Addressing weight bias and discrimination: moving beyond raising awareness to creating change.

Weight discrimination is the unjust treatment of individuals because of their weight. There have been very few interventions to address weight discrimination, due in part to the lack of consensus on key messages and strategies. The objective of the third Canadian Weight Bias Summit was to review current evidence and move towards consensus on key weight bias and obesity discrimination reduction messages and strategies. Using a modified brokered dialogue approach, participants, including researchers, health professionals, policy makers and people living with obesity, reviewed the evidence and moved towards consensus on key messages and strategies for future interventions. Participants agreed to these key messages: (1) Weight bias and obesity discrimination should not be tolerated in education, health care and public policy sectors; (2) obesity should be recognized and treated as a chronic disease in health care and policy sectors; and (3) in the education sector, weight and health need to be decoupled. Consensus on future strategies included (1) creating resources to support policy makers, (2) using personal narratives from people living with obesity to engage audiences and communicate anti-discrimination messages and (3) developing a better clinical definition for obesity. Messages and strategies should be implemented and evaluated using consistent theoretical frameworks and methodologies.

A spatial analysis of community level overweight and obesity.

BACKGROUND: Rates of overweight and obesity are now considered to be epidemic. Few studies have examined the spatial distribution of overweight and obesity at the community level, an area of geography recommended for prevention and intervention. Therefore, the present study aimed to examine the spatial variation of overweight and obesity using community geographic boundaries. METHODS: A cross-sectional secondary spatial data analysis was conducted using three combined cycles of Canadian Community Health Survey data for the province of Nova Scotia with community level boundaries. Descriptive rates were calculated using standardised incidence ratio values and spatial analysis was carried out using Global and Local Moran's I and the GetisOrdGi* statistic for cluster identification. RESULTS: Maps illustrating local cluster analysis showed a significant degree of similarity between neighbouring communities in urban areas more so than rural communities. Hot spot analysis maps showed communities clustering together in the urban centre tended to have lower incidence of overweight and obesity ('cool spots'), whereas clustered communities in a more rural area had a higher incidence of overweight and obesity ('hot spots). CONCLUSIONS: The present study showed that there was geographical variation in overweight and obesity between urban and rural communities, and also there was a tendency for communities to cluster based on the incidence of overweight and obesity. This highlights the importance of understanding community level obesity rates and associated behavioural determinants, such as diet and physical activity, as well as the role that urbanisation or rurality may play in intervention initiatives for these behavioural determinants. Specifically, public health nutrition efforts for community level food environments in rural areas should ensure an individualised approach is used, whereas urban areas may be amenable to more general approaches aiming to support healthy weight status among the broader population.

Does nausea and vomiting of pregnancy play a role in the association found between maternal caffeine intake and fetal growth restriction?

The aim of this study was to explore the relationships between nausea and vomiting in pregnancy and (a) fetal growth restriction; and (b) maternal caffeine metabolism and fetal growth restriction. A cohort of 2,643 pregnant women, aged 18-45 years, attending two UK maternity units between 8 and 12 weeks gestation, was recruited. A validated tool assessed caffeine intake at different stages of pregnancy and caffeine metabolism was assessed from a caffeine challenge test. Experience of nausea and vomiting of pregnancy was self-reported for each trimester. Adjustment was made for confounders, including salivary cotinine as a biomarker of current smoking status. There were no significant associations between fetal growth restriction and nausea and vomiting in pregnancy, even after adjustment for smoking and alcohol intake. There were no significant differences in the relationship between caffeine intake and fetal growth restriction between those experiencing symptoms of nausea and vomiting and those who did not, for either the first (p = 0.50) or second trimester (p = 0.61) after adjustment for smoking, alcohol intake and caffeine half-life. There were also no significant differences in the relationship between caffeine half-life and fetal growth restriction between those experiencing symptoms of nausea and vomiting and those who did not, for either the first trimester (p = 0.91) or the second trimester (p = 0.45) after adjusting for smoking, alcohol intake and caffeine intake. The results from this study show no evidence that the relationship between maternal caffeine intake and fetal growth restriction is modified by nausea and vomiting in pregnancy.

The association between childhood overweight and obesity and otitis media.

OBJECTIVE: The objective of this study was to examine the association between otitis media and childhood obesity in a population-based sample of elementary school children in the Canadian province of Nova Scotia. METHODS: The study design is a prospective cohort study, linking data from a population-based survey of Grade 5 students (aged 10-11 years) in the Canadian province of Nova Scotia in 2003 with Nova Scotia administrative health data. Measured body mass index was used to define weight status based on the age- and gender-specific cut-off points of the International Obesity Task Force. Health administration data for each child was linked via Health Card numbers. The primary outcome was healthcare utilization (physician visits and costs) for suppurative otitis media (International Classification of Diseases [ICD]9: 382; ICD10: H65-66) with no previous diagnosis of otitis in the last 30 days. RESULTS: Relative to normal weight children, obese children had more healthcare provider contacts for otitis media (adjusted incidence rate ratio 2.03, 95% confidence interval [CI] 1.66-2.49), incurred more costs per otitis media-related visit ($47 vs. $24, P = 0.0001) and had higher odds to have repeated otitis media (adjusted odds ratio 2.27, 95% CI 1.54-3.35). Socioeconomic factors, a history of breastfeeding, presence of an allergic disorder or chronic adenoid/tonsil disorder did not change the association between obesity and otitis media. CONCLUSION: There is a clear association between childhood obesity and otitis media that cannot be explained by confounding by socioeconomic factors or clinically associated disorders.

Effective weight management practice: a review of the lifestyle intervention evidence.

OBJECTIVES: Despite the existence of guidelines for obesity management, uncertainty remains as to what interventions comprise effective practice. This uncertainty could act as a barrier to busy health care professionals, who may lack the time and expertize to fully appraise the huge amount of literature that is published each year on obesity management. Therefore, the objectives of this review were to synthesize the available evidence, determine most effective and most promising practices for obesity management in adults, using an established methodology, and present this information according to its quality. EVIDENCE ACQUISITION: This synthesis review was conducted from January 2009. A detailed search of relevant databases was conducted to September 2010. Most effective and promising practices were defined using the Canadian Best Practice Initiative Methodology Background Paper, with systematic reviews (with/without meta analysis) as the most rigorous methodology for developing recommendations that were deemed most effective (level 1), and non-systematic reviews for developing recommendations deemed as most promising (level 2). Literature was reviewed and classified across these two levels of rigor, and supplemented with primary studies to further refine recommendations. RESULTS: Evidence from systematic reviews and meta-analyses was classified into three intervention themes or areas of context, in which more specific most effective and/or promising practice recommendations could be nested. These intervention themes were (1) targeted multi-component interventions for weight management, (2) dietary manipulation strategies and (3) delivery of weight management interventions, including health professional roles and method of delivery. Specific recommendations accompanied each theme. CONCLUSIONS: This review highlights the value of multi-component interventions that are delivered over the longer term, and reinforces the role of health care professionals. The findings will help to inform evidence-based practice for health care practitioners involved in obesity management and prevention.

Characterizing the obesogenic environment: the state of the evidence with directions for future research.

Despite the explosion of obesogenic environment research within the last decade, consensus on what constitutes the very environment we are trying to measure has not yet been reached. This presents a major challenge towards our understanding of environmental research for obesity, and the development of a desperately needed contextualized evidence base to support action and policies for curbing this epidemic. Specifically, we lack the application of a cohesive definition or framework, which creates the potential for confusion regarding the role of the environment, misinterpretation of research findings and missed opportunities with respect to possible avenues for environmentally based interventions. This scoping review identified primary studies and relevant reviews examining factors related to body mass index, diet and/or physical activity with respect to the obesogenic environment. Using a comprehensive framework for conceptualizing the obesogenic environment, the Analysis Grid for Environments Linked to Obesity (ANGELO), we identified 146 primary studies, published between January 1985 and January 2008, that could be characterized according to the dimensions of ANGELO. Gaps in the literature were clearly identified at the level of the macro-environment, and the political and economic micro-environments, highlighting key areas where further research is warranted if we are to more fully understand the role of the obesogenic environment.

Can peer educators influence healthy eating in people with diabetes? Results of a randomized controlled trial.

AIMS: To assess whether the Expert Patient Programme (EPP), adapted for people with Type 2 diabetes, can be used to promote healthy eating to improve glycaemic control. METHODS: Adults with Type 2 diabetes (n = 317) were randomized to receive either a diabetes-specific EPP (n = 162) or individual one-off appointments with a dietitian (control group) (n = 155). The diabetes-specific EPP followed the standard National Health Service programme although all participants in the group had diabetes only, rather than a mix of chronic conditions. Participants attended a group session for 2 h once per week for 6 weeks. In addition, a final seventh-week 2-h session was included that was specific to issues concerning diabetes. Outcomes were assessed at baseline, 6 and 12 months. RESULTS: There were no statistically significant differences between the control and the intervention group in any of the clinical outcomes measured. There was no significant difference between the groups in any dietary outcome. There was a higher starch intake in the EPP group, although this did not reach statistical significance (effect size for starch adjusted for baseline values 8.8 g; 95% CI -1.3 to 18.9). There was some loss of participants between baseline measurement and randomization, although this did not appear to have had an important impact on baseline balance. CONCLUSIONS: In this study of people with Type 2 diabetes, the EPP approach was not effective in changing measures of diabetes control or diet.

Comparison of plasma biomarkers with dietary assessment methods for fruit and vegetable intake.

OBJECTIVE: To assess the variability and validity of plasma-based biomarkers of antioxidant vitamin, and fruit and vegetable intake. SETTING: Leeds, Wakefield, Huddersfield and Bradford, England. SUBJECTS: A total of 54 free-living, nonsmoking women recruited from participants of the UK Women's Cohort Study (UKWCS). METHODS: Two fasting blood samples were taken at two time points, 18 months apart. A 4-day food diary was completed prior to the first blood sample and a 24-h recall was conducted at the time of the second blood collection. All blood samples were analysed for ascorbic acid and four carotenoids. Associations between antioxidant vitamin intake from all food sources and supplements, as well as fruit and vegetable intake, and plasma levels of the antioxidant vitamins were assessed. RESULTS: Using the 4-day diary, positive associations were found between micronutrient intake from all food sources and plasma concentrations of ascorbic acid (P<0.01) and beta-carotene (P<0.01). No associations were seen between plasma micronutrient levels and specifically fruit and vegetable intakes. In general, associations between plasma levels and intakes assessed by the 24-h recall were less marked than those based on the 4-day diary. CONCLUSIONS: Plasma ascorbic acid and beta-carotene are good indicators of previous vitamin C and beta-carotene intake, from all food sources. However, caution is required in extrapolating these results to include individual food groups, rich in these vitamins. The results imply that the practice of using plasma biomarkers simply as a proxy measure of dietary intake is not valid and emphasise that plasma biomarkers are not simply a reflection of dietary intake, but also of a number of physiological processes. Biomarkers in nutrition epidemiological studies are however useful to measure nutrient status at the tissue level.

Dietitians' views of overweight and obese people and reported management practices.

OBJECTIVES: To examine dietitians' views of overweight and obese people, to explore the role of level of severity on these perceptions (overweight vs. obesity), and to explore the relationship between dietitians' views and their reported weight management practices. DESIGN: An independent measures survey, questioning dietitians about either overweight or obese people. PARTICIPANTS: One-hundred and eighty-seven members of the British Dietetic Association. MEASUREMENTS: A questionnaire exploring beliefs about the causes, attitudes, perceptions of responsibility and reported weight management practices. RESULTS: Physical inactivity was identified as an important causative factor for both overweight and obesity. Mood, eating too much of the wrong foods, repeated dieting and interpersonal factors were also seen as relatively important for both groups. Attitudes were mixed, but were generally neutral to positive. The most negative attitudes were described in terms of perceived reduced self-esteem, sexual attractiveness and health. Dietitians rated obese people more negatively than overweight people. They viewed both overweight and obese people as being responsible for their excess weight. They also reported very similar management practices for overweight and obese people. Beliefs about the causes of overweight explained more of the variance in practice than dietitians' attitudes towards or perceived responsibility of overweight and obese people. However, these associations were not consistent and strong, and other factors not investigated here are likely to have a greater influence on weight management practices.

An updated systematic review of interventions to improve health professionals' management of obesity.

The objective of this article was twofold (1) to determine the existence and effectiveness of interventions to improve health professionals' management of obesity or the organization of care for overweight and obese people; and (2) to update a previous systematic review on this topic with new or additional studies. The study design was a systematic review of intervention studies, undertaken according to standard methods developed by the Cochrane Effective Practice and Organization of Care (EPOC) Group. Participants were trained health care professionals and overweight and obese patients. The measurements were objective measures of health professionals' practice and behaviours, and patient outcomes including satisfaction, behaviour, psychological factors, disease status, risk factors and measures of body weight, fat, or body mass index (BMI). Twelve studies were included in the original review. A further six were included in this update. Six of the 18 studies were randomized controlled trials of health professional-oriented interventions (such as the use of reminders and training) and one was a controlled before-and-after study to improve collaboration between a hospital clinic and general practitioners (GPs). Ten randomized controlled trials and two controlled clinical trials of interventions comparing either the deliverer of weight-loss interventions or the setting of the delivery of the intervention, were identified. The heterogeneity and generally limited quality of identified studies make it difficult to provide recommendations for improving health professionals' obesity management. To conclude, at present, there are few solid leads about improving obesity management, although reminder systems, brief training interventions, shared care, inpatient care and dietitian-led treatments may all be worth further investigation. Therefore, decisions for the improvement of provision of services must be based on the existing evidence on interventions with patients and good clinical judgement. Further research is needed to identify cost-effective strategies for improving the management of obesity. A full version of this review (including detailed descriptions of the included studies and their methodological quality, and results and excluded studies tables) is available in the Cochrane Library. The Cochrane Library is a database of systematic review and other evidence on the effects of health care, continuously updated as new information emerges. It is available on CD ROM from Update Software. For further information see: http://www.update-software.com/cochrane.

Factors affecting food choice in relation to fruit and vegetable intake: a review.

The present review provides an investigation into the food choice decisions made by individuals in relation to fruit and vegetable consumption. A comprehensive body of evidence now exists concerning the protective effect of fruit and vegetables against a number of diseases, particularly cardiovascular disease and certain forms of cancer. Current UK recommendations are to increase intakes of fruit and vegetables to 400 g/person per d. In the main body of the review the factors that affect food choice decisions of adults in relation to fruit and vegetable consumption are studied, following a suggested framework of food choice. Factors covered include sensory appeal, familiarity and habit, social interactions, cost, availability, time constraints, personal ideology, media and advertising and health. The content of the review shows just how complex the food choice process can be. Health promotion techniques can be better targeted towards certain groups of individuals, all holding similar sets of values, when making food choice decisions. Food choice, in relation to fruit and vegetable intake, needs to be studied in more depth, in order to provide effective nutrition education programmes, in particular the sets of priorities that different sub-groups of the population consider when making food choice decisions.