Applied Research Collaborations for Health (ARCH) is the research group for Dr. Sara Kirk. Sara Kirk holds a Canada Research Chair in Health Services Research within the School of Health and Human Performance at Dalhousie University and a cross-appointment with the IWK Health Centre.

ARCH uses a social-ecological approach to understand lifestyle factors influencing health status and health services utilization, particularly in relation to excessive weight gain. In particular, ARCH is looking at how obesity is managed within the health setting, as well as in understanding the contribution of the "obesogenic" environment to population weight status.

The following is cross-posted from Dr. Yoni Freedhoff’s blog Weighty Matters. It was written by Sara in response to a guest post on Yoni’s blog by a medical student who was frustrated by her lack of training on counselling obese patients.

The recent guest post “Do Medical Schools Teach Future Doctors About Weight Management?” by medical student, Jill Trinacty, highlights a number of shortcomings with the current model of medical education when it comes to doctors counselling obese and overweight patients. The frustration Jill feels is indicative of the health care system as a whole: as we grapple with rising rates of obesity and an overburdened health system, there is a lack of clarity around who the key players in managing obesity are, particularly in the primary care setting, and how they view this problem. Many health care professionals feel ill-equipped to identify and deal with issues around weight management and are unsure of their roles and responsibilities.

These deficiencies deserve attention within the Canadian health system, and indeed elsewhere, and innovative research in Nova Scotia is tackling them head-on. Through a series of in-depth interviews, we have examined the experiences of individuals living with obesity, the perceptions of health care providers and the role of social, institutional and political structures in the management of obesity. This study is the first, to our knowledge, to look at the challenges of managing obesity from these multiple perspectives.

In over 40 interviews, we observed how the management of obesity within the health care system is rife with weight bias, stigma and blame. Individuals living with obesity felt that they did not receive the support they needed from their health care providers, while health professionals did not know how best to raise the issue in a respectful way. Furthermore, many participants shared that the relationship between the individual and the health professional was critical for successful weight management. Individuals living with obesity reported feeling that, due to the sensitive nature of the topic of weight, the existence of a trusting, mutually respectful relationship with their health care provider was essential. Unfortunately, this was not their experience in practice. On the other side of the therapeutic relationship, health professionals shared their views related to their own professional frustrations regarding the challenges involved in managing obesity within a system that is not structured to support chronic health conditions and a health issue for which they receive inadequate training. Many health professionals wanted to be able to offer more support, but simply did not know how to within the constraints they faced. Our findings highlight the need for better education for health professionals as Jill identified in her post.

The rich narratives we obtained from our participants have subsequently been developed into a dramatic presentation, depicting the relationship between a health professional (family doctor) and an individual living with obesity (patient). In this dramatic presentation, both internal and external dialogue highlights the spoken and unspoken tensions that were identified by our participants. Early data from pilot work suggests that the presentation offers a powerful medium to raise awareness of these tensions and to provoke a constructive dialogue to address them. We have shared two videos (also embedded down below), one discussing the study findings and a shorter recording of the dramatic presentation. These are available for educational use. This dramatic presentation is ideal for use as an educational tool for health professionals to address the tensions identified through this study. We will also be showing the live drama at interprofessional education events across Atlantic Canada. If you are interested in having the dramatic presentation performed live at an event, please email for details.

Our findings add to a growing body of literature that challenges a number of widely held assumptions about obesity within a heath care system that currently is not designed to provide the support that individuals living with obesity need. It is our goal that the study data inform obesity policy management practices for the future. We think helping health professionals see what is going on behind the scenes is a step in the right direction and we look forward to hearing the views of your readers on our approach.

Video Discussing Study Results

Video of dramatic presentation

SIGN UP for this webinar to learn how you, your school board and your community can support students to succeed. New evidence links healthy eating and physical activity to better academic outcomes.  Register to hear the evidence and find out how you can be involved.

Sept. 26th from 12:30 – 2:00 p.m.

RSVP:  Sherry Jarvis at Sherry.Jarvis@ns.cancer.ca

CLASS II is featured in the Health Promotion Clearinghouse August bulletin as profile of the month. Health Promotion Clearinghouse is a network that supports health promotion activities across the Maritimes. Check out this month’s bulletin to see why CLASS II is important for health promotion, and see what other health promotion activities are taking place near you.

Yoni Freedhoff’s excellent Weighty Matters blog has been featuring a series focusing on the “Parental No files“. These blog entries highlight the difficulties experienced by many parents in providing healthy choices for their children in a society that insists on normalising unhealthy food choices at every opportunity, typically without any corresponding balance of healthy choices. Often, the knee-jerk response to any calls for regulation to promote healthier food choices focuses on the argument that these are the foods that kids like and that if healthier choices are provided, then they won’t sell as well. One of the comments provided a link to a great blog post from the US called “Beyond Nachos: Rethinking Concession Stand Food“, which describes the process of introducing healthier food choices at concession stands in recreational facilities in Lexington, Kentucky. Through creative menu planning, strategic promotion and strong leadership, the team have introduced a range of healthy choices that are fun and affordable. As Brian Rogers, Deputy Director of Enterprise for the Lexington Department of Parks and Recreation said “We’re doing it because it’s the right thing to do.”

The media attention to the issue of the widespread availability of unhealthy foods in school fundraising highlighted how much work still needs to be done to make the healthy choice the easy choice for our children to grow up healthy. ARCH sought to provide some much needed balance and evidence to the discussion:

The position of the critics to the policy brought me in mind of the excellent discussion paper by Kelly Brownell and Kenneth Warner, The Perils of Ignoring History: Big Tobacco Played Dirty and Millions Died. How Similar Is Big Food? which outlines the tactics used by the food industry to promote their products and deflect criticism. Consciously or not, 4 out of 7 of these tactics appeared in the discourse of this issue:

Two news stories caught my eye this week. The first was that Nova Scotians are among the most highly taxed in the country (see http://thechronicleherald.ca/opinion/101860-how-high-and-how-fair-are-our-taxes) and the second was of concerns from parents in response to a reminder from the Departments of Education and Health and Wellness that unhealthy fundraisers, such as cake walks are not in line with the School Food and Nutrition Policy (see http://www.cbc.ca/news/canada/nova-scotia/story/2012/06/02/ns-school-sweets-ban.html and http://thechronicleherald.ca/novascotia/103142-ns-takes-cake-out-of-cake-walk). How are these two stories connected? The provincial health budget in Nova Scotia currently consumes more than 50% of the total budget, with much of this needed to address the burden of chronic disease in this province. Nova Scotians are among the least healthy in the country – with the highest rates of heart and lung diseases and the second-highest rates of diabetes and hypertension. We also have the highest proportion of individuals with multiple chronic conditions. One in three children in Nova Scotia is overweight or obese, and this is impacting their health. Obese children have 21% higher physician and hospital costs than their normal weight peers (Kuhle et al 2011), a cost differential that will only increase as these children age, threatening to overwhelm our health system unless we do something about these disturbing trends.

The reasons for the increasing rates of obesity and associated chronic diseases are complex. One key factor is that we live in an “obesogenic environment” – an environment that promotes the unhealthy choice as the default choice and in which healthy behaviour is the abnormal behaviour. Schools are one place where we can help our children to learn about healthy eating and active living, where we should be modelling the behaviours we want our children to adopt, yet these healthy messages are undermined by the constant barrage of unhealthy foods promoted by the food industry and by a culture that equates junk food with “having fun”.  Junk food is everywhere and cheap to buy, but it is costing us dear in increasing rates of poor health. We cannot have it both ways, wanting lower taxes when our very behaviours are one reason why our health system is so expensive. I applaud the schools and the Government for making an effort to promote healthy foods to our children, through the Nova Scotia Food and Nutrition Policy. This is an effort that is grounded in evidence – the provincial food and nutrition policy was developed partly in response to research from Nova Scotia that highlighted that children attending schools with a comprehensive health promoting schools program had better diets, were more physically active, had less screen time, were 50% less likely to be overweight and 72% less likely to be obese (Veugelers and Fitzgerald, 2005 ). Further, grade 5 students with the best diet quality were 30% less likely to fail their Elementary Literacy Assessment (after adjusting for things that we know might influence this finding such as socio-ecocomic status, Florence et al, 2008). We need to connect the dots and recognise that promoting healthy behaviours could actually save money as well as lives, and that healthy children learn better. Investing in our children’s health should go hand in hand with investment in their education. Why would we not want our children to live a long, healthy and prosperous life?

The New York Times ran a very interesting piece this week that explored the use of mathematics to understand the obesity epidemic. The article involves an interview with Carson C. Chow, a mathematician with the US National Institutes for Health. Using applied mathematics, he and his colleagues have concluded that the obesity epidemic is a result of the overproduction of food. Click here to read more. Not something many people want to hear but important none-the-less.

Research at Dalhousie University is helping us to understand how students’ health has changed over the past eight years.The Children’s Lifestyle and School-performance Study (CLASS) is a province-wide research project that studies the relationships between nutrition, physical activity, mental wellbeing, school performance and children’s overall health in Nova Scotia. CLASS I was completed in 2003 with over 5000 Grade 5 students and their parents/guardians in 282 schools across the province. Since 2003 there have been many changes in Nova Scotia schools through increased investment in health promotion policies and initiatives. CLASS II is helping to understand how these changes have influenced children’s health and school performance by collecting similar information from Grade 5 students in 2011.

The CLASS II team visited 272 schools in 2011. Parents/guardians provided consent for their children to take part and completed a survey about aspects of the home environment of relevance to healthy eating and active living. Students completed two short surveys about the foods they eat and activities they do, and had their growth and development measured in private. In partnership with the Physical and Health Education Canada National Conference, over 80 representatives from the Provincial Government, School Boards, District Health Authorities, schools and communities came together on Thursday May 10th 2012 to learn more from the preliminary CLASS II results. The event was also attended by the media, with both CBC and CTV featuring the research on their evening news shows. Click here to watch the CBC video. Click here to watch the CTV video.  Click here to read more about the CLASS studies.

Balancing the Scales is a one-day, informative and interactive session on obesity management in the Nova Scotia health care system to be held on Friday, June 8 2012, at the Future Inns Halifax Hotel & Conference Centre, Halifax, Nova Scotia. This event will share the results of a recently completed study on obesity management in the Nova Scotia health care system. Bringing together health care providers (physicians, nurses, dietitians and other allied health professionals) and individuals living with obesity in a facilitated dialogue, the day will also explore challenges and solutions to better support individuals living with obesity as they navigate the health system. Click here for more information.

ARCH Director, Dr Sara Kirk, was featured on Radio Canada International’s “The Link‘ program today, discussing a recently published research study. The study involved a national survey of Canadians and their weight management practices, finding that surprisingly few overweight or obese patients reported receiving advice about weight management from physicians. Specifically,  of 2004 respondents, 33% were classified as overweight and 20% as obese. In the 12 months before the survey, 48% of overweight and obese respondents reported asking their physician about weight loss, while 30% reported that their physician advised them to lose weight without them specifically asking. These findings have implications for the way weight issues are managed within the health system as well as more broadly for chronic disease management.