Intro: Welcome to Obesity: A Disease, the official Obesity Medicine Association podcast exploring the many facets of the disease of obesity. In this episode we'll be hearing from obesity medicine specialist and OMA clinical education director Dr Nicholas Pennings. Joining him is Dr Sylvia Gonsahn-Bollie Dr Gonsahn-Bollie lead physician for Embrace You Weight & Wellness. She presented at the 2022 OMA Spring Obesity Summit on the topic of Obesity and Black Women: What Are We Missing? Today our speakers discuss the role of BMI in assessing obesity in Black women and the reasons why clinicians should consider the unique features of excess weight in Black women when diagnosing metabolic disease. Obesity: A Disease podcast is brought to you by the Obesity Medicine Association, a clinical leader in obesity medicine.
Nicholas Pennings, MD: BMI of 25 to 29 is considered overweight. BMI of 30 is considered obesity. Waist circumference should be less than 35 inches for women and 40 inches for men. These are commonly used cut points in obesity medicine, but what populations do they reflect? Do they apply to all adults, regardless of age or race? Does a BMI of 33 look the same in a man compared to a woman? In an 18-year-old compared to a 68-year-old? Does it look the same if you're white, Asian, Black, or Latino? One of the many limitations of BMI is that much of the health risk data is based primarily on middle-aged Caucasian populations.
Hi, I'm Dr Nick Pennings, chair of family medicine at Campbell University School of Osteopathic Medicine and executive director of clinical education for the Obesity Medicine Association, and with me today is Dr Sylvia Gonsahn-Bollie, MD, CEO, and lead physician for Embrace You Weight & Wellness. Dr Bollie presented at the 2022 OMA Spring Obesity Medicine Summit. Her topic was “Obesity in Black Women: What Are We Missing?” where she provided insights on assessing obesity in Black women and why we should be considering some of the unique features of excess weight and Black women. Welcome, Sylvia.
Sylvia Gonsahn-Bollie, MD: Hi Dr Pennings, great to be here. I still call you Dr Pennings because we first met at fundamentals of obesity medicine years ago. You taught me everything I know. [laughs]
Pennings: Well, thank you, but you can call me Nick.
Gonsahn-Bollie: Alright, Nick then.
Pennings: So BMI is a calculated ratio between height and weight. It does not give any consideration the muscle mass or fat distribution, which can vary widely by age, gender, or race. When you're assessing BMI in Black women, what are some of the unique considerations, particularly with respect to health consequences you look for in this population?
Gonsahn-Bollie: This is a fascinating topic and I think it's because of, very much like what you said in the introduction, we were not considered in the norm, right? A lot of the standards that we use for body mass index is based on population-based data but if our unique features weren't considered when that population was made, then it does pose…it poses a discrepancy when we start to use BMI. So in particular, what the recent data has shown is that Black women or Black people in general, particularly seen in Black women, have more muscle mass at a higher BMI, body mass index. So what that means is that our body composition needs to be taken into account when we're using the body mass index. And also what type of fat and where that fat is distributed really matters as well. So even though total body weight might be up, but if that most of that, that is subcutaneous fat and not visceral fat, then that also plays a role in, “Is this really correlating with someone's health risk?” Which is ultimately what we're using the body mass index for. It's supposed to be an indicator at what weight would someone might be at risk for metabolic disease, but we see that in Black women that if we're using that same norm, it's a bit off, and so it's so important to consider these discrepancies.
Pennings: And we see why variation in body fat distribution in individuals in all population, and that correlates with health risks. When we see more fat distribution in areas of subcutaneous fat, particularly lower body subcutaneous fat, we are less likely to see disease. So do we see more common patterns in Black women than we do in other populations?
Gonsahn-Bollie: Yes, absolutely. So in regards to subcutaneous fat, there was a study that was done that looked in a population of African women, which so Black women, and what they found is that at a higher… And they looked at waist circumference and not BMI, but we can extrapolate some of that data there. And what they found is that at the same…at a waist circumference of 35 inches, that didn't correlate with insulin resistance because there was more subcutaneous fat, and it wasn't until 38 inches that we actually saw that there was higher rates of insulin resistance. So what that is, what that's telling us is that yes, maybe at this given weight, Black women may have higher subcutaneous fat, but that's not corresponding or correlating with higher rates of insulin resistance or metabolic syndrome, just more than metabolic consequences we look at with said adipose tissue.
Pennings: And that's a good point when we measure waist circumference, it is thought to be a reflection of visceral fat. But the tape measure doesn't distinguish between the visceral fat and the subcutaneous abdominal fat, which also may pose some risk, but not the same risk as visceral fat.
Gonsahn-Bollie: Exactly. Exactly, and that's what they saw in that study, which had about 1000 women in it.
Pennings: And so the cutoff point of 35 inches was established by the ATP III—or National Education Cholesterol Program Adult Treatment Panel III in 2001—and it's kind of held since then. So you're saying there's a different cutoff for Black women? How universal is that? How kind of widely accepted is that number for Black women?
Gonsahn-Bollie: Well, these are still early studies, right? So it's not widely accepted, which is why we're having this conversation, but it does raise the conversation with Black women having, being diagnosed…as 57% of Black women having been having obesity. It does raise the question, well, let's reexamine the diagnoses. Because maybe if the diagnosis is off we're overestimating obesity in these populations, or we're not adequately reflecting the risk of metabolic health. So I think that's why it's important to reevaluate it, but it's not widely accepted right now and it's still pretty early in the investigation.
Pennings: Right, because I also remember in 2009 there was an article published in JAMA on harmonizing metabolic syndrome and they used race, different cutoffs for waist circumference based on race. They actually used, if I recall, a lower cutoff in Black women, but you're saying it's actually a higher cutoff in Black women.
Gonsahn-Bollie: Yes, and I think again this speaks to the heterogeneity of race in general, right? Because when we talk about race, we're just making a determination based on someone's skin tone, but there could, because especially Black in the diaspora could actually be interspersed with many ethnicities, depending on the population, where I believe in that study you're referring to, it was more a western population. The study I'm talking about is in an African or sub-Saharan African population, and so that was one of the things that was brought up is that if we, what would happen if we were to bring this to a western context and look at that. Because I do think that when we talk about race, the role of ethnicity and other genetic changes that has happened in the diaspora is important. But I think the key thing that these conversations raise is the need for individualization. Because even I've seen it where today our topic is Black women, but I've seen such studies done where if we look at European populations and where the waist circumference has been proposed that it needs to be lower in certain European populations or even in certain Asian populations where there needs to be a lower cutoff, as well. Or for men in those populations, that might be slightly higher. So I think what we're really coming to, and as we continue to grow in obesity as a disease, is to understand that there's so much heterogeneity with individuals that our population-based studies are just the start of the evaluation and the conversation.
Pennings: And continuing with that idea of heterogeneity, the perceptions of what an ideal body shape has been based more on social constructs than on health factors. Historically, body weight has been assigned to health and fertility. You look at paintings of women in the 1700s, often a larger body side. Do look even and much of African art that women have a different body shape, a larger body shape, more excess fat and that was a sign of health. As an obesity medicine specialist, I think it's important that we maintain awareness that there are, is cultural variation in preferences for the amount of body fat. What are some of the cultural considerations we need to be conscious of when discussing weight with Black women?
Gonsahn-Bollie: Absolutely, such a great point that you bring up. So again, Tiffany Powell is a great researcher out at NIH who's done a lot of work on this. And so, in one of the studies what she found is that Black women actually have higher rates of body acceptance at a higher BMI, so they're more likely to feel healthier than the higher standard BMI rate. And so what that translates is to we as health care professionals could be telling them, “Oh, your weight is unhealthy,” but they're thinking, “Actually I look good and I feel good at this weight,” and so and so there's a disconnect there.
How I reconcile this in my own practice, I think of it as two separate entities that have to be married so there's the healthy weight, and that's facts. That's clinical figures. That's no judgment. This is just based on what are your metabolic risks. At what weight, or what body fat percentage, or what waist circumference are you most at risk for the metabolic consequences of excess adiposity? That's healthy, weight. Happy weight, that's all feelings, that's on you. Where do you feel best? And I think if we could think about it kind of in those two entities and then try to meet in the middle it's very helpful because the data suggests when we don't speak this or not when we aren't communicating that effectively, there's a disconnect that is a disadvantage for Black women. Also, going back to your community—in your community a lot of times, losing too much weight is looked down upon. Even as a Black woman myself, I cannot tell you what was said, “Uh oh, don't get too skinny. You're getting too skinny now.” [laughs] Conversely, these are the same people that when you're starting to plump up, you might say, “Oh, you're getting too big,” or, “Look at you,” and have these comments. So I think it is important to be aware of what are the cultural norms and the best way to know that is asking people like where are you happy with your size? What weight do you feel most comfortable at? Before we even begin that conversation about healthy weight.
Pennings: Yes, I think it's very important to meet patients where they're at. To be able to know what the patient's wishes and the patient's perceptions are, and working with that and being able to understand what their wishes and desires and expectations are. But you also tie in another, I think, very important point in that we have to advise patients with respect to their weight in terms of how it's impacting their health. And so even though they may think they look good or feel good at that weight, if there's health concerns around that, then I think it's, we have an obligation to express what our concerns are. And so is it, do you find that a difficult conversation at times?
Gonsahn-Bollie: I think it definitely can be challenging, but again, the perspective that I come from is that we have to recognize that we're still fighting a lot of weight bias, right? And then in the Black woman, it's even harder because weight bias meets racial bias and racial discrimination, as well. And so especially sometimes…and even yes, these studies have been shown where there's a racial discordance when there is a maybe a non-Black provider trying to give advice that it's a bit harder or there's disparity in actually that advice being disseminated, but even when there's racial, when there's racial similarity there, we still can have a disconnect in the bias.
So I think it can be challenging, but the first thing is to be aware of our own biases so that the perspective that we're coming is from a nonjudgmental perspective and that this is a conversation about health, and actually that weight is just one symptom of the disease of obesity. Because so often we get caught up on those numbers on the scale and focus on oh the weight, the weight. But that's just one symptom. What we're really trying to address is to what we can't see. What we're trying to address is some of the other inflammation, some of the other metabolic consequences of obesity. And that also can have like, to your point, symptoms that affect people's lives—their energy level, their mood, their happiness, their sex life. Like all of these things, could all be impacted by something that we can actually make an intervention on. So I think what I—and actually after I gave the talk, this was a common question—people say, well, I want to have these conversations with my Black patients, but sometimes they seem defensive or they come then it's not well received. And then what happens is people feel more intimidated, they don't want to, then it makes you feel less confident as a clinician having these conversation. To that person and to the people that asked me that after the conference, my response was number one, is to don't be scared. [laughs] Don't be afraid, because I know it can't be intimidating, but the first step is to check, make sure that you say, “I come in peace. I come with no harm, I'm not judging you for your weight. I simply want you to be as healthy as possible, and this is one of the ways that I think we can make easy intervention beyond.” But I think it's really a lot. It's hard, it's a hard conversation. It's aligning with the person's goals and figuring out what those goals were and those goals may not be scale goals, initially. It might just be, I want to have more energy. It might just be, I want to feel lighter. And lighter may be like, I want to feel less stressed because I'm not carrying around so much extra weight. So these are the things that we need to find: what their goals are, and to have those conversations.
Pennings: Yeah, finding your patient's why is really important and then also recognizing that your perceptions of what a healthy weight may be is, may not be in line with the patients perceptions of what a healthy weight may be. So being in tune to that. And also I think it's very important when I talk to my patients, I try to sense, am I touching on a topic that they may be uncomfortable with and that they're starting to pull back from and disconnect? And in the course of the encounter, and I think we need to be in tune to our patients with for that behavior, to see that they're starting to pull away or shutting down or not maybe engaging as they were initially.
Gonsahn-Bollie: Exactly, and the thing is, you know I always say weight is not just a number, it's a story, right? Behind everyone's weight there's a journey that has brought them to this point and we don't know if they've experienced weight bias because 69% of women say they have experienced weight bias in the doctor's office, right? So we don't know if they've come in guarded because another doctor has insulted them or has insinuated that they're lazy or whatever because of the…and so we have to tread lightly and carefully when we're having these conversations, because it actually can unpack a lot of what we like to call little-T trauma. And these are traumas that could come—I mean in the work that I do, in which I do a lot of work in terms of emotional eating, emotional wellness, and the triggers of those triggers for weight, I unpack a lot of childhood trauma. So that's something that comes up over and over again, and so sometimes when we're bringing up these conversations, we're not realizing or recognizing the other things that are subconsciously being opened in the conversation.
Pennings: And I would agree: the why you eat is more important than what you eat in in most patients. And I love that every weight is a story, and I think that's important for us to keep in mind. And so when we're addressing that story, we have a number of different treatment options today, dietary options and behavioral interventions and anti-obesity medications and bariatric surgery. What are some of the strengths and limitations of these treatments for obesity care in Black women?
Gonsahn-Bollie: Wow, so again when we look at the literature that for Black women there's huge disparities in terms of both access to the treatment and even being offered the treatment. So again, looking at some of the data that's out there, when we looked at Black women being given…who met criteria for obesity based on the standard BMI, only 46% of them receive lifestyle counseling from their clinician. And so I think we're seeing that at every angle, Black women are not receiving, even being offered the care. Much less then, this issue with access because of insurance considerations or socioeconomic factors. And even perception of these things. I cannot tell you how many conversations that I have about obesity medications, and people think they're cheating or it's a quick fix. And so even if they're being offered it, there's misconceptions there that make them not want to take the medications. So I think it's definitely multifactorial at an individual level, clinician to patient, that there's limitations in those conversations. And then on a systemic level that there's bars to access, as well, which insurance being one or affordability, but even perception is a big thing, too.
Pennings: So to that end, amongst Black women is there, do you think there's a perception that they shouldn't have to take an anti-obesity medication or they shouldn't have to undergo surgery?
Gonsahn-Bollie: Well, again, this is anecdotal. Now I'm not going to quote, I have no real studies to quote, but yes, definitely, because I'm having the conversations. A lot of times because the misconception that obesity is strictly a lifestyle choice and it's a lifestyle disease, there's still that widespread misconception there. So if I can't lose weight, or if I can't treat my obesity by willpower in calories in/calories out, exercise, move more than I have failed, and taking those medications is a sign of failure, or sign that taking the easy way out. Or even the bariatric surgery. So I see a lot of shaming when I'm going through—I'm big on social media—so when I'm going through social media, reading the comments, there's a lot of shaming of people who, “Oh, she has surgery. She took medications.” But I always want to emphasize to all of my patients, everyone that I speak with, it is never cheating to choose to take a anti-obesity medication or to take an obesity medication because all it is doing is putting you on a level playing field of everyone who has the, who does not have obesity. Because if there's so much hormonal dysregulation that occurs in the disease state of obesity. So that's the first thing, and it's never easy to choose to have surgery. That's never an easy decision. Because there's a lot of ramifications that come with that, and it's a careful decision, so always reminding people of that.
Pennings: Yes, then you know that we're treating, when we're using anti-obesity medications we're treating the physiologic abnormalities just as we do with diabetes and hypertension and dyslipidemia. So that's very, very enlightening. Thank you very much for this conversation. I'd like to just ask one more question. What is your favorite piece of advice that you like to give patients when treating obesity?
Gonsahn-Bollie: So my favorite piece of advice to give patients when treating obesity is to remember that it's so much more than calories in versus calories out. Think about the common areas that people overlook: our stress. And especially when we're talking about obesity in Black women, that stress is heavy to carry around, and the hormonal effects of that. So really look deep and say what other things am I carrying, emotions, that may be heavy? So am I stressed? Am I getting enough sleep? Am I in supportive community? All of these things really matter when it comes to treating obesity. And always be open to other opportunities, like medicine is not a cheat, it is a way of treating the underlying cause. And so don't limit yourself to the opportunities that are available to you.
Pennings: That's great. Treating obesity is definitely a process, and it is something that evolves over time and evolves over the relationship. So I think it's very important we listen to our patients and we adapt to their needs as they go on this journey.
Well, thank you very much, Sylvia. It was great to have you on the podcast today. You can find Dr Sylvia Gonsahn-Bollie talk on the OMA Academy. It is Obesity and Black Women: What Are We Missing? Thank you for being here today.
Gonsahn-Bollie: Thank you, Nick. Great to be here. What a pleasure.
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