Obesity management: a women's health approach

By Dr. Liji Thomas, MDMay 1 2023Reviewed by Lily Ramsey, LLM

About 650 million people are diagnosed as obese globally. However, managing obesity in women is often different from that in men. This premise is explored by a new paper published in the Journal of Progress in Cardiovascular Diseases, which provides a women's health perspective on obesity.

Study: A Women's health perspective on managing obesity. Image Credit: JacobLund/Shutterstock.com

Introduction

The researchers present a holistic consideration of the condition and its management against the background of female physiology. Such recognition could pave the way for better prevention and treatment of female obesity.

Little is known about the differential factors in male vs. female obesity. The effects of sex, ethnicity, and comorbidities must be further explored.

However, several hypotheses have been raised surrounding the observed differences between the sexes when it comes to weight gain.

These include weight gain associated with female life stages, namely, puberty, pregnancy, and menopause when enormous changes in female sex hormones occur. The effects of age are exacerbated by reduced ovarian function and increased androgen production in perimenopause.

Neural and behavioral factors are also postulated to affect women's greater response to calorie-dense foods, especially those high in carbohydrates.

Measuring body fat

Body mass index (BMI) is the most common benchmark for diagnosing obesity.

As described by many researchers, however, the BMI fails on many counts. Not only is it unable to distinguish lean from fat body mass, but it also does not take race and sex differences into account, nor does it leave room to accommodate differences in bone density.

These are critical in differentiating healthy body mass from unhealthy and contribute to pushing a large proportion of the population into the obesity zone, albeit falsely. Other measures like the waist circumference and waist-to-hip ratio also fail to distinguish visceral fat mass from other body components.

More accurate methods like dual-energy x-ray absorptiometry (DEXA) are available to assess body fat mass directly but are not cost-effective in a clinical scenario. Digital anthropometry may fill the gap, but further studies must confirm it as an affordable alternative.

Diagnosing obesity

How can the issues mentioned above be remedied? The paper suggests a comprehensive assessment of the individual as the first step. This begins, as always, with a history focused on periods of weight gain, factors that drove weight gain, including dietary factors, physical exercise, and medications and life events. The impact of pregnancy and menopause are crucial among women, as is the family history.

Sleep and stressor history is also important, as well as the socioeconomic environment which often forces unhealthy food choices on the individual and/or family.

Medications like steroids, often used in chronic inflammatory conditions, antihistamines, and anti-psychotics, are associated with metabolic alterations leading to weight gain.

Finally, psychological conditions such as bulimia and night-eating syndrome also occur frequently in obese patients and require specific interventions to improve their mental health.

Such an assessment…

…recognizes that obesity is not merely caused by an individual's choices (i.e., diet, amount of exercise, or willpower)"...

…thus reducing social stigma related to obesity and providing healthy ways to move ahead.

How to treat female obesity?

Considering the breadth of factors affecting female obesity, its treatment must be equally multifactorial and tailored to the individual patient and cultural surroundings. Financial well-being is equally important, as is the sustainability of the intervention plan.

For instance, a complete medication review is indicated to weed out, substitute, or complement those that induce or encourage obesity.

Lifestyle therapies are the linchpin of weight loss efforts, with adjunctive medical or surgical interventions as required. Nutritional advice and support are crucial to allow the patient to adapt to a nourishing but non-obesogenic pattern of food intake.

Physical activity helps prevent weight gain but cannot usually promote it. However, when conjoined with a nutritional program, it builds cardiovascular fitness, improves physical function, and boosts energy expenditure, thus helping maintain a stable weight.

It is important to identify and correct sleep disorders, and diseases like gastro-esophageal reflux disease (GERD) and depression, or asthma, that contribute to obesity and intensity its morbid effects.

Stress relief should also be a part of the intervention since both external stressors and weight stigma may oppose the success of weight-loss efforts.

Pharmacotherapy is restricted to those with failed weight-loss goals using only lifestyle therapy, provided the patient is not lactating and is obese or overweight with related disease conditions. Several approved medications are in use at present for long-term use. A few other anti-diabetic medications are used off-label for the same purpose.

Bariatric surgery is another option for such patients, with most procedures involving removing the major part of the stomach and diverting the gastric contents to bypass part of the small intestine, promoting malabsorption.

These are highly effective in producing acute severe weight loss, but their long-term effects are less certain, and their use is associated with malnutrition, micronutrient deficiency, and acid reflux.

Pregnancy is a special risk factor for obesity in women, and vice versa. Pregnancies in women with excessive weight may be complicated by fetal anomalies, large babies, preterm birth, stillbirth, gestational diabetes, and pre-eclampsia. The latter may persist or arise unusually early in later life as well.

Women who are already overweight or obese before pregnancy should lose weight at this point via lifestyle strategies to optimize their chances of a healthy pregnancy.

Ovulatory disorders like anovulatory polycystic ovarian syndrome are often corrected or benefited, and the efficacy of assisted reproductive technologies (ART) is often improved by weight loss.

However, intensive support is required to maintain pre-pregnancy weight loss throughout pregnancy. About 50% of women experience excessive weight gain during pregnancy, which carries forward into later life.

Again, about three-quarters of pregnant women retain the weight they gained into the first year postpartum, with a mean gain of 4-5 kg at one year.

Exclusive breastfeeding and psychological support may mitigate such retention, which is associated with long-term weight issues, cardiovascular disease, type 2 diabetes and endometrial/breast cancer, irregular menstrual cycles, and fertility issues, besides pelvic floor disorders.

Physical activity is known to improve maternal well-being but requires social support, in most cases, to become a part of life.

What are the implications?

Multiple causes may underlie female weight gain leading to obesity and related comorbidities.

Obesity in women may increase the risk of cardiovascular disease, especially after menopause which is itself a cardiovascular risk factor for women of all body weights.

From a biological perspective, the treatment of obesity in women is different in contrast to men and varies accordingly to the woman's age and stage of development."

This should drive the framing of interventions to lose weight and keep it off while successfully navigating the various life stages in a woman's lifespan. Future steps should also explore disparities in obesity rates and treatment options in high-prevalence sections of the population.