Weight Matters

I am a midwife, cis-gender woman, mother, and friend, but I still struggle to find the right words when talking about weight. When talking with patients about their health and the connection to weight, we often look past the elephant in the room – obesity. Clinically, we know how being overweight or obese increases women’s risk of cardiovascular disease, diabetes, some cancers, infertility, pregnancy complications, and mental health struggles. But I also know all too well how charged talking about weight. I’m not sure I can uphold my oath to “do no harm” if I have to talk to someone about their body size or weight. Conversations about weight matters feel even more hopeless because there are so few effective tools or diets for weight loss.

This post aims to start a safe, informative, and supportive dialogue about overweight, obesity, and women’s health. I understand that talking about body size, obesity, dieting, and weight can be traumatic, hurtful, scary, and hard, so please take care of yourself as you read, however you need to.

The Dangerous Connection Between Heart Health and Obesity

You are still reading, so we are grateful for your willingness to join us on our deep dive into this fraught health topic. Are you a person with a larger-sized body? You are not alone. More than 2 in 3 women in the United States older than 20 are overweight or obese. Obesity is a medical term used to describe any person with a body mass index (BMI) greater than 30.

Calculating a person’s BMI allows healthcare providers to quantify how much fat tissue they have. However, what matters more than body size or weight when it comes to heart disease is the amount of fat tissue (adipose tissue) you carry on your body. Using BMI when talking about body size and health is complicated because BMI is not a perfect measure. However, BMI does allow healthcare providers to quantify how much fat tissue a person has.

Carrying too much weight puts extra stress on your heart, causes your coronary arteries to narrow, and affects the rhythm of your heart beating. In addition, too much abdominal fat can raise inflammation levels and increase insulin resistance. Women with obesity are at higher risk of cardiovascular disease (CVD) and insulin resistance (pre-diabetes or Type 2 diabetes). When obese, women, compared to men with obesity, are at higher risk of developing heart failure and dying earlier. Women who are overweight or obese are also more likely to have hypertension (high blood pressure) among women.

What About Metabolic Syndrome and Women?

Women with metabolic syndrome are more likely to have cardiovascular disease. Metabolic syndrome is a cluster of co-occurring conditions that increase your risk of heart disease, stroke, and type 2 diabetes. These conditions include increased blood pressure, high blood sugar, excess body fat around the waist, and abnormal cholesterol or triglyceride levels. Up to one out of every three U.S. adults now has metabolic syndrome.

Polycystic ovarian syndrome (PCOS) is one type of female-specific metabolic syndrome. Women with PCOS are more likely to have abdominal obesity, abnormal glucose control or diabetes, elevated blood pressure, and dyslipidemia (high cholesterol). All of these factors make it more likely that you will someday develop CVD if you have PCOS.

Are Women At Greater Risk For Obesity Then Men?

We don’t know. We know there are currently more obese and severely obese women than men in the United States, according to data from the CDC reviewed in 2018. Pregnancy and menopause are two key times women tend to gain the most weight and adipose tissue in ways men do not. In addition, during their childbearing years (ages 18-50), women gain weight more rapidly than men and women of other age groups.

Obesity and Pregnancy

Being overweight or obese when you first get pregnant increases your chances of gaining too much weight during pregnancy. Excessive weight gain during pregnancy makes losing that extra weight postpartum harder.

Postpartum weight retention is a significant contributing factor to obesity in women. In other words, preventing obesity and heart disease could start even before your first pregnancy. So, even if you don’t have any risk factors or symptoms of heart disease, living a healthy, active lifestyle at your ideal body size, even before you start building your family, may keep your heart healthy in the long run.

Some healthcare providers describe pregnancy as a “stress test” for your heart and body. Women who have pregnancy complications such as gestational diabetes, pregnancy-induced high blood pressure, prematurity, or pre-eclampsia are at higher risk for developing cardiovascular disease later in life. Many healthcare providers and cardiologists now believe that preventing overweight and obesity before pregnancy is the best way to prevent heart attacks and heart disease – the number one killer of adult women in the U.S.

Is Weight Gain In Menopause Inevitable?

Many women gain weight during menopause. We don’t yet know all of the reasons behind the “Meno Belly” or “middle-aged spread” so many of us dread or are living with. We’d like to blame it all on hormones, but weight gain in the years just prior to stopping periods (perimenopause) and after menopause is more likely related to aging and lifestyle changes.

Normal age-related changes make it harder for us to remain physically active enough to maintain a healthy weight.  Lean body mass decreases with age. With less muscle, our bodies don’t burn as much energy (calories). These extra (unused calories) are more likely to be stored as fat, especially in the belly and hip areas. Weight gained in these areas (also called visceral fat) is harder to lose and puts your health at risk as you age.

Research shows that women with more visceral fat are more likely to develop heart disease, high blood pressure, type 2 diabetes, some types of cancer, and osteoarthritis. Incidentally, women with overweight or obesity also have worse hot flashes and night sweats during perimenopause.

Menopausal hormone therapy (also known as hormone replacement therapy or HRT)  is one of the most effective ways to treat these vasomotor symptoms of menopause (like hot flashes or night sweats). MHT has not been shown to significantly reduce weight but may help with where fat is stored in your body.

Diets Don’t Work For Most of Us

Part of what makes women’s healthcare providers’ jobs so challenging is that diets don’t work for most of us. Modern medicine has not yet been able to give us an effective or long-lasting way to help us lose weight. Statistically, the odds are against you being able to lose a significant amount of weight (defined as 10 percent of your current body weight) and keep it off for at least one year.

For example, a 2007 review of long-term weight-loss studies found that the average weight loss amount maintained across diet interventions was only a couple of pounds. In other words, people who started in the “obese” BMI category stayed obese. Other people gained weight during the diet interventions. People were also still regaining weight at the end of the studies—and up to 66 percent of people regained more weight in the follow-up period than they lost during the intervention.

There are several theories why diets don’t work for many of us:

• We have a genetically-determined weight range (setpoint theory). If we lose too much weight, our bodies rebel and adapt.
• Restricting calories creates a psychological stress response that stimulates emotional eating and changes our metabolism to store more fat and crave unhealthy foods.
• Chronic dieting can lead to a loss of awareness of hunger and fullness cues, leading to disordered eating.
• Many diets only work for the short term – they set you up to fail because they are overly restrictive and unsustainable.
• Diets don’t consider different body types or metabolisms – they tend to be one-size-fits-all.
• Diets focus on food – only. Physical activity (at least one hour most days) is critical to maintaining health but ignored by many diets.

Yo-Yo Dieting or Weight Cycling Do More Harm Than Good

Additionally, we know that repeated cycles of losing and then regaining weight (known as weight cycling or yo-yo dieting) are physically and emotionally harmful. Physically, repeated cycles of gaining and losing weight are linked to higher rates of diabetes, high blood pressure, cardiovascular disease, chronic inflammation, loss of bone mass and lean muscle mass, and even diabetes. Emotionally, the feeling of being a diet failure is toxic. Women who lose weight only to gain it back again and again feel increased shame and self-loathing. Yo-yo dieting leads to yo-yo emotions. This chronic emotional turmoil can lead to restricting-bingeing cycles and other disordered eating patterns. Ultimately, chronic dieting can lead you to give up on yourself in general, not just on dieting.

Does Calling Obesity a Chronic Disease When Talking About Weight Help?

Given the diet industry and healthcare establishments’ failure to find successful ways to end obesity, it is not surprising that we all want to step up our game in the battle of the bulge. One approach some medical providers advocate is to consider obesity a chronic disease. 

Many advocates (especially obesity medicine doctors) believe that treating obesity with medicine as we would other chronic diseases such as asthma or diabetes is the way to end our harmful blaming and shaming approach to obesity. Our culture’s collective anti-fat bias can lead to blaming people living in larger bodies for a perceived lack of willpower, laziness, or for being unhealthy.

While not for every woman, research shows that newer weight loss drugs like semaglutide (Ozempic or Wegovy), paid for by the pharmaceutical companies who developed these drugs, can help higher-risk people live longer, healthier lives without heart disease. Medications like semaglutide work to adjust hunger cues and how the body stores fat.

These powerful new medicines offer new hope for some people who haven’t been able to lose weight any other way and for whom losing weight is a matter of life and death. As women’s health providers, we are always excited about new ways to help our clients stay healthier. We want to empower you with the knowledge of all available treatment options. That way, we can decide, together, what can help you achieve your healthiest, happiest weight.

The Anti-Diet Movement and Health At Every Size (HAES)

Critics of the medical approach to treating obesity as a disease argue pathologizing fatness only perpetuate the stigma and fear that keeps many women of size out of doctor’s offices. The Health At Every Size (HAES) approach emphasizes health and well-being over body weight or BMI. HAES proponents feel that a person can be healthy even at a higher weight. They champion counteracting obesity at a population level by ending weight stigma and improving access to health care.

They also point out several big strikes against these anti-obesity medications (also known as GLP-1 agonists): 1) Their high cost (most insurances do not yet cover the medications; 2) They require a once-weekly injection; 3) Some (not all) people have to continue to take the drugs to maintain their weight loss and experience significant and rapid weight re-gain if they try to stop taking them, and 4) We don’t know the long-term health risks from these medications. As a result, the U.S. Food and Drug Administration (FDA) released them with a “black-box warning” because they can have “rare but serious side effects,” including pancreatitis, gall bladder disease, and kidney damage.

Talking About Weight Can Help You Find Your Healthiest, Happiest Weight

Confused and frustrated? I am too. I wish there were more effortless, affordable, and effective ways to stay at our healthiest, happiest weight across our lifespans. One good piece of advice to offer is to follow the Mediterranean Diet. I hesitate to call it a diet. Instead, try to see it as a healthy shift to a sustainable, enjoyable, and satisfying way of eating. According to the American Heart Association, this type of meal plan calls for:

• eating plenty of fruits, vegetables, bread, and other whole grains, potatoes, beans, nuts, and seeds
• using olive oil as your primary fat source
• consuming dairy products, eggs, fish, and poultry in low to moderate amounts, and red meat less often.

One research study of menopausal women found that, after following the Mediterranean Diet for just 8 weeks, all participants showed an improvement in their body composition (less visceral fat) and blood pressure values, even without starting any new exercise plans.

The other consistent piece of evidence-based info we can offer is to find a type of movement that makes you feel good and keep moving. Physical activity and moving your body with joy will help you feel better, physically and emotionally.

So while the science of treating obesity evolves, I stand alongside you, curious about new treatment options and supporting you in finding what works for you. Our bodies are not one size fits all, nor is the healthiest, happiest weight the same for everyone. My hope is to give you information about the health risks of staying at a higher weight. We can work as a team to balance your need to feel good in your body now with preserving your future health. I believe that knowledge is power. Talking about your weight can help us develop a healthy lifestyle plan for your mind and body.