Health At Every Size intervention® under real-world conditions: the rights and wrongs of program implementation.

Implementation integrity is known to be critical to the success of interventions. The Health At Every Size® (HAES®) approach is deemed to be a sustainable intervention on weight-related issues. However, no study in the field has yet investigated the effects of implementation on outcomes in a real-world setting. Objective: This study aims to explore to what extent does implementation integrity moderate program outcomes across multiple sites. Methods: One hundred sixty-two women nested in 21 health facilities across the province of Québec (Canada) were part of a HAES® intervention and completed questionnaires at baseline and after the intervention. Participant responsiveness (e.g. home practice completion) along with other implementation dimensions (dosage, adherence, adaptations) and providers' characteristics (n = 45) were assessed using a mix of qualitative and quantitative data analysis. Adaptations to the program curriculum were categorized as either acceptable or unacceptable. Multilevel linear modeling was performed with participant responsiveness and other implementation dimensions predictors. Intervention outcomes were intuitive eating and body esteem. Results: Unacceptable adaptations were significantly associated with providers' self-efficacy (rs (23) = .59, p = .003) and past experience with facilitating the intervention (r(23) = .47, p = .03). Participant responsiveness showed a significant interaction between time and home practice completion (B = .07, p < .05) on intuitive eating scores. Conclusion: Except for participant responsiveness, other implementation dimensions did not moderate outcomes. Implications for future research and practice are discussed.

Does HealthAtEvery Size® fit all? A group-based trajectory modeling of a non-diet intervention.

OBJECTIVE: Health At Every Size® (HAES®) interventions have been increasingly recognized as a sustainable strategy in obesity management. Nevertheless, heterogeneity among obese individuals leads to challenges as it translates in mixed responses to treatment. In this context, our objective was to identify trajectories of responses to a non-diet intervention for adult overweight/obese women to highlight profiles of responders. METHOD: Based on data from a multicentric quasi-experimental study, a latent class growth modeling (LCGM) was performed. Two hundred and ten women with high body mass index (BMI ≥ 25, MBMI = 36.53) who followed a non-diet intervention offered in Health and Social Services Centres completed questionnaires at T = 0, 4 and 16 months. Outcomes used in the LCGM were intuitive eating and body esteem, two central components in HAES® interventions. Types of responders were then profiled on sociodemographic, weight, lifestyle, psychological and eating variables. RESULTS: The LCGM revealed a 4-trajectory model (p < .001), comprising non-responders (14.67%), moderate improvement with low maintenance responders (49.89%), moderate improvement with high maintenance responders (29.28%) and high functioning partial responders (6.56%). Analysis of variances showed significant differences between all types of responders with medium to large effect sizes on depressive symptoms, self-esteem and disinhibited eating (p < .001; η2 = .23, 0.30 and 0.16 respectively). Fewer differences were found on sociodemographic, lifestyle, health and weight variables. Overall, non-responders (14.67%) had a distinctive profile compared to the other groups by consistently expressing poorer psychological functioning, less adapted eating behaviors and reaching more frequently the clinical cutoff for severe depression (p = .001). CONCLUSIONS: Findings strongly support the relevance of considering psychological characteristics to move towards personalized healthcare in obesity management.

Eating-Related and Psychological Outcomes of Health at Every Size Intervention in Health and Social Services Centers Across the Province of Québec.

PURPOSE: To report the outcomes of a Health at Every Size (HAES) intervention in a real-world setting. DESIGN: Quasi-experimental design evaluating eating behaviors and psychological factors. SETTING: The HAES intervention is offered in Health and Social Services Centers in Québec (Canada). PARTICIPANTS: For this study, 216 women (body mass index [BMI]: 35.76 [6.80] kg/m2) who participated to the HAES intervention were compared to 110 women (BMI: 34.56 [7.30] kg/m2) from a comparison group. INTERVENTION: The HAES intervention is composed of 14 weekly meetings provided by health professionals. It focuses on healthy lifestyle, self-acceptance, and intuitive eating. MEASURES: Eating behaviors (ie, flexible restraint, rigid restraint, disinhibition, susceptibility to hunger, intuitive eating, and obsessive-compulsive eating) and psychological correlates (ie, body esteem, self-esteem, and depression) were assessed using validated questionnaires at baseline, postintervention, and 1-year follow-up. ANALYSIS: Group, time, and interaction effects analyzed with mixed models. RESULTS: Significant group by time interactions were found for flexible restraint ( P = .0400), disinhibition ( P < .0001), susceptibility to hunger ( P < .0001), intuitive eating ( P < .0001), obsessive-compulsive eating ( P < .0001), body-esteem ( P < .0001), depression ( P = .0057), and self-esteem ( P < .0001), where women in the HAES group showed greater improvements than women in the comparison group at short and/or long term. CONCLUSION: The evaluation of this HAES intervention in a real-life context showed its effectiveness in improving eating-, weight-, and psychological-related variables among women struggling with weight and body image.

A Health at Every Size intervention improves intuitive eating and diet quality in Canadian women.

BACKGROUND & AIMS: Health at Every Size® (HAES®) interventions focus on healthy lifestyle by promoting behavioral changes related to diet and physical activity while emphasizing self-acceptance and well-being through an empowerment and intuitive approach. The purpose of this study was to investigate the effects of a HAES® program on intuitive eating and diet quality in women. METHODS: The HAES® intervention, offered by professionals from Health and Social Services Centers in Quebec (Canada), was composed of thirteen 3-h weekly meetings and a 6-h intensive day. For this study, 216 women (1.9% normal-weight, 21.1% overweight, 77.0% obese) who took part to the HAES program were compared to 110 women (3.9% normal-weight, 23.3% overweight, 72.8% obese) from a control group (waiting list). Intuitive eating was assessed using the Intuitive Eating Scale and diet quality was evaluated through the calculation of the Healthy Eating Index (HEI) from a validated web-based self-administrated food frequency questionnaire. Measurements were performed at baseline, post-intervention, and at one-year follow-up. RESULTS: Women who participated in the HAES® program significantly increased their intuitive eating score compared to women in the control group at post-intervention and at follow-up (group by time interaction, p = 0.0002). A significant improvement in diet quality was also observed in the HAES® group in comparison with the control group at post-intervention (group by time interaction, p = 0.0139). The intuitive eating score and the HEI score were positively associated in the HAES® group at post-intervention (r = 0.20, p = 0.0237) and one-year follow-up (r = 0.22, p = 0.0359), but no such associations were noted in the control group (post-intervention, r = 0.04, p = 0.70; one-year follow-up, r = -0.15, p = 0.30). CONCLUSIONS: The HAES® program seems effective in improving intuitive eating and also favours improvements in diet quality. However, the association between intuitive eating and diet quality remains unclear, being positive and significant only after the HAES® intervention.

Restricting marketing to children: consensus on policy interventions to address obesity.

Obesity presents major challenges for public health and the evidence is strong. Lessons from tobacco control indicate a need for changing the policy and environments to make healthy choices easier and to create more opportunities for children to achieve healthy weights. In April 2011, the Alberta Policy Coalition for Chronic Disease Prevention convened a consensus conference on environmental determinants of obesity such as marketing of unhealthy foods and beverages to children. We examine the political environment, evidence, issues, and challenges of placing restrictions on marketing of unhealthy foods and beverages within Canada. We recommend a national regulatory system prohibiting commercial marketing of foods and beverages to children and suggest that effective regulations must set minimum standards, monitor compliance, and enact penalties for non-compliance.

Association between perceived self-efficacy related to meal management and food coping strategies among working parents with preschool children.

OBJECTIVE: This study assessed the associations between the perception of self-efficacy related to meal management and food coping strategies among working parents with preschool children. METHODS: In this cross-sectional study, 417 working parents with at least one child between the ages of 2 and 5 years completed a self-administered questionnaire. The association between perceived self-efficacy related to meal management and food coping strategies referred to as home-based or "away from home" food strategies, and was verified with logistic regression analysis. RESULTS: High self-efficacy among working parents was associated with planning a menu for the upcoming week (OR=1.171-1.959), preparation of healthy meals with only few ingredients on hand (OR=1.152-1.495), and preparation of meals in advance (OR=1.131-1.364), which are home-based food strategies. Low self-efficacy was linked to adoption of «away from home¼ food strategies such as eating in fast-food restaurants (OR=0.713-0.898). CONCLUSION: self-efficacy related to meal management stands out as one of the priority consideration in planning nutrition interventions targeting working parents. Actions related to acquiring cooking skills, planning menus, and drawing up grocery lists would also be of value.

Foods offered in Quebec school cafeterias: do they promote healthy eating habits? Results of a provincial survey.

OBJECTIVE: A school environment that encourages students to opt for food with sound nutritional value is both essential and formative in ensuring that young people adopt healthy eating habits. The aim of this paper is to describe the food offered for lunch in the cafeteria service lines in Quebec schools on regular school days. METHODS: A cross-sectional survey was conducted between November 2008 and June 2009 with a representative sample of 207 French-speaking schools in the province of Quebec. The response rate was 71%. The cafeteria food available from the service line was observed directly and systematically by research assistants trained in observational procedures. Bivariate and descriptive analyses were performed. RESULTS: While most schools offered a vegetable side dish, only 71% of primary schools, 71% of public secondary schools, and 54% of private secondary schools did not offer cold-cut dishes, stuffed pastry, or a fried food on their daily menus. The sandwiches available were rarely made with whole-grain bread. Public secondary schools had more cookies, biscuits, muffins, and chewing gum than private primary and secondary schools. Milk was available in 85% of the primary schools. Most of the schools had eliminated sodas but were still offering fruit cocktails instead of 100% fruit juice. CONCLUSION: The school eating environment changed significantly from 2002 to 2009, presumably as a result of the government action plan and the Framework Policy. Improvements must be made with respect to reducing added sugar in beverages and desserts and promoting baked rather than fried snacks. Vigilance is required since many new products are making their way into the market.

Psychological Impact of a "Health-at-Every-Size" Intervention on Weight-Preoccupied Overweight/Obese Women.

The aim of the present study was to assess the impact of a "Health-at-every-size" (HAES) intervention on psychological variables and body weight the weight-preoccupied overweight/obese women. Those women were randomized into three groups (1) HAES, (2) social support (SS), (3) waiting-list (WL), and were tested at baseline, post-treatment and six-month and one-year follow-ups. All participants presented significant psychological improvement no matter if they received the HAES intervention or not. However, even if during the intervention, the three groups showed improvements, during the follow up, the HAES group continued to improve while the other groups did not, even sometimes experiencing some deterioration. Furthermore, in the HAES group only, participant's weight maintenance 12 months after the intervention was related to their psychological improvement (quality of life, body dissatisfaction, and binge eating) during the intervention. Thus, even if, in the short-term, our study did not show distinctive effects of the HAES intervention compared to SS and WL on all variables, in the long-term, HAES group seemed to present a different trajectory as psychological variables and body weight are maintained or continue to improve, which was not the case in other groups. These differential long-term effects still need to be documented and further empirically demonstrated.

Health-At-Every-Size and eating behaviors: 1-year follow-up results of a size acceptance intervention.

BACKGROUND: Poor long-term success observed with current weight-control strategies stresses the relevance to explore new weight management approaches. OBJECTIVE: To assess the effects of a Health-At-Every-Size (HAES) intervention on eating behaviors, appetite sensations, metabolic and anthropometric variables, and physical activity levels in women at 6-month and 1-year postintervention. DESIGN: Randomized controlled trial; measurements at baseline, at the end of the intervention period (4 months), and at 6-month and 1-year postintervention (10 months and 16 months, respectively). Intervention and testing took place from September 2003 to August 2006. PARTICIPANTS/SETTING: Premenopausal overweight/obese women (n=144; mean age of 42.3+/-5.6 years), recruited from free-living, general community. INTERVENTION: Women were randomly assigned to: HAES group (n=48), social support group (n=48), or control group (n=48). MAIN OUTCOME MEASURES: Eating behaviors (restraint, disinhibition, and susceptibility to hunger), appetite ratings (desire to eat, hunger, fullness, and prospective food consumption), anthropometric and metabolic variables (body mass index, waist and hip circumferences, blood lipid levels, and blood pressure), and engagement in moderate to intense physical activity (energy cost > or =1.2 k cal x kg(-1) x 15 minutes(-1) [> or =4.8 metabolic equivalents]). STATISTICAL ANALYSES PERFORMED: Changes for each dependent variable were assessed by linear mixed models according to a group (HAES vs social support vs control) by time (baseline vs 4 months vs 10 months vs 16 months) split-plot design. RESULTS: Situational susceptibility to disinhibition and susceptibility to hunger significantly decreased over time in both HAES group (-0.9+/-0.2 and -1.3+/-0.5, respectively) and the social support group (-0.4+/- 0.2 and -1.4+/-0.5, respectively). Although eating behavior scores observed at 16 months did not differ between HAES and social support groups (situational susceptibility to disinhibition: 2.5+/-0.2 in HAES group vs 2.7 +/- 0.2 in social support group; susceptibility to hunger: 4.2+/-0.5 in both groups), they were lower in these groups than scores noted in the control group (3.3+/-0.2 for situational susceptibility to disinhibition and 5.9+/-0.5 for susceptibility to hunger). CONCLUSIONS: These results suggest that, when compared to a control group, an HAES approach could have long-term beneficial effects on eating behaviors related to disinhibition and hunger. In addition, our study did not show distinctive effects of the HAES approach in comparison to a social support intervention.

Short-term effects of a "health-at-every-size" approach on eating behaviors and appetite ratings.

OBJECTIVE: To assess the effects of a "Health-At-Every-Size" (HAES) intervention on eating behaviors and appetite ratings in 144 premenopausal overweight women. RESEARCH METHODS AND PROCEDURES: Women were randomly assigned to one of the 3 groups: HAES group, social support (SS) group, and control group (N = 48 in each group). Interventions were conducted over a 4-month period, and measurements were taken before and after this period. Eating behaviors (cognitive dietary restraint, disinhibition, and susceptibility to hunger) were evaluated by the Three-Factor Eating Questionnaire. Appetite ratings (desire to eat, hunger, fullness, and prospective food consumption) were assessed by visual analogue scales before and after a standardized breakfast. RESULTS: More important decreases in susceptibility to hunger and external hunger were observed in the HAES group when compared with the SS group (p=0.05, for susceptibility to hunger) and the control group (p=0.02 and p=0.005, for susceptibility to hunger and external hunger, respectively). In addition, women from the HAES group had more important decreases in postprandial area under the curve for desire to eat (p=0.02) and hunger (p=0.04) when compared with the control group. The change in the desire to eat noted in the HAES group was also different from the one observed in SS group (p=0.02). Women from the HAES group experienced significant weight loss at 4 months (-1.6+/-2.5 kg, p<0.0001), which did not differ significantly from the SS and control groups (p=0.09). An increase in flexible restraint was significantly related to a greater weight loss in both HAES and SS groups (r=-0.39, p<0.01; and r=-0.37, p<0.05, respectively). A decrease in habitual susceptibility to disinhibition was also associated with a greater weight loss in HAES and control groups (r=0.31, p<0.05; and r=0.44, p<0.05, respectively). DISCUSSION: These results suggest that a HAES intervention could have significant effects on eating behaviors and appetite ratings in premenopausal overweight women, when compared with an SS intervention or a control group.

A model of mechanisms underlying the influence of media on health behaviour norms.

Media-based interventions are common in health promotion, yet their conceptual underpinnings tend to be based on a simple linear model of direct influence on individuals' health behaviour. Recent studies have suggested that the processes through which media influence health behaviours are actually far more complex. This paper presents a conceptual model of how the medias influence the emergence and maintenance of the social norms that can contribute to shaping health behaviours. Through positive (amplifying) and negative (dampening) loops, a total of six potential influence pathways are proposed, and the role of opinion leaders and specialists is specified. Future directions for empirical tests of the model are identified.

[Media treatment of messages on weight loss products by the Association for Public Health of Quebec and its reception]. / Le traitement médiatique des messages émis sur les produits, services et moyens amaigrissants par l'Association pour la santé publique du Québec et sa reception.

BACKGROUND: The results of a study on weight loss products and services were released during a press conference organized by the Association pour la santé publique du Québec (ASPQ). The media widely covered this press conference. The purpose of this article is to answer the question: "How are messages emitted by public health institutions transmitted by the media and received by the population?" METHOD: The transcripts of the press conference, the press release as well as 43 documents from the print and broadcast media were evaluated according to a press analysis method. The analysis of these documents was based on the concept of the information unit. The compilation of these information units was used to produce charts which include data such as the frequency, partiality, weight tendency ("poids-tendance") and tendency-impact ("tendance-impact"). Furthermore, two focus groups of persons using weight loss products and services were conducted. RESULTS: In this article, we compare the emitted message with the one transmitted. The analysis of the message emitted by the ASPQ and that conveyed by the media revealed that for almost all subjects dealt with during the press conference, the media have been more partial than the ASPQ. The media not only expanded on the emitted message but also gave a negative image of weight loss products and services. Furthermore, the message transmitted by the media was very similar to the initial message. The focus groups on how the message was received by persons using weight loss products and services also revealed that the message was lost in the flow of information on weight loss products and services. CONCLUSION: This analysis of the emitted, transmitted and received messages has given us some indications on how to readjust the initial message and on what to emphasize in future press conferences.