Heather Bradford

We also know if you look at trends of discrimination in the US are discrimination against someone because of their race, or their sexuality or gender identity have all decreased in the last two decades, and weight bias has not changed. Wow. That to me is super, super important to just call out that we we really need to be talking about this.

Tanya Tringali

Hey, everyone, I'm your midwife Tanya Tringali. Welcome to the mother wit podcast, a show about the issues we healthcare consumers and providers face every day as we interact with the medical system. We'll talk about its blind spots, shortcomings, and share strategies we can use to feel seen and heard no matter which side of the table we sit on.

Tanya Tringali

My guests today are Heather Bradford and Sydney Olson. Heather Bradford, she her pronouns is a midwife educator whose goal is to expand and diversify the midwifery and Women's Health Nurse Practitioner workforces. She is super passionate about addressing inequities within health care and improving perinatal outcomes. She is the Assistant Program Director for the nurse midwife, Women's Health Nurse Practitioner program at Georgetown University. And she has provided full scope midwifery care for over 20 years. So full scope means that she does all the things not just births. That includes GYN primary care, literally all the things. She does this for the lucky people of Washington State. She has a laundry list of accomplishments including having played a pivotal role in helping nurse midwives achieve equitable Medicaid reimbursement for the services we provide. She has published numerous articles in peer reviewed journals. She's written many chapters in midwifery and women's health textbooks, and she is a hop skip and a jump away from earning her PhD at Vanderbilt University. And I'm sure you've already guessed it, her dissertation was on weight bias among midwives. We also have here today signee Olson they them pronouns. signi is a midwife and nurse practitioner in Washington, DC. She's also full time faculty at Georgetown University's nurse midwife, Women's Health Nurse Practitioner program. They have degrees in nursing, political science and community development and enjoy focusing their time on the intersection of these topics. Their doctoral work focused on ways to increase eating disorder screening within the outpatient setting, and how weight stigma may negatively impact clinical outcomes. So you can see why they're on together. Sydney worked in IVF and fertility for over a decade. But now they own their own clinical practice focusing on counseling and education regarding reproductive endocrinology and the fertility treatment process. Their specialties include impact of trauma on the body and care for patients with disordered eating patterns. They have developed national curriculum guidelines on gender affirming hormone and weight neutral care for medical and nursing education programs. As you can see, individual midwives have such diverse interests, and we have the ability to contribute in so many different ways. So Heather reached out to me through my podcast survey listeners, please take a moment to complete it. It is in the show notes. Anyone interested in being a guest on the show, this is how you make your pitch. Anyway, she wanted to talk about weight bias among health care providers. And as you can see, it is both her passion and a huge part of her academic work. So when I reached out to say yes, please come on, let's have this discussion. She said signee needs to come along with me too. So I'm so excited to have both of them. I think today's topic is one that many listeners are going to learn from so that's providers and healthcare consumers alike. I have no doubt that I'm going to learn a lot. And I just want to start by saying that I come to this conversation prepared to challenge my own deeply held beliefs about health and wellness, and how that pertains to weight, weight bias stigma, and particularly as it pertains to ideas around weight loss. Welcome, Heather and Signey.

Signey Olson

Yeah, excited to be here.

Heather Bradford

Great. Thank you. Thanks for having us.

Tanya Tringali

Okay. I think in order to get started, we should just like lay the framework I clearly have introduced who you are and what you do and all your wonderful accomplishments. But if you could just take a moment to kind of connect the dots for people in the sense that what is it that brought you to midwifery? But then how did it end up here? How did it end up that this becomes your focus or your academic interest?

Signey Olson

Yeah, so I'll take that one first. So I worked in IVF and reproductive endocrinology in my nursing career and I loved it, I knew I wanted to be a midwife. And so I completed my training, I had an amazing clinical experience and, you know, really envisioned myself in the role of someone who attended birth and clinic work and etc. And then right before I graduated, I was presented with the opportunity to essentially build my own practice within an IVF practice, which is very different than what I do now. But it gave me space to have really specialized care for the people that I I interact with, and my GYN visits got to be longer, my preconception visits got to be longer. And I also had access to this really high intensive level of care for people who needed IVF, or who needed GYN specialists or endocrinology specialists. And I started to see a lot of patterns around people coming in, with pretty vague symptoms. A lot of chronic fatigue, a lot of people feeling like their bodies just weren't working in a way that felt good to them. And so with a lot of those conversations, comes care of people who have experienced medical trauma, people have had really bad experiences, with the medical system being dismissed, feeling like their symptoms weren't taken seriously those sorts of things. And a lot of those individuals expressed either difficulty losing weight, or difficulty with some aspect of their body size. And just like most of us, I was, you know, given the standard tools of the medical toolbox of, you know, diet and exercise, etc. And, you know, most of us who enter clinical practice, find that those really are not particularly effective. And, at worst, they're harmful, you know, there's something that we tell people over and over again, without there being a change without it being compassionate. And so it felt kind of like lip service, you know, I was repeating the things that I had been taught in textbooks and, you know, kind of talking about things as if they were standard of care. But then people weren't, you know, receiving care that changed their health or improved their health. And I had a couple of people in my life who were really generous and compassionate in their own education of me, who called me in and said, hey, you know, you work in a field where, for example, weight loss is talked about a lot in endocrinology, you already work with a lot of people who are in really vulnerable positions in the medical system? Can I introduce you to a new way of looking at this? And just like most clinicians who enter this space, I had a very long period of time of going, Yeah, but what if this and what about this, because it's so ingrained in us from day one, not even just of our, our medical or nursing education, but from living in the society that we live in, that this is just how it is, and really replacing that framework, you know, it takes a lot of work, it takes a lot of cognitive dissonance to be able to kind of counter that with something that you've been taught for so many years. So it is not an overnight process. And for those people who are in that, that learning curve, currently know that, you know, most people don't get here overnight. And also, it's super, super important work. So the farther I dived into the research, the more I realized that the research really did not at all support, the approach that I had been taught and that most clinicians had been taught. And that was mind blowing to me, you know, to say, this thing that we have taken for granted and just been told, of course, you know, all of these assumptions underlying are not true like that. That's a big shift. And and the more work I do in the field, the more I learned about my own bias and and the ways that that is shown up previously and currently and it's it's it's work that is really passionate and something that I I wish that all clinicians could or were open to engaging in my god i So resonate with so much of what you said, there's so much to unpack there. I've literally been taking notes so I can try to keep my thoughts straight. I thought I knew what my questions were but now I have more.

Tanya Tringali

Mmm, that's, that's really great. And I just want to say I also feel slightly emotional because you are saying so many things that I agree with, and that I find really near and dear. And in terms of the struggle of finding your way and how you land in this place, like it's never intentional. We don't we don't like beeline for this. It's something that comes because of so many experiences that lead you to this, like, idea that we're really missing something here. And I think we all get there uniquely. And I definitely want to hear more about like, when you talked about people taught you things, and where the research stands in terms of what those standard approaches are, I just want to really unpack that a little bit in a little bit. Because I think that's where I'm looking to learn because I kind of taught myself what I'm doing. And you know, I'm creating probably new biases while doing so. So that's gonna be pretty interesting for me. Okay, Heather, let's I want to hear the same version of that for you.

Heather Bradford

Sure, absolutely. It's always hard to follow Signey, I also got emotional hearing Signey tell her story. So I knew that I always wanted to pursue a PhD, I went to Penn for my midwifery training of School of Nursing. And I knew that I wanted to dive into clinical practice as a midwife first. I didn't really know what I wanted to pursue for my PhD. But I knew that that was my ultimate goal was to move into academia and do research and help grow the midwifery workforce. That was really my passion from the beginning. And then when I was in clinical practice, I remember very clearly, my lead midwife said, Hey, Heather, I've talked to you about something, you know, patient made a comment about the type of care that you're provided. And she was really bothered by it. And it was, you know, I'm a perfectionist. So I was like, what, you know, I just felt terrible, absolutely terrible. But essentially, the patient shared that I had commented on their weights, I had looked at the amount of weight that they had gained, and, you know, perhaps a four week or whatever timeframe, and I made a face of like, oh, that's concerning, you know, and that I really, you know, caused harm. And that was such a life changing moment for me, because I felt like, wow, like, here we are, we're supposed to be, you know, as midwives were with, you know, with our patients, and really providing, you know, ideally, very patient centered care, and I had caused harm. And that was very hard. And I really did a lot of reflection around that. So that was one piece of it. I didn't say in my head, oh, that's what I want to study. But I, I really felt, you know, I was following the rules, right, you're supposed to gain X amount per week over the course of the pregnancy based on Institute of Medicine guidelines, and this is the normal recommend, you know, the recommendation. And so that was hard. And then secondly, I had also been really interested in looking at our data, I practice at evergreenhealth, in Kirkland, Washington, we are in a full scope, we attend about 50 births a month. And I'm really interested in data, you know, I guess, classic researcher, and I was really looking at our patients, we had a 9% C section rate, and, you know, we provide what I consider true midwifery care very hands on care where with our patients and labor, you know, really no time clock, you know, just really allowing our patients to, I shouldn't say Allow, encouraging our patients to labor as they as they, as they would like, and our C sections, I was noticing that when you looked at the risk factors for our patients that were for our first time, you know, primiparous patients having C sections, many of them, we had noted that their BMI was over 30. And I was really interested in that, like, why is that, you know, we're providing supposedly the same care to all of our patients, when, you know, there's no stipulations around. And our hospital, we have very open, you know, opportunities, everyone is allowed to birth and to labor in the tub, everyone's allowed to birth in whatever position they'd like to birth in. While we have a very low epidural rates. We are patients can, you know, pursue a trial of labor after cesarean, you know, all the we had no restrictions. And yet, when he looked at who was having a C section, that was the patient population, the trend that I noticed, so that was really interesting to me. So I really started diving into the literature around that and really talking to colleagues, midwife, colleagues, physician colleagues, nurses, labor and delivery nurses, but really trying to unpack that. And it really led me to to this work of studying weight bias and really seeing how we can improve outcomes by examining the care that we're providing to patients that live in larger bodies.

Tanya Tringali

So you just took me back to a very early memory that I think I can now say, okay, that's another mark on the timeline that I had completely forgotten about that probably links some pieces together. For me, I don't remember what year this research came out. But it's old news. Now, when we started recognizing that people in larger bodies have a different way of I can't remember the details, but there, they don't have quite as many Pitocin or oxytocin receptors, right. And we finally started understanding that, depending on someone's body type, they may need a lot longer in labor. And I don't know if that's where exactly your mind was, as you were unpacking that. But I'm remembering that and I'm remembering that the time in my life where I started advocating even harder for more patients. In those situations, patients as in like, tranquila, let take your time, not like or basis. But that was such a shift. And it was something really concrete that affected our practice. And that makes it a little easier. But the rest of it is so frickin muddy, right? There's nothing else that I can think of that's as concrete as that moment.

Heather Bradford

Yeah, absolutely. I think that so the date just to give you a data point, people with a BMI body mass index, and we know that's a terrible marker or measure of health, but it's in the research world, it's used very clearly to define different categories. So the category of BMI over 30 is considered obese, which is a terrible term and Cigna will talk about that. But essentially, three times more likely to have a C section with no risk factors. If you take someone who's completely healthy, no risk of gestational diabetes, gestational hypertension, spontaneous labor, so taking out inductions still three times greater risk of birthing by section in someone with a BMI over 30. And so the question for me is why, and just comes back to from the moment that person walks into the you know, Birthing Unit or hospital in labor to when they end up on the or table for the C section, what has happened in that time period, what is the care that's been provided? And I have to believe that it's related to how, you know, how we're how we're caring for them the clinical decision making this happening during the labor process that is not evidence based. That's really where I'm interested in my research.

Tanya Tringali

Are you pregnant, or a new parent looking to ensure a better postpartum experience? Or are you a birth worker looking to improve your postpartum care skills? Check out thriving after birth, an online self paced course by me midwife and educator Tanya Tringali. It's 10 and a half hours of video content featuring experts in lactation mental health, pelvic floor health, pediatric sleep issues, you also get worksheets in a workbook as well as options to have a one on one session with me sign up at mothewitmaternity.com/thriving. And let's improve postpartum care together.

Tanya Tringali

So you're really trying to unpack where bias filters into this equation? Because the truth is, or I think the truth is, this is where I want you guys to like put the kibosh down. I mean, if I say something to black and white, the what I'm just gonna say it the truth is, there are medical conditions that affect pregnancy that affect our, our labor and our birth that are, I'm going to say correlated, because I don't know for sure if we know actual cause and effect. I'll let you guys told me that. But we know that there's a correlation. So at some point, there is an interjection of bias and the way we treat people, the way we view people, and the choices they make in life, etc, etc. But then there is this real component. That's why I said the truth is there's a I believe there to be a real component. But how do we distinguish between those two things? And how do we make sense out of that? I think that's what you're working on?

Heather Bradford

Yes, well, my my dissertation is really focused on step one, which is measuring way bias among midwives, we don't even we can't even say for sure that midwives have weight bias. So that's my first step. And I'm trying to understand, you know, different characteristics that might increase certain midwife's bias over another. So looking at it by region of the country, perhaps you could say that people that live in certain parts of the country have more bias than others. Looking at years of experience is someone who's been practicing a long time perhaps have more bias than someone who's you know, graduated more recently and has been introduced to more topics that are, you know, focused on more person centered care. So looking at different characteristics, so that's step one. But then step two is really looking at the data around. Heather, I'll just use my use myself as an example. Heather attended, let's say 100 births. So, last year, and the of the patients that I attended their birth, how many had C sections? And what was my weight? What is my weight bias? Versus comparing to another provider? How many? What is their level? Score, I should say, of weight bias, both implicit and explicit weight bias is what I'm measuring. And, and and of their patients, how many had C sections? So really looking at it is, is there an association between, you know, the care, the bias and the outcomes? There's a lot of other pieces in the middle there of when are you starting Pitocin? If you're starting Pitocin, you know, are we allowing them to, you know, again, I used that word allow I correcting myself, in terms of pushing like, okay, you've been pushing for X number of minutes, and we're probably going to need a C section anyway. So let's just do it now, sort of those kinds of pieces, or I think about, I'm not sure this this patient is has the, here's the, here's a classic weight bias, stereotype of explicit bias, I'm not sure that this person has the stamina, to walk to ambulate. So I'm just gonna encourage them to stay in bed, and then we're not promoting physiologic birth, or I'm not really sure that this person, you know, wants to be in the tub. Or can can, it can easily get in and out of the tub. So I'm not going to offer the tub for, you know, aqua therapy for them. I'm going to just encourage an epidural. Let's just rest right here, those very small nuances. But it's that's our weight bias coming out in our clinical decision making really not supporting physiologic birth. Again, these are my theories, I haven't I haven't measured this, I'm just at step one of really measuring weight bias, but a long way to go.

Signey Olson

Yeah. And what comes up for me when you're talking about that is how many people are even excluded for midwifery care in the first place. Whether that is because those midwives practice out of hospital and they have a BMI cut off. But even within a hospital, you know, is that, you know, there's hospitals where it's like, if you have three risk factors, you're a physician patient, and is BMI considered in that. So how many people could have midwifery care, and don't even get to that? That place?

Tanya Tringali

So I want to pause for a minute. And because we were diving so deep already, and I love it, but I want to make sure everybody's with us. Can one of you take a moment to talk about what BMI is? And maybe just a little bit about why that was believed? Or may still be believed to be an appropriate measure? And maybe what your thoughts are? I mean, you kind of already said, you have many thoughts you want to share about that. So whatever it is that you think is critical, but then like, how should we go about doing this differently? What is it you want providers and healthcare consumers both to know about a different way to think about their bodies?

Heather Bradford

Go ahead, Signey.

Signey Olson

Oh, I could talk about this for hours. I mean, in a nutshell, the BMI is not an accurate measure of health in any way. And if I could wave a magic wand, I would, you know, get rid of that tomorrow. It was invented hundreds of years ago by a Belgian mathematician and astronomer to look at a really homogenous population of white sis men. And it does not give us valuable data in a healthcare system. It really categorizes people pathologizing his people's body sizes in a way that is not helpful and doesn't provide certainly doesn't provide person centered care, but also doesn't help us get to good clinical outcomes. So that would be my short answer. And I'll just I'll just add, it doesn't measure it doesn't measure adiposity. It doesn't take into effect. Genetics, bone, you know, the size of bones. It does. The number is created from height and weight. But it really does not incorporate anything about that person's health. It's just purely a calculation that was used to measure populations, but it was never designed to measure an individual person's health. And that's the that's the biggest issue with it. And so do either of you have a measure that you propose instead of or in addition to BMI? So, in short, I don't think we need a measure that's related to a person size. There's no reason that we need to do that, you know, we are still as you know, evidence based clinicians, we are looking at a person's health overall, we're taking to account Yeah.

Tanya Tringali

Well, I guess from a research perspective, is there a reason I think that for the reason?

Heather Bradford

The reason BMI is used is because it's all we have. It's clean. There are it's clean, right? It's super easy. It's like a fifth vital sign. It's you know, you look at it before you even walk into the exam room to see your patient, it's quite standardly used. The problem is it does not measure capture into the full picture. And we if you could do feasibly body scans, right to measure adiposity, if you were trying to understand that, which is a very expensive test, and you would never, you would never do that. So I think the idea is to just eliminate it. You know, there are many examples of where signee was saying earlier, BMI is used for access to midwifery care, but also access to infertility treatment, or access to being able to birth at a birthing center, or, you know, the list goes on and on. So it's really quite prohibitive in terms of, of options for care.

Tanya Tringali

Yeah, and some settings, your BMI affects whether or not you can get in the tub. I mean, that's, that's rough. Absolutely.

Signey Olson

And I would go as far to say that we don't need a measure of adiposity, that when we think about adiposity, as a really normal variation of human size, and makeup, that we don't need to replace it with something because adiposity, by definition, doesn't need to be pathologized. We as humans and clinicians have pathologized it. But fat is super normal, it's normal to have on humans, and there's a very natural diversity and body size that exists. And of course, the question around, you know, does body size affect health? We can talk about that. But really what the research says is probably not. And this research has been around for decades, it's not brand new, I think it's more that people are finally talking about person centered care, and reflecting back, like when Heather and I have done our deep dives for different presentations. You know, some of this data is so old that it seems silly to cite it, but it's the data that's existed for decades.

Tanya Tringali

Yeah, when the data's old, but But it's we haven't redone it, we haven't done better. That's all we have.

Heather Bradford

I was just going to add that when if you look at mortality, you know, if you think about risk factors for mortality, and who, which, you know, behaviors contribute to a longer mortality, the, the, like living longer the behaviors are eating fruits and vegetables, looking at alcohol intake, cigarette use exercise, it's not about your BMI. And so that data is really clear thinking about healthy lifestyle behaviors. And singing, I also talked about the word health also has, you know, a lot of we talked about healthy foods, or you know, there's a lot of it's a very value based word. And so we try to avoid that, but thinking about, you know, eating to satiety and nutrition, focusing on new foods that are nutritive, but, you know, really thinking, so I'm talking started, I'm actually getting a little ahead of us talking about Health at Every Size, which is something that synchronize share with our own when we talk to our students about, you know, reframing this in a different way. And Health at Every Size is a framework that we've recommended in our in our work.

Tanya Tringali

Are you saying, across the board definitively that there isn't a relationship between one's weight which I realized is different than saying BMI? And, specifically, well, we'll just go with diabetes, just one thing? And and can you unpack that idea a little bit, because those are the places I'm coming from. So people come to me asking for help to improve certain aspects of their health, diabetes and related diseases, metabolic disease, things like that are generally those things. And I find it incredibly difficult to help them without talking about weight in some capacity. And so just putting it all out on the table, and people can throw tomatoes at me if they need to over the internet. I do ask what people's BMI is. Because in part, I'm sitting on a computer screen and I truly have no sense of what I'm dealing with like what where are we in the spectrum? I have no idea. So I do ask BMI. But then we unpack BMI. We talk a lot about what that means. We you know, we kind of like put it to the side. But I do ask that question. And then we layer on all the other things. My personal standpoint, is somewhat in line with you guys just to put that out there in that I don't actually care so much about people having fat or even more fat than average. What I care about the perspective I come from to help people change their selves metabolically speaking, is let's put on some muscle mass, that's the place I'm generally coming from is let's build some muscle because muscle is such a great healthy metabolically active tissue. And it doesn't matter so much if somebody's super lean and you can see their muscles or if their muscles are covered up in some fat, so I'm just kind of wondering like if there's a place where is the is the lane that I'm in sounding reasonable to you, or you like, Tanya, we got to do some bias checking, because tell me if that's the case.

Heather Bradford

Well, just to start, everyone has bias. And you know, I will say that you are not human if you don't have bias. And so we our goal is to mitigate and minimize harm. That's really our goal. In our in our work. So don't, I would say no tomato throwing is needed.

Tanya Tringali

I don't get tomatoes, but people will do it anyway. It's the internet.

Heather Bradford

Yeah, I think that, you know, what we talk about is move movement that brings you joy. So instead of a prescription of you will do cardio three times a week for 30 minutes, which is what's in the ACOG guidelines in pregnancy, it's very prescriptive, but really changing that to what brings you joy in terms of what types of movements you know, do you enjoy doing and not as a prescription, and there's no guilt, if that did not happen, you know, so it's, it's not about guilting someone into this, it's really trying to reach optimal, you know, feeling being your best self feeling your best self. And what do you do that helps you, you know, reach being your best self. And then in terms of eating, you know, thinking about eating to satiety and eating foods that help you feel good, you know, not foods that, you know, you eat, and you don't feel good after. So again, just think reframing it that way, I think is what I have done in my, my one on one care with patients Signey, I'm sure you have something to add or thoughts or I'm curious, your thoughts around that.

Signey Olson

I think, you know, in my clinical practice, whether it was in person or my current practices, virtual, you know, I don't, I don't ask, wait, I don't ask BMI. Partially, because I don't have a ton to glean from it. But it can be, I think, really triggering for a lot of people to talk about their way to talk about their BMI, when we know that it's not a great predictor. I do a lot of work with folks who have either history of eating disorders or who have really complicated relationships with food. And, and sort of centering those voices. You know, when we talk about things like nutrition, I'll usually ask, you know, are there any foods that you eat that don't make you feel good? Or that you avoid? Because they don't make you feel good? You know, lots of people will say, yeah, I, I love dairy and cheese, but I don't feel good when I eat it. That's helpful information to know. You know, do you have diagnose food allergies, or you notice these patterns? And that's kind of the main piece about nutrition. I do a lot of work with people who have PCOS. or something similar. And, you know, we might get to the point where we're talking about, are you eating enough? You know, I find so many of my patients throughout the day, are not eating enough. Because a they may not understand what a full full day of nutrition looks like. But they also may not be getting enough protein. And maybe protein is the thing that helps them feel better. So when we keep the emphasis on how are you feeling throughout the day, you know, how can we avoid those kind of spiky glucose patterns that keeps the emphasis on the embodied experience of the person and how they're experiencing their body? And then in terms of movement, you know, like Heather said, what are some things you like doing? If you hate running, oh, my gosh, please don't make yourself run. If you love weightlifting, great like that. Those are helpful pieces. I think it's also, you know, and Heather and I talk about this a lot in the work that we do that. Even though we have all of this evidence around nutrition, I often say we have an obnoxious amount of research that exercise is good for us. I think two things, one, that it is important to note the equity issues around food and exercise, that there's a lot of privilege and being able to tell someone to eat more protein than not having them be able to execute that in their life because of food scarcity issues or financial concerns. Even executive dysfunction like ADHD plays a big role in how someone's able to feed themselves throughout the day. And you know, same thing with movement in terms of people who have chronic pain disability. You know, it's it's pretty disrespectful to tell somebody with chronic pain, like you should just exercise more, because that's not going to be helpful. And then on the other side, I think, you know, we have limited data about what the the true scope really looks like but there's some there was one study that showed 65% of women have some disordered eating patterns. And that I think that speaks to sort of the cultural context and narrative around how we think about food. And 10 additional percent have a diagnosed or meet the criteria for eating eating disorder. So that's 75% of people who have some form of disordered eating thoughts or patterns or behaviors. And that's huge. And now that's just, you know, one, one study, but in my patients who do not have diagnosed eating disorders, I still hear those, you know, kind of echoes of diet culture and, and knowing that diet culture is really rooted in white supremacy, you know, and thinking about sort of the very racist roots and branches of that whole paradigm. I think it gets really complex and really nuanced because we as clinicians, oftentimes have 15 minutes 20 minutes to try to capture these things. And eating is something that we all have to do, and therefore it makes it inherently more complicated.

Signey Olson

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Tanya Tringali

Well, I definitely dug into that research or rather not research. But just I read a bunch of articles about the connection between white supremacy and diet culture before coming on to this talk with you guys. Because I had not I had heard those connections before. And if I'm completely honest, they would go over my head, I was like, I don't really get it, I only get it at the most superficial level of like women are being objectified, right? Like on that level, I got it. But I needed to really hear an essay. In order to get deeper on that. And I do totally understand it. I still end up feeling super conflicted. I can know all of these things intellectually. But when somebody is asking for a specific type of help, that's where I go, what what is the right move here? Right? So I try to use the language that somebody brings to me, for starters, I try to use the tools that they want to use that they're open to. But at the same time, I'm still kind of sitting on the sidelines coaching somebody so to speak, who's moving in the direction whose focus is essentially weight loss in some capacity? And I guess I wonder, do you think that that's a role anyone should ever be in with someone?

Signey Olson

Yeah, I mean, this is, this is a huge part of my clinical practice. And I think about, you know, the people that I care for, who are planning to get weight loss surgery, and that I won't get super deep into it, because that can be a whole second conversation. But I do think about, you know, my role in as an expert, evaluating research, and knowing sort of the depth and breadth of the research and knowing that weight loss really isn't compatible with the human body in almost any case. And of course, when people are thinking about that they're thinking about themselves as the exception. And we think that, you know, quote, unquote, weight loss may occur in a, an OK way, maybe, you know, plus or minus 10 pounds, when people may start to move their body more in a healthy way, or maybe add in some fiber to the diet, you know, something like that. But knowing what I know about the evidence behind weight loss, I can't ethically recommend that you to anybody, I can talk about the nuance, but I really, but now I also see a lot of patients who come to me and say I want to lose weight. And that's challenging, certainly. But what we usually do is we sort of gently break down what the research has with evidence says, and I find in general, refocusing a person's attention and awareness back on their body is usually my first step. Although with weight loss comes a lot of people who will say things like, I just feel better in my body, I feel like I can do more, I feel more confident. And then we really have to look at more of the societal pieces of, of course, that makes sense. You know, we have evidence that everybody in your life will treat you better in some capacity, when you are smaller. And that narrative goes back to thinner bodies being more valuable. And so there's a lot, a lot to unpack in different capacities.

Tanya Tringali

Can one of you speak to that I kind of set it and then I tied in a whole other thought, and we got sidetracked, it was totally my fault. But back to this idea of the data, not supporting weight loss for health, back to my initial question of connecting diabetes and weight, because what I'm aware of is that weight loss helps people, it even reverses diabetes, right, in some cases, and so am I aware of a body of research that you don't think is legitimate? Can you just to unpack that a bit?

Heather Bradford

I think, what we know, what research has shown is that people who lose weight to lose weight oftentimes gain it back. That's, that's, that's the problem with you know, aiming for weight loss. I think the experience of someone who has, so think about someone who has experienced harm in the healthcare setting, right, they have been dismissed, shunned, not offered care that they were, they were seeking, they came in for a sinus infection and left and being told to lose weight, you know, that that is so you know, just so many experiences of harm in the healthcare setting. But someone that comes in and you are thinking, helping them reframe this in a different way. Have I mentioned Health at Every Size, so just thinking about how your body feels, and sort of the things that we touched on of, you know, what you're eating and joyful movement, and really reframing it over time, they might lose weight, as sort of a secondary, you know, benefit. But the goal is, you know, think as you said, muscle mass, thinking about what you can do and how your body feels, that's more of the goal, and the weight might come off. But that is not the focus, it is not you need to lose weight. That is not that that is not the lead. Yeah, and I want to just also mention, I feel very much a guest in this work, especially when we talk about the history of racism and, and its impact on body weight. But Sabrina stress springs, I think it's important to mention Sabrina strings in her book carrying the black body. If this is something that is really interested to the listeners, it's I highly recommend that book. And she's really I would say the expert in in that content. So just want to call that call attention to that. Great.

Signey Olson

And then to answer, you know, the piece about, you know, does this research of around diabetes, for example, exist. You know, the, the research is pretty clear that regardless of you know, whether we're talking about diabetes, or just intentional weight loss or hypertension, that you know, as Heather was mentioning earlier, there's several studies, but one in particular that talks about the effect the physiological effects of things like exercise. And again, obnoxious amounts of research, that exercise is good for the human body. But we can't divorce in that research the effect of exercise from the effect of weight loss. And so when we come into a lot of the research around weight and body size, it is when you read it with a really critical eye it it asks the reader to come in with the cultural assumption that higher weight bodies are bad and more unhealthy. And, you know, if somebody engages in if they newly engaged in exercise, and we measure biophysical markers, like blood pressure, we see things like blood pressure start to change before weight loss ever happens as soon as 14 days for some people. And so I think that's one illustration. And then like Heather said, maybe weight loss happens. Maybe it doesn't, it doesn't really matter, but the emphasis is more on the exercise than the person's weight. And so the body of research that we have that talks about weight loss related to things like hypertension, diabetes, you know, is really infused with weight bias to begin with, and relies on a kind of, you know, lazy interpretation of some of the data.

Tanya Tringali

I really like how you framed that the second, you said you can't separate exercise from weight loss to figure out what component it is here. I instantly understood. And that was super duper helpful. Shoot, I had another thought that just went out, because you guys are making me think so many things the same?

Heather Bradford

Actually, I have a question. Actually, I wonder if we should basically, we haven't really talked about weight bias and defined it. And I don't know, for the listeners, if that would be helpful, because I mentioned both implicit and explicit bias and what that what that is. So I think it's just important to share, you know, you also could have a bias towards someone who lives who lives in a smaller body. But in the US culture, you know, the rates are very high of people who have bias towards people that live in larger bodies. And so we can think about in two ways implicit is, you don't really realize that you have it, but it's those decisions or things that you think that are implicit about how, how someone how someone lives, their life, assumptions that they don't exercise, when you look at someone's body size, or assumptions, that they have a very unhealthy diet, that they're lazy. You know, the list goes on, but that it's basically you don't, you must not love yourself, because look at how you've let yourself go, you have those thoughts. They're there, you would never say them. But they're there. That's implicit way bias versus explicit way, bias is just saying, I think you really need to know, I think I think that this would help you, I need to tell you that, you know, you are, you know, whatever word you want to use, you live in a larger body. And, you know, I think that you need to lose weight, you know, it's just very, it's much more out there. And so I think it's important to recognize that everyone has both. But we also know, if you look at trends of discrimination in the US, are discrimination against someone because of their race, or their sexuality, or gender identity have all decreased in the last two decades. And weight bias has not changed. Wow, that, to me is super, super important to just call out that we we really need to be talking about this. I just was actually looking at the research yesterday, and the only other discrimination that has not decreased discrimination towards someone with a disability. But all other forms of discrimination have decreased. But not not we bias. So we have a lot of work to do.

Tanya Tringali

That's an amazing detail. But my positive thinking brain just said, Well, maybe because we've done, we collectively have done a lot of good work on the other areas. Maybe we can move faster now on this because we have learned so much from the other areas because there is such overlap.

Heather Bradford

I like your optimism. I like your optimism.

Tanya Tringali

Well, we'll see right, you'll still be researching this in a in a number of years, I'm sure so you'll let us know.

Tanya Tringali

Hey, everyone, it's me, Tanya, your host here at the mother wit podcast. You know, I sometimes invite my clients on the show to talk about their birth stories and postpartum experiences. But I want to tell you a little bit more about what those clients and I actually do together. I started mother wit to help people in the perinatal period achieve their health and wellness goals. That means whether you're hoping to conceive and struggling with high blood pressure, or high blood sugar, or you're having trouble managing anxiety or depression in the postpartum period, or maybe you just need support and advocacy between prenatal or postpartum visits, I can help get a discount on your first consultation with me at motherhood maternity.com using the code firstconsult10%off. That's one 0% symbol, all one word. I'm looking forward to working with you. And maybe having you on the show too.

Tanya Tringali

You know, it's also making this conversations making me think, yeah, of course, I'm I'm really thinking about myself a lot in this conversation. But I'm of two minds in a certain sense, because it's almost like there is a particular conversation to be had with the providers that are doing the grind that are seeing patients and 15 minute slots. And I've been that person I was there. It's been a while since I've done it, thank God but I've done that. And that was a very different way of making decisions about interacting with conversations around weight compared to what I'm doing now, which is I meet with people, you know, for an hour every couple of weeks. We text message all the time. I'm like literally supporting them through whatever it is and look Wait there's only one piece of what I do with people but it's something that does come up a lot for me. So these, it's two completely different animals, they almost can't overlap. One thought I came into this conversation having is, with all the issues that you've just unpacked around weight bias among healthcare providers. Another thing that we haven't talked about is just the provider that doesn't talk about it at all, either because they don't have any time, or because they're uncomfortable with the conversation, probably some degree of both for different people. So it's kind of like, how do we even get started, when on one hand, we have an inability to talk about it. And on another hand, when people do talk about it, there's probably a lot that we're doing wrong.

Heather Bradford

Absolutely, yeah, there has been a lot of data that has shown that providers don't feel comfortable talking about this and this topic, and again, it's, you know, meeting the patient where they are at, focusing on a topic that is appropriate for that day, you know, as I said, if you come in for a sinus infection, they should not be left leaving the office saying it's, you know, you need to you need to lose weight. But I think that, you know, as I mentioned, is digital medicine has guidelines for recommended, how much should you gain in pregnancy, and it's a standard topic at the first prenatal visit of you know, this is this, you need to under this is what the guidelines are. And for someone who lives in a larger body, they're there, the recommendation is to gain less weight, it's not 25 to 35 pounds, it's, you know, 15 to 25, or five to 15. And so then how does a provider, you know, approach that topic, and I think that this is something that, you know, they didn't teach us this in school. This is not something that, you know, this is really, I think, a very nuanced conversation. And the first thing is, you mentioned earlier using the language that the patient wants to use. So some people identify as fat, some people identify living in a larger body. But starting with that, you know, the language that the patient uses, but really asking permission to have the conversation is the absolute first step. And any patient that walks into your office that lives in a larger body, they this is not this is not a big mystery. They, they fear this conversation that because they have been harmed in so many ways. Since childhood, probably right. For many people, they lived in a larger body, their whole life, they've been bullied in school, they're, you know, they were not selected to be the first team on a, you know, spawn, Pick Me Pick Me, right, this has been ongoing for a long time. So the harm that can be done from the conversation that goes, you know, if you're not coming to it with a good understanding, the harm that can be perpetuated, and then, you know, I was just reading his research about higher rates of people who chant transfer care during their pregnancy, because they've experienced harm from their provider. So how unfair is that, like, it's a lot of work to transfer care. And, you know, think about, that's just awful. And so I think asking permission is the first step, and not not talking about the recommended weight gain, but just really talking about lifestyle, you know, like, tell me about your life, you know, let me let me help you and help me understand about what's your world, like, in terms of your ability to, you know, live your day, take care of yourself, you know. And so I think that starts there. And then the second piece, as you said, is the language is really important. We don't want to use words that are uncomfortable to them. Again, another opportunity to cause more harm.

Tanya Tringali

I'm going to disagree with you on the on one point. And that is, I actually like to talk to people about the IOM guidelines, and then tell them that they don't hold any meeting.

Heather Bradford

Perfect, perfect.

Tanya Tringali

So I do bring them up, and we go over them, and we look at the big picture, and then we kind of unpack it from there. I think, for me, conversations feel like this is how my brain works. A game of double dutch, like, how can I get into this conversation, and I'm looking for opportunities to turn the conversation over to the other person. So I take these little moments to see what they throw back at me. And that's kind of how I start to navigate that, because then they instantly start telling me Oh, thank God, I was so worried or whatever it is, right? That it's they just start talking.

Signey Olson

Pregnancy, I think is a unique scenario. But I don't think wait needs to be brought up. But what I do is similar to what you just mentioned, is I'll explicitly say, you know, at my annual exams, I don't take people's weight, you know, unless you would like me to weigh you, I'm happy to do that. But thinking about what it's going to tell us, you know, it's not going to really be a beneficial piece of the puzzle. And, and this was something that kind of came up when we were talking about something else. I think there is in specific in midwifery, sometimes a particular particularly high risk of harm because a lot of our education is we were taught to do Talk about nutrition and lifestyle so much, you know, that's something that sets us apart. And, and I have found that sometimes midwives can be more harmful in that conversation because it's brought up so much, versus a clinician who does not mention it at all. If the options are, don't talk about it at all, or have a harmful part to the conversation. You know, I think that that former is actually better. I often say a, an unpopular opinion to say in a room of clinicians is that we are not experts in nutrition, we think that we are 100% Yeah, and people, you know, act as if they are, but really, we're not. And so unless that clinician has, you know, additional training, they understand body neutrality or size neutrality, they understand the fat liberation movement, I don't really think we should be talking about it in the exam room, because the potential for harm is so high.

Heather Bradford

And I'll see you mentioned that those high rate of people who have a history of disordered eating, and so that, you know, it's quite common. And so we typically just say, we recommend that you talk to someone who has expertise in this area, and I am not that person.

Tanya Tringali

This is such a great conversation, I'm actually hoping that people will send me voice memos, both providers, and clients and share their experiences with this. So like, if you're a clinician, and you're that person that like doesn't talk about it, I want to know what's going on for you, if you're that person who's talking about it, but you are listening and going, maybe I've done some harm, I want to hear those thoughts, we can keep you totally anonymous. And likewise, on the consumer side of the equation, I want to hear what has been helpful from providers, and what has been harmful. So we can continue this discussion because it is so important. And I spend an insane amount of time thinking about it, but probably not enough time digging into the research like the two of you. And I'm just I'm absolutely grateful to be having this conversation with you guys in such a candid sort of way.

Signey Olson

Yeah, I think centering the voices is the thing that medicine and nursing don't always do a great job at, we like to think that we do, but especially when we talk about marginalized bodies, you know, we can sit here and and you know, talk about different marginalized groups all day. But unless we take the voices of those groups, and put them into our guidelines, put them into our research. And I think body size discrimination is a really, really good example, because we have millions of people who are in larger bodies who say, hey, these words are really harmful and stigmatizing. Every time. You know, provider does X, Y, and Z, I never want to see them again. And we know that people put off life saving preventative care, when they have bad interactions. And that clinician may never quite understand that that interaction was so harmful, because they can be really well intentioned, you know, people go into health care, because we want to help people typically. But that power dynamic is so inherent to the roles, that it makes it really challenging. It's a lot of work for the clinician to break down, I think and do the work.

Tanya Tringali

Yeah. And I would, I would actually guess that it's very rare for someone to find out that they caused harm, because the patient just leaves. So the experience that Heather had, what a blessing that someone spoke to you. I mean, you it led you down this path. That's amazing. And I just think that the providers that are causing harm, don't even know it. And so I'm hoping that they're listening, and at least reflecting on their choices and the language that they're using. And maybe just starting to think about a different way of doing this, I absolutely will be thinking differently about this. You've really opened my eyes to seeing this a different way. It doesn't negate a lot of the things that I am doing with people. But it gives me a different perspective. And it gives me insight into what they are thinking and feeling. So I can come at this from a couple different angles than I ever have before. Is there anything else that you were like just dying to get out there? Before we wrap up, I want to make sure that there wasn't something on either of your agendas that we didn't get to

Heather Bradford

No agenda, but I was just going to add motivation for clinicians to really do some self reflection around this work. Just what you were mentioning about not coming back, but we have data that says higher rates of gynecologic cancer, people who do not want to have a pelvic exam because of harm that they've experienced higher rates of breast cancer because they do not want to go for a mammogram because of the experience around that and higher rates of unintended pregnancy and people who live in larger bodies because they don't want to go in for care because of harm that they've experienced? So those are just really three GYN simple examples. I could go on.

Tanya Tringali

Okay, now I have another question since you said that. So you just opened up like another can of worms around conditions that we are taught, they are drilled into our mind, our once again, I'll use the word correlated, since I don't know the studies well enough correlated to quote, obesity. So whether we're talking about endometrial cancer, breast cancer, whatever it is, we know that we see obesity listed as a risk factor on these things, as I understand it, what you're starting to unpack is the role of bias and how it affects the choices that patients make around their care. And so it's a delay in diagnosis, to some extent, we don't know how much right? Is that correct? Is that an accurate way of saying where we're at with the state of the science?

Heather Bradford

Correct, correct. And also, if you take out the size of the patient, right, so people that so you could experience harm of, you know, experience weight bias, if you're even slightly, quote unquote, overweight, right, you don't meet the criteria for BMI over 30. But because we hold women to a higher standard, and so it's at so if you take obesity as a risk factor for breast cancer out or take obesity, for other that you were just mentioning, the research is quite strong about weight bias is associated with a delay in those diagnoses and higher rates in the long term.

Signey Olson

And one thing that I wanted to also, one more layer of nuance is, I don't think this is a conversation that clinicians can have unless they have done a few a bit of this work. But if there are higher rates of a particular disorder, or condition, cancer, etc, I think a, you know, the onus really needs to be on the clinician, you know, it is us who needs to do better.And secondly, when we look at research around more marginalized bodies, you know, the effect of allostatic load can't also be taken out of the equation. And so when we look at higher rates of conditions, disorders, in people who have high Allostatic loads, we have to take that into account as well, you know, does the daily effect of having a body that society tells you is wrong? What does that do to your inflammatory markers throughout your day to day living in life? And, you know, ultimately, that is still weight bias causing that? And really, you know, weight bias seems to be kind of the root of a lot of these pieces.

Tanya Tringali

Yeah, totally, you just reminded me that that's a big piece of one of the avenues I take with people is, we're not going to do any of the stuff that you are coming to me wanting to do until we look at your sleep and look at your this and look at your that. And we talk about cortisol and we talk about all of it. So again, I see my role as giving people insight into the various tools that they can use to change their life in whatever way they want to change their life. And, you know, whether where weight fits into that equation. You know, I I'm looking forward to seeing how I can reframe a bit and start to maybe see weight loss the way you guys have just talked about it as this like secondary, almost unintended consequence of positive life changes, if that makes any sense. So you're both nodding at me. So I think that's a good thing. Yes, yes. Oh, thank you guys so much. I wish I could give you big hugs, because I'm really grateful for this conversation that was way overdue. And yeah, thank you guys. You're so smart. Yeah, at some point, we might have to do a part two, depending on what kind of feedback comes

Tanya Tringali

Thank you for listening to the mother whip podcast. If any of the issues we discussed today resonate with you or your experience, I'd love to hear from you. Leave me a voicemail at 917-310-0573. Or better yet, email me a voice memo at Tanya@MotherWitMaternity.com. I really want to hear what worked for you what didn't work, what support you'd wished you had, how you got through the tough times how you advocated for yourself, or especially any tips you want to share with our listeners. I want to hear all of it. And if you'd really like to work together, you can get a discount on your first consultation with me at Motherwitmaternity.com using the code firstconsult10%off. That's 1-0 percent symbol, all one word. Okay. That's all. That's wonderful being in community with you all. Thanks again for listening and see you next time.

Carolina

And remember, listeners nothing we discussed on this show should ever be considered medical advice please speak to your local provider about anything that comes up in this show that resonates with you and your needs and your health care.

Transcribed by https://otter.ai