by Kori Kostka, BSc, RD
Sometimes we all need a little R&R (what I like to call rest and rejuvenation), taking a break from the work we do so that we can come back with a fresh perspective. Over the last several months I have had the opportunity to attend conferences and visit people working towards a health approach. Currently, I work as a registered dietitian in a Family Health Team just outside of Toronto, Canada where I have been practicing Health At Every Size® (HAES®) for the last several years. A Family Health Team is a unique place to work because of the extended resources available and coverage offered by the Ontario Health Insurance Plan (OHIP) that go above and beyond the traditional family doctor’s office. Our Family Health Team is fortunate to have an amazing group of social workers, a pharmacist, doctors, nurse practitioners, and nurses.
Implementing a HAES approach at our Family Health Team has been exciting, challenging, energizing, exhausting and everything in between. I am ever so thankful that I can reach out to the people who “get it”—like colleagues on various HAES networks, which fortunately seem to be plentiful these days! Recently I have had the pleasure of organizing one of these, a local Greater Toronto Area HAES Professionals Network, which includes a range of participants beyond registered dietitians, like social workers, nurses, teachers, moms, exercise physiologists, and personal trainers. So far, we have held three meetings to work on building and developing the network, and showcase various speakers and topics such as: the National Eating Disorder Information Centre (NEDIC), The Difference between Fitness and Fatness, Intuitive Exercising, Mindful Eating and Marketing a HAES Approach. We have also explored several challenges and gaps within our communities that would benefit from the development of local subcommittees, for example, on how to prevent and manage the increased prevalence of disordered eating and eating disorders in the youth population.
Last month I was invited to speak about the Health At Every Size paradigm at the Black Physicians’ Association of Ontario (BPAO) in Toronto. In my presentation, I focused on the important theme of intersectionality, which has been highlighted in ASDAH’s recent release of its updated HAES Principles:
Respectful Care: Acknowledge our biases, and work to end weight discrimination, weight stigma, and weight bias. Provide information and services from an understanding that socio-economic status, race, gender, sexual orientation, age, and other identities impact weight stigma, and support environments that address these inequities.
The research that looks at the prevalence of eating disorders in the Black community is limited and much relies on the assumption that Black women traditionally have had positive body images. However, the National Survey of American Life (Taylor, 2007) research along with anecdotal evidence from patients in my practice suggests that eating disorders are on the rise in the Black community, who like everyone else, are bombarded with weight loss messages. Often, obesity is commonly associated with chronic diseases such as hypertension and diabetes in the Black community and there is little mention of the importance of applying a ”respectful care” approach in this population. A few months back, I had posted on the ASDAH listserv about this upcoming presentation, looking for insight, and there was an overwhelming interest to continue this conversation. I was pleased to see this and receive feedback from the conference that this subject was a much needed and appreciated perspective. Perhaps this is a group who could connect with ASDAH to continue the conversation.
In January I had the pleasure of presenting two webinars to over 100 live participants on behalf of the National Eating Disorder Information Centre (NEDIC) and the Central East Local Health Integration Network (CE LHIN). The webinars have been archived (hyperlink provided above) online due to high demand, which tells us that people are searching for an alternative approach to health, especially in light of recent controversy in the media of using the Body Mass Index (BMI) as a proxy for health. Many are unaware of what to do differently and which resources are available. It is making for a timely introduction to the HAES paradigm , which offers an evidence-based alternative to the medical model that can help prevent and manage eating disorders, disordered eating, yo-yo dieting and potentially, unnecessary weight preoccupation.
For the past eight months, I’ve worked as part of the steering committee for the Ontario Public Health Association (OPHA), which hosted the Nutrition Resource Centre’s annual one-day conference. This year’s theme was Health in All Policies (HiAP). The agenda was packed with inspiring speakers who shared a common message of using an intersectoral approach to promote healthy eating in Ontario, to move beyond our traditional silo approaches. A silo approach is one where nutrition policy makers, for example, would only consult with each other, instead of collaborating with others from related fields i.e., health promotion, public health, etc. It was a great opportunity to discuss some of the benefits of intersectoral policies, but also to start a dialogue on how we can evaluate and work together to develop consistent messaging about health promotion. There were many registered dietitians in attendance who work in public health, community health centres and Family Health Teams. Some of the challenges reported by these frontline dietitians were secondary to recent policies implemented by their colleagues, such as recent changes to Ontario legislation that requires fast food restaurants to post the calorie counts on their menu items , and also the messaging interpreted from the province’s Healthy Kids Strategy. Following a session on Healthy Food for Healthy Kids, I discussed the challenges I face when trying to help my clients connect with their intuitive cues of hunger and fullness and make quality food choices with the posting of nutritional information itemizing high and low calorie foods. Throughout this conference it became increasingly evident that the world of food policies unfortunately does not have a standard evaluation process, nor is there a way for front-line health care providers and educators to communicate with the policy makers. The Nutrition Resource Centre (NRC) and the Primary Health Care Action Group (PHCAG) are working together to get all levels of nutrition players to function within an intersectoral framework in Ontario health care and community settings. This is an evolving process, but after attending the NRC’s Provincial Roundtable Meeting this past Monday, it is evident that there are lots of eager stakeholders wanting to continue the conversation (and interestingly, the HAES approach was mentioned several times as a topic for future learning opportunities)!
Lately I have been inundated with referrals for young women (and increasingly young men) struggling with their body image who may be self-harming and/or showing signs of an eating disorder or disordered eating. In our geographic area, we have several options for treatment but the frustration of long wait times and often unaffordable private treatment plans led me to increase my own knowledge and competencies in managing patients with eating disorders to help meet their needs while they wait for formal treatment. Recently, I and nine other health professionals working in eating disorders, including dietitians, psychotherapists, and doctors, were invited to visit Oliver-Pyatt Centers (OPC), a comprehensive treatment centre for eating disorders in Miami, Florida. I had the opportunity to meet some of the OPC team at the last ASDAH conference in Chicago, but seeing the center firsthand gave me a whole new appreciation for the work done at OPC.
Our visit at OPC was packed with a full day of visiting the grounds, various buildings, residential apartments, eating yummy food (of course!) and meeting almost the whole OPC team who function very cohesively. Most impressively, they utilize and share common language and messaging no matter their role, and complement and reinforce each other’s work with the aim of coaching patients back to intuitive and mindful eating habits. Part of a patient’s treatment includes visiting restaurants and eating once “forbidden” foods with the accompaniment of the therapist and/or dietitian to provide extensive coaching and support. Together, the patient and team member work through the experience of dining in a social environment and overcoming the fear of food while addressing other emotions or anxiety that accompany the dining experience.
As a registered dietitian, I most enjoyed meeting with Mary Dye, the Director of Nutrition Services, and the other registered dietitians at the Center. I asked Wendy Oliver-Pyatt, owner of OPC, a question that I recall being asked at the ASDAH conference in 2013 on whether or not we should be so focused on a patient’s weight during treatment for an eating disorder. Her response involved the many side effects of patients who are not adequately nourished as evidenced by being severely underweight: the inability to concentrate and make conscious decisions, altered moods, increased anxiety, weakening of the cardiovascular system and the inability to respect hunger and fullness cues. The best tool we have to identify if a patient, particularly one with anorexia nervosa, has restored his/her nourishment is to compare current body weight to “ideal” body weight. The nutrition team added to this response later in the day by explaining how at the patient level, rather than focusing on calories and weight, they coach patients using intuitive and mindful eating practices, which works well regardless of an individual’s eating disorder type and degree of illness. Part of this coaching involves the use of beautiful laminated, colourful cards, which list hunger and fullness levels on one side and various emotions on the other. At each meal, patients sit with a team member to help identify their hunger and fullness levels and how they are feeling before and after. In the beginning, it can often be difficult to feel these cues and connect them to emotions, but patients are encouraged to take part in this exercise no matter where they are in the recovery process. Mary commented that often, as patients progress through their recovery journey, these cues change and become easier to sense, especially once detangled from the emotional component.
I went to OPC hoping to simply learn about the program, but I came away with a focus on how we could use a similar approach in primary care. Last month, I and one of our primary care physicians shared our experience of implementing HAES principles to the Peterborough Family Health Team. One of the physicians in the audience commented that dietitians need to be consistent with their messaging. He’s right, but not only do dietitians need to be consistent, there is a need for all of us working within nutrition to work intersectorally and to share the same language. It excites me to think that we are on the horizon of integrating Health in All Policies in Ontario, which may be the evidence-based solution to an intersectoral approach or perhaps a universal Canadian nutrition policy that just might parallel the Health At Every Size approach. We can always learn from the frameworks used in other practices, like how Oliver Pyatt Center works collaboratively in healing eating disorders to ultimately promote a healthy lifestyle and minimize unintended consequences. Many of us encounter daily challenges of practicing HAES, whether it is resistance from our clients, our colleagues or society. Sometimes we need to take a step back from our individual HAES settings and look at the good that is going on in the world. If you were to look back a few years ago, would you have known as much about the HAES model as you do today? Would you have heard as many success stories? I sometimes watch Dr. Ivan Joseph’s TED talk on self-confidence and he recommends to write your own “brag sheet” so that you can look back and read all of your HAES successes, big or small. Maybe it does not have to be as much of a “brag sheet” as a way to show the HAES movement is growing and gaining momentum. And I am thankful to have each of you on my team!
Reference: Taylor, J.Y., et al. (2007). Prevalence of Eating Disorders among Blacks in the National Survey of American Life. Int J Eat Disord, 40(Suppl), S10–S14. doi: 10.1002/eat.20451
Kori Kostka is a Registered Dietitian with the West Durham Family Health Team in Ontario, Canada. She has experience in coaching patients to make healthy lifestyle changes in a non-weight biased environment. A graduate of Ryerson University’s Nutrition and Food program, she has received continuing education from numerous sources that have influenced her to access and develop effective self-management programs using the Health At Every Size® paradigm. As a consultant through her business KorNutrition, Kori enjoys maximizing the accessibility of evidence-based nutrition through the use of social media. Kori actively participates in HAES communities and communicates the HAES philosophy to multiple networks, having been the vice-chair for the Dietitians of Canada – Ontario Family Health Team Registered Dietitian network, Secretary for the Association for Size Diversity and Health (ASDAH), a member of the Nutrition Resource Centre’s Steering Committee, a member of the Central East Local Health Integration Network’s Health Professionals Advisory Committee, the lead for the Greater Toronto Area HAES® Professionals Network, and steering committee member of both the Dietitians of Canada – Ontario Family Health Team Registered Dietitian network’s Annual Conference 2014 and the National Eating Disorders Information Centre’s (NEDIC) Annual Conference 2015. You can follow her at:
Twitter: @kornutrition, www.kornutrition.com, Facebook: www.facebook/kornutrition.