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Obesity

Obesity and Women’s Health

Caroline M. Apovian, MD, FACP, FTOS, DABOM; Louis J. Aronne, MD, FACP; Sarah Barenbaum, MD 
Reviewed on July 24, 2024
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Introduction

The prevalence of obesity (body mass index [BMI] ≥30 kg/m2) among individuals of reproductive age around the world is reported to be as high as 30%. Up to 85% of women in developed countries are considered to have overweight or obesity. Among women of reproductive age, the prevalence of overweight and obesity has been estimated at approximately 40‑60% in developed countries and 30-40% in developing countries. Over the years, the increase in calorie intake in women has been more pronounced compared to men. Between 1976 and 2000, The United States (US) Centers for Disease Control and Prevention (CDC) reported an increase in daily mean average energy intake of 355 kilocalories (23.3%) for women as opposed to 179 kilocalories (7.3%) for men.

In the United States, the prevalence of obesity in both women and men is rapidly increasing at a rate of almost 6% per year. The percentage of women who have Class 3 (BMI ≥40 kg/m2) obesity is higher than the percentage of men who have Class…

Introduction

The prevalence of obesity (body mass index [BMI] ≥30 kg/m2) among individuals of reproductive age around the world is reported to be as high as 30%. Up to 85% of women in developed countries are considered to have overweight or obesity. Among women of reproductive age, the prevalence of overweight and obesity has been estimated at approximately 40‑60% in developed countries and 30-40% in developing countries. Over the years, the increase in calorie intake in women has been more pronounced compared to men. Between 1976 and 2000, The United States (US) Centers for Disease Control and Prevention (CDC) reported an increase in daily mean average energy intake of 355 kilocalories (23.3%) for women as opposed to 179 kilocalories (7.3%) for men.

In the United States, the prevalence of obesity in both women and men is rapidly increasing at a rate of almost 6% per year. The percentage of women who have Class 3 (BMI ≥40 kg/m2) obesity is higher than the percentage of men who have Class 3 obesity (11.5% vs. 6.9%). Obesity has been associated with many complications in both men and women, including cardiovascular complications, diabetes and cancers (Figure 11-1).

Enlarge  <strong>Figure 11-1:</strong> Medical Complications of Obesity in Women. Source: <em>Adapted from Maxwell CV, et al. Int J Gynaecol Obstet. 2023;160 (suppl 1):35-49. </em>
Figure 11-1: Medical Complications of Obesity in Women. Source: Adapted from Maxwell CV, et al. Int J Gynaecol Obstet. 2023;160 (suppl 1):35-49.

Psychosocial and Environmental Factors Associated With Obesity in Women

Sociocultural and Environmental Factors

Social and environmental factors which may affect the development of obesity in women include economic status (increased risk for low socioeconomic status individuals), geography (increased risk in the Southern and Midwestern states), food availability (e.g., increased risk with lack of healthy grocery options or increased fast food availability) and other local conditions (e.g., increased risk with higher neighborhood crime prevalence). In addition, access to healthcare systems is an important factor for the proper management of obesity in women. Important work still remains to be done to ensure that patients from disadvantaged socioeconomic backgrounds gain adequate access to the full continuum of medical care including the treatment of obesity, including referral resources for behavior change counselling, access to providers or clinics specializing in weight loss strategies or weight loss surgery and removal of care barriers (e.g., reducing appointment wait times and expanding insurance coverage of anti-obesity medication).

In women, obesity prevalence increases with decreasing income and educational attainment, though in non-Hispanic black women, obesity prevalence differs by education gradients but not by income gradients. One study of neighborhood physical disorder (e.g., vandalism, abandoned areas, garbage, property defacement, etc.) in Chicago found that women who live in highly disordered neighborhoods have a 1.43 greater chance of having obesity. The same study also found that women living in neighborhoods with high crime have increased weekly snack consumption. Furthermore, the prevalence of obesity differs across racial and ethnic groups that experience food insecurity. Non-Hispanic (NH) white women with food insecurity are 41% more likely to have overweight or obesity compared to NH white women without food insecurity. By contrast, Hispanic women with food insecurity are only 29% more likely to have overweight or obesity than Hispanic women without food insecurity. A United Kingdom (UK) study of 119,669 individuals 37−73 years of age reported a strong association between higher BMI and lower socioeconomic status, especially in women. Women with overweight are more likely to work in lower-paying jobs and earn less compared with women with normal weight.

Body image and stigma

Dissatisfaction with body image is correlated with obesity, and is often linked to eating disorders, poor self-esteem and depression. One meta-analysis reported that women expressed greater dissatisfaction with their body than men (Figure 11-2), a finding likely influenced by current cultural attitudes in Western societies, which favor slenderness. Another study found that, compared to men, women tended to perceive themselves as overweight regardless of their actual weight, with a significantly smaller percentage underestimating their own weight status and body size. The psychological effects of body image perpetuate the cycle of obesity in many patients.

Women are more likely to suffer weight-based discrimination compared to men, which can contribute to inequalities in employment and education. Women are particularly stigmatized due to their weight across multiple settings, including employment, education, media and romantic relationships. Women with overweight or obesity are less likely to be represented on television and are more prone to cyberbullying, hostility and verbal aggression on the internet (Figure 11-3). Weight-based discrimination of individuals with overweight and obesity also occurs at work, including being less likely than individuals with normal to get hired (even with identical qualifications) and receiving less pay for the same work.

A major concern is that weight stigma may lead to avoidance of necessary clinical care for both men and women if they perceive that their body weight will be a source of embarrassment. Women with obesity are particularly less likely to seek health care or recommended screening for some cancers due to body stigma (Figure 11-4). Obesity is associated with a significant number of comorbidities in both men and women. Delaying care due to weight stigma can worsen the severity of the comorbidities and lead to worse health outcomes. In contrast, treating obesity can lead to resolution of comorbid conditions. Therefore, it is essential to address weight stigma and bias in order to improve the overall morbidity and mortality associated with obesity.

Enlarge  Figure 11-2: Influence of Body Weight and Gender on Body Satisfaction. Source: <em>Adapted from Weinberger NA, et al. Obes Facts. 2016;9(6):424-441. </em>
Figure 11-2: Influence of Body Weight and Gender on Body Satisfaction. Source: Adapted from Weinberger NA, et al. Obes Facts. 2016;9(6):424-441.
Enlarge  Figure 11-3: Comparison of Female Body Types on Television vs Reality. Source: <em>Adapted from Greenberg BS, et al. Am J Public Health. 2003;93(8):1342-1348. </em>
Figure 11-3: Comparison of Female Body Types on Television vs Reality. Source: Adapted from Greenberg BS, et al. Am J Public Health. 2003;93(8):1342-1348.
Enlarge  Figure 11-4: Women Who Delayed Seeking Healthcare or Cancer Screening Because of Their Weight, by Body Mass Index. Source: <em>Adapted from Amy NK, et al. Int J Obes (Lond). 2006;30(1):147-155. </em>
Figure 11-4: Women Who Delayed Seeking Healthcare or Cancer Screening Because of Their Weight, by Body Mass Index. Source: Adapted from Amy NK, et al. Int J Obes (Lond). 2006;30(1):147-155.

Obesity-Associated Health Risks for Women

Cardiovascular Disease

Obesity is a major risk factor for cardiovascular disease in both men and women. Women with obesity are more likely to develop high blood pressure, high cholesterol and type 2 diabetes (T2D), all of which increase the risk of heart disease. In addition, cesarean birth and obesity are independent risk factors for the development of postpartum venous thromboembolism (VTE). Pre-pregnancy and postpartum BMI are independent risk factors for VTE.

Type 2 Diabetes

Obesity is a significant risk factor for the development of T2D in both men and women. Among postmenopausal women, metabolic health and obesity are directly correlated with the risk of developing T2D, due to increased visceral fat redistribution, insulin resistance and glucose intolerance that occurs during menopause. The Women’s Health Initiative (WHI) evaluated the risk of T2D among 161,808 postmenopausal women, including women with metabolically healthy normal weight (MHNW), metabolically unhealthy normal weight (MUHNW), metabolically healthy overweight/obesity (MHO) and metabolically unhealthy overweight/obesity (MUHO). Overall, 13.3% participants developed T2D over a mean follow-up time of 15.6 years. Compared to women with MHNW, an increased risk of incident T2D was observed in women with MUHNW (HR 2.24, 95% CI 1.74-2.88, P <0.0001), MHO (HR 1.68, 95% CI 1.40-2.00, P <0.0001) and MUHO (HR 4.51, 95% CI 3.82-5.35, P <0.0001). Therefore, postmenopausal women with MUHNW had a two-fold greater incidence of T2D as individuals with MHNW, while women with MUHO had nearly a four-fold greater risk of developing T2D (Figure 11-5). The risk of diabetes also increases with increasing BMI in premenopausal women; in one Korean study, the relative risk of diabetes in women with a BMI of 25 and greater was higher premenopausal than postmenopausal women. Women with obesity are more likely to develop gestational diabetes (GD), which increases the risk of developing T2D in all women, but more so in women with overweight and obesity. Women with polycystic ovary syndrome (PCOS) are also at a markedly increased risk of T2D, compared to women without PCOS.

Enlarge  Figure 11-5: Incident Rates of Diabetes per 1000 Person-Years Among Postmenopausal Women Without Known Diabetes at Baseline. Source: <em>Adapted from Cordola Hsu AR, et al. Menopause. 2020;27(6):640-647. </em>
Figure 11-5: Incident Rates of Diabetes per 1000 Person-Years Among Postmenopausal Women Without Known Diabetes at Baseline. Source: Adapted from Cordola Hsu AR, et al. Menopause. 2020;27(6):640-647.

Cancer

Obesity is associated with an increased incidence of several types of cancer, including endometrial, renal, esophageal, ovarian and breast cancers in postmenopausal women and colorectal cancer in premenopausal women. Women with obesity are at higher risk for these cancers than women with normal weight. The development of cancer may be influenced by the insulin–IGF-1 axis, as well as sex hormone and adipokine mechanisms. In women with obesity, non-surgical obesity management or bariatric surgery can reduce risk of cancer.

Respiratory Diseases and Sleep Apnea

Obesity-related dyspnea is characterized by a reduction in lung volume and function. Increased BMI, decreased partial pressure of oxygen (PaO2) and increased partial pressure of carbon dioxide (PaCO2) all contribute to worsening dyspnea. Additionally, obesity is a major risk factor for obstructive sleep apnea (OSA), a condition in which breathing is interrupted during sleep by upper airway obstruction. The systemic inflammation, cardiometabolic risk factors and endothelial dysfunction that often characterize obesity are major contributing factors leading to worsening intermittent hypoxia and metabolic dysfunction. Obstructive sleep apnea is also an independent risk factor for heart failure and mortality among women. The prevalence of OSA varies amongst women based on menopausal status. The prevalence in premenopausal and postmenopausal women who are on hormone replacement therapy (HRT) is 0.6% and 0.5%, respectively. By contrast, postmenopausal women who are not on HRT have an OSA prevalence of 2.7%. Women with OSA typically have increased comorbidities – including morning headache, insomnia, mood problems and anxiety – compared to men with OSA. Pregnancy has been associated with both an increased risk of and exacerbation of sleep disordered breathing, including OSA. Physiological changes during pregnancy and menopause lead to different sleep patterns and clinical presentations in women with OSA compared to men with OSA.

Liver, Gallbladder and Kidney Disease

The prevalence of nonalcoholic fatty liver disease (NAFLD) increases with increasing BMI. NAFLD is associated with a higher incidence of GD and early pregnancy miscarriages and can also lead to more severe hepatic complications over time. Similarly, obesity, female sex and multiparity are associated with increased risk of cholelithiasis; screening for cholelithiasis and associated complications in women with obesity is therefore recommended. Obesity and metabolic syndrome in pregnancy are risk factors for pre-eclampsia and persistent glomerulonephritis postpartum, diabetic nephropathy and end-stage kidney disease.

Musculoskeletal

Obesity increases the load and stress on the hip and knee joints, which can lead to the development of osteoarthritis (Figure 11-6). Each additional kg of body weight adds 6 kg of load to each knee, and every 1 unit increase in BMI increases the risk of knee osteoarthritis by 15%. Excess weight can eventually cause cartilage degeneration, reduced mobility and chronic pain due to greater mechanical stress on weight-bearing joints. In women with overweight (25 < BMI < 30 kg/m2), the relative risk of requiring joint arthroplasty is 1.80.

Enlarge  Figure 11-6: Cycle of Obesity, Osteoarthritis and Reduced Mobility in Individuals with Obesity. Key: *abdominal obesity is defined clinically as waist circumference > 88 cm for women and > 102 cm for men. @: improved with physical activity.<em> </em>Source: <em>Adapted from Duclos M. Ann Phys Rehabil Med. 2016;59(3):157-160. </em>
Figure 11-6: Cycle of Obesity, Osteoarthritis and Reduced Mobility in Individuals with Obesity. Key: *abdominal obesity is defined clinically as waist circumference > 88 cm for women and > 102 cm for men. @: improved with physical activity. Source: Adapted from Duclos M. Ann Phys Rehabil Med. 2016;59(3):157-160.

Urinary Incontinence

Excess body weight is thought to increase abdominal and bladder pressure, increasing urethral mobility and leading to urinary incontinence. It also exacerbates detrusor instability and overactive bladder. Urinary incontinence affects almost 50% of middle-aged and older women and profoundly impacts quality of life; it has been estimated in the early 2000s to account for more than $30 billion USD in annual direct costs. Urinary incontinence in women is associated with higher BMI and weight: each 5-unit increase in BMI is associated with an approximate 20%–70% increase in the risk of daily incontinence. Conversely, weight loss has been associated with changes in urodynamic measures and decreased incontinence. Risk factors for incontinence in women include high waist-to-hip ratio, waist circumference and weight gain.

Psychological

Women with obesity may experience negative psychological effects, such as decreased self-esteem and body image issues. This can lead to depression and anxiety, which can in turn exacerbate obesity and related health issues. Adolescent women with obesity are predicted to have a 4-fold increased risk of major depression, which is not present in men. Furthermore, many medications used to treat anxiety and depression can lead to additional weight gain, further exacerbating obesity.

Obesity and Reproductive Health

Obesity can have a range of negative effects on women's reproductive health. The gynecologic complications of obesity may occur at any point during reproductive and post-reproductive years. Some examples include irregular menses, infertility, pregnancy complications and, following menopause, increased rates of breast or endometrial cancers.

Childhood Development and Puberty

In girls, childhood obesity is linked to earlier onset of puberty and menarche. Available evidence suggests that this is mediated by the actions of the hormones leptin, kisspeptin and insulin on the hypothalamic-pituitary-ovarian axis. Elevated levels of leptin and kisspeptin in children with obesity correlate with adiposity and BMI, representing a possible neuroendocrine mechanism for the earlier onset of puberty and menarche in these individuals.

Higher body fat percentage, higher BMI percentile, or larger waist circumference, as well as larger increases in percent body fat and waist circumference in school-age children are associated with earlier pubertal development, often by the age of 9 years. Girls with elevated BMI were more likely to experience thelarche by age 8 to 9.6 years, pubarche by age 8 to 10.2 years and menarche by age 10.6 to 12.9 years, compared to girls with normal weight. Obesity-related developmental precocity can lead to adverse mental health and psychosocial consequences for girls during this very important developmental period.

Menstruation, Ovulation, and Polycystic Ovary Syndrome

Women with higher BMIs (≥25 kg/m2), higher waist circumferences (greater than 80 cm) and higher waist-to-hip ratios (indicative of central adiposity) are more likely to have irregular menstrual cycles, with a 2-fold increased chance in women with obesity. Obesity is prevalent in peri- and postmenopausal women who experience menopause-related physiologic and lifestyle changes. In 2017 to 2018, the prevalence of obesity (BMI ≥30.0 kg/m2) and Class 3 obesity (BMI ≥40.0 kg/m2) in women 40 to 59 years of age in the US was 43.3% and 11.5%, respectively. In women 40-60 years of age, increased weight gain may occur, which increases the risk of developing obesity.

Obesity can disrupt the hormonal balance in the body, which has many effects on menstruation. Higher BMI, waist circumference and waist-to-hip ratio have been positively associated with increased fasting insulin and testosterone levels and a higher free androgen index (FAI). Furthermore, obesity is negatively associated with sex-hormone binding globulin (SHBG) levels, which increases clearance of free sex steroids including testosterone, dihydrotestosterone and androstenediol. This in turn activates a compensatory mechanism leading to hyperandrogenism, long and irregular menstrual cycles and impaired ovarian function. Heavy menstrual bleeding in individuals with obesity is hypothesized to be due to two mechanisms: first, increased aromatization of androgens to estrogens in adipose tissue; and second, production of adipokines by adipose tissue leading to a proinflammatory state.

Insulin resistance and elevated unopposed estrogens in women with obesity contribute to the high rate of abnormal uterine bleeding and PCOS, which can result in infrequent or absent menstrual periods, as well as heavy menstrual bleeding. PCOS manifests as reproductive and hyperandrogenic features that include oligo-amenorrhea, hyperandrogenemia, impaired fertility, hirsutism, acne and androgenic alopecia.

The majority of women with PCOS (38%-88%) have either overweight or obesity. Weight-gain and obesity contribute to the development of PCOS, and, in a positive-feedback loop, PCOS can also contribute towards further weight-gain and hamper effective weight reduction (Figure 11-7). Conversely, weight loss can result in improvements in the reproductive, hyperandrogenic and metabolic features of PCOS.

The adverse effects of PCOS – including a heightened risk for the development of conditions such as T2D, impaired glucose tolerance, dyslipidemia, liver disease and obstructive sleep apnea – are greatly amplified by obesity. It is recommended to refer women with obesity and abnormal menstrual cycles to a specialist (e.g., gynecologist or endocrinologist) for evaluation.

Enlarge 
Figure 11-7: Mechanisms linking obesity and PCOS. Source: Adapted from Barber TM, et al. Clin Med Insights Reprod Health. 2019;13:1179558119874042.

Sexual Health

Women with obesity may experience sexual health issues, such as decreased libido, decreased sexual satisfaction and difficulty achieving orgasm. The reasons for this are multifactorial, including changes in sexual hormones, body image concerns leading to reduction in sexual desire, and physical limitations.

Infertility

Obesity can also make it more difficult for women to become pregnant. Infertility is three times more likely in women with obesity than for women with normal weight. Women with obesity may experience changes in the secretion of gonadotropin-releasing hormone by the hypothalamus, which can increase the secretion of luteinizing hormone by the pituitary gland and reduce the level of follicle-stimulating hormone. Androgen and estrogen levels increase, as does the FAI. Together, these hormonal changes decrease the chance of conception (Figure 11-8).

Enlarge  Figure 11-8: Mechanisms Linking Obesity With Infertility. Key: TNF-α, tumor necrosis factor-α; IL-6, interleukin-6; FFA, free fatty acid; GH, growth hormone; SHBG, sex hormone binding globulin; IGFBPs, insulin-like growth factor-binding proteins. Source: <em>Adapted from Gambineri A, et al. Int J Obes Suppl. 2019;9(1):65-72. </em>
Figure 11-8: Mechanisms Linking Obesity With Infertility. Key: TNF-α, tumor necrosis factor-α; IL-6, interleukin-6; FFA, free fatty acid; GH, growth hormone; SHBG, sex hormone binding globulin; IGFBPs, insulin-like growth factor-binding proteins. Source: Adapted from Gambineri A, et al. Int J Obes Suppl. 2019;9(1):65-72.

Women with obesity are more likely to require assisted reproductive technologies (ART) to conceive. Following in vitro fertilization, individuals with obesity are significantly less likely to become pregnant and give birth to a live infant, and are more likely to experience pregnancy complications. Women with obesity may have a suboptimal response to gonadotropin stimulation from ART, present with fewer follicles on ultrasound and have fewer oocytes upon retrieval.

Pregnancy Complications

Obesity is prevalent in women of reproductive age in the US, affecting nearly 25% of women who become pregnant. Women who have obesity during pregnancy are at higher risk of obesity-related adverse pregnancy outcomes (APOs), including miscarriage, pregnancy-related insulin resistance and GD, hypertensive disorders of pregnancy (HDP; including gestational hypertension, chronic hypertension and preeclampsia), complications with anesthesia and postpartum hemorrhage. Recurrent APOs are associated with higher long-term cardiovascular risk than single APO events.

An analysis of National Vital Statistics System birth data showed that 6.1% of women with an overweight pre-pregnancy BMI (range, 25.0-29.9 kg/m2) developed GD compared to only 3.6% of women with a normal pre-pregnancy BMI (range, 18.5-24.9 kg/m2). Gestational diabetes occurred in 8.8% of women with Class I obesity (BMI range, 30.0-34.9 kg/m2), 11.2% of women with Class II obesity (BMI range, 35.0-39.9 kg/m2) and 13.9% of women with Class III obesity (BMI >40.0 kg/m2), indicating that the prevalence of GD increases with higher pre-pregnancy BMI. Furthermore, GD often leads to development of T2D in women with obesity. Studies revealed that women with GD were more likely to independently develop T2D and cardiovascular disease postpartum than women without GD. An increased birth weight and childhood obesity is associated with higher risk of obesity and metabolic disorders, including diabetes, later in the child’s life. Furthermore, macrosomic birth weight (>4000 g) is associated with higher maternal T2D risk in later life.

Similarly, the risk of HDP increases proportionally with BMI. The Women’s Health Initiative Study conducted in 48,113 postmenopausal women revealed that women with a prior APO had a higher prevalence of chronic hypertension and atherosclerotic cardiovascular disease compared to those without a prior APO. Pre-eclampsia, a notable APO, occurs in 2–8% of pregnancies worldwide and is responsible for 30% of maternal deaths. The risk of pre-eclampsia in mothers with obesity is 3-4-fold higher than in mothers with normal weight.

Labor and Delivery

Obesity in pregnancy also increases the risk of complications during labor and delivery, including slower labor progression, increased gestational size and fetal distress; obesity also increases the risk of operative vaginal delivery and caesarean delivery. Women with obesity who undergo cesarean delivery have a higher risk for anesthesia-related complications, epidural failure, aspiration under general anesthesia and postoperative hypoxia. Additional complications during pregnancy include early pregnancy loss and preterm birth. Increasing BMI is strongly correlated with risk of still-birth, and obesity is associated with 25% of stillbirths between the 37th and 42nd gestational week (Figure 11-9).

The metabolic environment during fetal development influences the child’s short-and long-term health outcomes, such as potential childhood obesity, diabetes, asthma, heart disease and neurodevelopmental disorders. Epigenetic modifications and programming of reproductive cells from both parents may impact the health of future generations.

Enlarge  <strong>Figure 11-9:</strong> Risk of Stillbirth by Gestational Period. Source: <em>Adapted from Yao R, et al; Perinatal Research Consortium. Am J Obstet Gynecol. 2014;210(5):457.e1-457.e4579.</em>
Figure 11-9: Risk of Stillbirth by Gestational Period. Source: Adapted from Yao R, et al; Perinatal Research Consortium. Am J Obstet Gynecol. 2014;210(5):457.e1-457.e4579.

Postpartum – Breastfeeding

Breastfeeding carries metabolic benefits for women as well as their children; however, parents with obesity have been found to have lower breastfeeding rates in some communities. Women with obesity have lower rates of breastfeeding initiation and shorter feeding duration throughout the first year after delivery and are less likely to breastfeed exclusively. This may be due to mechanical issues (breast engorgement, more adipose tissue, flattened areolas and edema) and hormonal factors such as delayed lactogenesis. Women with obesity may also experience both physical and psychological barriers to the initiation and continuation of breastfeeding, which includes poor body image and low intention to continue breastfeeding.

More than 50% of women with obesity have a breastfeeding problem in the first and second days postpartum, compared to ~40% of women without obesity. Children of women with obesity are 2.8 times more likely to have difficulties with latching and positioning during breastfeeding compared to children of women without obesity. Women with obesity are also more likely to have low milk supply because of changes in prolactin levels, mammary gland hypoplasia and reduced stromal tissue. Consequently, there is a higher chance of earlier formula supplementation.

Weight Loss Optimization Pre- and Postpartum

Evidence suggests that pre-pregnancy and inter-pregnancy weight loss can significantly reduce the risk of incident and recurrent APOs, such as gestational hypertension and preeclampsia. Excessive dietary restriction may result in nutritional intake deficiencies and cause additional health problems; therefore, dietary adjustment is most effective when combined with exercise therapy.

After completion of breastfeeding, women of reproductive age should escalate therapy to treat obesity. A pre-pregnancy weight loss goal of 5–7% has been cited as a reasonable target to reduce risk of APOs, which is in line with generally accepted initial body weight reduction goal (5%) for both male and female patients with obesity. Like with all patients with obesity, the ultimate focus of care for women with obesity should be on improving health outcomes rather than focusing solely on weight loss.

Treatment and Management of Obesity in Women

Given its association with serious conditions including T2D, cardiovascular disease and some forms of cancer, appropriate treatment and management of obesity is of critical importance in both men and women with the disease. Successful treatment of obesity can lead to improvement in or resolution of the comorbid conditions. Obesity treatment comprises lifestyle changes, pharmacotherapy and bariatric interventions; counseling and support represent additional important management strategies.

Lifestyle Interventions

Lifestyle interventions, such as nutrition education, physical activity and stress management have demonstrated efficacy in improving the health of women with obesity. Dietary interventions may include specific diets to improve overall nutrition, including low-carbohydrate/high-protein, Mediterranean and low-glycemic-load; however, the main goal of dietary interventions should be calorie restriction, with a daily deficit of 500-750 kilocalories to achieve 0.5 to 0.75 kg of weight loss per week. Moderate aerobic physical activity (e.g., brisk walking or cycling) is recommended at a minimum weekly amount of 150-180 minutes. However, unless it is combined with a caloric deficit, physical activity is unlikely to produce significant short-term weight loss. Ideally, changes in diet and physical activity should be accompanied by behavioral therapy designed to facilitate and perpetuate them. Most obesity management guidelines recommend at least 6 months of participation in structured lifestyle intervention program, in which specially trained interventionists provide advice and guidance on dietary intake modification and increased physical activity. Benefits of lifestyle interventions include improved body composition (i.e., BMI, waist-hip ratio), blood lipid levels, gonadal hormone balance and psychosocial factors. activity

Pharmacotherapy

Available pharmacological interventions to treat obesity include orlistat, phentermine, phentermine/topiramate, naltrexone/bupropion, liraglutide and semaglutide.

Typically the treatment of obesity in women is the same as in men. However, antiobesity medications are contraindicated in pregnancy and breastfeeding.

Women of reproductive age should be closely monitored for pregnancy if they take medications for the treatment of obesity and should be counseled about options to prevent pregnancy, including contraceptives. If pregnancy occurs, medication for the treatment of obesity should be stopped. In women with obesity who are of childbearing age, a history of obesity-related APOs (such as GD or HDP) should be considered when deciding to escalate therapy.

Lifestyle interventions should always continue in combination with pharmacologic measures aimed at achieving a healthy weight.

Bariatric Surgery

Bariatric surgery is among the most effective weight loss strategies for sustained weight loss for men and women with obesity. About 80% of all patients undergoing bariatric surgery identify as women, with 56% being between 30 and 46 years of age.

Bariatric surgery and the resulting significant weight loss may decrease the risk of developing a variety of obesity-related obstetric conditions during and after pregnancy, including GD, gestational hypertension and cesarean delivery. The benefits of bariatric surgery for reducing obesity-related APOs must be balanced against short-term and long-term risks associated with gastric bypass procedures. For example, gastric bypass is associated with nutrient deficiencies that could potentially affect the growing fetus.

Bariatric surgery may result in adverse events, including gastrointestinal symptoms and vitamin deficiencies. Fertility and pregnancy outcomes are generally improved following significant weight loss, including that resulting from bariatric surgery. Although there is no consensus on the ideal time to conceive following bariatric surgery, patients should generally wait at least 12 months before attempting pregnancy, to avoid conceiving during the period of rapid weight loss and malabsorption that occurs after bariatric surgery.

Counseling and Support groups

Primary care providers and community healthcare providers, in conjunction with fertility clinics, contraception clinics and obstetrics and gynecology services should support women with of reproductive age with health and weight optimization before pregnancy. In addressing weight related concerns with patients, HCPs should ask permission to discuss weight and health, perform a physical assessment and an assessment of the root causes of obesity, discuss available care options and create a follow-up plan. Important considerations when discussing obesity and women's health include weight bias, stigma and discrimination, inclusive language and imagery and cultural sensitivities(Figure 11-10).

Counseling interventions, including dietary and physical activity counselling, have demonstrated efficacy in clinical trials for weight maintenance or weight loss in women 40 to 60 years of age with normal or overweight BMI. More frequent counselling sessions were more effective at weight maintenance or loss. However, the optimal type, intensity, periodicity and delivery method of counseling for women with obesity, and its effect on long-term health outcomes remains to be established.

Enlarge  Figure 11-10: Important considerations when speaking about obesity and women’s health. Source: <em>Adapted from Gambineri A, et al. Int J Obes Suppl. 2019;9(1):65-72. </em>
Figure 11-10: Important considerations when speaking about obesity and women’s health. Source: Adapted from Gambineri A, et al. Int J Obes Suppl. 2019;9(1):65-72.

Conclusion

Obesity is highly prevalent in men and women and but may present additional health management complexities in women. As many women of a reproductive age have obesity, the implications have long-ranging effects both on the mother and her child. In particular, women with obesity are more likely to develop complications during pregnancy and childbirth, and have an increased chance of developing chronic health issues after menopause. Future avenues of improvement in the management of obesity in women include more investment in reducing stigma, intensive health education and amelioration of health services.

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