 My name is Conrad Cunger, I'm a private GP in Prosopine in North Queensland and I've got the privilege of being your facilitator for tonight's session. It should be a fantastic ride for us. Like many of you, I'm in private practice and I don't have the luxury of having esteemed experts such as we've got joining us tonight around the door. So, hoping that just like many of you, we can get a lot out of tonight's session. Talk about how we can best work towards supporting the mental health of people living with obesity. I'm going to just quickly run through the members of the panel that we've got tonight. Hopefully you've all had a chance to peruse the information which was circulated previously. I'm going to start off with introducing Dr. Gary Killov. Gary is a GP who's working in Lonseston. He's got a special interest in chronic disease management. Gary, I'm just wondering if you'd be able to give the audience a little bit of an idea about what actually does a special interest in metabolic health mean in daily practice? So as you mentioned Conrad, the interest is very much centred on diabetes and many of our patients with diabetes, particularly type 2, also struggle with weight. So metabolic health is looking, when one looks at the context of BMI, if we look at obesity as defined or WHO definitions of BMI over 30, we're looking at the health of the individual rather than just how big they are. So we want to know how sick they are, which means that in addition to their phenotypical presentation, we also know what their biochemistry looks like. We also want to know whether they are any comorbidities or significant risk factors. Wonderful. Thanks, Gary. We're now going to move on to introduce Glenn McIntosh. Glenn's a psychologist working in prior practice in Queensland. Glenn, I wonder what was it about this area that brought you into this area of practice? Conrad, people ask me that all of the time because I'm very passionate about the area, but the reality is that I kind of fell into it. I did a degree of sport and exercise psychology back before there were health psychology degrees, and I actually was one of the weirdos who fell in love with the exercise side of things and the interesting exercise for the average person. And then I had a great mentor who had actually transformed his life through the psychology of eating. And I just find that the weight management is such a complex and multifactorial challenge that it's really meaty enough for me, but I feel like we can get really, really good outcomes and I feel like psychologists have a lot to add to it. So that's kind of how I fell into it. That's fantastic, Glenn. Next, my pleasure to introduce Ms Fiona Sutherland. Fiona is a dietician in Victoria and is a specialist in eating disorders. Fiona, what are the particular areas of satisfaction that you get out of your line of practice? Oh my gosh, where do I start Conrad? Look in all honesty, the clients that I work with and the colleagues that I have are incredible. They're really inspiring and their ability to overcome a myriad of challenges, whether that's physical, psychological and also cultural challenges of living in a world that is very complex when it comes to food and eating and our bodies. So I'm inspired by the people that I choose to surround myself with every day. So very privileged. Wonderful. So I would not least like to introduce Professor Philippa Hayes, a psychiatrist in New South Wales and Professor Hayes, the Foundation Chair of Mental Health at Western Sydney University. Professor Hayes, I'm just wondering, what does transitional research into mental health sort of become as an area of practice? Well, I think it's about translating what we know from psychology labs and science into real-world world settings, into programs that we can take into our clinics and into our hospitals and into our practices that affect change, real change for people and that are feasible, practical, acceptable. We can have the most fantastic randomized controlled trial, but if it's only worked for, you know, 10% of people with a problem or 1% of people with a problem and it doesn't work in the real world, then it's not going to be that helpful. Indeed. Well, thank you very much, everybody. So what we're going to move on to, just if anybody hasn't been familiar with the MHPN webinars previously, just a little bit of familiarity with the webinar platform. So you'll notice that there's an open chat box little tab in the bottom of the screen which will then open up the chat box into a separate window. If you're wanting to contribute to the discussion, please feel free to put your comments in there. We'll try to get through them as we can. You'll also find there's a little resource library tab down the bottom of the screen. You'll be able to find any supporting resources for tonight's presentation. And we've also got the technical support, frequently asked questions tab down there which you will find that can actually help you out with most of the areas you might be struggling with. But of course if there's something there which we can't help you out with, we do have the number that it calls if you're having difficulty. And we'd also like to make sure that everybody take the opportunity to provide feedback at the end of tonight's webinar as well which will be available shortly at the conclusion. Now we are just going to go briefly through the ground rules for these sessions. We just want to make sure that everybody is enjoying the experience and gets the most out of it that we can. That's what that really means. It's just being respectful of the other participants and the panelists who we've got on. So even though we're in a virtual space, remember that behaviors are in the same room. And please, we do encourage you all to participate using the chat box. But just please try to make sure you keep the comments that you're generating on topic because we are trying to peruse through nearly 500 participants worth of input as we go. So moving on to tonight's presentation, we're not going to revisit the case study. I hope you've all had a chance to visit Natalie's story. But what we're hoping to achieve out of tonight is being able to describe the general principles of a supportive environment for people with obesity who have poor mental health. Also wanting to make ourselves aware of established appropriate referral pathways to coordinate better services for people with obesity who have poor mental health. And also make sure that we are able to identify challenges, tips and strategies for a collaborative response that offers people with obesity who have poor mental health access to improved and better care. So after the delayed start that we had, we're going to move straight on to the story of Natalie that you're hopefully all well aware of. Natalie's our 32-year-old woman who's coming along to see a GP talking about the struggles that she's been having. You'll be aware she's had a long-term struggle with her weight and body image and some pretty disordered eating habits that have developed around that. So Gary, wondering as the GP who's seeing Natalie for the first time, how would you move on to helping her out? Yes, so this is the first consultation which means that at this point I don't know anything about Natalie. She's an open book, so to speak. So the first thing that I need to do is once I invite her in, make sure that she's settled, is to keep quiet and let Natalie speak and listen to her story and allow her to express what she considers to be the pressing and the most important aspects of the reason for her consultation. The likely thing is that she's been sitting in the waiting room for a little while. She's probably been rehearsing what she wants to say to me. She may well be a bit nervous. And so for me, the most important skill to demonstrate at this stage is to respectfully listen to this actively and allow the story to unfold. Now as she tells the story and which will be familiar to all of you by now, what will be apparent is that she has struggled with managing her weight. She's struggled with self-esteem. She's probably had some fairly unpleasant encounters maybe within the healthcare profession as well. And so what I'm going to do is I'm going to assume that there has been an unspoken question. And that unspoken question would be about what my attitude, what my beliefs, what my approach to her would be. And so I think to get this out of the way, I would actually talk about my views and make sure that she feels comfortable and secure and able to express in more detail the sorts of things that she wants to talk about. She may well be a little guarded initially, but hopefully allowing her the space particularly in a secure way would allow her to expand on what she's talking about and what she's requesting. As you know, she has come in requesting either pharmacotherapy or referral for surgery. And at this point it's become quite clear that she... There's a whole lot going on and certainly I would be uncomfortable with simply writing out a prescription or referral for bariatric surgery. And so it's important that at this point we make sure that our agendas align so that she feels she's being listened to, that she doesn't feel she's being fobbed off. But on the other hand, that she has a clear understanding why it would be inappropriate for me to write out that referral or that prescription until we know each other better, until we've explored a whole lot of other options. So where we move on from here is of course to end on a good note. Make sure that the consultation leaves Natalie with hope, making her feel that she is on a trajectory that is positive for her. And what I would do is I would walk with her to the reception desk and I would make sure that we reschedule the next meeting so that she feels that rather than this consultation ending, that it's really a transition to the next one. And I think at this point a lot would depend on what she's happy to do. What I would be looking to do is to involve individuals who I feel can help with what has now become apparent that whilst the ticket of entry has been her weight, if you look under the bonnet, we really see that there's some disordered eating, there may be some other issues that really need to be addressed in a mental health setting, in addition to of course addressing the physical concerns that she's presented with. Thanks so much, Gary. Thanks so much, Gary. That's a fantastic introduction into the air. And certainly no doubt at all about the importance of building a strong and supportive team who can be empathetic, but also have the knowledge and the real command of the area that we want to make sure we're putting the right people. Because this is obviously going to be a very sensitive area and we want to make sure that we get this right. Glenn, there's no question at all that the involvement of a good psychologist would add a lot to Natalie's care. If you'd be happy to add in your perspective here. Yeah, absolutely. I think that Gary started us off on the right foot, certainly from the medical, but also from the psychological perspective because the first thing that we would look to do is first to do no harm. And I think it's really important that we all consider the impact of weight bias and stigma and discrimination. It does create a whole range of adverse outcomes from depression to relationship problems and actually makes people less likely to come back and see any of their health professionals. And as Gary said, Natalie might have experienced this from previous health professionals. We do live in a world that kind of idealizes thinness and stigmatizes fatness, so we could almost assume that Natalie's experienced some of this at some stage. I think it's really important for people to realize, I know there is this kind of idea of giving someone tough love or the truth that they need to hear, but often people do interpret those in a very stigmatizing way and that's actually quite harmful for weight management behaviors. It kind of pushes people into restrictive eating patterns that lead to disordered eating. It can result straight directly in overeating and it stops people from exercising a lot, especially exercising out in public. There's a really cool little resource here, the Implicit Associations Test, which uses reaction times to measure your own implicit associations towards fatness and thinness. It's a great little resource that I'd recommend people have a look at just to explore your own weight bias. And that takes about probably 10 minutes to do, so a really good little resource. I think it's important that Gary talked about the type of person that we present to Natalie and also I think it's really important that we consider the environment and how friendly that is for someone who's living in a bigger body. So I think it's really important for us to consider our space, the furniture, the staff that we have put on and what they're wearing and their attitudes towards bigger people. And a really good thing to do for people who are looking to work more in this space, and I suppose because people are getting bigger and bigger these days that it almost becomes all of us to an extent, is just to have an audit of your environment and see how fat-friendly the environment is. After doing this at our practice, and I've been sort of specialising in this space for over 10 years now, we made a few changes like getting a downstairs room for our clients, getting bigger furniture because a lot of the standard furniture is not necessarily very comfortable for people, and then just looking at the staff and our attitudes towards people. So I think that's the first point. We can also really, it's important for us to look at language and of course Conrad spoke in this person-first language and say obese, we're not working with obese people, we're looking to work with people who have obesity, so we're putting the person first. But I think we can probably do a little bit better than that because of course a lot of people do find the words obesity stigmatising. So you might prefer to talk about a person who is above the most healthy weight. Then again, it may be worthwhile to sort of talk in more weight-neutral or weight-inclusive language and just talk about the person themselves. You know, a person who's looking to get better control of their eating, or a person who's looking to take better care of themselves. I think it's also important that we look at what we don't know about Natalie. You know, weight management and psychology of eating body image is very complex and very multifactorial. I think it's important that we look at her general psychological health and that's why it's so important to have someone like Philippa on the team. I think it's important that we look at those things like her metabolic health and that's why it's so important to have someone like Gary on the team. And even just worthwhile checking her actual BMI because she sort of self-reported that it's 32, but a lot of people might under-report or miscalculate it and that might factor into how we treat Natalie. But all that really underscores, like Conrad said, the importance of having an interdisciplinary team who are really on the same page about how we work with Natalie. Something that's very interesting to me as a psychologist is I think that we're probably going to be encouraging Natalie to set non-weight goals or aims, but they become a little bit abstract. And so I like to actually measure people's relationship with food, their self-esteem and body image. And we can use that as a bit of a baseline and check for improvements. I use that using a questionnaire that you can be located actually on our website. So for the last probably eight or nine years, I've been working with some academics to get a battery of psychologically validated tests, so empirically validated tests into a free resource. So that is something that you can use and your clients can use to measure how they're going. And it pretty much measures everything that we'd be interested in for Natalie. If we start to look at what we might do with Natalie to support her, I think that we first look at the things that we wouldn't do and I wouldn't be too interested in supporting Natalie to do another weight loss or diet approach. They tend to be very ineffective at best and can often lead to eating disorders, especially if they're unsupported or rigid or extreme. So we wouldn't want to give her a treatment that's going to make her challenges worse. I don't think that I'd be a fan of her doing bariatric surgery because she's just not in that BMI category of 35 to 40 with comorbidities or 40 and above without. And again, I wouldn't be too interested in her doing a pharmacological intervention for weight loss, maybe for her mood, maybe for her binge eating, but definitely not for weight loss as there's no evidence that that would result in a longer term change for her. Potentially what we would do to support her would be to do some CBT work or some what we call these as CBT plus incorporates a bit of media literacy and a bit of acceptance and commitment therapy or mindfulness principles, and that has been shown to be efficacious in improving body image and eating without needing the person to focus on their weight. We could also do a non-dieting or an intuitive eating or a health at every size approach that I know Fiona will talk to you a little bit more about that. And a final interesting thing I really like to do with almost everybody who has challenges with their body image is just look through their social media. We know that Natalie's become a bit of an Instagrammer and we do know that being repeatedly exposed to those thin ideal images does warp someone's sense of what's normal not only cognitively but perceptually and that results in detrimental effects to both their body image and their mood. So that's what I would sort of think for Natalie and there's a few references there for people who are interested in looking a little bit further. Glenn, fantastic. Thanks so much for that, Glenn. That's a brilliant insight and some really strong steps there that we could all probably put into place quite simply tomorrow but also building on further if we're looking into this area. Fiona, there's no doubt at all that Natalie's going to really need the support and help of a dietician who understands this area and certainly isn't out of her depth. Thanks for that so much. Well, first of all, I just really wanted to start off just by acknowledging that I have body privilege. I live in a smaller body so everything that I've learned about eating disorders and living in larger bodies, really, I've learned from my clients, I've learned from my friends and colleagues who have firsthand experiences of that so I just really wanted to pay tribute to that and acknowledge that as an educated, cisgender white, smaller-bodied person I think there's a lot to be said for elevating the voices of the people that do live in larger bodies that we can really learn a lot from them and currently over 15 years or so have gathered quite a lot of knowledge thanks to the people around me. So one of the first questions that I would be asking Natalie is a question that I ask most people who come through my door and that is, what was your relationship with food, eating and your body like growing up? Now this is a really interesting question because it sets up a really strong foundation for our assessment which helps me to understand Natalie's experiences in her own words and invites her to tell a story which reflects, you know, honestly her own experience. It allows me to listen uninterrupted and to gather, you know, lots of rich information. So in particular I'll be paying attention to timeline and to the way that Natalie talks about the way different experiences has influenced or affected the way she has related to food, eating and body. And yes, I'll be really focusing on that particular question and weaving that through the whole of the initial assessment. So in terms of specific questions that I'll be asking, I'll be covering off plenty of the physical questions as well as psychological and particularly when it comes to eating patterns, for example, I'll be asking about frequency of eating and just getting a bit of a snapshot of her eating patterns, particularly with regard not necessarily going to great detail about content but more around food rules, how much she's eating and when in the day just to get an idea really. I'm looking for evidence of restriction, restrictive beliefs and then how that restriction kind of turns into other kinds of behaviors in the day. I'll also be asking about things like menstruation, if there has been any diagnosis of PCOS because that's something that's actually very, very common amongst women who have been diagnosed with binge eating disorder in larger bodies. So that's something I'll be particularly asking about as well as any other diagnosis, any other bowel issues, anything else that might inform the way that Natalie is presenting to me. From my perspective as a dietitian I'm unlikely to weigh her. That's not something I would typically do in a first consultation. However, I will be asking her a lot of questions about her weight history and in particular what I'm going to be looking out for I guess is any particular escalation in weight or any dramatic drops in weight and the patterns of everything in between. So then moving on I'm going to be spending some time reflecting together with Natalie on any major experiences or events that have really affected her experiences around food eating and her body with particular emphasis on things like her mother's her mother seems to have been very strongly influential in terms of eating behaviour and then also her housemate who seems to have been highly influential. Reality is that Natalie may have had very limited opportunities to have exposure to people and experiences which give her an idea about what quote-unquote normal eating might look like. I prefer to call it natural eating myself and what it looks like to have positive and flexible relationship with your body. I meet many, many people in exactly Natalie's situation who say I think everybody's on a diet and everybody... I don't know anybody who likes their body so Natalie could be one of those people and that's one of those questions that I'll be asking her. So with regards to do we focus on weight or not I personally think this is a very important but very tricky conversation. It might be during the initial assessment that Natalie expresses a desire to lose weight and why should we be surprised we live in a culture where apparently bodies are meant to be fixed and controlled whatever the cost and Natalie perhaps would be no exception to this and it's back. She is presenting as somebody who may be in a great deal of distress about her body. So I guess my experience over time tells me that enacting weight loss behaviours as Glen said is also not going to be very helpful for Natalie and so I would be very willing to have conversations with her around her distress, around her body but be really aiming to help her calm down enough using some mindfulness strategies and self-compassion strategies to be able to move forward and stabilise her eating behaviours. So from a practical perspective as I said I'd be aiming to really help her to stabilise her eating passions and not only to help her to be better nourished but then also to help her move forward into a space of body trust because in terms of her eating disorder recovery that's going to be building the strongest foundation we can with moving forward into a place where she can eat with confidence where she can move her body with confidence and to be able to take care of herself long-term. So I find that in practice people who are quite highly distressed about their binge eating behaviours but don't always see the restriction as terribly problematic so I find it really important to have the conversation around how those two behaviours can influence each other and kind of bounce back one to the other. So I draw as you can see on the screen here what I draw is this kind of this kind of thing I've got a little whiteboard in my room which I find really helpful and I use that to illustrate that the restrictive eating can lead to binge eating and there is to help people kind of understand and explore what might natural eating look like for you. So we focus first really on stabilising the restriction and addressing any food rules also aiming to reduce and contain the frequency of weighing and counting whether that's counting calories steps, grams of food all of these behaviours can be very insidious and find their way right through people's behaviours. So depending on how chaotic these eating patterns are I probably wouldn't write out a meal plan as such but rather than doing that I would help her maybe explore her eating patterns maybe with the assistance of maybe a monitoring or appetite awareness journal through a sense of gathering mindful awareness and Natalie can be more aware of the events whether they are emotional experiences or sensations in the body whether they are engaging in restriction or engaging in eating disorder behaviours. As you've heard me say the two factors I think that are most important with Natalie for me are self-compassion so that sense of being kind when things don't go the way we wish and then developing mindfulness strategies too because in developing insight and awareness she'll be able to take better care of herself no matter which direction she heads in. So moving forward from the first consultation I'd really be aiming to get a team together for Natalie. I would say probably 50% of the time I see people for the first time they haven't come from another professional because often people who feel out of control with their eating think that maybe a dietitian can help them get their eating back in control and certainly if you happen to stumble across a non-diet dietitian health at every size or an eating disorder dietitian you've kind of hit the jackpot really and that's not necessarily going to be the case if you doctor Google people so and then the other 50% of the time I get referred from psychologist, psychiatrist, GP and other mental health experts so if I'm the first person I'd be aiming to establish a really fantastic team for Natalie to help her to really feel confident moving forward in terms of her recovery from an eating disorder and I tend to recommend like-minded people in terms of that weight inclusive approach who are going to really support Natalie from an appropriate therapeutic perspective so if team members are already in place and of course I would be asking Natalie for permission to contact them of course if Natalie's in Melbourne there is an option for her, she has been eating disorder and so she would be a suitable candidate for our ripe groups in Melbourne, it's a 14 week closed group therapy program but we've been running for 12 years every Saturday morning in Hawthorne so myself and Sarah Harry at Body Positive Australia that's specifically for women with binge eating disorder and bulimia nervosa so I would be recommending that as just one option, not everybody wants that option that's absolutely fine so just to pull it all together in summary I'd be offering Natalie a weight neutral approach on weight inclusive approach which prioritises recovery from the eating disorder and addresses her body dissatisfaction and supports her to build knowledge inside an awareness in terms of her eating behaviours so one thing that I saw today that I might thought might add just a little something tonight and you'll forgive me for just reading straight off my paper because I thought it just reminds me of all the Natalie's in the world and many of whom I have the privilege to work alongside so please forgive me indulging the next 30 seconds so we blame ourselves for failure to fit into clothes and boxes and labels and personalities that are too small to contain who we are. We become afraid to take up space because we're afraid of what others might think and because we get really good at following the rules the rules that make us feel safe and accepted the rules that keep us trapped so that's for all the Natalie's in the world many of whom cross my path so thank you so much. Thank you very much that's a wonderful a wonderful set of great tips and really just some really practical real insight there on what this area of work involves day in day out and how we really can stay positive and keep engaging as well as we can. Philippa there's no question at all that in the case of a patient such as Natalie that there might actually be a significant mental illness which is underlying the situation that she's arisen in now. Philippa I'm just wondering as a psychiatrist working in this area what might be your insights into Natalie's case? Well I think Fiona and Glenn they've really covered a lot of the things that we hope will be covered by other people working in the multidisciplinary team so what these psychiatrists really bring the skills looking that's beyond that and looking at the other problems that may be present as well. So all the things on the left hand side Fiona and Glenn have really covered in terms of assessing the eating disorder and the diet and the weight history which also is very important but for the psychiatrist you're probably looking also is there a concomitant mood disorder is there an anxiety disorder? Social anxiety is a very common disorder for people with eating disorders and as well how is she in terms of herself and her interpersonal function and also the medical side of things because psychiatrists are also doctors would be also wanting to think about that and check that she's had a good GP and has had the appropriate investigations done and then as Fiona was talking about taking a developmental narrative. So moving to the next slide so with that we would take it all together and review and discuss with Natalie how her eating disorder has developed and how it is in relationship to other problems that she might have in her life and to her physical and border mental health problems and like Fiona I like to on the next slide I like to draw this out on a computer or on a white board with the person to sort of get an understanding and there's very much patients very appreciative for this because you're giving them a sort of a picture of how their eating disorder has developed and they very often say yes that's exactly it makes sense for them and then they can understand better themselves and there's less of that sense of blame or guilt or for having a mental illness problem or having an eating disorder and in Natalie's case there is certainly for example we would talk about the culture that she's grown up in the dieting culture, the broader culture that Glenn also talked about with weight and stigma related to obesity we know that in her narrative there may be things that happened earlier in her life and also this is all added in how she views herself and we know that she has become a person who values herself in terms of her body weight and shape and body image which then leads into the disorder eating behaviors as Fiona had outlined that then tend to perpetuate upon each other and other eating behaviors which she hasn't had to date such as the acts of abuse we may talk about with someone with bulimia nervosa Natalie we would say has been eating disorder at this stage but she is engaged in probably a vicious cycle of dieting and binge eating but that's certainly a background of who she is how she was feeling about herself as she grew up and the culture and society that she comes from and then we bring it together to see how we might be able to value add to the very excellent treatments and going to the next slide we would explore with her what treatment she's had today what therapy she's had today has she had specific evidence based therapies such as cognitive behavior therapy has she had therapies specifically for that might integrate that with problems with weight disorder or weight management has she had therapies that Fiona was talking about such as body self compassion type therapies mindfulness broader therapies that we know are also very helpful for people with eating disorders is there a role for her for medication is there a medication for any specific mood disorders that may be or even for binge eating disorder the binge eating is very very frequent we have some medications that we use I put role of surgery very much in brackets at the bottom doesn't appear to be at all in her case it all about surgery but going back to the top of the slide as well just thinking about where she is in terms of what she is looking for in therapy as well and we should never forget that vast majority of people who seek treatment or seek help for an eating disorder actually are presenting for weight loss they come and they say I've got a problem with my weight and as Fiona said often it's getting away from thinking about weight or even weighing people to thinking about the eating disorder and thinking about the associated psychological issues that are related to the eating disorder and helping the person with that rather than with any degree of weight loss at this stage but we know that they are presenting for help with weight loss so where are they in terms of wanting treatment for the eating disorder wanting to start addressing some of the eating disorder behaviors as opposed to wanting to seek further weight loss so that's a very important aspect I think particularly for people who are overweight who have eating disorders and kind of directing them down down a path of help for their eating disorder which for many if that's addressed then hopefully the issues around weight and shape and needing to lose weight will be much attenuated and become not a part of themselves and how they value themselves which is the major goal for me when I'm trying to help someone with an eating disorder is moving away from that overvaluation self-evaluation in terms of one's body image or weight or shape and valuing oneself for one's personal merits and other domains of one's life that's my last slide I think OK thank you so very much Phillip and that's you're absolutely right it's such a depth and often it's not really until you can sort of step back and take that overall approach of not just focusing on what's happening right now but what's the whole story being that has led us to this time that you can really sort of bring that perspective in and go with it well we're going to move on to our question and answer session I know that a lot of you have been struggling with the progression of the slides but hopefully you'll be still receiving the audio and rest assured that from here on in most of the benefits you'll get will be following the audio so there won't be much more in the way of content that you're needing to go through we've had some good sessions some good questions which have come in during the session this evening we're going to try to catch up on some of those we've also got some of those which have been submitted prior to tonight's discussions Gary I'm going to open with a question to you which has been circulating a bit there seems to be a strong genetic component to obesity how do we best assist parents to avoid multiple generations of VC affecting one family that's that's a very good question and and it really deserves a very long answer which unfortunately we don't have the time for but I think there's been a recognition that obesity is intergenerational for all sorts of reasons if we think of obesity as we would any other chronic progressive condition we can summarize it as genes loading the gun environment pulling the trigger and age determining the outcome and if you think about the individual who may be on a trajectory to gain excessive weight some of those environmental influences actually begin within the uterus and those first few years including the intrauterine environment and early years of feeding in fact would set up probably 80% of the long-term trajectory of weight for that individual so it may sound terribly depressing that essentially what happened to you in your first four or five years of life is what you're going to be fighting against for the rest of it but understanding this means that as you said Conrad the information the education begins actually with the perspective parents before they even become parents so ideally if for example Natalie were to meet somebody and want to start a family then there would be many good reasons for her to lose weight. Now I do appreciate that much of the discussion has been that weight is really the ticket of entry is actually the presenting symptom rather than the problem but in a situation where we would be talking specifically about reducing the risk of intergenerational obesity then weight loss in this particular instance would be appropriate another example would be if she had diabetes weight loss would be very beneficial thankfully Natalie doesn't have any of those issues and so for her really the big ticket item is her eating disorder so I think it's about working out what it is that we want to tackle and then we tackle it with the appropriate tools Thanks Gary that's brilliant hey Phillip Margaret and some other participants have been asking about certainly for many patients with mental illness their medications may actually be compounding their issues with weight gain and especially when we're talking about medications like antipsychotics especially clozapina etc do you find that there are particular effective medications which are more favourable in this profile than others Yes there are some more recent antipsychotics like leucidone which appear to be less associated with the weight gain and definitely in someone with a weight disorder or an eating disorder I would avoid medications like alansapine because they are so significant weight gain often with my when I've worked with people it's been working to find the antipsychotics that doesn't cause or the weight gain and then people often lose quite a lot of weight when you find them on the right antipsychotic so not just leaving them on the antipsychotic but send them to a psychiatrist and find a antipsychotic that doesn't cause them to have severe weight gain and they will lose the weight gain that they had on whatever it was particularly with spiradone and alansapine are very problematic in this regard and as well being associated with metabolic syndrome which you don't want people to have either No question about it being able to restore some hope that it's not or lost and that there are some better alternatives out there would really be fantastic for all of us to be able to share Glen a interesting question about how do we challenge the sense of futility that people living with obesity feel in taking on exercise or diets when it all seems too hard and that their self-esteem is already gone what might be your approach there mate? Yeah it's a very interesting question because a lot of people have a really strong desire to lose weight at all sorts of weights and shape incisors and they naturally have also a sense of this learned helplessness that while they're hoping that something's going to help there's a big part of them that's really lacking that self-efficacy and it's a bit of an interesting answer because if we look at the research on most weight loss approaches so behavioural diet and exercise programs which is the go to for most people they're actually very ineffective in the medium to long term and the more restrictive or unsupported ones can actually lead people to eating disorders so what we actually try and do often is actually encourage that sense of learned helplessness in the diet and exercise for weight loss paradigm in that approach and help people understand that it's not their fault that that hasn't worked because it is terribly ineffective for people in the medium to long term but what that then does is open the door for new approaches so say if Natalie did have some sort of metabolic health issues to actually go and treat those health issues directly or like we've discussed with Natalie a weight neutral or weight inclusive non-dieting type of approach or it is really medically indicated for someone not in Natalie's case but if it's medically indicated for someone of a very large BMI or a BMI above 40 or 35 and above with comorbidities then look at exploring other options like some of the various bariatric surgeries which with good support and the right chosen candidate can actually be quite effective at improving mental health and physical health Thanks Glenn That's great Fiona we've spoken quite a bit tonight about the stigma that is associated with living with obesity what are your tips for assisting people with obesity to overcome that self-stigmatisation that can sometimes become a feature of their presentation well self-stigmatisation is most commonly known as the internalised weight stigma so what happens is that through life and now research is showing it's happening unfortunately from very young ages from about the age of three that we are internalising ideas and ideals about bodies and weight and that extends of course to our food and exercise and eating and so forth but when it comes to internalised weight stigma to be honest with you I really think we need to start with amongst ourselves as health professionals it's taking a really good look at our own attitudes and our own beliefs around the bodies of the people that we work with and our fellow human beings because I think when we're working with people in a variety of different body shapes and sizes and particularly people who live in larger bodies I think just creating that compassionate awareness that a lot of people do not enjoy the comfort of being able to walk around in the world without being noticed or without being criticised so I think internalised weight stigma is one thing and I think there's a lot of really great things around self-compassion and some beautiful psychological approaches that can really encourage people to develop that sense of kindness towards themselves but really to be honest I think that when we're looking at big picture I think it really comes down to us as health professionals really leading the way and being incredible leaders when it comes to the way that we're approaching people particularly in marginalised populations and people who are in larger bodies That's wonderful. Thank you very much for that. We've had some questions from the audience about sometimes one of the useful motivational tools which we're finding particularly in the 21st century is that there are some handy self-sort of help apps around and resources that are available in that regard. Just wanted to get the panel's opinions on any useful apps that they've found or are there any particular resources or do we actually have any value to these at all? Have you had any experiences on this area? So certainly apps around diabetes management and also health and fitness particularly with the explosion of fitness trackers the literature is mixed and it appears that the people who derive a benefit with those who are already engaged in other words somebody who's not engaged if you give them an app or you give them a fitness tracker they remain disengaged. So I think on their own as a tool they have been a little disappointing. The statistics around apps in general not just around health are that the vast majority get opened once only. So I think like every other tool it's got to be the appropriate tool for the individual and as I say for those who are engaged it can be very beneficial but it's certainly not a panacea. Cleen have you had much experience with the apps at all? Conrad I've had a look around and my opinion is that I'm not a big fan of calorie counting type apps and those type of sort of anything that any tool can be potentially used as a dieting tool so anything that's going to fire up a sense of restriction or a real focus on weight loss I'm not too big a fan of and then we work more on this mindful eating intuitive eating size acceptance type space and I have had a pretty good look around I'm not sure if Fiona has anything but I haven't found anything that I really like in that space at this stage. The only thing that I do I think that it's always important but with all of our people we zoom out from the number on the scales and focus on the whole person so the only app that I find quite useful in this space app I like in general mindfulness apps but unfortunately I haven't found anything that I really like in this space in terms of developing intuitive eating skills or body acceptance. Fiona are there any freely available resources that you'd recommend or that you're a fan of? Look I'm with Glen to be honest I really love a lot of the mindfulness apps because I think that when we're developing those skills we're able to notice our own experience and we're able to notice what's going on for us so I think essentially with someone like Natalie in particular that's a skill that I've been looking to build from the ground up but there is one called Am I Hungry which is really a mindful eating app which is probably the best of the bunch but you know there's a bit of evidence around pen and paper and writing it down the only thing with that is people's privacy they really prefer to make sure that there's a sense of guaranteed privacy but to be honest I'm a bit of a fan of pen and paper when it comes to any kind of journaling or tracking it just doesn't have that over focused component on it that Glen mentioned. And Phillip I wonder are there any online or digital tools that you recommend to your patients? There is the centre for clinical interventions in Western Australia has a lot of online information which is very helpful of online resources like one page on you and Ion for example in terms of nutrition and also information for psychoeducation type information for people with eating disorders. I have used online apps in terms of with use of cognitive behaviour therapy we ask people to monitor their eating patterns whether they've had episodes of binge eating for example where they were in the context but I'm with Fiona I think I think most patients when they do it and they bring it along on their phone it's very hard to read and I think it may just something about writing it down on paper and bringing along the compositions on paper and the narratives that go with that seems to be more meaningful to people, seems to be something that they can much more easily share in the therapy session than the app that's on the phone or on iPad for example so I don't use apps very much clinically but I certainly do use online information quite a lot and it's a very good way of quickly downloading and giving people psychoeducational information. We shouldn't make assumptions about exercise that people who are living with a larger body are unwilling or unable to exercise and we certainly should be taking an honest history and asking that that is part of our area but we also know that exercise has lots of positive benefits psychologically as well. Glen how would you recommend to your patients that they build exercise into their routines? Yeah that's a wonderful question Conrad and I think the people who are messaging there are exactly right there are plenty of big unfit people and there are big fit people and there are small people who are unfit and there are small people who are fit as well so it's definitely not a one to one correlation and as always our plan is to zoom out and consider the overall health benefits and I say to people if you're exercising to lose weight it's like going on holidays just so you can take the pictures it's just such a very small benefit that you're looking for there and if we zoom out as the doctors will know that it's exercise is like a magic pill for your body and as the psychologist and psychiatrist will know it's like a everything that we can measure gets better with exercise. I think it is also important and a good point that you mentioned there Conrad is how we actually build the physical activity because with my background in sport and exercise psychology I think a lot of people will try and build their exercise like an athlete would and do stuff that's probably too gunk over them it's focused on weight loss or fitness or health and in doing so they create a pattern of exercise that they actually don't enjoy and of course then enjoyment is the biggest predictor of exercise adherence so they don't stick with it and they don't get the benefits so we have an approach at weight management psychology and we have some personal trainers that we call size-diverse or body-positive PTs and that they actually prioritise the psychology around the relationship with food over the physical benefits so do they enjoy it reducing embarrassment problem solving any barriers from a place of empathy rather than just suck it up or be disciplined and making sure that they have a sense of self-efficacy or confidence in what they're doing and what we find is that people actually become it takes a little bit more time but they become a lot fitter because they stick with their exercise over time and it becomes a want to rather than a has to that gets dropped off the list when the other more important priorities sort of take precedence. That's wonderful Glenn and certainly it's the message to me that regardless of whether talking about Natalie or for other patients who might be living above their ideal weight we want to make sure they're happy before we start talking about the way it is being the path forward. Gary what other would you have a take home message for the audience coming out of tonight? Yeah I think to a large extent I need to particularly with the case such as this defer to my colleagues who really have far greater skills in terms of dealing with the psychological aspects of what first and foremost is an eating disorder with a whole lot of other things attached to that. My role really is as the GP as the coordinator making sure that the appropriate referrals are made that the appropriate interventions are coordinated I think it's already been mentioned that we also need to make sure that other aspects such as metabolic health and possible emerging comorbidities or complications of being overweight are dealt with. So once again certainly support and endorse the team approach and this is a long journey this is something that is not necessarily going to be linear it's not necessarily going to be predictable and we address issues as they present we'll have some victories we'll have some challenges but I think it's a matter of sticking with Natalie making sure that she doesn't feel that she's been abandoned or that she has to do this alone. No question about it at all Gary that's the fundamental role of every general practitioner that's the what we should be able to offer our patients that through the tough times and the good that we're going to be there with them and that we're going to see them through the entire journey. Phil I'm wondering would there be any take home messages that you'd like to share with the audience this evening? I'd like to emphasise that we have good treatments very good for people with binge eating disorder and believing in a vote for another eating disorder and when people are able to access those treatments and engage in them with a therapist whom they trust then the outcomes are often very very good so we can be very optimistic I'd like to leave a very optimistic message about seeking those sort of treatments and although as I said very often people are worried about their eating treatment for their weight very often as the eating disorder is addressed and they really are helped to be more active, feel happier in themselves as a person, often the weight problem becomes much easier Fiona I don't know if we can come any better with the letter that you shared at the end of your presentation but what would be the key message that you'd like the audience to take away from? I really love what Phillip has said about having a sense of optimism there are some wonderful therapists working in the eating disorder recovery space who are taking this very weight inclusive and health at every size type of approach so if anybody here you know isn't for anybody here who those words are new then I really encourage you to get in touch with MHPN because information from tonight will be available on there and just to know that recovery from a eating disorder is absolutely certainly possible and that when we can see the real human being and when we can treat them with compassion and care and help them to develop resilience within a culture that is sometimes not very kind to people in larger bodies I think that the support that we can offer to these people can go a million miles and those people can then also be leaders in the community and really help other people in their lives particularly if they're parents for example you know to really create an environment where their kids can grow up feeling good in their bodies regardless of what shape or size it is and I think that's the best you know that's kind of the best future we could hope for for the kids coming through Thanks Yona and Glenn finally over to you we've covered so much Harry already but what are you really hoping the audience might be able to take away with tonight? We have covered so much you know it's been an absolute pleasure for me to be a part of this and I think to have anything this webinar has just reinforced to me the real importance of working in an interdisciplinary team I think you know every member of this team has really worked into more of a trans-disciplinary way we've all done a little bit of each other's jobs and then we've all got that specific part of our job that no one else does as well as we do and I think that I say to people you know the psychology of eating, movement, weight body image it is definitely a team sport with I don't think everybody and you might have heard it here I don't think everybody has to be necessarily on the same page all of the time but we've got to be like-minded and in the same book and I think that the last person that we of course add in here is Natalie and her as an expert on herself and I think that if we take an attitude of collaboration and an attitude of focusing on Natalie as a whole person then I always feel with the group of health professionals working with a person like this then we're going to find a really good answer Thanks Glenn and look I've got no doubt at all that if Natalie walked into my room tomorrow I certainly would feel as though I'm more able to recognize what might actually be those important underlying issues there be able to develop a safe and supportive network for her and most importantly for myself we'll be able to assure her that we'll be here with her throughout the course of this progress because getting help is always that toughest first part asking for her help to know that there actually is hope in the future that we're going to get there and things are going to get better from here on in that's the best that we can hope for so thank you very much to everybody for your participation to the panelists for those wonderful insights and experiences that you've shared sharing with us through what I know has been challenging with the audio hassles and the delayed start but also for the very insightful comments and experiences that you've been sharing through the chat rooms as well please make sure that you do complete the feedback survey before you log out of tonight's session and you'll see the tab at the bottom of the screen for that we'll then also be able to forward out your certificates of attendance surely to the email that you used to register what you'll also get when you receive that certificate of attendance is the link to the online resources that we've been speaking about tonight and then you'll also be able to access the recording if any of you had the audio drop out along the way Mental Health Professionals Network our next webinar is going to be understanding the impact of veterans' mental health on their families and that's going to be coming up in a few weeks time on Thursday the 5th of October from quarter past 7 to 8 30 p.m. Australian and Eastern daylight savings time we'll be chained over at that stage so make sure you do log on to the MHPN site and register for that at the time and of course we need to make sure that we do continue to grow the Mental Health Professionals Network because this is such a valuable resource not only just in the online space but also for your local community so if you are interested in actually forming one have a look at if there's one around or if you might be interested to get into it yourselves so before I close we would just like to acknowledge the consumers and carers who have experienced mental illness in the past those who are continuing to live with mental illness in the present thank you everybody to your participation this evening good night