Obesity, diabetes & women’s health: the perfect storm looming in the horizon?

Diabetes is a chronic metabolic disease that requires lifelong treatment and is a leading cause of various comorbidities and death all over the world. In 2021, there were 529 million people living with diabetes, but numbers are expected to rise to more 1.3 billion people by 2050 according to recent estimates (GBD 2021Diabetes Collaborators 2021). Type 2 diabetes (DM2) should be the most prevalent form of the disease (The Lancet 2023). The astounding figures appear to be the result of a perverse equation involving the global obesity epidemic and inequity in health care which sadly will increase diabetes burden (The Lancet 2023).

Such projections sent alarms all over the planet and the World Health Organization responded by launching the Global Diabetes Compact in 2021 (The WHO Global Diabetes Compact 2024). The initiative aims to attack the problem in various fronts including DM2 prevention by fighting obesity, promoting healthy diets and physical activity as well as providing proper treatment of diabetes to all. The task is herculean as obesity has been relentlessly on the rise for the past 40 years and health-care resources are scarce as the world emerges from the pandemic.

In a recent series of articles, The Lancet exposed the diabetes situation which is looming in the horizon despite recent advances in treatment and initiatives to boost exercise, healthy diets and weight control in addition to awareness campaigns (The Lancet 2023). Much of research and clinical treatment is focused on glycemic control and prevention of complications, namely cardiovascular, renal and retinopathy. Reproductive health is a topic somewhat left aside but should also be included in the diabetes agenda for various reasons: the number of women affected, influence on women’s life-cycle (puberty to menopause), pregnancy and preconception care as well as the adverse impact it may have on the health of future generations. One should never forget the intrauterine environment is decisive for human health. The periconceptional period which encompasses the time window of 14 weeks before up to 10 weeks after conception during which a variety of harmful exposures may signifcantly affect prenatal and postnatal health. Published data confirm associations between parental preconceptional health, pregnancy complications and offspring health. The mother’s age, diet, and BMI for example may influence the development of non-communicable diseases such as diabetes in her children (Rousian et al. 2021).

To make matters worse, the incidence of type 2 diabetes is growing in young people, including women due to the adoption of unhealthy lifestyles and increased obesity. A hazardous effect on fertility and pregnancy complications is expected due to the association of obesity, hyperinsulinemia both endogenours and exogenous as well as polycystic ovary syndrome. The theme nevertheless remains understudied (Thong et al. 2020). Available guidelines unfortunately overlook the harmful effects DM2 may have on female reproductive function and most concentrate on gestational diabetes only. The development of guidelines to care for women living with diabetes which include pubertal development, contraception, fertility issues and menopause are urgently needed.

Obesity has been recognized as a complex disease involving psychological, environmental, genetical and socioeconomical aspects. In addition to the much publicized physical complications which make obesity is the 5th leading cause of mortality worldwide, it also bears a tremendous negative effect on wellbeing as excess body weight is frequently associated with stigma and discrimination (Tucker et al. 2021). Unfortunately, over the last 40 years no single country has been able to reduce the ever growing obesity and overweight numbers. In fact, data released by a recent global analysis by The Lancet informs more than one billion people are now living with obesity. The prevalence of obesity has risen since 1990 in the majority of countries not only in adults but also in school-aged children and adolescents. Sadly, the number of women living with obesity in 2022 reached 504 million whereas in men there are 374 million (NCD Risk Factor Collaboration 2024). Women living with obesity may present with various reproductive disorders such as polycystic ovary syndrome (PCOS), abnormal uterine bleeding, endometriosis, infertility, and pregnancy-complications (Venkatesh et al. 2022).

The alarming obesity numbers have already caught the attention of the World Economic Forum as the health hazards associated with increased body weight puts tremendous strain on the costs of health-care systems worldwide (The World Economic Forum 2024). Such concerns resulted in the publication of a document last January calling attention to the dire consequences of not taking obesity seriously enough in terms of individual health, as well as the social and economical burden. Unfortunately, despite the plethora of data urging obesity should be given proper care, it remains a neglected disease with a heavy load of stigma.

Obesity treatment has changed tremendously over the years with the development of medications such as the GLP1-agonists and a better understanding of the multifactorial pathogenic mechanisms involved but the disease remains poorly diagnosed and treated. It is true pharmacological treatment alone does not solve the problem as obesity management requires multiple approaches including the adoption of a healthy diet and exercises as well as mental health support (The Lancet 2024). Estimates reveal only about 20 percent of people living with obesity receive proper care despite all the risks involved, including heart disease, diabetes and reduced longevity. Access to care is also restricted as the costs of the newest medications are high and a healthy diet much expensive than the easily available ultra-processed foods (Tucker at al., 2021; NCD Risk Factor Collaboration, 2024). Another aspect is that as far as obesity treatment is concerned, one size does not fit all and individualizing management is vital. The aim should be overall health improvement rather than a target weight. Benefits can be seen with modest weight losses staring at 5 percent of body weight but shedding and maintaining weight loss remains a challenge (Ryan and Yockey 2017)

The evil twins obesity and diabetes have been described as a syndemic: as they may affect an individual simultaneously as a result of an adverse genetical, social and economical environment and concur to produce a number of complications which can be life-threatening, leave sequelae and increase health-care costs (Swinburn et al. 2019). No one so far has been able to effectively counteract the advance of “diabesity” all over the world. The term describes how the evil twins conjoin to produce illness and various comorbidities (Michaelidou, Pappachan, and Jeeyavudeen 2023).

Women seem to take the heaviest blow as far as diabesity is concerned in terms of incidence, complications and mortality. The numbers show both obesity and diabetes prevalence have increased more in women than in men. It is also clear the gender diferences should be taken into consideration when guidelines and policies are discussed. Obesity adds to the health and reproductive burden of diabetes and recent published data reveals the importance of preconceptional care for the health of the mother and the infant. The effect of the intrauterine environment for the health of the future individual has been demonstrated. In fact, providing guidance and preconception health care to women is vital not only to improve maternal pregnancy outcomes but also to the wellbeing of the growing fetus and the resulting individual. Unfortunately, very few guidelines address the topic and preconception care is not universally available to all. A life-cycle approach considering both obesity and diabetes care for women is urgently needed if we are to prevent a foreseeable disaster for women themselves, their children and families (Piccinini-Vallis et al. 2024).

The time to prioritize reproductive and preconception health as well as implement a life-cycle care to women living with obesity and diabetes is long overdue. The International Federation of Gynecology and Obstetrics (FIGO) recognizes the importance of providing proper care to women living with obesity and diabetes and has published best practice papers in an effort to provide guidance for health-care professionals dealing with both diseases (Adam et al. 2023; Maxwell et al. 2023). Canada has taken the lead and published a guideline on “Weight Management Over the Reproductive Years for Adult Women Living with Obesity” (Piccinini-Vallis et al. 2024). FIGO has also provided a checklist for preconception care which is considered vital for the health of both mothers and babies. The list includes obesity, comorbidities, nutrition and lifestyle factors that influence pregnancy outcomes (Benedetto et al. 2024). Implementing such practices worldwide is a colossal task that will require the cooperation and hard work of governments, health-care professionals and policymakers.

There is no doubt caring for diabesity in women poses incredible challenges and there is a clear need for specific strategies and national health plans that take into consideration cultural, social, economical and regional differences. Despite the advances in terms of the pharmacological treatment for both diabetes and obesity, drugs alone are not miraculous and the costs are a barrier to many (The Lancet 2024). Providing proper equitable, comprehensive and affordable care for both diseases requires the cooperation of medical societies, health-care providers, policymakers and society as a whole as one size does not fit all. It seems we do not have a choice as the resources required to care for so many are simply not available in the best scenarios depicted by the World Economic Forum. The effects of ignoring the situation will influence generations to come and further compromise health-care systems as well as economic growth. Women’s health has received little attention and investments over the years but the available evidence shows the alarming need to change course as the diabesity storm is far from running out of rain. There are not enough umbrellas nor a safe haven for everyone. Aristotle said we become brave by doing brave acts. The time to be brave and face the diabesity storm is now.