Oregon Health & Science University researchers explored counseling as a tool to prevent obesity for women aged 40-60, also referred to as their “midlife.” Obesity is a common condition for women in this group and counseling may be an effective way to prevent it. We learn more from Amy Cantor, an associate professor at OHSU and the lead researcher on the study, on how women can benefit from these discussions.
The following transcript was created by a computer and edited by a volunteer:
Dave Miller: This is Think Out Loud on OPB, I’m Dave Miller. Counseling can be an effective tool in helping to prevent obesity in women between the ages of 40 and 60. That’s according to a new review of seven earlier clinical trials. The review was done by the Women’s Preventive Services Initiative. Amy Cantor is a family physician and associate professor at OHSU. She was the lead author of the study and she joins us with the details. Amy Cantor, thanks very much for joining us.
Amy Cantor: Hi thanks for having me.
Miller: What is the Women’s Preventative Services Initiative?
Cantor: The Women’s Preventive Services Initiative is a national expert panel of more than 21 health professional organizations and patient representatives that develops reviews and updates, and also disseminates evidence-based clinical recommendations for women’s preventive health care services in the US. And they, as a panel, make recommendations to the federal government regarding which preventive services should be covered by health insurance plans to address health needs specific to women without cost sharing. So under the Affordable Care Act, most private health insurance must provide coverage of women’s preventive health care, such as mammograms for breast breast cancer screening, screening for cervical cancer, contraceptive and prenatal care, and other services such as this one, like counseling, to prevent obesity in midlife women, all without cost sharing.
Miller: Do insurance companies follow the recommendations that come from this initiative? Do they listen?
Cantor: So it’s not so much that they need to follow it. But they do need to cover it. And importantly, I think the message is that clinicians should have an awareness of these services so they can provide them to their patients. And on the flip, that patients understand that these services, some of the few that I mentioned, but there are more, are things that they have access to and can be covered as part of their routine preventive care.
Miller: Can you describe the purpose of this particular study? What question were you interested in answering?
Cantor: So that’s a great question. Part of the charge of the WPSI is to identify gaps in current preventive services recommendations that are services that are specific to women. So, by focusing on these gaps, they may include services that other leading guideline groups may have recommended to be selectively offered, or maybe where there wasn’t enough evidence. So the WPSI intends to hone in on these evidence gaps to provide the specific services for women.
Previous studies and guidelines have focused on the benefits and harms of behavioral weight loss approaches among patients who are already obese. But this review addresses prevention of obesity among midlife women who are not obese, to inform a recommendation for women with a normal or overweight BMI so they can be supported to help maintain their weight or limit any weight gain to then prevent obesity.
Miller: Why this particular age range, 40 to 60?
Cantor: That’s a great question. Obesity is a really common condition for women during this life, and it affects over 40% of American women in this age cohort. And in the US, nearly two thirds of women, 40% to 59%, or almost 60% have overweight or obese BMI, and the average woman in midlife gains around a pound and a half per year. Women during this period can struggle with weight gain due to physiologic changes that are related to aging or menopause, or hormonal changes, often due to reduced physical activity or changes in body composition. And compared with other hormonally driven life phase transitions, such as a menarche or pregnancy, that some of the hormonal changes that influence weight gain during the menopausal transition often correspond to increases in fat mass and increased abdominal fat, which are independent risk factors for cardiovascular disease.
Miller: How strong is the connection at this point between that increase in weight, the increase in BMI and actual health problems? I’m asking because in the last 10 years there has been a real movement in this country to de-stigmatize fatness, and many people saying that the correspondence between weight and health is not as clear as we used to think it was.
Cantor: I think you bring up a couple really important points. The de-stigmatization of that particular issue is important. And I think when we think about counseling, we really have to take into consideration all of those individual pieces and perspectives.
Going back to the first question about risk factors for obesity and what the risks associated with obesity are, those are more clinically clear. We know that obesity increases risk for many chronic conditions, including hypertension or high blood pressure, abnormal cholesterol, type two diabetes, coronary artery disease or heart disease and stroke, in addition to some very important cancers specific to women. So these are important when we’re looking at the clinical connection.
But the other piece is that the individual approach to counseling that really does consider some of those factors like chronic stress, trauma, socioeconomic conditions when we’re counseling women and that we’re sensitive to weight stigma that were sensitive to cultural considerations of body image and individual variability and body composition, these are all really important.
And BMI is the best measure that we currently have to kind of measure those risk factors for obesity. It’s not perfect, but it’s the best thing that we’re doing clinically to sort of predict risk and understand the important associations that do impact long term long term health and chronic disease.
Miller: This wasn’t a randomized trial where some patients got counseling and others didn’t, then you could look at how they did. This was a survey of seven earlier trials. What exactly did you find?
Cantor: So, a quick correction. What we did was a systematic review of the evidence. And so what that means is that we reviewed randomized controlled trials, and we actually only included trials where they did compare interventions such as a counseling intervention, versus no intervention. So these were randomized trials.
But what we did was collectively, systematically review those trials that fit these key research parameters. So we did this by identifying a specific population, saying we really only want to look at trials of women in this particular age group that compared counseling or another behavioral interventions like exercise to no exercise, or no counseling. And so what was really interesting and important was that in four of five trials of counseling, but not in the two trials of exercise, the effectiveness of interventions to maintain or reduce weight in midlife women was favorable, meaning that there were weight changes that were statistically significant from the control participants.
Miller: So when you say counseling, what does it mean in this context? Because we’re not talking about people seeing therapists or or licensed counselors, we’re talking about conversations with their primary care doctors?
Cantor: Absolutely. So the research didn’t specifically find one approach. I would say that the kind of results are not prescriptive, meaning that counseling interventions could include an individual assessment of diet and exercise habits. Individual counseling for patients with overweight BMI, Or patients who have unhealthy diet or exercise habits. And in order to do that you have to have the conversation about what those are. and this can occur during a routine well-woman or a routine preventive visit, and potentially could lead to more intensive interventions or referral when appropriate.
And making these conversations routine helps destigmatize them, since overweight and obesity affects so many women during this life stage, it really is important that we normalize conversations around weight gain and reduce the stigma surrounding weight gain and obesity.
Miller: What are you most hoping will follow from this study and these recommendations?
Cantor: I’m hoping that more women, and people in general, understand that recognizing risk factors and recognizing the importance of healthy lifestyle, which includes not being sedentary, I think some people might find it daunting to say “oh now I have to start an exercise program.” But I’m a primary care physician and I see women every week, and having these conversations and just talking about “what are you doing now to move your body every day?” And if they’re like” I really don’t do anything,” then we talk about what are the recommendations for physical activity. 150 minutes of moderate exercise a week, cardiovascular exercise, and incorporating some weight bearing exercise as well, in particular for this group as risks of other diseases like osteoporosis increase.
So we think about adopting healthy lifestyles. Adjusting what you’re eating and finding healthy foods. You know, we in the Pacific Northwest are particularly lucky, because many people have access to very healthy and fresh food and so. Making those healthy choices are kind of simple steps that you can take by walking to your local farmers market. So then you’re taking a walk, in the day and you’re making healthy choices. But right now, less than 20% of adult women meet recommendations for aerobic exercise and muscle strengthening activity. So in just making some simple lifestyle changes, taking a walk in the morning, taking a walk in the evening, that can accumulate to getting closer to some of those recommendations for physical activity.
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