[0:32] Shireen: In today’s episode, we celebrate the work of Dr. Lauren Butler. Her Paramount efforts in weight inclusive behavior health interventions, redefine and challenge traditional norms striving for social justice and health equity for marginalized communities. Join us as we delve into her transformative work, challenging biases and championing holistic wellbeing for diverse communities. Stay tuned. Dr. Lauren Butler is a registered dietitian and nutrition epidemiologist. Dr. Butler works as an assistant professor in the nutrition and foods program at Texas State University. She leads the food freedom research team, a team of students, researchers, community members and other stakeholders with the shared goal of ending weight stigma and advancing nutrition equity and social justice. Welcome, Dr. Butler.

[1:26] Lauren Butler: Thank you, Shireen. And I’m glad to be here.

[1:28] Shireen: An absolute pleasure having you on. Dr. Butler, I want to start a little bit. I want to take a step back and really try to understand what inspired you to pursue your current career. And can you just tell us a little bit more about what was it in your journey that led you to this point?

[1:43] Lauren: Sure. I think yeah, I would love to the way that I would really want to answer that question is to say, you know, I haven’t always been a weight inclusive, dietitian and researcher. I have been a registered dietician, since 2009. And I have worked in a variety of settings, clinical settings, community settings, academic settings, always working with in for historically marginalized communities and towards the goal of ending health disparities. It wasn’t until about 2018, when I had finished my doctorate and was working in my own private practice that I transitioned from a weight centered weight loss focus to await inclusive focus. And the interesting thing about that, there’s lots of interesting things. But where I was in my academic and professional journey, then is I was actually working at a substance use disorder, alcohol use disorder treatment facility, and working with folks who were in recovery not only from substance and alcohol use disorder, but from eating disorders as well, there’s a lot of CO occurrence of eating disorders with substance and alcohol use disorder. And at that point, things just really started to click for me, I would see my patients come in and be so anxious about weight regain, and really more focused on their their weight and their body shape and size than their recovery. And I saw that it was really a barrier to the overall health that they were seeking. And at that point, I was introduced to intuitive eating and started to study weight bias and it progressed from there. And so eventually I returned to academia. And vowed you know that I would only return to the academic space in a place where I would be able to practice and research from a weight inclusive lens. And I found that here at Texas State. So I’ve been really lucky.

[3:33] Shireen: And thank you for sharing a little bit about that journey. And I do want to double click on what you mentioned about being weight inclusive and sort of focusing on that. So your work in weight, inclusive behavior, health interventions really aligns with fostering health equity, like you mentioned, how do these interventions really contribute to a more inclusive and diverse approach to health and nutrition? And with a specific focus on marginalized communities?

[3:59] Lauren: Yeah, I think that’s a great question. And if we think about the way that health disparities are framed in our country, right, health disparities are typically framed as those with marginalized identities are the ones that are experiencing the most nutrition related disease, right? We hear all the time, for example, that black women have the highest rates of obesity, and that Hispanic persons and in the Hispanic community that are the highest rates of diabetes, just for example. And so I think that the way that weight inclusive interventions, how is an address this is they really help to provide and support a more inclusive environment.

[4:40] Shireen: So that’s interesting that you mentioned that, Dr. Butler, and specifically when you mentioned around weight inclusivity. I do want to double click into that. So your work in wait inclusive behavioral health interventions really aligns with fostering health equity, right? How do these interventions really contribute to a more inclusive and diverse approach to health and nutrition, especially when we’re talking about marginalized communities.

[5:04] Lauren: Thanks for sharing, this is a great question. So to answer the question, I think we need to understand one of the key tenets of weight inclusive care and weight inclusive interventions and practice, are really founded on the understanding that the social determinants of health are key in understanding in this case, we’ll talk about weight, right, so that the social determinants of health are key in contributing to a person’s body weight, shape and size, right. And so the social determinants of health are things like race, sexual orientation, gender identity, access to health care, access to food. And if we understand and agree that folks with marginalized identities in this country have not had equitable access to those things, and when we think about the social determinants of health and how they impact those who are marginalized in this country, then we can understand how important it is when working with folks from the inclusive lens to ask about those social determinants of health. So I asked my clients, you know, about sexual orientation and gender identity, and I’ve had people question that in the classroom and say, Why are you asking about that in a nutrition assessment, you know, I don’t care who that person loves. And I say it’s because they’re experiencing discrimination and experiencing factors that are impacting their health, their body weight, shape, and size that are outside of their control, which are encompassed in the social determinants of health. And so I think that’s a key component and understanding how weight inclusive interventions and inclusive care contributes to a more diverse way of treating and working with people.

[6:42] Shireen: That is helpful to know now in your, in your research, specifically, how do you navigate the intersectionality of identities with marginalized communities when addressing issues like weight stigma, body image, or even disordered eating behaviors?

[6:59] Lauren: Great question again. So I think one of the things that’s really important for me is thinking about the way that health disparities are framed in this country. And if we think about that key issue, most health disparities are focused towards marginalized communities. So for example, we are told often that black women are living with the highest rates of obesity, and that Hispanic persons are living with the highest rates of diabetes. We also know that race and ethnic minorities, for example, tend to have larger body size, if we look at rates of obesity, which I try to avoid using that word. But we know that that is what we see right through the health disparities research. And so if we think about that intersectionality, for example of living as a race and ethnic minority, and also in a larger body, with those, just those two, multiple those two intersecting marginalized identities, then, you know, it’s really important for me that I take that into account in my work. And so with regards to weight stigma, for example, in my research, it’s really important to me that I’m making sure that when I’m collecting data that I’m collecting as accurate data as possible on race and body size, so that when I run the analysis, for example, I’m able to have large enough sample size that I can look at folks that are race and ethnic minorities and living in larger bodies. And that’s just one way that I take that into account. Another way is making sure again, that using appropriate assessment tools for sexual orientation and gender identity, for example, which is often overlooked, or not accurately. And so that’s just one way in the research realm that some tools that I use to navigate intersecting identities.

[8:38] Shireen: From a nutrition and wellness perspective, how can a weight inclusive approach really positively impact the Cardiometabolic Health within diverse populations?

[8:49] Lauren: I love this question, because this is something I get really passionate about. So we know as dietitians that and health care providers and public health researchers all should know and understand that there’s research out there that shows let’s talk about high cholesterol for example, that exercise just exercise independent of weight loss with no weight loss at all. Regular exercise can lower cholesterol levels. Additionally, intake of fiber can lower cholesterol levels without having any weight loss at all. Smoking cessation can be beneficial for lipid levels. So the way that a weight inclusive approach can be helpful for cardio metabolic health is that there’s many things that folks can do without focusing on weight loss that can improve their cardio metabolic health. Now, I’ve mentioned lipids but also think about blood glucose and diabetes and prediabetes. Again, same thing we see that with exercise, folks are able to more to manage their glucose levels more accurately and to prevent those highs and lows. Another way to prevent those high highs and low lows is just by eating regularly which is not a weight focused taking Hey, it’s something you know, that I use with my clients is how many meals a day are you eating, and you’d be surprised how many adults are not consuming regular three regular meals a day. And so in the case of blood sugar management that can really wreak havoc. Another thing that can really wreak havoc is avoiding carbs altogether, many of the folks that I worked with that were living with diabetes or prediabetes, we’re terrified of eating carbohydrates, which we all need carbohydrates for our brain to function properly. And so what would happen is they would avoid carbs, avoid carbs. And then of course, because our body needs carbs, there would be a compensation as what I like to call it, where they would eat a lot of carbs in one sitting. And again, this is just spiking those blood sugars from very low to very high. So without focusing on weight at all, I could have a whole session with a client on just supporting them, and eating regularly and what we call consistent carbohydrate intake throughout the day.

[10:52] Shireen: So which leads me to how does the mixed methods system approach influence the development of strategies that combat weight bias, especially again, in the context of nutrition and wellness?

[11:04] Lauren: Thank you. You know, for me being a practicing registered dietitian in the past, and also a trained nutrition epidemiologist, I feel really lucky that I can use my clinical experience to help guide my research questions. And then my epidemiology techniques to conduct secondary data analysis. So I use datasets like our nationally representative, nutrition, health, and sorry, National Health and Nutrition Examination Survey. And I will conduct quantitative data analyzes to help me generate hypotheses and think about questions. And then or collect data. I also collect primary data from communities I currently collecting data from mentors and community health workers and in and around Central Texas. And so what happens is, I can use that quantitative data and say, Okay, this is what we saw, for example, we saw that Mexican American women are reporting that they’re using supplements to try to lose weight often. And then I can take that to a qualitative study, and have focus groups or in depth interviews with folks and ask more in depth questions around the supplement use, or around the weight loss, you know, what are the motivators? Why are you doing this? Where do you get the supplements from, and have more of an in depth discussion that helps to understand what’s happening in a much broader level. And so having both that quantitative and qualitative data is really important in terms of developing interventions. I also in my qualitative studies, interview healthcare providers, so I have been working on a study with a healthcare organization to interview nurses around their own experience of weight stigma, for example, and to understand more details around their experience, when they go to receive health care, and also how that may be impacting their patient interactions. And that’s where the system’s level really comes in, is moving from focusing on individuals who are experiencing health disparities who are experiencing the discrimination and the adverse social determinants of health, and really going, Okay, let’s move from the individual level, to the system’s level to the healthcare workers to the actual structures and policies that are in place that need to be changed to help support folks health. So that’s really what I mean when I say mixed methods. It’s the quantitative, the qualitative, and then the system’s level, how can we make changes within organizations? And one other thing I’ll add, that’s very interesting is I’m working with an interior design faculty member, actually assessing the space in a health care, a primary care clinic to examine occurrences of weight bias by design. So for instance, are the chairs big enough? Are the exam tables big enough for accommodating for all body sizes? And so that’s another way that we get systems level is by looking at what’s going on in the environment and the design of structures. So those are just a few things that I have going on.

[14:09] Shireen: That is so interesting. And I’m going to go on this brief tangent. So please bear with me, Dr. Butler, you know, when you mentioned about stigma than even talking to nurses specifically, can you shed some light on what some of those findings have been?

[14:22] Lauren: Well, we’re just starting the study now. And so I can tell you even in trying to get the study rolling, we faced barriers related to the social determinants of health. As you can imagine, there have been some nuances that we’ve needed to address. For example, initially, we wanted to ask questions about the nurses own bias and stigma that they how they felt about patients and larger bodies. So we got pushed back, and we’re told, you know, you can’t ask those questions because what are your findings going to show? Are they going to show them that our nurses are fat phobic and And they’re contributing to stigma. And we don’t want to put that out in the world, right? So we’ve had to reframe and go back to the drawing board to ask instead, you know, how did nurses experience weight stigma, when they go out into their own health care visits, and try to take the focus off of the potential stigmatizing behavior that they may be enacting on, folks? And so we’re still working on that, you know, how do we navigate that to still answer the important what we think are important research questions, I can tell you that the research shows that primary care doctors and nurses are among some of the top two sources of weight stigma, according to the studies that have been done in the US.

[15:43] Shireen: And I find it fascinating that as you’re trying to even try to collect that data, that there’s a little bit of a push back resistance that you’re hitting up against, and having to sort of redesign the way that you’re approaching some of those questions.

[15:56] Lauren: Yeah, I did, too. I didn’t expect that that was an unexpected part of the process.

[16:02] Shireen: In the second part of what you mentioned, around the interior design, so that I find that quite fascinating, because you don’t, I guess you don’t actively think about the space that you’re walking into. But it also has a lot of bearing in the way that you would be perceived in, you know, case in point to what you mentioned with, you know, the chairs and the chairs being wide enough. Can you speak to some more examples of those types of things when considering the environment of the space within which you’re seeking care?

[16:28] Lauren: Yes, I’d love to, you know, it’s really sad, actually, the discrimination that goes on you some people may call it micro aggressions towards folks in larger bodies that are occurring in not just healthcare environments, but will focus on healthcare environment. So some other examples are not having gowns that are accommodating for folks in larger bodies. So the gowns not covering, you know, folks properly, blood pressure cuffs not being accommodating, and not the right size for all body shapes and sizes, speculates that are used for different types of gynecological exams not being made correctly and designed correctly for all body types. It even goes to the extent of vaccines. And so there was some research that I heard around the time of COVID, where folks had found that, for some reason, folks in larger bodies are more susceptible to COVID, well come to find out the needles weren’t accommodating and weren’t actually the right size and length to provide an effective vaccine. And so there was some issues around that. And so these are things that we if you’re not have never experienced that never had that lived experience, you may not be aware, more subtle things that to somebody who’s not living in a larger body would be just the literature that’s on the tables, you know, have you ever gone into a health care providers office, and they have Marie Claire, or these other magazines of you know, thin white women, or really muscular beefed up men, the fitness magazines and things of that nature. So that can even be a microaggression and perpetuate weight, bias and internal weight stigma within oneself that someone who’s living in a larger body.

[18:11] Shireen: And what I’m implying from there is to when you create that environment that is more inclusive, and when you take away some of those magazines a scale one way, you’re creating that environment that is more inclusive, acceptable, that that almost sets the tone for the care to be received.

[18:26] Lauren: That’s right. And there’s simple ways to do that showing I mean, having loveseat rather than individual seats that have bars, there are tools and gowns that can be ordered and blood pressure cuffs that can be ordered in some cases. So it’s a little more difficult. For example, exam tables really need to be made in a different way than what they are. And so, again, getting back to that systems level, how do we encourage folks to make those changes in ways that will be meaningful?

[18:56] Shireen: That is helpful. And speaking of systems, it starts with students, right? So in, in mentoring students and really leading the food freedom research team that you do, what key principles of strategies do you really emphasize to combat photophobia help is and ableism racism, and just really weight bias in general in the pursuit of again, health equity.

[19:18] Lauren: Thank you. I really am proud of my food freedom research team. And as part of mentoring always, for me, cultural humility is a really important principle. One of the ways that I try to instill that is when I have tasks for the team members to work on, especially with students, I will oftentimes ask them, you know, let’s meet and talk about what you’ve done. And one of the ways that I foster cultural humility is I really work with them on including representative imagery. So if they’re creating a presentation or creating a handout or creating a recruitment flyer, I work with them on okay. So how does this represent the population that have interest? You know, where are the photos, where is the language. And so thinking about cultural humility and representation that way, also, I talked with them directly about how important it is to have representation from the community involved in everything we do. So for example, I mentioned the project with parameters and community health workers earlier, I have now three paid community health workers on the food freedom research team that work with us in creating questionnaires, creating recruitment materials, going out into the community and scheduling interviews and talks and collecting data, and getting their perspective and, and feedback on everything that I think is a great idea, because I might think it’s a great idea, but I am not a member of the Hispanic community. And so I need their input. And I default to their input. And so I show this to the students through a lived example, and also talking to them about how important it is. The other thing is, we have those hard discussions around fatphobia. And around the whiteness and the thinness that has been the crux of the nutrition and dietetics field. And I have even taken students and advocated for students to come to the weight inclusive Nutrition and Dietetics conference that was held a symposium that was held in Austin last year. And I give talks to the students and to our interns about weight inclusive care. So I challenged them in a lot of ways. And I asked them a lot of questions to help them think so I really tried to help them to think on their own. But those are some of the key things that we do as a team.

[21:40] Shireen: You’re also a member of various professional organizations, and how do some of these affiliations really support your mission to advocate for health equity and social justice really within the context again, of nutrition and behavioral health?

[21:54] Lauren: Well, I mentioned weight, inclusive nutrition, and dietetics, which I think is a fabulous nonprofit organization that has free membership for students. So any students out there should definitely check out wind weight, inclusive Nutrition and Dietetics. I have been fortunate to attend that symposium in Austin. And I think they just do a great job of bringing in folks that represent the communities that are most important and most impacted by fat phobia, and weight stigma. I’m also a member of the Association for Size, diversity and health, which is the association that actually started the Health at Every Size, social justice movement, they often don’t get the credit that they deserve for that. And I think that it’s really important. These are not like the Association for Size, diversity. And health, for example, was not an organization that I had heard of until I started doing my own research on weight, stigma and weight bias. And so now I bring that into the classroom, I talk about that association, I have assignments where I have students go and learn more about Health at Every Size, and the Association for Size, diversity and health. And I think, you know, as a nutrition professional, I’ve had to do a lot of work to go out and bring in new resources that I share with my students to help them to see, hey, you can be an advocate, you can be an ally, and the resources are out there, we just have to have an open mind and realize that we’re not always shared those things. When we’re taught in school, the traditional nutrition curriculum, which is very whitewashed, and oftentimes doesn’t include some of these key concepts and principles that are really important to nutrition equity.

[23:32] Shireen: I love that approach. And I would love to even just get your take on for any providers sort of listening to this episode today or watching it today? How can the broader nutrition and wellness community really embrace more of that inclusive and diverse approach while moving away from weight centric methodologies to providing care?

[23:53] Lauren: Well, there’s some great research that’s out there. There’s a recent article published by Malden at all about shifting the paradigm, the weight centered paradigm in healthcare. So I would encourage folks who are very interested in academic and peer reviewed resources to look for that moulden article. There’s also a great paper by toca at all. That’s a literature review focused on weight inclusive care. And if you’re looking for books, Dr. Sabrina strings, fearing the black body is a great resource to start your journey. The book on Intuitive Eating is also a place to start. So my overall idea is saying there’s research out there, there’s books, there’s peer reviewed publications, it’s really if you’re interested, we have to go out there and seek them though because in a lot of cases, there’s not right now consolidated places that are well known. Now I’ve mentioned Association for Size, diversity and health. They have a whole website on health sheets that come at different medical concerns from a weight inclusive lens. That’s a great resource, the weight inclusive nutrition in dietetics, organization is another great resource. The resources are out there. If you just simply start the journey, you’ll find what you’re looking for. And you’ll find those groups and other like minded folks. And there is great peer reviewed publications that support weight inclusive care. So whenever you’re feeling alone, or you’re feeling like no one is listening, or they think you know that you don’t know what you’re talking about. Get yourself up to date on those articles, so that you can share them with people and so that you can know that what you’re doing is just as valid as the research that is more popular, and well known.

[25:39] Shireen: Lovely. And on that note, Dr. Butler, we are toward the end of the episode. At this point, how can our listeners connect with you and just learn more about your work?

[25:48] Lauren: I would love for folks to connect with me, I always love to take emails, my email address is Lauren Butler at Texas state.edu. It’s Lauren Butler at TX state sta t.edu. You’re also able to find me on LinkedIn, have Instagram, Dr. Lauren Butler. And those are three great ways to get in touch with me. And I’m always willing to have mentoring sessions to talk to share my ideas. So please don’t hesitate to reach out if you have any questions.

[26:21] Shireen: Perfect. And so we’ll link up everything in the show notes. If you missed anything, we’ll link it up in the show notes for this episode. On that note, thank you, Dr. Butler. So very much for your time, it was an absolute pleasure having you on this episode, and really sharing your insights and all the progressive work that you’re doing in this space that is much much needed. So I want to applaud your work and to thank you so much for spending that time here. And to our listeners who joined us here today. Thank you for another great episode and for joining us on this. And you know exactly what time it is we head over to social media next to answer this quick question, which is how do you envision applying the principles of inclusivity and diversity within your own approach to nutrition and wellness? Again, head over to social media at Yumlish on Instagram, Facebook, find this very podcast post and comment below to tell us again, how do you envision applying the principles of inclusivity and diversity within your own approach to nutrition and wellness? We will continue the conversation there. And with that, Dr. Butler, thank you again for your time.

[27:21] Lauren: Sure

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