred health framework salutogenic? Some thoughts on unhinging certain dietary ideologies. Social Theory & Health, 3, 315-340.
Austin, S. B. (1999). Commodity knowledge in consumer culture: the role of nutritional health promotion in the making of the diet industry. In J. Sobal & D. Maurer (Eds.), Weighty issues: fatness and thinness as social problems. (pp. 159-181). New York: Aldine de Gruyter.
Barr, S. I., Yarker, K. V., Levy-Milne, R. & Chapman, G. E. (2004) Canadian dietitians’ views and practices regarding obesity and weight management. Journal of Human Nutrition & Dietetics, 17(6), 503-512.
Buchanan, D. (2004). Two models for defining the relationship between theory and practice in nutrition education: is the scientific method meeting our needs? Journal of Nutrition Education and Behaviour, 36(3), 146-154.
Cavin, A. I., Rich, M., Smith, N., Stern, K., Thomas, C. F., Thompson, C. (Eds.) (2004). Omichinski. Current Biography International Yearbook p. 378-382. H. W. Wilson Company: New York.
Ciliska, D. (1990). Beyond dieting: psychoeducational interventions for chronically obese women: a non-dieting approach. New York: Brunner/Mazel.
Edwards, P. (2004). The mouse that roared: a marketing and health communications success story. Canadian Journal of Public Health, 95(2).
Flegal K, Graubard B, Williamson D, Gail M. (2005). Excess deaths associated with underweight, overweight, and obesity. JAMA, 293(15), p. 1861-1867.
Friedman, S. S. (2002). Body thieves: help girls reclaim their natural bodies and become physically active. Vancouver, BC: Salal Books.
Gingras, J. R. (2005). Evoking trust in the nutrition counsellor: Why should we be trusted? Journal of Agricultural and Environmental Ethics, 18, 57-74.
Hawks, S. R., Gast, J. A. (2000). The ethics of promoting weight loss. Healthy Weight Journal, 14(2), 25-26.
Health Canada. (2000). The Vitality Approach: A Guide for Leaders.
Honoré, C. (2004). In praise of slow: how a worldwide movement is challenging the cult of speed. Toronto, ON: A. A. Knopf Canada.
Kalucy, R. S., Gilchrist, P. N., McFarlene, C. M., & McFarlene, A. C. (1984). The evolution of multitherapy orientations. In. D. Garner & P. Garfinkel (Eds.), Handbook of psychotherapy for anorexia and bulimia. New York: Guilford Press.
Manzer, J. (2002). Name dropping. Medical Post. [On-line]. Available: http://www.medicalpost.com/mpcontent/article.jsp?content=/content/EXTRACT/RAWART/3807/47A.html.
Menzies, H. (2005). No time: stress and the crises of modern life. Vancouver, BC: Douglas & McIntyre.
Neumark-Sztainer, D. (1999). The weight dilemma: A range of philosophical perspectives. International Journal of Obesity, 23(2), S31-S37.
Parham, E. S. (1999). Meanings of weight among dietitians and nutritionists. In: J. Sobal & D. Maurer (Eds.), Weighty issues: fatness and thinness as social problems. (pp. 183-205). New York: Walter de Gruyter.
Polivy, J. & Herman, C. P. (1983). Breaking the diet habit. New York: Basic Books.
Statistics Canada. (1999). National Population Health Survey.
Taubes, G. (2001). The soft science of dietary fat. Science, 291(5513), 2536-2545.
Travers, K. D. (1995). “Do you teach them how to budget?”: Professional discourse in the construction of nutritional inequities. In D. Maurer & J. Sobal (Eds.), Eating agendas: food and nutrition as social problems. (pp. 213-240). New York: Aldine de Gruyter.
Tremblay, M. S. & Willms, J. D. (2000). Secular trends in the body mass index of Canadian children. Canadian Medical Association Journal, 163(11), 1429-1433.
This article is from the Health at Every Size Journal and can be cited as Jacqui Gingras, “Throwing Their Weight Around: Canadians Take on Health At Every Size” from Health At Every Size 19:4 (Winter 2006).
