Ultra-processed foods have become increasingly prevalent in modern diets. They are heavily modified and contain unhealthy fats, added sugars, and salt. While ultra-processed foods may taste appealing, their excessive consumption can lead to weight gain and other health problems.

How Ultra-Processed Foods Contribute to Weight Gain

Several factors contribute to the weight-gaining potential of ultra-processed foods:

  1. High Energy Density: Ultra-processed foods are often packed with kilojoules, providing a large amount of energy in a relatively small volume. This can lead to overconsumption and an imbalance between energy intake and expenditure.
  2. Palatability and Overeating: Ultra-processed foods are engineered to be highly palatable, triggering the release of dopamine, a pleasure neurotransmitter. This can lead to overeating and difficulty controlling their intake.
  3. Lack of Satiety: Ultra-processed foods often lack fibre and protein, nutrients that promote satiety and fullness. This can lead to increased hunger and frequent snacking, contributing to weight gain.
  4. Disruption of Hormones: Ultra-processed foods can interfere with the production and regulation of hormones that control appetite and metabolism. This can lead to increased hunger and an increased tendency to store excess weight.

Studies Linking Ultra-Processed Foods to Weight Gain

Several studies have investigated the association between ultra-processed food consumption and weight gain. A 2019 study published in the journal “PLOS Medicine” found interesting results. Participants who consumed a diet high in ultra-processed foods were more likely to gain weight over a two-year period compared to those who consumed a diet low in ultra-processed foods.

Another study, published in the journal “Cell Metabolism,” investigated what would happen if they gave people two different diets in a very controlled setting. Using 20 volunteers, they randomly allocated whether these people would be fed either ultra-processed or unprocessed diets for 2 weeks immediately followed by the alternate diet for 2 weeks.

Meals were closely matched for energy (kilojoules), energy density, macronutrients, sugar, sodium, and fibre. The people in the study were asked to consume as much or as little as desired.

The researchers found that more energy (kilojoules) were eaten with the ultra-processed diet (consuming more carbs and fat, but not protein). Weight changes were strongly associated with energy (kilojoules) eaten.

Additional Health Concerns Associated with Ultra-Processed Foods

In addition to weight gain, ultra-processed foods have been linked to a range of other health problems, including:

  • Increased risk of heart disease: Ultra-processed foods are often high in saturated and trans fats, which can raise LDL (bad) cholesterol levels and increase the risk of heart disease.
  • Increased risk of type 2 diabetes: Eating ultra-processed foods is linked to worsening of insulin resistance, a precursor to type 2 diabetes.
  • Increased risk of certain cancers: Ultra-processed foods may contain harmful compounds that have been linked to an increased risk of certain types of cancer, such as colorectal cancer.
  • Disruption of a healthy gut microbiome. Ultra-processed foods can disrupt the gut microbiome by not delivering it enough fibre and through containing a variety of additives, such as emulsifiers and preservatives, which can have harmful effects on the microbiome and change these healthy bacteria.

Recommendations for Reducing Ultra-Processed Food Consumption

To reduce the risk of weight gain and other health problems associated with ultra-processed foods, consider the following recommendations:

  1. Prioritise whole, minimally processed foods: Focus on consuming whole, minimally processed foods such as fruits, vegetables, legumes, nuts, whole grains, and lean proteins.
  2. Limit consumption of packaged and ready-made meals: Packaged and ready-made meals often contain high amounts of ultra-processed ingredients. Opt for cooking meals at home using fresh ingredients whenever possible.
  3. Read food labels carefully: Pay attention to food labels and identify ingredients that indicate ultra-processing. These include preservatives, emulsifiers, sweeteners, and artificial colours and flavours.
  4. Make gradual changes: Gradually reducing your consumption of ultra-processed foods can be more sustainable than making drastic changes overnight.
  5. Seek support: Consider seeking guidance from an accredited practising dietitian to develop a personalised plan for reducing ultra-processed food consumption and achieving your health goals.

Do you need help in making changes to your dietary routines?

Our specialist maternal health dietitians are able to tailor a program to support you to adapt guideline recommendations to your lifestyle and preferences. If you need support, please make an appointment to help you achieve your goals.

 

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We think ‘diet’ is a four-letter word.

Food restriction or “dieting” means intentionally depriving yourself. Ongoing deprivation is generally only ‘successful’ for a certain amount of time before we ‘fall off the wagon’ and start eating for comfort or to rebel against the ‘diet’.

Initially we might feel temporarily better before we inevitably become disappointed or frustrated with ourselves that we ‘failed’ and decide to “diet” again.

Why does the diet industry thrive? Repeat business!

Does this cycle sound familiar?

The majority of clients that we see for weight management are already aware of what an ‘everyday’ food and a ‘sometimes’ food is, yet struggle to reach or maintain their most comfortable weight. Why is that?

When working towards your weight loss goals it is imperative to not only look at what you eat but also why you eat, how you eat and where you eat.

We are all capable of eating when we are not physically hungry and it is quite normal to do this on occasion. This is called ‘non-hungry eating’. Do it too often however and this type of eating behaviour can result in unwanted weight gain or difficulty losing weight.

If we can reduce the amount we are eating when we don’t really want it, as well as reduce the amount we are eating when we don’t really enjoy it, it will make reaching a healthy, comfortable weight easier without relying on extreme diet restrictions.

Experience tells us that in many situations, a particular type of food might taste great initially, but if we pay attention to the taste, texture and flavour, surprisingly quickly the food becomes less pleasurable.

Being more aware of whether or not we are enjoying the food we are eating is an important step in reducing the overall amount of food we eat.

Do you start off enjoying something but then just keep eating to finish it off?

The If not dieting© ‘Law of Diminishing Pleasure’ is a concept that can assist us to eat less, while at the same time increase our enjoyment from food. It can show us that if we eat with awareness, the more we eat of a particular food the less pleasure we receive as we continue to eat that particular food. It applies to all types of food that we eat although the rate of decrease will vary for various types of foods.

By being more mindful of this decrease in pleasure we can continue to eat all types of foods (everyday and sometimes foods), however learn to eat less by stopping earlier – when our enjoyment has diminished.

Lifestyle Maternity Dietitians specialise in dietary counselling methods that focus on the behaviour of eating. We use a coaching approach to weight management and healthy eating that draws on evidence based strategies to promote a ‘life-skills’ focus to facilitate lifestyle change to assist our clients achieve a more comfortable and healthy weight.

For further information or advice on being a healthier you, make an appointment here.

 

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One of the most common techniques our Lifestyle Maternity Dietitians use with clients is a range of strategies to help them identify their patterns of Non Hungry Eating, also known as NHE.

WHAT IS NHE?

 Non hungry eating is eating when you aren’t physically hungry for food.

HOW CAN I TELL IF I DO ANY NHE?

 Ask yourself the following questions:

  • Do I usually eat a piece of cake that someone has baked for me even if I am not hungry, because I don’t want to offend them?
  • Do I finish what is on my plate when I am eating out, even if I feel full before all the food is finished, so that I don’t waste it?
  • Do I ever overeat a food because it is really delicious? (E.g. sometimes it is hard to eat just one Tim Tam!)
  • Do I ever eat something like a chocolate bar or have a few glasses of wine after a really long, stressful day to make myself feel better?

These are just some examples of NHE – and there are many more!! Some NHE is normal and many people do it. When we end up doing a lot of NHE it can be hard to maintain a comfortable weight and it may also contribute to weight gain.

WHAT ARE SOME TIPS I CAN USE TO REDUCE MY NHE?

  • Question your hunger levels before eating. Do your best to only eat when you are physically hungry.
  • Don’t restrict foods; tell yourself, “I can have it if I want it, but am I really hungry for it?
  • Avoid eating when you are distracted (E.g. in the car, in front of the TV, when you are working) as it is hard to really assess hunger levels when you are doing other things.
  • Eat off a plate. Don’t eat out of packets as you can’t see the volume you are eating when you do this. This will help increase your awareness of how much you are eating.
  • Keep a food diary and also record your hunger levels before and after meals and snacks.
  • If you are consuming high calorie foods and fluids to comfort yourself (E.g. after a bad day) consider other options other than eating to comfort yourself such a going for a walk, taking a hot shower or long bath, talking to a friend or streaming an episode of your favourite show.

If you would like to learn more about identifying your NHE triggers, strategies to reduce NHE episodes or how to eat mindfully make an appointment here.

To read more about NHE and other techniques to help you be the healthiest you can be, resulting in achieving and maintaining a comfortable and healthy weight without being deprived of food or losing quality of life AND to enjoy food without feeling guilty, visit Dr Rick Kausman’s website.

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What is PCOS?

Polycystic Ovary Syndrome (PCOS) affects around 10% of Australian women in their reproductive years. This is due to hormonal changes.

This ‘syndrome’ is linked to a range of health issues for affected women, trans or non-binary people. In the short term, those with PCOS may have reduced fertility and difficulty conceiving. In the longer-term obesity, diabetes and cardiovascular disease are more likely for people with PCOS.

Normally the ovaries produce large amounts of the female hormone oestrogen, lesser amounts of the male hormone testosterone, and the pregnancy hormone progesterone (which is only produced in greater amounts after ovulation and during pregnancy). In PCOS, testosterone levels are often mildly increased.

The causes of PCOS are unknown. In some cases, it seems to run in the family whereas for other women the condition only occurs when they are above their most healthy weight.

Women who have PCOS may experience:

  • Irregular menstrual cycles – menstruation may be less frequent due to less frequent ovulation, and may be either heavier or lighter than average.
  • Amenorrhoea – some women with PCOS do not menstruate, in some cases for many years.
  • Infertility – related to less frequent, incomplete or absent ovulation.
  • Increased body hair (hirsuitism)
  • Obesity
  • Acne

There may also be long-term health risks. Recent research suggests that PCOS is related to insulin resistance and the development of type 2 diabetes. Some women with PCOS develop type 2 diabetes, especially if they are overweight.

What is the latest research on PCOS and lifestyle changes?

Recently, new international evidence-based guidelines for the assessment and management of PCOS were released. This large body of work documented results from studies around the world and gives direction for the best treatment steps to take.

A take home message from these guidelines is the important role of ‘lifestyle management’ as the first line of therapy for PCOS and outline the clear benefits that result from a very achievable weight loss and increase in physical activity.

Do I have to get back to my ‘healthy’ BMI range for me to see improvements in my health?

No, the good news is that research shows that achieving a loss of just five to ten percent of your body weight, whatever weight you are at now, has significant effects for fertility and symptom management in women with PCOS. What might this look like? For most women, it is a loss of only 4 to 5 kg. Further health benefits come from greater losses, and are enhanced by increasing physical activity.

How active do I have to be to get health benefits?

A good goal is at least half an hour of moderate-intensity physical activity on most, preferably, all days. You do not have to do it all at once. Your exercise can be spread over the day, in ten minute blocks. Try three ten minute walks, or two fifteen-minute periods of activity.

What does moderate-intensity activity mean? Moderate-intensity means you are exercising at a comfortable pace. A good guideline is the “talk test” – you should be able to maintain a conversation easily without being short of breath.

What happens if I am already in my healthy BMI range?

Maintaining your weight in the healthy range can help prevent symptoms and longer term health risks for women with PCOS. Being a healthy weight is a balancing act: having a good knowledge of nutrition is important, but we also need to understand the reasons for why we eat, how we eat, what we eat, who we eat with and where we choose to eat. Believe it or not, there is a lot more to reaching and maintaining a comfortable weight than counting up kilojoules!

Dietitians are trained to take a key role in assisting women with PCOS to manage their symptoms. Here at Lifestyle Maternity, specialist women’s health dietitians are able to tailor a program to support you to adapt guideline recommendations to your lifestyle and preferences. We look forward to supporting you on your journey to better health and quality of life. For further information book an appointment with a Lifestyle Maternity Dietitian or enrol in an online, self-paced course.

 

Interested in the new PCOS app that was produced to accompany these guidelines? Check it out here

 

 Figure 1. The Lifestyle and PCOS infographic produced to accompany the new PCOS guidelines.

 

 

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It is well known that nutrition during pregnancy is important. However, many of us forget our habits and dietary patterns before falling pregnant can affect our baby’s health at birth, as well as for their entire lifetime.

Getting it right can be challenging – there is lots of information available about what foods we should and should not be eating to improve fertility, but often this information is misleading or conflicting.

When it comes to dietary advice, how do I know what to believe?

We’ve taken some of the leg work out for you and put together a summary of the latest evidence-based nutrition advice to improve fertility. Read on to find out the important things you can do to improve your reproductive health and prepare your body for conception.

Weight matters

Losing weight, if you are above the healthy weight range, is recommended for good health now (and for increasing your chances of falling pregnant), as well as for a healthier pregnancy. It is important to remember to still focus on a nutritious, balanced meal plan to ensure your nutrient stores are optimised. To kick start your way to a healthier weight, remember:

Folate and folic acid

Folate is needed for healthy growth and development for your baby and reduces the chance of neural tube defects (e.g. spina bifida). Daily supplementation with 400 micrograms (µg or mcg) folic acid is recommended for women one month prior and 3 months post conception (i.e. in the first trimester of pregnancy). A supplement is good, but it is still important to focus on eating a diet rich in folate including green leafy vegetables, fruit, and breads/cereals fortified with folic acid.

Choose the right types of fat

Balancing the types of fats we eat is important. We do know that eating less ‘trans fats’ can improve fertility, whilst adding in healthier unsaturated fats can boost fertility further. We hear a lot about trans fats in the media – especially out of the United States. This is because they have a very different food supply to us. The Australian diet is very low in trans fats – our dietary goal is no more than 1% of energy (we currently consume 0.6% of our energy from trans fats, while Americans eat almost 3%). However, it is still wise to limit foods that contain high amounts of saturated fats, as trans fats usually turn up in these foods. Trans fats can be found in foods such as partially hydrogenated vegetable oils e.g. vegetable shortening, most commercial baked goods such as biscuits, pastries and donuts, and many fried foods.

Unsaturated fats, including mono and polyunsaturated fats, are important structural components of cell membranes, the central nervous system, and retinal cell membranes. It is especially important to make sure to include polyunsaturated fats in your diet as these essential fatty acids cannot be made by our body. Therefore, we must get these through dietary sources including oily fish, flax seeds, walnuts and vegetable oils. The fatty acids from fish are a lot more potent than those in nuts and seeds.

Slow not low (or no!) carbohydrates

Successful conception requires a balance of the right hormones, at the right levels, at the right time. It is known that higher levels of circulating insulin can have a negative impact on a woman’s hormone cycles – specifically ovulation. Low GI carbohydrates are absorbed slowly in our bodies and lead to a gentle rise in blood glucose levels, thus minimising insulin spikes. This, in turn, can improve fertility. Simple ways to include low GI carbohydrates are:

  • Choose wholegrain bread in place of high GI options such as white and wholemeal.
  • Opt for doongara or basmati rice in place of jasmine rice (also labelled as ‘Low GI Rice’)
  • Eat sweet potato instead of white potato
  • Select whole grain crackers in place of highly processed crackers and biscuits

Caffeine

Some evidence suggests that the consumption of caffeine may prolong the time to pregnancy and affect the health of your developing baby, most likely in a “dose-dependent” way (the more you drink, the longer it might take). This is thought to be due to the affect caffeine has on ovulation and corpus luteum function (secretion of hormones to maintain early pregnancy) through alterations to hormone levels. It is recommended that women trying to conceive limit their caffeine intake to the equivalent of 1-2 cups coffee per day.

Be a flexitarian!

You need protein every day. Protein comes from either animal or plant sources. Research shows that fertility is enhanced when you aim to get your daily protein from as many sources as you can. Aim for at least half of your protein intake from plants – beans, lentils and legumes, nuts, peanut butter, whole grains and seeds. Choose fish, eggs, and poultry for most of the rest, while limiting red meat to once or twice a week.

Putting it all together – the ‘Fertility Diet’

Unfortunately, there is no one food that you can eat that will improve your fertility. Each different food group has a role in helping you conceive and priming your body for pregnancy. Similarly, by following diets that cut out entire food groups you are potentially restricting your intake of essential nutrients that may cause nutrient deficiencies that alter your body’s ability to conceive and the growth and development of your baby.

  • Choose foods from all food groups in line with the Australian dietary guidelines. This includes cereals/grains, fruits and vegetables, dairy and dairy alternatives, and meat and meat alternatives
  • Include a folic acid supplement with at least 400 µg of folate
  • Include unsaturated fats such as vegetable oils (olive, sunflower, canola), avocado, nuts, and oily fish, whilst limiting trans fats such as biscuits, pastries, fried foods (as well as other ultra-processed foods)
  • Choose low GI carbohydrates
  • Limit your caffeine intake to1-2 caffeine containing drinks per day
  • Choose half your protein from animal sources, half from plants

If you would like further information book an appointment with a Lifestyle Maternity Dietitian or enrol in one of our online, self-paced courses.

 

 

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Weight gain in pregnancy – it’s a hotly debated topic. Whether we post about it or discuss it with our antenatal colleagues we get some strong opinions and concerns.

“Yet another thing to feel guilty about while pregnant!”

 

“Is there any evidence that it makes a difference?”

 

“Setting a number for weight gain is just simply the wrong conversation!”

We agree!

Only focusing on a number, a simple target out of context, is not helpful and potentially even harmful.

Read on to see the history of weighing in pregnancy. We outline why it is important and how we are approaching best-practice care around healthy pregnancy weight gain for women at Lifestyle Maternity.

The history of weighing in pregnancy

Pregnancy weight gain advice has changed considerably over the years. This is because evidence has emerged about its links to the health of both a mother and her baby. The demographics of childbearing women has also changed (1).

  • In the 1930s, all women were advised to gain 14 pounds (in metric that’s 6.3kg) to decrease the risk of pregnancy complications.
  • In the 1970s, it was observed that increased pregnancy weight gain was associated with increased birth weight. It was surmised that pregnancy weight gain should not be restricted as it would likely be harmful with respect to birth weight.
  • From the 1970s to 1990s, there was a move away from the ‘one size fits all approach’. And in 1990 the US Institute of Medicine released their pregnancy weight gain guidelines. These were developed primarily in response to concerns about low birth weight infants and, at the time, there was very limited data for women with high body mass indices (BMIs).
  • Since then, overweight and obesity levels in childbearing women have increased dramatically. So too have complications associated with excess pregnancy weight gain. These include gestational diabetes, ‘large for gestational age’ babies and caesarean sections. Additionally, overweight levels amongst pre-schoolers have risen dramatically. These changes suggest excess weight gains are associated with negative maternal and infant outcomes. As a result the Institute of Medicine guidelines were revised to reflect optimal pregnancy weight gain for best outcomes for mothers AND infants.

 

Why do we focus on healthy weight gain in pregnancy?

Studies tell us that weight gain outside of the guidelines is linked with negative health consequences for both a mother and her baby. Pregnant women who gain weight in accordance with the US Institute of Medicine guidelines (adopted for use in Australia) have the lowest risk of pregnancy and birth-related complications.

These include both health and delivery complications. Women who gain weight above recommendations are more likely to have longer hospital stays, caesarean sections, high blood pressure and diabetes in pregnancy. They are also more likely to have trouble losing this weight after their baby is born and have difficulty breastfeeding. Women who do not gain enough weight are more likely to deliver their baby early.

What are the current pregnancy weight gain guidelines?

The amount of weight to gain in pregnancy differs based on a woman’s pre-pregnancy BMI. To work out your BMI divide your weight (in kilograms) by your height (in metres), squared. If you are using your calculator on your phone divide your weight by your height, and then divide it by your height again. Look in the table below to see the weight gain range for your BMI.

 

BMI (kg/m2)

Singleton (one baby) pregnancy total weight gain range (kg) Rates of weight gain in 2nd and 3rd trimester (kg/week)

<18.5

12 ½ – 18

0.51 (0.44-0.58)

18.5-24.9

11 ½ – 16 0.42 (0.35-0.50)
25-29.9 7 – 11 ½

0.28 (0.23-0.33)

≥30 5 – 9

0.22 (0.17-0.27)

We take a holistic approach to supporting healthy pregnancy weight gain at Lifestyle Maternity.

Weight is more than just a number …

Having a focus on the numbers on a scale (or in a table!) can be unhelpful. It doesn’t tell us the quality of what a mum is eating and nourishing her growing baby with. It doesn’t tell us how full or hungry she is. And it doesn’t tell us how active she is.

An obsessive focus on weight out of context can be stressful and cause anxiety – so that’s why we believe that monitoring weight is just one part of the puzzle with healthy pregnancy weight gain. As dietitians we also want to make sure that women are making healthy food choices, eating to appetite, and being physically active, and that baby is growing appropriately on scans.  We also believe that we have a duty of care to support women in achieving these healthy lifestyle goals.

However, it is still important to track how a woman’s weight gain is progressing – to be able to make clinical decisions and to provide more support, when required. Just as action is taken when a blood pressure is shown to be high rather than just expecting it to change once it’s identified, we need to link the monitoring of weight gain to helpful ways to address it through dietary and lifestyle changes to ensure women have the healthiest pregnancies possible.

How do Lifestyle Maternity Dietitians talk about weight?

Societal stigma associated with obesity has relevance for all health professionals striving to maintain good patient relationships, whilst providing evidence-based care. Lifestyle Maternity Dietitians have undertaken a lot of work in this area to make sure they are supporting the women they see in the most caring and respectful way (2, 3, 4).

We have also been involved in training for our maternity colleagues who have told us that providing best-practice care is important to them, but they are scared of offending women and causing anxiety or blowing things out of proportion.

The research we have been looking into reminds us all that “words matter” and that terminology acceptable to women may differ from that routinely used by health professionals  (5). We are learning from research that words such as ‘weight’ and ‘BMI’ are more likely to be positively received than references to ‘fat’ and/or (morbidly) ‘obese’ (6,7)(No surprises there!).

We support the approach that when we have conversations with pregnant women about healthy weight gain goals we avoid direct reference to BMI categories (e.g. ‘underweight’, ‘overweight’, ‘obese’ etc.).  Simply stating “Based on your weight at the beginning of pregnancy, this weight gain is recommended for the healthiest pregnancy possible” is both respectfully and clinically appropriate.

Further to this, we also like to raise the important topic that food is neither good nor bad – it is morally neutral. Eating healthy food does not make someone good, just as eating less healthy food does not make someone bad. Rather than referring to food as good or bad, terms like every day and sometimes food are more appropriate.

What resources do Lifestyle Maternity Dietitians use to support healthy pregnancy weight gain?

We use a resource our Director and Principal Dietitian, Dr Shelley Wilkinson, developed during her PhD studies. This resource is called the Lifestyle Maternity Personalised Pregnancy Weight Tracker©. This evidence-based resource was developed to support healthy lifestyles during pregnancy. This easy-to-use tool takes the guess-work out of weight gain during pregnancy by allowing women to track their weight gain each week against international and Australian guidelines. All women who see the dietitians at Lifestyle Maternity will gain access to their BMI specific tracker in the Members’ section of our website.

Studies show that when a woman knows how much weight to gain during her pregnancy AND is provided with continual feedback about how she is progressing, she is more likely to gain an appropriate amount of weight.

Rather than a one-size-fits-all approach, this approach tailors a weight gain goal to each and every woman during her pregnancy.

 

Instructions provided with the Pregnancy Weight Tracker show how to start using the tracker. Watch our instructional video that accompanies the Tracker to help you complete it. Discuss it at each visit with us or any of your other health care providers.

References:

  1. Institute of Medicine. Weight gain during pregnancy: Reexamining the guidelines. 2009, Washington, D.C.: The National Academies Press.
  1. Wilkinson SA, Stapleton H. (2012). Overweight and obesity in pregnancy: the evidence-practice gap in staff knowledge, attitudes and practices. Aust N Z J Obstet Gynaecol. 52:588-592.
  1. Wilkinson, SA. Wilkinson, Shelley A., Poad, Di and Stapleton, Helen (2013) Maternal overweight and obesity: a survey of clinicians’ characteristics and attitudes, and their responses to their pregnant clients. BMC Pregnancy and Childbirth, 13 117: 1-8. doi:10.1186/1471-2393-13-117
  1. Wilkinson, Shelley A., Donaldson, Elin, Beckmann, Michael and Stapleton, Helen (2016) Service-wide management of healthy gestational weight gain following an implementation science approach. Maternal and Child Nutrition, 13 2: . doi:10.1111/mcn.12266
  1. Gray C, Hunt K, Lorimer K, Anderson A, Benzeval M, Wyke S. (2011). Words matter: a qualitative investigation of which weight status terms are acceptable and motivate weight loss when used by health professionals. BMC Public Health, 11(531). 29 June.
  1. Thomas S, Hyde J, Karunaratne A, Herbert D, Komesaroff P (2008). Being ‘fat’ in today’s world: a qualitative study of the lived experiences of people with obesity in Australia. Health Expect, 11:321–330.
  1. Wadden T, Didie E (2003). What’s in a name? Patients’ preferred terms for describing obesity. Obes Res, 11(9):1140–1145.