Season II Episode 6: Addressing Body Image In Nutrition Education

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[00:00:03] Colby D'Onofrio: Welcome to Stocking the Pantry: a CalFresh Healthy Living Podcast from Leah's Pantry. We'd like to acknowledge our funder, the CalFresh Healthy Living Program, an equal opportunity employer and provider. On this show, we discuss any and all things community nutrition, food equity, and nutrition security. This is a space for thought leaders to share success stories and strategies for equity-centered and resilience-building initiatives.

We hope to foster collaboration and community, as well as leverage strengths among listeners, guests, and hosts, as we share ideas and dreams of building a more equitable future where everyone has access to healthful, nourishing food.

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[00:00:51] Colby: Hello and welcome to Stocking the Pantry. I am Colby.

[00:00:56] Tee Atwell: I'm Tee, and we're your hosts.

[00:00:59] Colby: On today's episode, we are really excited to discuss strategies for addressing body image and anti-fat bias in SNAP-Ed programming and messaging.

[00:01:09] Tee: Before we begin discussing this topic with our guest today, we want to lay a foundation of understanding. Most importantly, what is anti-fat bias, and how does it influence our work as nutrition and community educators?

[00:01:28] Colby: We all have biases. It's how our brain works. Thinking takes a lot of time and caloric energy, so our brains have evolved a mechanism that makes it easier to make quick decisions and be more energy-efficient. This is what allowed primitive humans to survive and what aids our learning today. For example, we observed over time that dark clouds produce a storm, and it becomes an unspoken assumption that when we see dark clouds in the sky, a storm is likely coming. We don't always get it right, but it did serve our ancestors well because especially when humans lived outdoors, it could've been an issue of life or death. Our brains are still wired to work that way today.

[00:02:18] Tee: We also evolve the ability to stereotype people. It's a way of a shortcut to determining who was friend or foe using category, simplification, and generalizations. We especially tend to stereotype people when we have fears and anxieties of our own, but the problem is that stereotypes are also a way to reinforce unfair and untrue things and treatment. None of us like to be stereotyped, I know I don't, or have assumptions made about us. We are wired with this feature, which can support safety and survival, but also division and separation. Many of our biases are socially constructed.

Meaning, they are created and reinforced by explicit and implicit messages around us and within our society. They may become so ingrained in our culture and beliefs that we don't even think about them, or reevaluate them. They are just accepted and then set in stone.

[00:03:33] Colby: We can overcome biases, or just even rely less on them by engaging the conscious, thinking parts of our brains. Having curiosity about ourselves and others is how we start to shift and change biases. It is really important that we examine our habits and assumptions, talk to our fellow humans, consider different perspectives, and look at and evaluate our own fears and anxieties.

[00:04:04] Tee: This can be a difficult muscle to exercise. One bias in particular that can pose challenges in our line of work as nutrition and community educators is anti-fat bias.

[00:04:20] Colby: Anti-fat bias is the assumption that people who live in a bigger body don't care about their health or body, are inherently unhealthy, or their bodies are that way due to their own moral failings. In public health, this can lead us to place more blame and responsibility on the individual and ignore the significance of social and environmental factors.

[00:04:46] Tee: This bias may be explicit or implicit, and it's important that we are conscious of it when we're providing services and programming in our communities. Although we may have the best of intentions, we can accidentally or inadvertently deter someone from making helpful changes if they are disempowered and stigmatized, because of our anti-fat bias.

[00:05:11] Colby: Here to talk with us about her work as a community programs manager is Jennie Altman from AZ Health Zone. AZ Health Zone is Arizona's SNAP-Ed program, and they are working toward building resilient communities through the lens of health equity. Health equity is the idea that everyone should have fair and equal opportunity to reach their optimal health goals.

[00:05:40] Tee: AZ Health Zone is committed to reaching this goal through multilevel interventions that enhance engagement in communities with limited resources. These services and programmings are rooted in meeting the needs, strengths, and desires of that community. AZ Health Zone is also adopting a trauma-informed approach to ensure the interventions prevent implicit re-traumatization or avoid causing harm while meeting individuals and families where they are.

[00:06:14] Colby: AZ Health Zone does this by collaborating with partners across the health and nutrition sector, including farmers and growers, community gardeners, early care and education system providers, and advocates for healthy community design and healthy living opportunities.

[00:06:35] Tee: I am very excited. Welcome to the show, Jennie. Thank you so much for joining us today.

[00:06:43] Jennie Altman: Thank you for having me. It's great to be here.

[00:06:46] Colby: Can you start by telling us a bit about yourself, how you got to where you are now, and what it is you do with AZ Health Zone?

[00:06:56] Jennie: Well, I became a registered dietician in 2016. I wasn't too sure where I wanted to go in my career, but I knew I was very passionate about community nutrition education. At the time, I felt like everyone could achieve their best health possible if they just had good and accurate health and nutrition information. My first job was at a Federally Qualified Healthcare Center, and it was really exciting because the model of these centers are to take a community-focused and integrative approach to health. Patients would see their medical providers. Then I'd follow up with some nutrition education or medical nutrition therapy.

It wasn't too long before I realized that information and education are not as effective as it could be if it's not personally or culturally relevant, practical, or easily actionable or if it's not relatable to a person's life or the resources they have available to them. I began focusing on more tailored education that meets people where they're at, but also became more aware of community resources and how to increase access to food for the patients. I scheduled some food distributions, helped run the Summer Food and Backpack Program at my clinic. All of this work really helped me be prepared for a career in public health nutrition with SNAP-Ed.

My first role at AZ Health Zone was the community nutrition specialist position at the State Implementation Team where I was able to incorporate my interest in nutrition education with the work that my wonderful colleagues do with PSEs for that multilevel approach to health programming. As you mentioned, at AZ Health Zone, we're really committed to a trauma-informed approach. Part of my role is to stay up-to-date on research and practices and provide support for our local agencies, as well as being an advocate for trauma-informed organizational and policy changes at the state level.

I have to say that I couldn't do the work that I do without the support, trainings, and curricula provided by Leah's Pantry. You all built the foundation of what this work could look like in SNAP-Ed.

[00:09:16] Tee: Oh, wow. Thank you so much for that. We really appreciate that Jennie. We really feel the same about you and all implementers out there doing the work, boots on the ground, and really taking on all of these amazing services that you mentioned. Thank you for that. I want to highlight that AZ Health Zone has developed a toolkit called The Language of Health, which provides guidance on how to speak with individuals and provide messages for communities about health, nutrition, physical activity and fitness, diet culture and weight and body size in an asset framing and strength-based approach.

The link for this toolkit is in our show notes, and we highly recommend checking it out. It is a phenomenal guide for community health educators. Jennie, if possible, could you summarize the main takeaways or highlights from this toolkit and tell us about why AZ Health Zone felt it was so important to create it?

[00:10:26] Jennie: The Language of Health: Editorial Style Guide to Effectively Communicate to the Public was written in 2019 by Dr. Cori Lorts, a registered dietician who has a wealth of knowledge in the area of effective nutrition communication, marketing, and research. The purpose was to support how our state agencies, such as the Department of Health and the Department of Education, or state-serving organizations such as the Dairy Council were talking about food, nutrition, health, physical activity, and body size.

The goal was for all agencies to be consistent in their messaging because research shows that when there's inconsistent messaging, recipients of those messages are less likely to incorporate behavior change, and the ones creating the messages are less likely to be considered trustworthy or credible. You can imagine that various agencies and organizations all talk about these topics in a variety of ways. It was really important to try to get on the same page as we're often speaking to the same audiences. Consistency was one goal, and the other goal was to incorporate positive and strength-based messages into broad communications.

Traditional health messages or campaigns often relied on shock value or fear-based messaging to get points across. However, Dr. Lorts found that having positive messages resonate better with audiences and are more inviting for behavior change.

[00:12:07] Colby: I was really impressed by this toolkit. Even as someone who isn't doing work directly in the community anymore, I felt like it was really good knowledge to have as a person just in our world. There is so much negative messaging and things about don't do this, don't eat that, don't work out this way, don't look this way. To have a positive way to talk about health and how health doesn't have to be based in weight or body image felt really freeing. I also hold a degree in health sciences with a concentration in nutrition.

While I was going through my program, it sometimes felt like things were rather stringent, black or white, right or wrong, especially when it came to dietetics and talking about meal plans, micros, macros, prescribe this, don't prescribe this, eat this, don't eat that. What would you say to implementers who may feel that the information provided in The Language of Health is at odds, perhaps with what they learned in higher ed?

[00:13:17] Jennie: I like to say that the education we hold is more complimentary than at odds with The Language of Health messaging. Both what we learn in higher education and what's in The Language of Health are valuable and evidence-based. It's about learning how to combine nutrition science with behavior science to make decisions on what information to share and why, or when and how you can share this information more effectively with the audience in mind. It's important to have knowledge as nutrition experts, and it's important to know that the people we work with also hold knowledge and are the experts of their lives and what can work for them.

The Language of Health is all about being positive and trying to take the more effective and actionable approach that meets people where they're at. A great model I like to refer to when I talk about meeting people where they're at is the Hierarchy of Food Needs developed by the Ellyn Satter Institute. This is a pyramid image that outlines the level of need individuals have when it comes to food and how food needs grow or change as they move to different levels. At the base of the pyramid, we have the basic need just to get enough food. Then a person can work towards getting enough food consistently.

Towards the top of the pyramid, we start to see people making food choices based off of personal preferences or the desire to try something new. At the very top of the pyramid, we have instrumental food or eating for health. Many times, our education and the knowledge we want to share goes directly to the top or the higher levels of the pyramid, and doesn't consider that many of the people we're working with or talking to, especially those who have limited access to resources and food are not at that place.

I remember times when caregivers would tell me their child is a picky eater. I would give them tips like, "Introduce a new vegetable each week and prepare it different ways," because we learned in school that exposure to variety and repetition to unfamiliar foods can help choosy eaters expand their palates and the foods they accept. However, in a practical setting, we could be working with families who are in the stage of just getting enough food and may not be ready or able to take that advice. The Language of Health really helps to provide ways to think about the audience we're speaking to and reframe messages to be more collaborative and inviting rather than dictating.

[00:16:05] Tee: Talk about being able to meet people where they're at, that is just exactly what we need and what is so powerful to be able to empower individuals. I would love to take this one step further and ask you, Jennie, if you can share how taking the focus off of weight really allows people to approach their health in a positive way.

[00:16:34] Jennie: When people focus on lifestyle behavior such as eating a variety of nutritious foods, being more active, managing their stress, their mental, physical, and other aspects of their health can improve even if their weight doesn't change. People can pursue healthy lives at any weight. Actually focusing on weight can be counterintuitive to achieving optimal health if people are overly stressed, fostering a negative relationship with food and exercise, or engaging in harmful behaviors in pursuit of a smaller weight or "ideal size."

[00:17:15] Colby: I love what you brought up there about the other indicators of health. So often, we get really focused on how someone looks and how that is the indicator of their health. As you said, and as you know, and we know, and I think many listeners know, our weight is not the only indicator of our health. There are so many other things to focus on. This is a really holistic approach, and I loved what you said earlier about balancing our education along with our approach to meet people where they're at.

How do we reconcile that medical clinicians especially may consider weight to be a big factor in someone's health, while recognizing that larger body sizes are the result of many factors, and that health is much more dependent on many other things besides just body size?

[00:18:10] Jennie: It's important to consider that the relationship between health and weight is very complex. There's research that shows an association between weight and certain diseases, but not exactly that weight causes diseases to occur. Also, as you mentioned, there's many factors that contribute to a person's weight and body size that are not impacted by individual choice. For SNAP-Ed, our scope is just general nutrition, so providing that education and guidance based on healthful behaviors, not focused on weight. The Language of Health provides some great examples of messages to try using.

If a client or participant does have specific medical concerns or questions, we always want to encourage them to follow up with a medical provider. Of course, we want our clients, participants, community members, all to receive adequate healthcare. We also have to acknowledge that since anti-fat bias can show up anywhere, it can also show up when people are seeking healthcare. Sometimes, people in larger bodies are mistreated, misdiagnosed, or not getting appropriate care when they go to see their medical providers. Sometimes, these patients are just told to lose weight regardless of whatever symptoms they're having, or whatever their concerns are.

This can be extremely harmful, not just for the current situation someone is seeking care for, but also for the future. Patients who have this experience can develop mistrust in medical professionals and avoid routine or follow-up visits. When I was working at a health center, I would encourage medical providers to talk with their patients about what behaviors they're engaging in and refer patients to me for health reasons beyond weight and BMI because as we know, weight is not an accurate indicator of health status.

[00:20:12] Tee: Wow, so eloquently said and so true. Really getting in and being able to develop that relationship with your healthcare provider and/or your patients is really vital and key. How can we help participants and clients consider a weight-neutral perspective on their health and counteract the messages they have internalized about weight?

[00:20:43] Jennie: This can be challenging because diet culture messages and anti-fat bias are so prevalent in everything we are exposed to, from our day-to-day interactions to media and the systems we work in or engage with. Just as it's challenging for us in our programs to address weight biases and adopt a weight-neutral approach, it's going to be challenging for our participants and clients to unlearn these messages and perceptions as well. It's going to take time, consistency with our messages, and modeling weight-neutral word choice and building trust.

Some participants have been on the receiving end of weight discrimination their whole lives and might find it difficult to trust a person sharing nutrition information or this different approach altogether. Some motivational interviewing techniques like listening with curiosity, responding nonjudgmentally, and asking permission to give advice can be really helpful tools to use.

[00:21:49] Colby: I think those are great tools for every provider, [chuckles] especially in this situation, but those are just great tools for providers, educators, and us regular people, when we're communicating with loved ones in our lives. How might you suggest implementers address any weight biases that they might be holding?

[00:22:11] Jennie: I encourage engaging in professional development around understanding biases. A good and simple starting point is the Harvard implicit bias tests for weight. They also have implicit bias tests for race, ethnicity, disability, and more. These tests will ask a series of questions about your attitudes and beliefs and will be able to detect if they sense a subconscious bias. It's good to be able to reflect on your result and ask yourself some questions. Whether or not you take the test, some questions you might want to reflect on to consider if you have a weight bias are, do I believe weight is a choice or a result of people's actions?

Do I provide different care, information, or advice to people based on their body size? Do I make assumptions about a person's lifestyle rather than asking questions?

[00:23:10] Colby: That implicit bias test from Harvard is a wonderful test, and I think it's important. I want to point out that when you take it, to have some compassion for yourself and take everything with a bit of grace. Everyone has biases. No one is perfect. Use this more as a tool to reflect and understand yourself, as opposed to putting yourself down feeling shame or even feeling angry at the test. It's just giving us insight, and it's a tool to better understand ourselves and how we might interact with the world. Now, I'm also curious, Jennie, what kind of feedback have you received from implementers in your state, and perhaps beyond, about the toolkit and its guidance?

[00:23:53] Jennie: We've received such amazing feedback and support for The Language of Health over the last few years. Our local agencies are using The Language of Health not just in their mass communications, but also in how they facilitate direct education and the word choice they use when they're working with partners. Over time, we can hopefully model a more inclusive and supportive way of communicating. I've heard people tell me they enjoy using the messaging because it allows them to be more flexible and relatable to participants.

Also, I'm always learning about other SNAP-Ed agencies adopting The Language of Health into their messaging or using it as a tool for onboarding or reviewing resources they use. We even had a dietetics group in Canada reach out to us to let us know they're promoting it as a resource in their work, so I'm just really pleased to see how widely it's been accepted and adopted. I think overall people are just hungry for a new way to talk about food, nutrition, exercise, all these topics. The traditional way hasn't shown to be very effective for improving and sustaining behavior change on a large population or public health scale.

Sometimes, traditional messages have even contributed to disordered eating patterns or body image issues. At AZ Health Zone, we think, why not try a new approach that's inclusive and positive and see if that can support sustainable change?

[00:25:25] Tee: Yes. Way to be a trailblazer in being able to pave the way, being able to make this accessible, and achieve that inclusive and positive approach. How can our listeners learn more and educate themselves about anti-fat bias and health as weight-neutral?

[00:25:50] Jennie: I can't stress enough, professional development. The fields of health and nutrition are always evolving, and there's always something new to learn. It doesn't have to be formal professional development either. There's a lot of great resources that are widely available, like weight-inclusive nutrition and dietetics groups, anti-diet dietitians you can follow on social media, or books and podcasts on this topic. Oftentimes, we talk about evidence-based practices and reputable resources, but I think it's really important to consider people with lived experience to be reputable resources as well. Try to learn about how anti-fat bias and weight discrimination has affected the lives of others. Humanize this issue and find connection with people.

[00:26:41] Colby: Find connection with people, I love that. That's always at the heart of what we teach and preach at Leah's Pantry too. It makes sense that we have benefited so much from The Language of Health and feel it's so in-line with what we talk about as well. Ultimately, at the end of the day, it is about relationships and connections that brings us together. How can our audience get in touch with you and learn more about your work at AZ Health Zone?

[00:27:10] Jennie: You can visit the AZ Health Zone website at azhealthzone.org. We have a lot of public-facing resources like recipes, articles, and information about nutrition assistance and where to find food. If anyone is interested in connecting or networking with me on weight-inclusive or trauma-informed approaches in nutrition, you can reach out to me via LinkedIn.

[00:27:35] Tee: Please know that all of these links will be in our show notes. Jennie, as you may or may not know, we like to close our show by asking our guests this question. What do you stock in your pantry, figuratively and/or literally?

[00:27:56] Jennie: That's a great question. Literally, I'm always stocking my pantry with canned artichokes because it's my favorite vegetable, and it goes great in everything or on everything. I love to add it to a frozen pizza or in a pasta or casserole. Figuratively, I love to stock my pantry by connecting with others. I enjoy a good conversation, learning from others, and having new experiences. Thank you so much for this experience. This really helped stock my pantry today.

[00:28:27] Colby: We definitely were stocking it up with good conversation. We learned so much from you, I'm sure our listeners have as well, so we want to say a huge thank you to you, Jennie, for joining us today. It's been an absolute pleasure chatting with you and learning more about the great work you are doing with AZ Health Zone.

[00:28:49] Tee: Thank you so much. When you said that, I thought about my favorite roasted artichokes in this beautiful garlic oil.

[00:28:59] Colby: Yum yum.

[00:29:00] Tee: Yes, right. I am ready for a salad or something to throw those on. I sometimes just take a fork to eat it.

[00:29:07] Colby: [laughs]

[00:29:08] Tee: Oh, well, thank you so much and thank you, listeners, for hanging with us today. Please join us next time for more fruitful conversations.

[00:29:17] Colby: Until then.

[00:29:19] Tee: Ciao.

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[00:29:21] Colby: Thank you so much for hanging with us today. Do you know a thought leader or someone doing great work in your community? We would love to interview them, and we would love to hear from you. Connect with us online at leahspantry.org or email us at [email protected]. We can also be found on Instagram, @leahspantry. This podcast is a product of Leah's Pantry, made possible by funding from the United States Department of Agriculture and their Supplemental Nutrition Assistance Program, an equal opportunity provider and employer. Visit calfreshhealthyliving.org for healthy living tips.

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[00:30:13] Colby: Stocking the Pantry invites guests with a wide variety of opinions and perspectives. Guest opinions are their own and do not represent the views of Leah's Pantry.

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