Diversity

Women and Health Committee

It is our mission to highlight and promote research, treatments and resources for women’s health. We will bring monthly features highlighting new, innovative and informative research relevant to women and women’s health accompanied by comments by the authors themselves and links for more information. Check back frequently for new highlights, and also check out our archive.

Featured Health Topic: Obesity disparities in women - the role of childbearing and stress

Davis, E. M., Stange, K. C., & Horwitz, R. I. (2012). Childbearing, stress and obesity disparities in women: A public health perspective. Maternal and Child Health Journal, 16 109-118. Comment by Esa M. Davis, MD, MPH, Assistant Professor of Medicine, University of Pittsburgh

Obesity disparities in women remain a public health challenge. For the past several decades the obesity prevalence has dramatically risen for adult men and women; however, women consistently have a disproportionate burden of obesity. Most concerning are the persistently high rates of obesity among young minority women and women of low socioeconomic (SES) status. Compared to White women, African-American and Hispanic women of childbearing age (20-39 years) have both higher rates of obesity (defined as BMI ≥ 35) and severe obesity (defined as BMI ≥ 40)(1). My colleagues and I have conducted several studies to understand, What factors are placing women and in particular minority and low SES women on a trajectory towards obesity(2-4)?

The featured article, “Childbearing, Stress and Obesity Disparities in Women: A Public Health Perspective” presents a novel conceptual framework that illustrates a potential pathway for the development of obesity and related disparities in women that will be useful in guiding interdisciplinary research and public health approaches. We developed this theoretical framework from a synthesis of findings and hypotheses generated from our own research and evidence from basic science, clinical, and population research, as well as, the disciplines of psychology and medicine. We identified from our qualitative research(2,3) and review of the literature(5) that childbearing and stress were contributing to weight problems in women. Our main hypothesis is that chronic stress contributes to weight change during the perinatal period and combined with increased parity and short inter-pregnancy intervals contributes to race and SES differences in the development of obesity in women.

The article discusses the evidence and proposes new hypotheses for how the disproportionate obesity rates among underrepresented minority and low SES women are due in part to a combination of genetic risk, suboptimal social and physical living environment, differential exposure and response to chronic stress, coping ability and health risk behaviors. We defined the perinatal period as the period between early in the first trimester (less than 14 weeks) to a year after childbirth as a time in which significant weight change occurs and when women experience both psychological and physiological stress. Specifically, women having a high pre-pregnancy weight, parity (# of live births), excessive weight gain during pregnancy and retention of weight postpartum appear to have greater weight gain and obesity 5-10 years after childbirth (5-8). Similar to obesity, racial/ethnic and SES differences in these childbearing-related risk factors exist and were recently summarized in several reviews (5,8,9).

Stressful life events and experiences such as pregnancy, racial and gender discrimination, or suboptimal living environments can influence an individual’s health. The model integrates the work by Folkman and Lazarus who provided the foundation for understanding psychological stress and its effects on health outcomes(10). Incorporation of McEwen’s work in the model provided the foundation for understanding physiological response to chronic stress that is coordinated via complex neuroendocrine pathways and the harmful effects on these biological systems overtime resulting in chronic diseases (e.g. cardiovascular disease)(11).

The main implication for this framework is that pregnancy-related obesity disparities are a potential area for obesity prevention. We discuss how this framework informs future research aims and study designs, as well as, its applicability to public health policy and clinical practice. We make recommendations on how these hypothesized relationships can be tested and propose new measurable and modifiable factors best addressed using multidisciplinary research. We have research underway to test the relationships proposed in the model. We recently completed the Pregnancy Weight Study, which was a prospective study of pregnant women from North East Ohio followed from early first trimester to 6 months postpartum to test the relationships between stress and post-partum weight retention. We have conducted a series of analyses using the National Longitudinal Survey of Youth cohort to investigate the relationships between parity, inter-pregnancy intervals and obesity risk illustrated in the latter half of the model. We recently reported that women having at least one child had twice the risk of obesity within 5 years after childbirth compared to women who never had children. Furthermore, minority women had greater risk of obesity related to childbirth.4 These results led us to examine these relationships over a 10 and 25 year period, which is currently under peer review. Using the same cohort, we examine the relationship between parity, length of the inter-pregnancy interval and obesity.

In conclusion, obesity and health disparities are two important public health and clinical issues that require a broad perspective of the influence of “life events” on health. Our article, and the framework presented therein, will be useful to funding agencies, researchers, health care providers and physicians to consider novel public health and clinical interventions that target the perinatal period for obesity prevention and risk reduction.

References:

1. Flegal KM, Carroll MD, Kit BK, Ogden CL. Prevalence of obesity and trends in the distribution of body mass index among US adults, 1999-2010. JAMA 2012: 307:491-7.
2. Davis EM, Clark JM, Carrese JA, Gary TL, Cooper LA. Racial and socioeconomic differences in the weight-loss experiences of obese women. Am J Public Health 2005: 95:1539-43.
3. Davis EM, Rovi S, Johnson MS. Mental health, family function and obesity in African-American women. Journal of the Nat Med Assoc 2005: 97:478-82.
4. Davis EM, Zyzanski SJ, Olson CM, Stange KC, Horwitz RI. Racial, ethnic, and socioeconomic differences in the incidence of obesity related to childbirth. Am J Public Health 2009:99:294-9.
5. Davis E, Olson C. Obesity in pregnancy. Primary care 2009:36:341-56.
6. Davis EM, Stange KC, Horwitz RI. Childbearing, stress and obesity disparities in women: a public health perspective. Mat and Child Health Journal 2012:16:109-18.
7. Gunderson EP, Abrams B. Epidemiology of gestational weight gain and body weight changes after pregnancy. Epidem Rev 2000:22:261-74.
8. Headen IE, Davis EM, Mujahid MS, Abrams B. Racial-ethnic differences in pregnancy-related weight. Adv Nutr 2012:3:83-94.
9. Viswanathan M, Siega-Riz AM, Moos MK, et al. Outcomes of maternal weight gain. Evidence report & technology assessment 2008:1-223.
10. Folkman S, Lazarus RS, Dunkel-Schetter C, DeLongis A, Gruen RJ. Dynamics of a stressful encounter: cognitive appraisal, coping, and encounter outcomes. Journal of Personality and Social Psychology 1986: 50:992-1003.
11. McEwen BS, Seeman T. Protective and damaging effects of mediators of stress. Elaborating and testing the concepts of allostasis and allostatic load. Annals of the New York Academy of Sciences 1999: 896:30-47.

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