Talking about obesity in the OB-GYN clinic

THE ROLE OF OB-GYN HCPS IN OBESITY DIAGNOSIS AND MANAGEMENT Given the multitude of associations between obesity and adverse health outcomes for women at different stages of life, and the fact that many women consider their obstetrician/ gynecologist (OB-GYN) to be their primary healthcare professional (HCP), OB-GYNs have a crucial role in educating women on the health risks associated with obesity and guiding appropriate management. Guidelines from the American College of Obstetricians and Gynecologists (ACOG) encourage OB-GYN HCPs to address overweight and obesity with women in their care, starting with the recommendation to screen for obesity as a standard part of all consultations.1 Following diagnosis of obesity, the organization encourages OB-GYNs to address the disease with women while being cognizant of the health and societal impacts and ensuring bias-free communication.1 MANY WOMEN WITH OBESITY EXPERIENCE WEIGHT-RELATED STIGMA AND BIAS IN HEALTHCARE SETTINGS Unfortunately, despite recommendations for respectful obesity care, many women with obesity experience weight-related stigma and bias, including in healthcare settings. In a study of 13,996 individuals taking part in a behavioral obesity management program, 67% of respondents who reported prior experience of weight-based stigma said that they had experienced stigma from doctors.2 Common HCP stereotypes about people with obesity include beliefs that they are lazy, undisciplined, and unlikely to adhere to treatment.3 It has been reported that HCPs have less respect for people with a higher body mass index (BMI),4 in addition to spending a shorter amount of time in consultations, and providing less health information to people with obesity relative to those with a healthy BMI.3,5 There are many ways in which obesity-related stigma in healthcare settings can have a detrimental impact on women’s health. Healthcare avoidance is a key issue: in the aforementioned study of 13,996 individuals, the majority (70%) of participants said that they needed to access healthcare in the past year, but 29% said they avoided visiting their HCP even though they suspected it was necessary.2 In line with these findings, another study found that more than half of 498 women with obesity said that their weight had been a barrier to getting appropriate healthcare.6 This association was stronger in women with more severe obesity; among those with BMI >55 kg/m2, 68% reported delays in seeking healthcare due to obesity, and 83% said that their weight was a barrier to getting appropriate healthcare.6 Obesity also has a detrimental impact on cancer screening, which can lead to missed or delayed diagnoses and, ultimately, worse clinical outcomes.5 A systematic review identified several barriers to screening uptake in people with obesity from HCP and patient perspectives, including body image concerns associated with screening attendance, prior negative experiences of screening, the impact of obesity on mammogram effectiveness, and issues with equipment, such as lack of larger speculums for cervical pap smears and women with obesity being unable to fit in mobile screening vans.7 Finally, it has been shown that HCPs may inappropriately attribute symptoms to obesity, leading to missed referrals and failure to consider treatment options beyond weight loss.3 A simulation study found that medical students were significantly more likely to give lifestyle advice in consultations with people with obesity (54% of 37) relative to those without (13% of 39), and were significantly less likely to recommend symptom management for those with obesity (5% vs. 23% in the group with healthy BMI).8 Furthermore, a study of 402 people with type 2 diabetes found that rates of appropriate treatment intensification were lower in people with versus without obesity, at 53.7% and 67.4%, respectively, suggesting that people with obesity may be vulnerable to therapeutic inertia in diabetes management.9 In summary, women with obesity are at risk of experiencing a range of issues related to stigma and bias in healthcare settings, which can cause serious harm. OB-GYN HCPs must be conscious of these issues and use self-reflection to identify any personal biases and ensure that bias does not undermine their ability to provide respectful and nonstigmatizing care.1 RAISING THE TOPIC OF OBESITY: PRACTICAL GUIDANCE FOR RESPECTFUL CONVERSATIONS When speaking about obesity in women’s healthcare clinics, organizations including ACOG and The International Federation of Gynecology and Obstetrics (FIGO) emphasize that obesity is a disease and should be recognized as such, and recommend the use of respectful, person-first language when speaking with people affected by obesity.1,10 It has been shown that the terms “obese”, “morbidly obese”, and “fat” are associated with the most stigma and blame, while “high BMI”, “unhealthy weight”, and “weight problem” are considered less offensive and more motivating.1,11 ACOG acknowledges that personal preferences may vary, and it may therefore be appropriate to ask individuals which terms they prefer.1 It is also important to be aware of cultural sensitivities and considerations, as obesity may be viewed differently depending on culture.10 FIGO suggests that HCPs should consider a trauma-informed approach to caring for women with obesity, as these women may have experienced difficult healthcare examinations in the past.10 The 5 As approach -- which originated from a smoking cessation framework by the US Department of Health and Human Services -- has been adapted into a tool to guide respectful discussions about obesity in the clinic and is included in Canadian clinical practice guidelines for obesity care.12–14 This approach, summarized in Figure 1, recommends first asking permission to discuss a person’s weight and assessing their readiness for change (ask). Secondly, it is important to assess the individual’s heath status, including severity of obesity and personal goals (assess), followed by asking permission to give advice and, if granted, advising on the health benefits of weight loss and how this can be achieved (advise).13 The fourth step involves agreeing on realistic goals, focusing on overall health gains rather than weight lost (agree). HCPs should then assist people with obesity by identifying and addressing barriers that may make obesity treatment challenging, and arrange follow-up to ensure continued support (assist).13FIG. 1: The “5 As” approach to respectful obesity management in the clinic.13,14Box 1 provides a list of suggested conversation-starters that can be applied to guide initiation of discussions about obesity in the OB-GYN clinic. It is important to note that the individual’s reason for attending the clinic should be addressed first, to show that they are being listened to and their needs are being prioritized.15BOX 1Conversation starters for talking about obesity in the OB-GYN clinic. MASLD, metabolic dysfunction-associated steatotic liver disease; OB-GYN, obstetrician/gynecologist.DIAGNOSIS AND DOCUMENTATION OF OBESITY While sensitive language is crucial when discussing obesity with affected individuals, ACOG emphasizes that medical terminology should be used when documenting a diagnosis of obesity in medical records.1 The organization recommends using terms such as “overweight” and “obesity” for the purposes of documentation, billing, and coding.1 Evidence suggests that obesity is under-documented in clinical practice; in a US study of medical records from 3,868 individuals seen in the primary care setting, 52% met the criteria for obesity (BMI ≥30 kg/m2), but only 5.6% of these people had a documented diagnosis of obesity.16 The presence of severe obesity (BMI ≥40 kg/m2) and a greater number of comorbidities were both associated with increased likelihood of a documented diagnosis.16 OB-GYN HCPs should ensure that obesity is reported appropriately in the medical records of those affected. Guidance from the American Association of Clinical Endocrinology (AACE)/American College of Endocrinology (ACE) for anthropometric classification of obesity recommends that all adults should undergo obesity screening annually using a BMI measurement, with a BMI of ≥25.0-29.9 kg/m2 indicating overweight and a BMI of ≥30 kg/m2 indicating obesity.17 It is essential to use clinical assessment and judgment when using BMI to diagnose obesity, especially among people with high muscle mass or sarcopenia.17 Lean mass, bone mass, and fluid status all contribute to body weight independently of fat mass, and this must be taken into account.17 Waist circumference (WC) should be measured in all individuals with a BMI <35 kg/m2 to assess obesity-related disease risk, with an overall recommendation to use a WC cutoff of ≥88 cm to indicate increased risk among women in the United States.17 BMI and WC cutoffs vary for some ethnicities, and the AACE/ACE guidelines recommend a WC cutoff of ≥74-80 cm for South Asian, Southeast Asian, and East Asian women.17Figure 2 summarizes the recommended steps for diagnosing obesity in the clinic.FIG. 2: Steps for diagnosing obesity as recommended by the AACE/ACE guidelines. AACE, American Society for Clinical Endocrinology; ACE, American College of Endocrinology; BMI, body mass index; WC, waist circumference.17Assessment of obesity-related complications In addition to the anthropometric-based diagnosis of obesity, there are multiple clinical assessments that should be considered. Given the strong associations between obesity and multiple related conditions (outlined in article 1 of this supplement, The Impact of Obesity on Women’s Health, Volume 32, Issue S1, S3-S9), the AACE and ACE recommend that all individuals with overweight or obesity should undergo clinical evaluation for obesity-related complications, as summarized in Table 1.17 These include prediabetes, type 2 diabetes (T2D), and metabolic syndrome (evaluated by assessing glycated hemoglobin [A1C], fasting glucose, blood pressure, and lipid levels), in addition to CV risk, osteoarthritis, and metabolic dysfunction-associated steatotic liver disease.17 For those with suspected hormonal disorders that can be associated with obesity, thyroid-stimulating hormone testing and either bedtime salivary cortisol, 24-hour urine cortisol, or overnight dexamethasone suppression testing is recommended.17TABLE 1: Common obesity-related complications with screening recommendations in the AACE/ACE guidelines.Moreover, it is important to consider family history of obesity and other related conditions, with one study suggesting that individuals with a family history of 1 cardiometabolic disease (obesity, diabetes, or a heart or blood condition) have a 1.1- to 5.6-fold increased risk of having another cardiometabolic disease.18 Previous weight loss attempts should also be taken into account. One systematic review and meta-analysis found that ≈ 45% of the general population in North America had previous weight loss attempts19; another study of 1850 individuals with obesity showed that 78.6% had attempted to lose weight in the previous year, but almost three-quarters of these people did not lose ≥5% of their baseline weight.20 Understanding each person’s history of weight loss attempts helps HCPs to better understand their patients’ journeys leading up to their diagnosis of obesity, and to provide supportive, individualized care. Other important health-related conditions that OB-GYN HCPs should consider when documenting a diagnosis of obesity include bone health,21 sleep status,22 body image,23 and psychological state.24,25 Guidelines recommend that all individuals with obesity should be evaluated for obstructive sleep apnea, and that polysomnography and other sleep studies, either at home or in a sleep lab, should be considered.17,26 As obesity is associated with multiple types of cancer, OB-GYNs should take each individual’s cancer history and other risk factors into account.10,27,28 The cancer types most strongly associated with obesity in women include endometrial (relative risk [RR] per 5 kg/m2 increase in BMI=1.59), breast (RR=1.12 in postmenopausal women), esophageal (RR=1.51), kidney (RR=1.34), and colorectal (RR=1.02-1.09).29 Moreover, in addition to cancer risk, obesity is associated with an elevated risk of cancer recurrence and poor outcomes.29 There are various mechanisms linking obesity and cancer cell migration, invasion, and metastasis.29,30 For instance, epithelial-mesenchymal transition at the primary tumor site is mediated by cytokines such as leptin and interleukin-6, while cellular migration is encouraged by factors including systemic hyperinsulinemia and signaling from nearby adipocytes. The physiological state of obesity also primes metastatic sites through a variety of processes such as the induction of chemokine (C-C motif) ligand 5 (CCL5) expression.30 Given their role as the primary HCP for many women in the United States, it is important for OB-GYNs to be aware of the increased risks of poor cancer outcomes in women with obesity and ensure appropriate screening and referral. Evaluating medication use Another important component of obesity diagnosis is evaluation for the use of any medications that could be aggravating weight increase. Certain medications used in psychiatry have a well-known association with weight gain, with the strongest associations seen for the antidepressants amitriptyline, mirtazapine, and paroxetine, and the antipsychotics olanzapine and clozapine.31 Moreover, systemic corticosteroids and several antiepileptic drugs can cause weight gain, in addition to nonselective β‐adrenergic receptor blockers and certain medications used for type 2 diabetes (insulin and sulfonylurea derivatives).31 These medications are summarized in Table 2. OB-GYN HCPs should establish whether women with obesity are taking any medications that could be causing weight gain and change to alternative medications if safe to do so.TABLE 2: Medications associated with weight gain and potential alternatives.WHAT ARE THE POTENTIAL BENEFITS OF WEIGHT LOSS? Following diagnosis and appropriate documentation of obesity, discussing the benefits of weight loss for different health outcomes in the context of each individual’s goals and values is a crucial step in obesity management.10,13 Different ranges of weight loss are associated with different health benefits, with the greatest benefits seen with ≥10%-15% weight loss (Fig. 3).33 For example, with minimal amounts of weight loss (2% to <5%), improvements begin to be seen in measures such as triglycerides and blood pressure, while weight loss of ≥5% is needed for improvements in high-density lipoprotein cholesterol.33 A greater degree of weight loss, ≥10%-15%, is needed for improvement in comorbid conditions, including sleep apnea and metabolic dysfunction-associated steatohepatitis.33–37FIG. 3: Benefits associated with different degrees of weight loss in people with obesity. GERD, gastroesophageal reflux disease; MASH, metabolic dysfunction-associated steatohepatitis; MASLD, metabolic dysfunction-associated steatotic liver disease; PCOS, polycystic ovary syndrome.33–37In terms of polycystic ovary syndrome (PCOS) and fertility, minimal amounts of weight loss are associated with improved ovulatory function, but there are more robust data supporting improved spontaneous pregnancy rates with weight loss of 5%-10%.33 For instance, one study of 18 anovulatory women with PCOS undergoing a 6-month lifestyle intervention program (average weight loss 2%-5%) showed that 50% of participants responded to the intervention with restoration of ovulation. This was accompanied by an 11% decrease in central fat and a 71% improvement in insulin sensitivity index.38 In another lifestyle intervention study of 33 anovulatory women with PCOS, in which 76% of participants lost ≥5% body weight and 33% lost ≥10%, those who lost weight experienced a reduction in ovarian volume and a reduction in the number of antral follicles, with greater benefits seen in those achieving ≥10% weight loss.39 The majority of women resumed regular menstrual cycles, and 10 spontaneous pregnancies occurred in those who had lost ≥5% body weight.39 These findings support recommendations that women with overweight or obesity and anovulatory infertility should consider weight loss prior to conception or initiation of fertility treatment. However, other patient factors such as age must always be considered. For example, the impact of age on live birth rates among women undergoing in vitro fertilization is much greater than the impact of BMI at older reproductive ages.40 It is also important to note that preconception weight loss may not improve the chance of pregnancy and live birth, especially in a non-PCOS population. In a randomized controlled trial (RCT) of 577 women with BMI ≥29 kg/m2 and infertility (≈75% with PCOS), taking part in a 6-month lifestyle intervention prior to fertility treatment did not increase the likelihood of having a vaginal birth of a healthy singleton compared with fertility treatment alone. Women in the lifestyle intervention group did, however, experience greater average weight loss versus those in the control group (4.4 kg vs. 1.1 kg).41 Another RCT (FIT-PLESE) investigated the impact of a 16-week preconception lifestyle intervention in 379 women with obesity but without PCOS. These women had regular ovulation and unexplained infertility, and were randomly assigned to either intensive weight loss intervention involving lifestyle changes and obesity medication (orlistat) or to control intervention involving increased physical activity alone. Women in the intensive intervention group lost more weight on average (6.6% vs. 0.3%) and experienced significant improvements in metabolic health relative to the control group, but rates of healthy live births were comparable in the two groups, at 12.2% and 15.2%, respectively.42 The authors concluded that improved cardiometabolic health may not lead to improved fecundity, but they cautioned that their findings may be specific to women with unexplained infertility and may not be applicable to those with ovulatory disorders such as PCOS.42 In light of the findings from these two RCTs, it is important for OB-GYN HCPs to be cautious in discussions on lifestyle-related weight loss interventions for women with infertility. Additionally, for women of advanced reproductive age, the time that it can take to achieve weight loss may ultimately decrease the chance of successful pregnancy. Ultimately, discussions regarding preconception weight loss must be individualized and should consider age, medical comorbidities, ideal family size, and reproductive disorders. COMMUNICATING THE BENEFITS OF WEIGHT LOSS AND SETTING REALISTIC TARGETS OB-GYN HCPs must also be cognizant of the considerable challenges associated with weight loss.1 Losing weight, and sustaining weight loss over the long-term, can be challenging due to biological mechanisms that favor weight regain. Obesity is a chronic disease caused by interactions between genetic, metabolic, behavioral, and environmental factors.43 weight, and are through and processes in which the a central In the context of weight loss, changes in biological in and These changes the processes that and favor weight OB-GYN HCPs women with obesity should be with these biological processes and the challenges of weight loss, ensuring that individuals do not any It is also important to individuals that even amounts of weight loss can have health ACOG recommends a approach to discuss weight loss and while such as for physical activity and healthy As in the 5 As for obesity it is essential to on treatment goals and with obesity management should on health gains rather than the amount of weight different individuals It is that the of obesity is between and and there are several factors that either an individual’s risk for obesity or the degree of obesity, which should be taken into when individualized treatment These factors the which provides a and physical activity for such as and lack of lack of sleep factors related to pregnancy adverse and psychological such as and poor body It is crucial to weight loss taking all of these factors into and ensure that women with obesity are in their treatment It is important to note that despite the of several obesity medications that can address the challenges associated with weight loss, these have been in clinical This is more however, with the and in obesity medications in article of this supplement, Obesity to Women’s Health Volume 32, Issue S1, Finally, OB-GYN HCPs can provide the care to women with obesity by for the for obesity management in their and and respect regarding obesity even if patient are not with the The different options for obesity are in article of this supplement, Obesity to Women’s Health Volume 32, Issue S1,

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