April 10, 2024

Beyond the Stigma: Obesity’s Impact on Women’s Health

The Centers for Disease Control and Prevention (CDC) describes obesity as “a common, serious, and costly chronic disease of adults and children that continues to increase in the United States.” The medical definition of obesity is excessive fat deposits in the body that can impair health. Many health organizations will use the measure of body mass index (BMI) as a screening tool for measuring overweight and obesity in individuals, but this measure has limitations. BMI does not account for the distribution of fats, types of fats (i.e., visceral fats, which are found deep within the abdominal cavity and are particularly dangerous), muscle mass, or body composition; nor does it have good sensitivity to identify people with increased adiposity or have performance that is equal across different ethnic groups. (The BMI screening tool was developed based on the bodies of non-Hispanic white men and may not provide accurate results for people who fall into other categories of sex, ethnicity, and race.) Its use as the primary tool to identify risk for obesity further complicates the field.

Obesity rates are rapidly rising in the United States and globally, posing challenges for individuals’ overall health, particularly for women. Obesity has been shown to increase an individual’s risk of other chronic conditions and diseases, such as type 2 diabetes, heart disease, infertilityPCOS, and some cancers including breast cancer. On February 20, 2024, the Society for Women’s Health Research (SWHR) convened an interdisciplinary working group of policy experts, researchers, clinicians, and patient advocates for a roundtable discussion on women’s health and obesity. During the meeting, the group discussed the impact of obesity on women’s health, with a particular emphasis on the impact of obesity on cardiovascular disease, health care costs, and related health disparities.

Obesity Terminology

Throughout the roundtable, the challenges posed by the term “obesity” and how to define obesity were underscored.

In 2013, the American Medical Association (AMA) recognized obesity “as a disease state with multiple pathophysiological aspects requiring a range of interventions to advance obesity treatment and prevention.” In 2023, a decade later, AMA released a policy titled “Advocacy Against Obesity-Related Bias by Insurance Providers,” calling for health insurance coverage parity for obesity. Still, not all health organizations or providers recognize obesity as a disease, which can cause confusion across medical practice. All stakeholders should use the same language, working groups members fervently repeated. Without agreement and buy-in on recognizing obesity as a disease, it is difficult to achieve productive research, access, and policy discussions.

“The language we use makes a huge difference,” said Lydia Alexander, MD, FOMA, fellow, diplomate, and President-Elect at the Obesity Medicine Association. She noted that the conversation around obesity should rarely be focused on weight loss but instead on addressing the fat deposits in the body, body composition, and long-term maintenance of weight loss. There is no concept of an ideal body weight or even ‘normal BMI’, and even modest amounts of weight loss can lead to major health benefits. For many individuals, a healthy weight for your body may change over time, so concentrating on getting to a certain number or size (including a specific BMI) is not necessarily beneficial. Good weight management can often be a more accurate term.

Language holds power, and for some, the term obesity is associated with stigma. Body weight and size (like language) can also be deeply rooted in cultural norms, so the translation of terms like obesity may not make sense for every group. Some languages may not have a true term for obesity, noted Millicent Gorham, PhD (Hon), MBA, FAAN, CEO of the Alliance for Women’s Health and Prevention, so engaging in conversations about healthy weight within the context of overall health and disease risk with many populations may require different terms and tools. Additionally, weight in some cultures such as immigrants from African or Latin American can be associated with good health, noted Francisco Lopez-Jimenez, MD, MSc, MBA, Chair of the Division of Preventive Cardiology and professor of medicine at Mayo Clinic School of Medicine. Understanding the specific cultural values and beliefs of a person related to weight are very important for health professionals.

Relatedly, issues around public education and awareness campaign messaging were raised as important needs. Obesity is often seen in U.S. society through a lens of blame rather than as a neuroendocrine disorder – blaming individuals for not being able to manage their weight. However, as working group members noted, there can be multiple causes of obesity, including genetics, metabolic factors, chronic stress, depression, medications, environmental factors, sex and gender, and more. Tackling misperceptions could provide great benefit in addressing obesity stigma. There is important work that needs to be done to combat the misinformation and stigma proliferating in the media and online, including on social media platforms. This misinformation can be particularly harmful to women and girls, who are often held to different physical body standards than men and boys. Anti-obesity and weight management medications have created a flurry of media attention, which working group members noted often uses problematic and unhelpful language, thereby exacerbating the stigma and misconceptions surrounding obesity as a cosmetic issue rather than a medical condition.

The Research Landscape in Obesity

There is a significant amount of existing research about obesity pathology, and the medical field has a deep understanding of the hypothalamus, hunger, and fat. “The weight regulatory system in the body both centrally and peripherally is actually pretty well defined, and this is why we are able to target medications and understand what is causing weight gain in drug research,” said Dr. Alexander. There is also acknowledgment that dozens of the most common chronic diseases, including sleep apnea and type 2 diabetes are directly related to weight dysregulation. But what we do know about obesity, noted Dr. Lopez-Jimenez, is largely based on research in men.

While some areas of obesity research are well defined, others could benefit from additional research. Working group members highlighted the need to better understand the role of the microbiome in obesity, the mechanisms of anti-obesity medications, how genetics may influence one’s predisposition to weight gain, and the relationship between obesity and endocrine system conditions. In addition to identifying research areas, working group members emphasized that researchers will need to be diligent in including the individuals most impacted by obesity within each of these clinical trials. Given the size and scope of the obesity epidemic, additional research investment must include people living with obesity who have multiple chronic conditions, people in different geographic areas, and people of different races, ethnicities, sexes, and genders – many of whom are often left out of current research.

Obesity and Women’s Health

A woman’s health span, from puberty to her potential childbearing years and through the menopause transition, puts her at a unique risk for obesity. Obesity impacts women differently than men, and rates of severe degrees of obesity are higher in women. Women have a higher percent of body fat compared to men of the same BMI. Obesity causes significant cardiometabolic changes in both men and women, yet the common symptoms for heart disease are often more difficult to recognize in women. Women’s experiences with obesity can also have distinct impacts on their physical, emotional, and mental health. During the roundtable, SWHR had the privilege of hearing from two women about their personal experiences with obesity.

Liz Paul, Obesity Action Coalition (OAC) Board Member and obesity advocate, recalls struggling with her weight growing up, but it wasn’t until age 37, while she was attending an OAC conference, that she heard obesity referred to as a disease. In that moment, she realized that she, too, had this disease. “It’s empowering for me to know that I have a disease. I can forgive myself for the shame that I’ve carried for a long time,” she said. Unfortunately, access to care and treatment has still been a struggle. Paul’s health insurance does not offer weight management care, so she does not have coverage for a dietitian, anti-obesity medications, or surgery; she must pay out of pocket for any obesity care. “It’s frustrating to live in a world knowing that there are tools and treatments that could give me better health that I don’t have access to,” Paul said. “The world and the health care system are not built for people with obesity. We’re blamed for who we are, but the reality is that it’s a disease with a lot of distinct factors.”

Michele Tedder, MSN, RN, another OAC Board Member and an obesity advocate, also shared her challenges with the health care system, and specifically the weight bias providers can carry. Years back, Tedder hurt her knee during a personal training session. She went to an orthopedic doctor to have them examine the joint, and the first recommendation was for her to lose weight and come back later. Another orthopedic doctor said the same thing. Then another. As she describes it, “they did not see me; they only saw my weight as my problem,” Tedder said. Finally, a friend referred her to a new orthopedic doctor who examined her knee and found she had a fracture that should have been repaired months earlier. She soon underwent surgery and regained full use of her knee. “Weight bias can really damage health if we don’t get a handle on how we’re seeing people when they come in for care,” said Tedder. In 2017, after many conversations with her trusted primary care provider about her weight, Tedder chose to undergo bariatric surgery, which has allowed her to stay active and play with her grandson. “I wish I knew earlier that [obesity] wasn’t my fault. I wish I knew that obesity is a disease that needs a serious health strategy and medical plan to address.”

Addressing Education in Obesity

As exemplified in these patient experiences, the health care experience for individuals living with obesity could be greatly improved through provider education. According to working group members, many clinicians do not consider obesity as a disease and therefore, may approach conversations around it too simplistically.

Groups like the American Board of Obesity Medicine certify physicians in how to manage obesity as a chronic disease and give physicians greater competency in providing obesity care, but there is still a long way to go when it comes to medical education around obesity. Many medical schools, residencies, and nursing schools still offer “almost no” material on obesity in their general training, said Dr. Alexander. In response to the 2022 White House Conference on Hunger, Nutrition, and Health (the first in 50 years), Obesity Action Coalition recommended a strategy to provide better funding for health care professional education to address the needs of people living with obesity.

In addition to medical education, physicians need more weight bias education, cultural sensitivity training, and compassionate tools for discussing weight. Across medicine, patients fare better when they are treated by providers who have the same race or ethnicity as them. If this isn’t an option, the health care system must equip providers with tools to effectively address cross-cultural barriers – particularly in weight management discussions, where topics like body size, foods, and diets can be intertwined with culture.

Additionally, providers should be prepared to navigate care options for patients living with obesity who are also managing multiple chronic conditions. In clinical care, working group member Marilyn Ritholz, PhD, Senior Psychologist at the Joslin Diabetes Center and Beth Israel Deaconess, observed that patients with obesity and diabetes have reported becoming overwhelmed with the need to track so many numbers, related to their weight, glucose levels, carbohydrate intake, and A1C levels. “They become worn out with these demands, so it’s important to find a way to talk about health generally, and not just focus on numbers,” she said. Finally, the importance of building trust with patients could not be overstated by working group members. “You need to approach patients where they are. If they are not there to discuss weight management, bringing it up straightaway might be stigmatizing,” said Paul. Treatment of obesity requires a foundation of trust, which is centered on a comprehensive understanding of a patient’s health care and a tailored plan to target underlying causes of weight gain—not just weight loss.

The U.S. Preventive Services Task Force (USPSTF), which provides independent, evidence-based recommendations on disease prevention and preventive screenings, is currently updating its recommendations on Healthy Diet, Physical Activity, and/or Weight Loss to Prevent Cardiovascular Disease in Adults, which could influence education, coverage, and care pathways for obesity. The Draft Research Plan released in May 2023 now includes FDA-approved pharmacotherapy interventions. The Final Research Plan released in November 2023 only included behavioral interventions for the disease.

Using Obesity Policy to Pave a Path Forward

Just as we must work to change the language for and education around obesity, without having a supportive health infrastructure in place, patients’ well-being will be impacted. “We need to show the urgency of taking action on obesity policy,” said Mila Becker, JD, Chief Policy Officer at the Endocrine Society. “Policymakers love to point out the costs of drugs [and treatments], but the cost of not covering obesity is exorbitant,” she added. Obesity cost the medical system an estimated $260.6 billion in 2016, and that number has continued to rise. Obesity has also been posed as a national security issue.

Currently, obesity coverage differs across states, federal programs, and insurance plans, which can be confusing for patients and providers alike. Working group members noted that regulatory approaches have been successful at the state level to expand access for Medicaid beneficiaries and other state insured populations. Kelsey Lang, MPP, previously a principal with Avalere Health and now Executive Director of Policy at Amgen, noted that Centers for Medicare & Medicaid Services (CMS) is reviewing its standard for essential health benefits in Marketplace plans and may update the standard to facilitate coverage of anti-obesity medications in the future. Coverage for Marketplace plans also differ; as of May 2022, only two states covered anti-obesity medications in benchmark Marketplace plans, but this continues to change state by state.

Coverage policies also differ across the federal government. The U.S. Office of Personnel Management (OPM) released guidance in 2023 to the federal health plans requiring them to cover comprehensive obesity benefits, including intensive behavioral therapy, anti-obesity medications, and metabolic surgery for all federal employees. Within the Department of Veterans Affairs, individuals who receive obesity medication under their VA insurance are required to be part of the VA MOVE! program, which aims to assist veterans in weight management to improve their health and reduce their risk for chronic health conditions. CMS, the largest payer for health care in the United States, covers various obesity interventions under Medicare and Medicaid plans. For example, Medicare covers bariatric surgery if it is deemed medically necessary and if the individual has a BMI of 35 or higher, but it does not cover anti-obesity medications; Medicare also does not cover nutritional counseling by a nutritionist unless there is another qualifying diagnosis, like diabetes. While distinct from obesity coverage, related as a healthy lifestyle intervention, the administration has begun exploring if Medicaid could cover “food as medicine” programs in certain states. Food as medicine is the concept that nutritious food is critical to health and resilience and that access to high-quality nourishment is essential for well-being—all of which are integral to the obesity care equation.

Other environmental and societal factors, such as access to affordable, nutritious food; elimination of food deserts; having an active lifestyle; access to childcare; challenges within the built environment (e.g., access to outdoor space and recreational facilities, neighborhood crime); and patients’ health literacy must be addressed to improve outcomes. Larger societal issues, such as structural racism, poverty, affordable housing, and the health care system’s physical infrastructure also play a role in the nation’s ability to address obesity. “Health care systems are not equipped and accessible to many people in larger body sizes,” said Tracy Zvenyach, PhD, director of Policy Strategy and Alliances at the OAC. “How are we really serving people when the health care delivery system infrastructure cannot meet their needs?” she asked.

Notable legislation discussed by the working group that could play a part in addressing obesity included the Preventive Health Savings ActTreat and Reduce Obesity Act (TROA), the Medical Nutrition Therapy Act, the Special Diabetes Program Reauthorization Act, and state legislation to protect against weight-based discrimination. As of 2022, Michigan is the only state with an anti-weight discrimination law (covering weight discrimination generally, outside of just health insurance) but several cities and other states are working to pass similar laws.

With nearly 75% of adults in the United States living with obesity pre pandemic (in 2018), expanding advocacy and improving policy is a national imperative. “Obesity shouldn’t just be seen as a personal failing,” said Dr. Alexander, but instead something that the entire health care system, from educators to health care providers to policymakers, must address.

As obesity continues to impact the lives of millions of Americans, SWHR’s Obesity Policy Program will highlight the gaps and opportunities most impactful to women’s health across the lifespan. SWHR will continue working alongside our working group members and other partner organizations to advance education, improve health care access and treatment options, and advocate for inclusive policies for individuals living with the disease of obesity. “We’ve come a long way in lots of areas across health care, and obesity is starting to catch up,” said Paul. “I trust and I hope we will dismantle weight bias around obesity, and I wish for a day when no one has to grow up with that stigma.”

Support for this educational program has been provided by Novo Nordisk, Inc. SWHR maintains independence and editorial control over program development, content, and work products.