Canadian Association of Occupational Therapists

Professional Issue Forum on

Obesity and Healthy Occupation

Whitehorse, Yukon CAOT Conference July 2008

Agenda

8:30  Welcome – Donna Klaiman

8:35  Introductions-  Mary Forhan powerpoint presentation document

8:45- 9:05   Setting the context – Kim Raine document

9:10-9:35    Medical Aspects of Obesity – Arya Sharma powerpoint presentation

9:35-10:00  Providing health services- Gaye Hanson powerpoint presentation

10:00-10:10   Health Break

10:15-10:45  Enabling healthy occupation - Mary Forhan

10:45-11:20 Comments from Madeleine Dion Stout and audience

11:20-11:25 Evaluation

Bios for CAOT 2008 Conference
Madeleine Dion Stout
With each step of her career, Madeleine Dion Stout has advanced the cause of providing inclusive and accessible health care for Aboriginal people. She will share her teaching and wisdom as the keynote speaker at the 2008 conference. CAOT is privileged to have Madeleine address the challenges of providing health care to northern communities.

For over three decades, Madeleine’s diverse career has provided her with an immense understanding and knowledge of the complexities of providing quality health care in the north. For many years, she worked for the Medical Services Branch of Health Canada and has been a member of dozens of First Nations health committees and task forces. She will provide delegates with her perspective on the initiatives and mechanisms that are needed to improve health care and healthy living for Aboriginal people.

Born and raised on the Kehewin First Nation in Alberta, Madeleine graduated as a registered nurse from the Edmonton General Hospital and later earned a Bachelor’s degree in nursing with distinction from the University of Lethbridge. With a passion for learning, Madeleine continued with her education and in 1993 received her Master’s degree in international affairs from the Norman Paterson School of International Affairs at Carleton University. She was a professor in Canadian studies and founding director of the Carleton Centre for Aboriginal Education, Research and Culture.

During her tenure with Health and Welfare Canada, Medical Services Branch from 1969 to 1986, Madeleine was an influential advisor, including her work as a public health nurse in two communities, director of the Indian and Inuit Health Careers Program in Ottawa, and most notably as special advisor to the Minister of Health and Welfare. Madeleine has served on several aboriginal and non-aboriginal boards and committees including the B.C. Women’s Health Research Institute and the Aboriginal Women’s Health and Healing Research Group. She was also president of the Aboriginal Nurses Association of Canada and member of the National Forum on Health.

Madeleine has been widely recognized for her contributions and leadership to aboriginal health care through the numerous awards she has received, including the Assiniwkamik Award from the Aboriginal Nurses Association of Canada, a Distinguished Alumni Award by the University of Lethbridge and an Honorary Doctorate of Laws by the University of British Columbia. Madeleine has also been selected to receive the Canadian Nurses Association (CNA) Centennial Award, honouring 100 exceptional registered nurses in Canada.

Since 2003, Madeleine has been self-employed as president of Dion Stout Reflections Inc. where she continues to work as a researcher, writer and lecturer on aboriginal health and health care paying particular attention to aboriginal children and women. In August 2007, Madeleine was appointed to the Mental Health Commission of Canada as an inaugural member and vice-chair of the Board of Directors. The goal of the Mental Health Commission is to help bring into being an integrated mental health system that places people living with mental illness at its centre.

We are honoured to have Madeleine Dion Stout, clearly a remarkable woman of vision and wisdom, as this year’s keynote speaker. We invite you to share in her experience and wealth of knowledge as she addresses delegates at the conference opening ceremony.

Mary Forhan
Mary is an occupational therapist with clinical experience in all areas of rehabilitation with special emphasis on mental illness, eating disorders and obesity management. Mary is a PhD candidate in the School of Rehabilitation Science at McMaster University and a strategic training fellow in rehabilitation research. Her study is focused on exploring the impact of obesity on occupational performance and participation. Mary has received funding in the form of a training award and doctoral research award from the Canadian Institute of Health Research and the Canadian Occupational Therapy Foundation. Mary is a member of the Canadian Obesity Network and strives to raise the profile of occupational therapy in the area of obesity.

Gaye Hanson
Gaye Hanson is an Aboriginal nurse leader who has remained committed to health and wellbeing of Aboriginal people throughout a diverse career. As the former President of Aboriginal Nurses Association of Canada and member of national groups, she draws on her practice experience to be a powerful voice for the interests of  people living in rural, remote and Aboriginal Canada. She contributed innovative policy ideas and community driven solutions in implementing health transfer and self government. As a consultant and researcher, she has worked to strengthen health systems in underserved regions. As a public speaker and author, she has advanced the areas of mental health and healing; health leadership; palliative care; cultural competence; health human resources; and quality worklife.

Gaye is the President of Hanson and Associates, a management consulting company based in Whitehorse, Yukon.  She has been consulting since 1994 and has a wide ranging practice in health, social and economic development. She holds degrees in nursing and public administration (Masters).  She is a qualified midwife and of Cree ancestry from northern Manitoba.

Kim Raine
Dr. Kim Raine is currently Director and Professor of the Centre for Health Promotion Studies, School of Public Health, University of Alberta, Edmonton. She received her PhD from Dalhousie University in Halifax. She is a registered dietitian.

Dr. Raine’s research focuses on social determinants of health, qualitative and participatory methodologies in community health research, and theoretical contributions in a social change based approach to health promotion. Since 1999 she has been a Health Scholar (now Senior Scholar) of the Alberta Heritage Foundation for Medical Research. She is also a CIHR/HSFC Applied Public Health Chair. In 2001 she was named the recipient of the University of Alberta’s Martha Cook Piper Research Award (social sciences) for outstanding accomplishment and demonstrated promise as a researcher. She is the leader of POWER (Promotion of Optimal Weights through Ecological Research), a $1.4 million New Emerging Team grant from CIHR and the Heart and Stroke Foundation of Canada. She recently published “Overweight and Obesity in Canada: A Population Health Perspective” for the Canadian Population Health Initiative of CIHI. She is also a Director of Healthy Alberta Communities, a community-based project to prevent obesity and chronic diseases. Dr. Raine serves on the Scientific Council of the Danone Institute of Canada. She hasn’t decided if she wants to be a researcher or an activist when she grows up.

Dr. Raine is the proud mother of two wonderful sons, Corey - age 17 and Dustin – age 13. She has completed 14 marathons and one Ironman triathlon. She doesn’t do anything that isn’t fun!

Arya M. Sharma
Arya M. Sharma is Professor of Medicine and Chair of Obesity Research and Management at the University of Alberta. He is also the Medical Director of the Capital Health Regional Weight Wise Program and the Scientific Director of the federally-funded Canadian Obesity Network. Past appointments include Canada Research Chair (Tier 1) in Cardiovascular Obesity Research and Management and Professor of Medicine at the Michael G. DeGroote School of Medicine at McMaster University, Hamilton, Ontario, Canada and Director of The Centre for Cardiovascular Obesity Research and Management at the Hamilton General Hospital.  Until 2002, he was Professor of Medicine, Department of Nephrology and Hypertension, at the Franz-Volhard-Klinik–Charité in Berlin, Germany.  His research focuses on the environmental and biological causes of obesity and an evidence-based approach to managing obese patients. He is also working on the development of novel interventions for treating obese patients and people with a propensity for obesity.  Scientific associations of which he is a member include the Canadian, American and International Societies of Hypertension and is a fellow of the Council for High Blood Pressure Research of the American Heart Association.  Dr. Sharma is on the editorial boards of several journals and has authored or coauthored more than 230 scientific articles.  He has also lectured widely on the etiology and management of hypertension, obesity, and related cardiovascular disorders.  Dr. Sharma graduated from the Free University Berlin, Germany and holds postdoctoral degrees in internal medicine and nephrology.

Executive Summary Report

(adapted from PIF Report by Mary Forhan)

The Canadian Association of occupational Therapists’ (CAOT) Professional Issues Forum on Obesity and Healthy Occupation was held at Yukon College on June 14, 2008 from 8:30-11:30am. The purpose of the forum was to hear about perspectives of obesity prevention, treatment and management in order to guide future directions in this area for CAOT.

Format

A panel of four presenters was followed by a summary of the presentations. Each panel member provided a presentation that ranged from 20 minutes to 45 minutes. There was a need to spend time on defining obesity, causes and consequences along with the spectrum of treatment options due to the limited knowledge in these areas by occupational therapists in general. Despite the fact that this took time away from an interactive discussion, it was determined by the facilitator that this was necessary in order to inform occupational therapists of the multidimensional nature of obesity. Feedback for the session reflected the limited time left for audience participation. The session went 15 minutes over time in order to provide an opportunity for participants to identify key components to include in the CAOT position statement on obesity. Delegates interested in participating in an ongoing discussion were invited to leave contact information with Donna Klaiman, CAOT Director of Policy. There were 30-35 participants throughout the forum. Mary Forhan was the facilitator for the forum. A discussion paper was posted in preparation for the forum and is published on the CAOT website http://www.caot.ca/default.asp?pageid=2242

Presenters (In order of presentation)

Dr. Kim Raine, Researcher and Director of the Centre for Health Promotion Studies, University of Alberta 
Dr. Arya Sharma, Professor of Medicine and Chair of Obesity Research and Management at the University of Alberta
Ms. Gaye Hanson, A nurse that practices in Whitehorse
Ms. Mary Forhan, McMaster University, PhD candidate
Dr. Madeline Dion-Stout, Health professional and advocate, she keeps Aboriginal perspectives and aspirations central to Aboriginal health and healing.

Objectives of the Forum

• Understand the health status, cultural, social and political issues related to obesity and opportunities for healthy occupation
• Understand the impact of limited access to occupational therapy services for populations with obesity issues
• Identify issues that impede access to occupational therapy services
• Identify strategies to facilitate access to opportunities for participation in healthy occupations
• Inform the development of a position statement and strategic plan to improve access to occupational therapy services for populations with obesity issues

Topics from this meeting are defined by the following themes:

Obesity Prevention and Public Health Policy

Content and discussions in this area target opportunities and initiatives that reduce the risk for individuals and populations to develop obesity. It was recognized by delegates at this meeting that all persons are at risk for developing obesity due to the toxic environments in which we live, work, learn and play. This includes food insecurity for remote and impoverished communities, reduced or limited opportunities to be physically active as a result of access to safe and appropriate play and leisure space, urban sprawl and a reliance on technology for mobility, leisure and communication. 

Opportunities to influence policies for the marketing of energy-dense, low nutrient foods to children and adults were identified. Initiatives that target school, work place, community, local, regional and federal policies exist in which occupational therapists have the potential to be active. It was recognized at this meeting that prevention for the development of obesity is important to promote healthy occupations and is done in the spirit of promoting health and wellness for all people regardless of size/shape.

Occupational therapists support public health messages that promote inclusiveness and do not marginalize obese persons with messages of blame and personal responsibility. It is recognized that messages and initiatives need to be multifaceted to have the potential to be effective in promoting healthy active living. It is also recognized that messages and initiatives must be culturally sensitive and include images and content relevant to populations including women, Aboriginal and First Nations people and people of all body sizes and shapes.

The prevention of obesity is a complex public health problem that requires social action. A social and rights based approach to the prevention of obesity was presented to the delegates.

Obesity was emphasized as a public health issue and not an issue that results from a lack of personal control. The role of the environment was strongly emphasized as contributing to the increasing rates of overweight and obesity in Canadian society. Environments in which infants, children and adults participate in everyday activities are described as toxic. The toxicity arises from the design of the spaces in which we work, live, learn and play, marketing strategies promoting unhealthy food choices, and limited access to healthy food.

Delegates were encouraged to consider ways in which the profession of occupational therapy could influence policy targeting the design and development of places where people work, play, live and learn. Physical activity is limited by safe and accessible places in which to participate in healthy, active living. Creating communities that have dedicated spaces for walking, rolling or cycling will reduce car use and promote physical activity in everyday living. Participation on committees that promote environments for active living is in keeping with the professions perspective of the role of the environment in enabling occupation.

Access to healthy food choices is another area in which the profession can contribute to the prevention of obesity in children and adults. Creating opportunities for communities to have access to healthy food is an important activity for the prevention of obesity. This includes education about healthy eating according to Canada’s Food Guide, access to resources to support the procurement of healthy foods and promoting skills for food purchases and meal preparations. Initiatives at a Federal, Provincial and local level should include input from the profession.


Obesity Treatment

 Despite obesity prevention strategies, there will always be people with obesity. Emphasis on evidence based obesity treatment continues to be as important as preventing obesity. Obesity was described as a chronic health condition or illness. As with other chronic illnesses, obesity is multidimensional and requires a comprehensive approach to management.

It was recognized by the participants that obesity is a disease that warrants the intensity of consideration given to all chronic illnesses. The complexity of obesity as a multidimensional disease that is caused by biopsychosocial factors that have an impact on body mechanics, mental health, microbiology and money was supported. A classification system proposed as the Edmonton Obesity Classification system was used to identify the functional and participatory impact of obesity that guides the need for interventions that target obesity. The classification was proposed to have 4 stages with stages 2, 3 and 4 having a role for occupational therapy. It is at these stages that persons with obesity experience challenges in the participation in activities of everyday living. Challenges in the areas of self-care and mobility are noted to have an impact on participation in obesity treatment. Occupational therapy services are needed to support clients to meet the demands required for obesity treatment including meal frequency, meal adaptation and participation in exercise. Research in the area of the impact of obesity on participation in daily living is limited. The role of occupational therapy in obesity treatment appears obvious however there is no empirical evidence to support the promotion of occupational therapy services on obesity treatment teams.

The profession is in a position to identify links between occupational therapy perspectives of health and wellness and the role that occupational therapy has to play in enabling participation in healthy occupations including active living and healthy eating.
In addition to lifestyle modification programs, surgery is becoming more accepted particularly for treatment of obesity in the rages of stage 3 and 4 of the Edmonton classification system or class III in the more traditional classification system that uses Body Mass Index to diagnose obesity. As in other surgical programs, occupational therapy has a role in pre-surgical and post-surgical interventions that contribute to the overall success of the procedure. Clients who are preparing for gastric bypass or banding procedures are required to make changes to their daily routine of eating and physical activity. Post surgical recovery is also an issue. Clients presenting for surgery may require assistive devices and hospital furniture to accommodate their body weight and size. The profession has the potential to participate in pre-surgical education and support and post-surgical recovery and realization of occupational potential.

 Working in the area of obesity treatment requires competencies in addition to those expected by the professions regulatory bodies. Additional knowledge about the complexities of obesity and evidence based treatments are essential. Dr. Sharma stressed in his presentation that it is unethical to make recommendations to change the obesity experience unless the professional is prepared to work with a client for the long term. Obesity, perceived as a chronic illness, requires a continuum of interventions and supports. Professionals, including occupational therapists, need to be able to provide appropriate services that meet the clients’ needs and be in a position to make referrals to services in situations that are better suited for the client. Dr. Sharma went as far to say that it is unethical to tell a person to lose weight if you are not prepared to support the individual to find an effective way to do so.

 Despite effective obesity treatments, some individuals will continue to live with obesity. Management of obesity is the third area of discussion in this forum.

Obesity Management

 Living with obesity is an area that has not been studied in depth. The delegates were informed about the challenges in the social and build environment that are attributed to obesity. These are the environments in which persons with obesity must go about their daily activities. The profession has a long history of enabling occupation for populations with chronic illness. The opportunities to enable occupation for persons with obesity are prolific and in need of attention.

 Participation in occupations has long been associated with health and wellness. Therefore it is anticipated that enabling participation in occupation for persons with obesity will contribute to the health and well being of this population.

 Efforts to create accessible environments for obese persons are one way to enable occupation. Opportunities to influence policy on accessibility to include obesity are one area for the profession to get involved. Appropriate seating, space and room for larger size mobility devices are other examples.

 Attitudes of employers, educators and the general public are known to be barriers to the occupational realization for persons with obesity. Advocacy for persons with obesity to have access to occupations and realize their potential is needed.

 The delegates heard stories from the panel members both personal and professional about the deprivation experienced by persons with obesity as a result of the stigma attached to obesity. Supporting individuals to participate to their full potential in meaningful occupation is important regardless of the fact the some people may or may not be seeking treatment for obesity. As was heard in the presentations, even with successful obesity treatment, some individuals will remain obese.

Cultural Context

 This forum was part of the CAOT conference that had a theme of Aboriginal health perspectives throughout several presentations, panels and forums. Aboriginal  people have a 2.5 times higher rate of obesity than the rest of the North American populations. Aboriginal people  are concerned about the consequences of obesity on the health and wellness of its communities and the lack of appropriate obesity prevention, treatment and management interventions currently available.

 Cultural competence is defined as the ability to relate to and function in the community of people being served and having an awareness of the community’s cultural ways. How obesity fits or is viewed in the Aboriginal communities is not known. How are the values and beliefs about occupation, wellness and health from an Aboriginal perspective integrated into obesity prevention, treatment and management?

Cultural safety is a result of the building of a bridge from dehumanizing to humanizing experiences. This applies to obesity in terms of the way in which obese persons are treated and viewed in North American societies. Occupational therapy has a role to bridge this gap. Humanize the experience of living and realizing occupation as an obese person.

Remote areas of the country will require interventions that build on the food, professional and built environmental resources that are available. Balanced diets and exercise are more challenging in remote areas of Canada that have limited access to fresh fruits and vegetables or safe places to by physically active outdoors. Future initiatives need to target policies that improve access to foods that are nutritious and for places of recreation that promote active living. All of these initiatives must consider the cultural context of remote communities and the associated values of obesity, health and wellness.


Key Points

Delegates were asked to identify key priorities for the profession related to obesity and healthy occupation. The following were identified at the end of the forum:

• Obesity to be considered within the chronic disease/illness paradigm.
• Include obesity in efforts to promote inclusivity in all healthcare and community settings.
• Explore habits related to healthy occupations in context (i.e. environmental, cultural, personal, other health issues).
• Enable activity.
• Address the stigma of obesity within the profession through research, education and reflective practice.
• Include obesity competencies in professional education.
• Address obesity across the obesity spectrum (stage 1-4 or class I-III) and the lifespan.
• Recognize that the profession has the skills and perspective to contribute to research and clinical practice in the areas of obesity prevention, treatment and management.
• Advocate for the profession to be represented in areas of obesity research, policy, advocacy and healthcare teams.

Recommendations

• Develop a position statement on obesity that reflects obesity as a complex, chronic illness and covers dimensions of prevention, treatment and management
• Identify delegates within the profession currently contributing to the obesity field and provide a means of collaborating to increase the profile of the profession in the area of obesity
• Collaborate with other disciplines in the areas of research and clinical practice

A wide selection of products, great offers and more. THE CAOT STORE