June 14, 2023

Dr. Michael Barry
Chair, U.S. Preventive Services Task Force 5600 Fishers Lane
Rockville, MD 20857

Re: USPSTF Draft Research Plan: Weight Loss to Prevent Obesity-Related Morbidity and Mortality in Adults: Interventions

Dear Dr. Barry,

As an organization focused on preventive health policy, the Alliance for Women’s Health and Prevention (AWHP) believes it is important to address obesity using equitable and holistic tactics and measures. We are therefore encouraged by the U.S. Preventive Services Task Force’s (USPSTF) prioritization of weight loss to prevent obesity-related morbidity and mortality in adults.

In our comments, we underscore the importance of considering the harms associated with unaddressed obesity and examining the issue through the lens of health equity. Prevailing myths and misconceptions about obesity are that obesity is a lifestyle choice or that those with obesity have a lack of willpower. Obesity is a complex and chronic disease expected to impact close to half of the U.S. population by 2030. It is also the leading cause of preventable deaths in the U.S. Further, obesity and excess body weight are risk factors for nine of the nation’s top ten leading causes of death.

As with nearly any disease, women experience obesity and its impacts differently than men. For example, obesity has a significant impact on fertility and pregnancy. Younger women with obesity have a threefold higher risk of infertility and increased risk of miscarriage, poor pregnancy outcomes, and impaired fetal well-being. As such, women’s unique experiences and challenges when it comes to weight management must be considered in the design of research plans and future recommendations.

Furthermore, weight gain and obesity are associated with multiple other medical conditions, including cancer, Type 2 diabetes, hypertension, and depression – making it even more critical that stakeholders work together in managing, treating, and preventing this disease.

Overweight and Obesity Disparities

The Task Force’s draft research plan is an important step forward in acknowledging and addressing obesity as a serious disease that must be treated. However, it is critical that the final plan comprehensively addresses disparities in obesity’s impact and the inequities in access to weight management care and treatment. Since women and people of color are consistently underrepresented in clinical trials, it will be important to ensure that the studies being reviewed include a representative population.

Women and Obesity

• Black women have the highest rates of obesity or being overweight compared to other groups in the U.S., and about four out of five Black women are overweight or have obesity.
• Black patients participating in lifestyle-based obesity interventions lose approximately half the weight that their white counterparts lose. In weight-loss programs, Black women are unlikely to transition from having obesity (BMI ≥30) or being overweight (BMI 25–29) to being a “normal” body weight (BMI <25).
• More than two in five Hispanic women (43.7%) have obesity, compared to 39.8% of non-Hispanic white women.
• If existing trends in obesity continue, 52.5% of Hispanic women and 49% of Black women will develop diabetes in their lifetime – compared with 31% of white women.
• Gestational diabetes is linked to obesity and is associated with greater risk of developing Type 2 diabetes. Hispanic women in the U.S. are at two- to fourfold higher risk for gestational diabetes compared with non-Hispanic white women. While Black women are generally less likely to suffer from gestational diabetes, those who do are more likely to have obesity and far more likely to subsequently develop Type 2 diabetes. The greatest disparity in subpopulation Type 2 diabetes rates are between Black women and white women, and appears to be due to risk factors such as obesity.
• There is also significant subpopulation variability in cardiovascular outcomes associated
  with obesity:
  • Hypertension and diabetes are more likely to lead to coronary artery disease and
    heart failure in women than in men.
  • Compared to men, women with heart failure have higher frequency rates of
    dyspnea on exertion, difficulty exercising, and edema.
  • Women with cardiovascular disease tend to have worse quality of life ratings
    than men for intermediate activities of daily living and social activity.
  • Depression is more common in women with heart failure than in men.
• Research should also address the fact that obesity is a recognized risk factor for the
  development and recurrence of breast cancer, especially because the efficacy of breast
  cancer treatments is significantly lower in women with obesity.
• Women typically have more body fat and less muscle mass than men, which affects
  metabolic rate. In addition, female-associated hormones and hormonal conditions
  affecting women can be a factor in weight loss and weight distribution.

Health Equity and Obesity

• The prevalence of obesity is higher in communities of color. For example, obesity prevalence in Black adults is over 20% in all U.S. states and territories and only one state has an obesity prevalence in Hispanic adults that is lower than 20%.
• For people ages 20 and older in the U.S., Black adults have the highest overall obesity rate (49.6%), followed by Hispanic adults (44.8%) white adults (42.2%), and Asian adults (17.4%).
• Complications of being overweight and managing obesity are prevalent in the Asian and Pacific Islander communities. In 2014, an estimated 12.8% of Native Hawaiians, 10.0% of Hawaii residents of Chinese descent, 13.0% of Hawaii residents of Filipino descent, 13.6% of Hawaii residents of Japanese descent, and 14.9% of Hawaii residents of other Pacific Islander descent were diagnosed with diabetes compared with 5.0% of white Hawaii residents.
• The prevalence of obesity is also approximately 6.2 times higher in rural areas than in urban areas.
• Social determinants of health play a role in an individual’s weight and weight management – such as the availability and affordability of food options, peer and social supports, community design, and conditions supporting physical activity.

Psychosocial Impact of Obesity

People who are overweight or managing obesity are often subject to discrimination, which can not only negatively affect their physical health and weight management objectives, but also take a toll on their mental and emotional health.

• As a disease, obesity is undertreated, and this is partially due to weight bias in
  healthcare settings. Of the millions of Americans suffering from obesity, studies have
  shown less than 2% of those eligible for anti-obesity drugs are prescribed anti-obesity
  medicine.
• Weight bias and negative self body image are two of the most prevalent effects on
  patients managing obesity.
• More than 40% of U.S. adults, across a range of body sizes, report experiencing weight
  stigma, also known as sizeism, at some point in their life.
• Weight stigma is shown to be more frequently directed at women.
• Further, weight stigma increases the risk for psychological problems, including
  depression, anxiety, substance use, and suicidality, particularly when people internalize
  sizeist attitudes and self-stigmatize.
• Patients who are overweight or have obesity that engage in supportive conversations
  with their physicians, rather than stigmatizing ones, are more motivated to comply with
  subsequent recommendations.

Next Steps

As with any disease, an approach to weight management must be tailored to each person, and the Task Force has the power to influence important clinical guidance that would impact the care that millions of women seek and receive. AWHP urges the USPSTF to consider examining the full continuum of obesity care, including behavioral therapy, medical nutrition therapy, pharmacology and the different types of surgical interventions. We welcome the opportunity to be part of the discussion on this important issue.

We ask you to leverage your position to advocate for recommendations that will support the
health and well-being of all women.