January 2024 letter regarding areas of concern and recommendations in the “Your guide to a healthy pregnancy.”

January 2024

Public Health Agency of Canada

130 Colonnade Rd

A.L. 6501H

Ottawa ON K1A 0K9

Sent via email: info@phac-aspc.gc.ca

Dear Public Health Agency of Canada,

Re: feedback on “Your guide to a healthy pregnancy” resource

Ontario Dietitians in Public Health (ODPH) is the independent and official voice of Registered Dietitians working in Ontario’s Public Health System. Our mission is to advance public health nutrition through member and partner collaboration to improve population health and health equity locally and provincially. We do this through evidence-informed, comprehensive population health promotion with a focus on health equity.

Access to high-quality information on pregnancy is a valuable role that the Public Health Agency of Canada plays for Canadians. As public health dietitians who work closely with staff, community partners and clients directly, we would like to draw your attention to the following areas of concern and recommendations in the “Your guide to a healthy pregnancy.”

1. Prenatal Section (page 9): BMI Table with Recommended Weight Gain

Recommendation: Remove the BMI table with recommended weight gain and the replace current text with the following: “Your body will experience many changes during pregnancy, including weight gain. Speak to your health care provider to determine what an appropriate amount of weight gain is for you.”

2. Physical Activity Section (page 33): “Exercise is safe and encouraged for healthy pregnant individuals who are receiving prenatal care. Exercise can:…Help prevent you from gaining excess weight.”

Recommendation: Remove the bullet “Help prevent you from gaining excess weight.”

3. Breastfeeding Section (page 55): “It reduces the risk that your baby will have diarrhea…or be overweight/obese when they are older.”

Recommendation: Remove “or be overweight/obese when they are older.”

Supporting Evidence:

1. The body experiences many changes during pregnancy and weight gain is different for everyone.

Pregnant individuals may gain more or less weight than the guidelines used by Health Canada for a variety of reasons. These include nausea and vomiting, weight loss or weight gain prior to pregnancy, weight/dieting/disordered eating/food insecurity history, genetic variation, current health conditions, current life/relationship circumstances, etc.

While some may appreciate learning approximately how much weight gain to expect, that is not always the case. Others may find it distressing or lead to unrealistic expectations. Changes to body size and shape during pregnancy are expected and should be normalized. Public health should be challenging the unachievable societal examples and expectations for gestational parents (1,2) rather than continuing to perpetuate harmful body image messaging and weight stigma.

Stereotypes and misconceptions about obesity that perpetuate weight stigma can create an unpleasant experience for pregnant individuals living in larger bodies as they are often victims of weight stigma and feel judged for their weight and shape (3). This can lead to increased stress and depression which can have negative impacts on both the individual and fetus (4) and continue to pose a risk throughout the postpartum period, parenting, and the child’s life (5).

2. The public health field no longer identifies weight management as a benefit to exercise.

Historically public health used weight loss and weight maintenance messaging as an incentive for exercise, resulting in media and social messaging associating exercise and weight (6). Focusing on weight control as a benefit of exercise may increase weight stigma (7). There are many benefits to physical activity regardless of any impact on weight.

3. Breastfeeding is only one of a multitude of factors that are associated with future weight status in children based on observational research.

Due to the risk of increasing weight stigma and shaming parents (5), attention to this association should be avoided in resources designed for the public. A child’s body weight is determined by many complex factors and should not be distilled down to infant feeding practices. Recognizing the limitations of observational research as well as the risks of weight stigma, such strong and potentially harmful conclusions should not be drawn.

It is our position that weight stigma contributes to discrimination, oppression, and social injustices – which are a significant public health problem that leads to health inequities. Weight bias, stigma and discrimination are independently linked to poorer mental and physical health. Public health messaging that focuses on weight and obesity contributes to weight stigma.

We urge you to please consider adopting a weight neutral approach in public health messaging and modifying the “Your guide to a healthy pregnancy” resource with the suggestions put forth in this letter.

We look forward to hearing back from you and invite you to connect with us should you wish to meet or seek further clarification.

Sincerely,

Amy MacDonald, Chair
Body Diversity and Health Equity Working Group
amacdonald@hpph.ca

Paula Ross, Chair
Family Health Nutrition Advisory Group
rossp@phsd.ca

Laura Abbasi
ODPH Co-chair
executive@odph.ca

References

1. Incollingo Rodriguez AC, Dunkel Schetter C, Brewis A, Tomiyama AJ. The psychological burden of baby weight: Pregnancy, weight stigma, and maternal health. Social Science & Medicine, 2019, 235. DOI: 10.1016/j.socscimed.2019.112401.
2. Tang L, Tiggemann M, Haines J. #Fitmom: an experimental investigation of the effect of social media on body dissatisfaction and eating and physical activity intentions, attitudes, and behaviours among postpartum mothers. BMC Pregnancy Childbirth. 2022 Oct 12;22(1):766. doi: 10.1186/s12884-022-05089-w.

1. LaMarre, A., Rice, C., Cook, K., & Friedman, M. (2020). Fat reproductive justice: Navigating the boundaries of reproductive health care. Journal of Social Issues, 0(0), 1–25. https://doi.org/10.1111/josi.12371

1. Cook, K., LaMarre, A., Rice, C. & Friedman, M. (2019). “This isn’t a high-risk body”: Reframing Risk and Reducing Weight Stigma in Midwifery Practice. Canadian Journal of Midwifery Research and Practice, 18 (1), 26-34. https://www.cjmrp.com/files/v18n1-weight-stigma-and- pregnancy.pdf
2. Gorlick JC, Gorman CV, Weeks HM, Pearlman AT, Schvey NA, Bauer KW. “I Feel Like Less of a Mom”: Experiences of Weight Stigma by Association among Mothers of Children with Overweight and Obesity. Child Obes. 2021 Jan;17(1):68-75. doi: 10.1089/chi.2020.0199.

1. Cox CE. Role of Physical Activity for Weight Loss and Weight Maintenance. Diabetes Spectr. 2017 Aug;30(3):157-160. doi: 10.2337/ds17-0013.

1. Myre M, Glenn NM & Berry TR (2021) Exploring the impact of physical activity-related weight stigma among women with self-identified obesity, Qualitative Research in Sport, Exercise and

Health, 13:4, 586-603, doi: 10.1080/2159676X.2020.1751690.

August 23, 2023

Public Health Agency of Canada

130 Colonnade Rd

A.L. 6501H

Ottawa ON K1A 0K9

Re: feedback on new resource “Your guide to postpartum health and caring for your new baby”

Ontario Dietitians in Public Health (ODPH) is the independent and official voice of Registered Dietitians working in Ontario’s Public Health System. Our mission is to advance public health nutrition through member and partner collaboration to improve population health and health equity locally and provincially. We do this through evidence-informed, comprehensive population health promotion with a focus on health equity.

Access to high quality information for pregnancy, postpartum and early parenting is a valuable role that the Public Health Agency of Canada plays for Canadians. As public health dietitians working with community agencies, pregnant and postpartum clients directly, we would like to draw your attention to the following areas of concern and recommendations for the newly released resource:

1. Nutrition Section (page 18): “What should I do to lose my baby weight? …Breastfeeding also helps, as your body uses energy to make milk…Talk to your health care provider about a healthy goal for weight loss.”
   Recommendation: Replace current text with the following:
   “It is common to want to return to your previous weight and shape after having a baby. Losing weight is more complex than just nutrition and physical activity. Focus on taking care of your health by listening to your body, finding ways to be active that you enjoy, enjoying time with family and friends, and resting when you can. If you have concerns about your nutrition, talk to your healthcare provider.”
2. Physical Activity Section (page 20): “Regular exercise is important after your baby’s birth and can: …help you lose weight”
   Recommendation: Remove the bullet “help you lose weight”
3. Breastfeeding Section (page 52): “Breastfeeding helps reduce your baby’s risk of… being overweight when they are older.”
   Recommendation: Remove “or being overweight when they are older”
4. Caring for yourself: Body changes after birth (page 6-11):
   Recommendation: Consider including content about expecting and accepting your body changes in future revisions.

Supporting Evidence:

1. Breastfeeding should not be associated as a method for weight loss.

Breastfeeding is beneficial for many gestational-parental and infant health outcomes. However, there is insufficient evidence demonstrating a clear association between breastfeeding and postpartum weight loss (1,2).

We recognize that questions about postpartum weight loss are common as many individuals feel pressure to return to their previous shape and size. Weight stigma has a detrimental effect on mental health and well-being (3). Preconception, pregnant and postpartum individuals are particularly vulnerable to weight stigma, which can have a direct impact on their health and that of their offspring (4). Instead of taking a weight-centric approach, the focus should be on health promoting behaviours and helping readers identify the supports in their lives.

2. The public health field has moved away from identifying weight management as a benefit to exercise.

Historically public health used weight loss and weight maintenance messaging as an incentive for exercise, resulting in media and social messaging associating exercise and weight. However, newer evidence refutes the widely held belief that weight loss will come with increased physical activity and will result in sustained weight loss. Focusing on weight control as a benefit of exercise may increase weight stigma and decrease motivation to exercise if weight loss is not achieved or maintained (6).

There are many benefits to physical activity regardless of any impact on weight.

3. Breastfeeding is only one of a multitude of factors that is associated with future weight in children based on observational research.

Due to the risk of increasing weight stigma and the phenomenon of shaming parents (7), attention to this association should be avoided in resources designed for the public. A child’s body weight is determined by many complex factors that should not be distilled down to infant feeding practices.

Recognizing the limitations of observational research as well as the risks of weight stigma, such strong and potentially harmful conclusions should not be drawn.

4. Include content about expecting and accepting body changes.

Pregnancy and postpartum changes to body size and shape are expected and should be normalized. Public health should be challenging the unachievable societal examples and expectations for gestational parents (8,9) rather than continuing to perpetuate harmful body image messaging and weight stigma.

Stereotypes and misconceptions about obesity that perpetuate weight stigma can create an unpleasant experience for pregnant individuals living in larger bodies as they are often victims of weight stigma and feel judged for their weight and shape (10). This can lead to increased stress and depression which can have negative impacts on both the individual and fetus (11) and continue to pose a risk throughout the postpartum period, parenting and the child’s life (12).

www.odph.ca info@odph.ca @RDsPubHealthON

It is our position that weight stigma contributes to discrimination, oppression and social injustices – which are a significant public health problem that leads to health inequities. Weight bias, stigma and discrimination are independently linked to poorer mental and physical health. Public health messaging that focuses on weight and obesity contributes to weight stigma.

We urge you to please consider adopting a weight neutral approach in public health messaging and modifying the “Your guide to postpartum health and caring for your new baby” resource with the suggestions put forth in this letter. We would welcome the opportunity to collaborate with you in the future. We look forward to hearing back from you and invite you to connect with us should you wish to meet or seek further clarification.

Sincerely,

Amy MacDonald, Chair                  Paula Ross, Chair

Body Diversity and Health Equity Working Group      Family Health Nutrition Advisory Group amacdonald@hpph.ca                 rossp@phsd.ca

Laura Abbasi ODPH Co-chair

executive@odph.ca

References:

1. He X, Zhu M, Hu C, Tao X, Li Y, Wang Q, Liu Y. Breast-feeding and postpartum weight retention: a systematic review and meta-analysis. Public Health Nutr. 2015 Dec;18(18):3308-16. doi: 10.1017/S1368980015000828.
2. Neville CE, McKinley MC, Holmes VA, Spence D, Woodside JV. The relationship between breastfeeding and postpartum weight change–a systematic review and critical evaluation. Int J Obes (Lond). 2014 Apr;38(4):577-90. doi: 10.1038/ijo.2013.132.
3. Ontario Dietitians in Public Health. Health and Wellbeing Philosophy and Approach to Weight: Position Statement. 2018. Update forthcoming. https://www.odph.ca/addressing-weight-bias-resources
4. Hill B, Incollingo Rodriguez AC. Weight Stigma across the Preconception, Pregnancy, and Postpartum Periods: A Narrative Review and Conceptual Model. Semin Reprod Med. 2020 Nov;38(6):414-422. doi: 10.1055/s-0041- 1723775. Epub 2021 Mar 16. PMID: 33728621.
5. Cox CE. Role of Physical Activity for Weight Loss and Weight Maintenance. Diabetes Spectr. 2017 Aug;30(3):157-160. doi: 10.2337/ds17-0013.
6. Myre M, Glenn NM & Berry TR (2021) Exploring the impact of physical activity-related weight stigma among women with self-identified obesity, Qualitative Research in Sport, Exercise and Health, 13:4, 586-603, doiI: 10.1080/2159676X.2020.1751690.
7. Gorlick JC, Gorman CV, Weeks HM, Pearlman AT, Schvey NA, Bauer KW. “I Feel Like Less of a Mom”: Experiences of Weight Stigma by Association among Mothers of Children with Overweight and Obesity. Child Obes. 2021 Jan;17(1):68-75. doi: 10.1089/chi.2020.0199.
8. Incollingo Rodriguez AC, Dunkel Schetter C, Brewis A, Tomiyama AJ. The psychological burden of baby weight: Pregnancy, weight stigma, and maternal health. Social Science & Medicine, 2019, 235. DOI: 10.1016/j.socscimed.2019.112401.
9. Tang L, Tiggemann M, Haines J. #Fitmom: an experimental investigation of the effect of social media on body dissatisfaction and eating and physical activity intentions, attitudes, and behaviours among postpartum mothers. BMC Pregnancy Childbirth. 2022 Oct 12;22(1):766. doi: 10.1186/s12884-022-05089-w.
10. LaMarre, A., Rice, C., Cook, K., & Friedman, M. (2020). Fat reproductive justice: Navigating the boundaries of reproductive health care. Journal of Social Issues, 0(0), 1–25. https://doi.org/10.1111/josi.12371
11. Cook, K., LaMarre, A., Rice, C. & Friedman, M. (2019). “This isn’t a high-risk body”: Reframing Risk and Reducing Weight Stigma in Midwifery Practice. Canadian Journal of Midwifery Research and Practice, 18 (1), 26-34. https://www.cjmrp.com/files/v18n1-weight-stigma-and-pregnancy.pdf
12. Gorlick JC, Gorman CV, Weeks HM, Pearlman AT, Schvey NA, Bauer KW. “I Feel Like Less of a Mom”: Experiences of Weight Stigma by Association among Mothers of Children with Overweight and Obesity. Child Obes. 2021 Jan;17(1):68-75. doi: 10.1089/chi.2020.0199. Epub 2020 Dec 29. PMID: 33373542; PMCID: PMC7815062.
13. Public Health Agency of Canada. (2019). Addressing stigma: Towards a more inclusive health system. The Chief Public Health Officer’s Report on the State of Public Health In Canada. (Pub: 190383). Government of Canada. https://www.canada.ca/en/public-health/corporate/publications/chief-public-health-officer-reports-state-public- health-canada/addressing-stigma-toward-more-inclusive-health-system.html
14. Hambleton J, McColl K, Raoufi S, Manowiec E. (Sept 2019). Weight Bias and Public Health: Review of the Evidence. Toronto Public Health.

Obesity Canada

2-126 Li Ka Shing Centre for Health Research Innovation University of Alberta

Edmonton, AB T6G2E1

We represent Ontario Dietitians in Public Health (ODPH), the independent and official voice of Registered Dietitians working in Ontario’s public health system. We advocate for system approaches that mitigate harm while promoting health equity across all populations. One of our focuses is shifting the paradigm from a weight-centric approach to a weight-inclusive approach, which aims to address the systemic injustices that result from weight bias, stigma, and discrimination.

We are writing to express our deep concern with Obesity Canada’s public congratulatory blog post on January 10, 2023 regarding the release of the 2023 American Academy of Pediatrics Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents with Obesity (AAP CPG). We urge Obesity Canada to not model the American recommendations when developing updated Canadian Clinical Practice Guidelines (CPG) for pediatric populations. The treatment recommendations in the AAP CPG are troubling, imposing possible mental, physical, and psychological harms to children and youth. We call on Obesity Canada to consider a weight-inclusive approach to care to better safeguard the children and families of our country.

We ask Obesity Canada’s Steering Committee to consider the following recommendations to inform upcoming guidelines:

1. Include studies that explore improvements to health independent of changes in weight status.

Healthcare interventions centered solely around weight neglect to acknowledge the decades of literature showing attempted weight loss results in weight regain 80-95% of the time, making long-term, sustained weight loss the exception, not the norm.^1,2 These weight-centric approaches also fail to acknowledge the emerging body of evidence demonstrating the harms of repeated weight-loss attempts, otherwise known as weight cycling. These harms include higher mortality of all causes including cardiovascular disease, poor cardiometabolic measures such as hypertension, dyslipidemia, and insulin resistance, increased risk of weight regain, and increased risk of disordered eating.^3,4 Further, growing evidence demonstrates successful improvements to health (i.e., blood pressure, cholesterol, cardiovascular fitness, mobility) can be achieved independent of changes to weight.⁴

Promoting health and well-being among children and youth should go beyond weight as an indicator. Instead, care should focus on fostering positive relationships with food, movement, body, and mind to encourage lifelong health behaviors regardless of how their growing bodies develop. The AAP CPG explicitly excluded studies that focused on health outcomes, rather than weight itself.⁵ We urge Obesity Canada’s Steering Committee to consider the benefits of including a wider range of evidence to promote healthy outcomes among children and youth,

avoiding what could be perceived as an unethical oversight.

2. Apply a comprehensive health equity lens, giving consideration to the social determinants of health.

Weight and body size are known to be complex and multifactorial, influenced by socio- ecological, genetic, and environmental factors. This includes, but is not limited to, genetics, racial or ethnic inequities, age, sex, living conditions, family history, trauma, income, culture, eating and physical activity habits, sleep, physical location, medical conditions, medications, and stress.⁶ Many of these are beyond individual control, and directly contribute to health inequities.⁷

Despite the established understanding of this complexity, clinical guidelines such as the recently released AAP CPG focus heavily on nutrition and physical activity behaviours as the primary means to address weight management.⁵ Writing guidelines that acknowledge the social determinants of health, but then go on to recommend solely individual solutions can worsen care outcomes and access.^6,8 Clinical practice guidelines should be created to support healthcare providers in doing comprehensive assessment that include addressing social challenges.⁹

We strongly urge Obesity Canada to adopt a health equity lens when formulating clinical practice guidelines, thereby better equipping health care professionals to assist individuals and families contending with systemic disparities. This holistic approach will not only lead to more inclusive and effective care but also contribute to the dismantling of inequities ingrained within our healthcare systems.

3. Endorse that all healthcare professionals participate in training and professional development in weight bias, stigma, and discrimination.

Frequently, practice guidelines maintain the notion of individual responsibility for health and weight control.⁹ This reinforces the cultural and societal preoccupations with weight, and places the blame and shame on individuals in larger bodies. As a result, people living in larger bodies often experience negative attitudes, assumptions, judgments, and even treatment as a result of these preconceived notions linked to their body weight, shape, or size. Increased childhood and adolescence experiences of weight bias, stigma and discrimination may lead to negative relationships with food and their body, deterring youth from enjoying and maintaining physical activity and healthy eating behaviors.¹⁰

Exploring how weight bias, stigma, and discrimination affects health care professionals, both consciously and subconsciously, is an essential step towards providing inclusive and equitable treatment to all. The AAP CPG provides surface level recommendations pertaining to weight bias, stigma, and discrimination, which disregards the impacts of these harms.⁵

We applaud Obesity Canada for their commendable effort by dedicating a chapter to address weight bias within the Clinical Practice Guidelines for Adults.¹¹ Our hope is that these insights and recommendations find their way into the forthcoming pediatric guidelines. Creating a healthcare system that is free of biases, stigma, and discrimination requires a multi-pronged approach where all players work together. We look forward to seeing further comprehensive projects that take a stance against weight bias, stigma and discrimination and that continue to include recommendations for practitioners to explore weight-inclusive evidence.

4. Recommend that healthcare professionals screen all clients, regardless of body size, for signs and symptoms of disordered eating and eating disorders.

Disordered eating and eating disorders can have severe consequences to mental and physical health, including cardiovascular, endocrine, gastrointestinal, and skeletal disorders, osteoporosis, dental problems, nutritional deficiencies, psychiatric disorders, and substance use.⁶ Across Canada, youth are experiencing a mental health crisis and growing eating disorder rates. In Ontario, 46% of students in grades 7-12 reported being preoccupied about their weight or body shape.¹² Similar to weight and body size, the existence of eating disorders is highly stigmatized as well. Contrary to common assumptions, less than 6% of people with eating disorders are classified as “underweight,” whereas 37-41% of people presenting for eating disorder treatment fall within the “overweight” or “obese” BMI classifications.³ This reinforces the notion that weight, BMI, and body size are poor indicators to guide health assessments and treatment.

The AAP CPG failed to acknowledge the risk of eating disorders among youth, only recommending screening for depression over 12 years of age.⁵ Children and youth living in larger bodies have likely experienced weight bias, stigma, and discrimination at the time of assessment, and have possibly had weight loss attempts. There is also a high prevalence of disordered eating and eating disorders among individuals seeking bariatric surgery; lifetime binge eating disorder prevalence rates range from 13-50%, compared to only a 4.5% lifetime prevalence among the general population.¹³ Incorporating trauma-informed, client-centred practices, as well as comprehensive disordered eating screening tools can significantly reduce harms for pediatric clients (e.g., Ottawa Disordered Eating Screen for Youth).¹⁴

5. Exclude pharmaceutical and surgical intervention recommendations for the pediatric population until further long-term research on safety is established.

The AAP CPG recommendation to consider invasive and metabolically altering surgery among growing, developing children and youth is especially alarming. Not only are short- and long-term harms largely unknown, capacity to understand the full extent of bariatric surgery may be limited in youth.¹⁵ Complications observed in adults, including malnutrition, increased risk of alcohol use disorder, ulcers, hernias, and the potential need for subsequent surgeries, pose a greater risk among young, developing bodies.¹⁶ This physiologically-altering surgery has lifelong implications, and the “success” of surgery later in adulthood could be impacted by factors like trauma, socioeconomic status, and living conditions that are largely unpredictable in children.¹⁷

As described in a recent AMA Journal of Ethics commentary:

“Pharmaceuticals have been described as the prescription for fat people of what is diagnosed as disordered in thin people …skipping meals (anorectics), diet pills (pharmacotherapeutics themselves), laxatives (orlistat), and vomiting (a common glucagon-like peptide 1-related adverse effect).”³

Considering the lack of data to support long-term safety outcomes, and the risk of eating disorder onset during adolescence, we urge Obesity Canada to consider the risks that these interventions (both surgical and pharmaceutical) pose among youth.

Comprehensive, evidence-informed guidelines that are sensitive to existing weight bias, stigma, and discrimination can help promote equitable and weight-inclusive healthcare. As a community of concerned healthcare professionals, we recommend that Obesity Canada and the appointed Steering Committee consider the above discussion and recommendations in the upcoming Canadian Pediatric CPG. We welcome the opportunity to discuss these recommendations and look forward to reviewing the guidelines anticipated for release in 2023.

Sincerely,

Laura Abbasi, Co-Chair Year 1
Ontario Dietitians in Public Health

Amy MacDonald, Chair 
Body Diversity and Health Equity Working Group

References

1. Mann, T., Tomiyama, J. A., Westling, E., Lew, A.-M., Samuels, B., & Chatman, J. (2007). Medicare’s search for effective obesity treatments. American Psychologist, 62(3), 220-223. https://escholarship.org/uc/item/2811g3r3
2. Chastain, R. (2021, November). Who Says Dieting Fails Most Of The Time? Weight and Healthcare. https://weightandhealthcare.substack.com/p/who-says-dieting-fails-the- majority
3. Floegel-Shetty, A. (2023). Should pharmaceuticals be used as weight loss interventions for adolescents classified as obese by BMI? AMA Journal of Ethics, 25(7), E478-495. https://journalofethics.ama-assn.org/article/should-pharmaceuticals-be-used-weight-loss- interventions-adolescents-classified-obese-bmi/2023-07
4. Bacon, L., & Aphramor, L. (2011). Weight science: evaluating the evidence for a paradigm shift. Nutrition Journal, 10(9). https://nutritionj.biomedcentral.com/articles/10.1186/1475-2891-10-9
5. Hampl SE, Hassink SG, Skinner AC, et al. Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents With Obesity. Pediatrics. 2023;151(2): e2022060640
6. Weight Inclusive Nutrition and Dietetics (2023). AAP Guidelines Response Toolkit — Weight Inclusive Nutrition and Dietetics. https://www.weightinclusivenutrition.com/aap- response-project-toolkit
7. Government of Canada. (2023, June). Social determinants of health and health inequalities. Canada.ca. Retrieved September 28, 2023, from https://www.canada.ca/en/public-health/services/health-promotion/population- health/what-determines-health.html
8. Puhl, R.M. and Heuer, C.A. (2009), The Stigma of Obesity: A Review and Update. Obesity, 17: 941-964. https://doi.org/10.1038/oby.2008.636
9. Andermann, A., & CLEAR Collaboration (2016). Taking action on the social determinants of health in clinical practice: a framework for health professionals. CMAJ, 188(17-18), E474–E483. https://doi.org/10.1503/cmaj.160177
10. Haqq, A. M., Kebbe, M., Tan, Q., Manco, M., & Salas, X. R. (2021). Complexity and Stigma of Pediatric Obesity. Childhood obesity (Print), 17(4), 229–240. https://doi.org/10.1089/chi.2021.0003
11. Kirk SFL, Ramos Salas X, Alberga AS, Russell-Mayhew S. Canadian Adult Obesity Clinical Practice Guidelines: Reducing Weight Bias in Obesity Management, Practice and Policy. Available from: https://obesitycanada.ca/guidelines/weightbias. Accessed September 14, 2023.
12. Boak, A., Elton-Marshall, T., & Hamilton, H.A. (2022). The well-being of Ontario students: Findings from the 2021 Ontario Student Drug Use and Health Survey (OSDUHS). Toronto, ON: Centre for Addiction and Mental Health.
13. Devlin, M.J., King, W.C., Kalarchian, M.A., White, G.E., Marcus, M.D., Garcia, L., Yanovski, S.Z., & Mitchell, J.E. (2016). Eating pathology and experience and weight loss in a prospective study of bariatric surgery patients: 3 year-follow up. International Journal of Eating Disorders, 49(12), 1058-1067.
14. Obeid, N., Norris, M., Buchholz, A., Hadjiyannakis, S., Spettigue, W., Flament, M., Henderson, K., & Goldfield, G. (2019). Development of the Ottawa Disordered Eating Screen for Youth: The ODES-Y. Journal of Pediatrics, 215, 209-215. https://www.jpeds.com/article/S0022-3476(19)31002-9/fulltext
15. Rana Halloun, Ram Weiss; Bariatric Surgery in Adolescents with Obesity: Long-Term Perspectives and Potential Alternatives. Horm Res Paediatr 21 June 2022; 95 (2): 193–203. https://doi.org/10.1159/000520810
16. Shiau, J. & Biertho, L. (2020). Canadian Adult Obesity Clinical Practice Guidelines: Bariatric Surgery: Postoperative Management. Downloaded from: https://obesitycanada.ca/guidelines/postop. Accessed September 5, 2023.
17. Fox, M. (2021, May). Social determinants of health and surgery: An overview | The Bulletin. Bulletin of the American College of Surgeons. Retrieved September 28, 2023, from https://bulletin.facs.org/2021/05/social-determinants-of-health-and-surgery-an-overview/