Cardiovascular Disease, Diabetes and Obesity in Women

November 20, 2023

Cardiovascular Disease Diabetes and Obesity in Women ,

A GUIDE FOR EMPLOYERS

NOVEMBER 2023

Cardiovascular Disease, Diabetes and Obesity in Women A Guide for Employers

Introduction .................................................................................................................................. 4 Cardiometabolic Disorders ........................................................................................................ 5 Women and Cardiovascular Disease .............................................................................................. 6 Women and CVD Risk Factors ................................................................................................... 11 Diagnosis, Treatment and Outcomes ......................................................................................... 11 PCOS, Obesity, Diabetes and CVD: A Complex Relationship ...................................................... 14 Diabetes, CVD and Women . .......................................................................................................... 15 Obesity, CVD and Women . ............................................................................................................ 17 Weight Stigma, Healthcare and Women ..................................................................................... 18 Actions for Employers: CVD, Diabetes and Obesity in Women ....................................................... 20 Promote a Healthy Lifestyle ....................................................................................................... 20 Educate and Inform .................................................................................................................. 22 Implement Awareness Campaigns ............................................................................................ 22 Design Women-Friendly Benefits ............................................................................................... 23 Support Women in Advocating for Themselves within the Healthcare System ............................. 27 Address the Underuse of Effective CVD Treatments ................................................................... 27 Address the Underuse of Effective Diabetes and Obesity Treatments ......................................... 29 Checklist: Actions for Employers ................................................................................................... 34 Resources ..................................................................................................................................... 35

Women are a critical component of the workforce in the U.S. In fact, women comprise more than half of the U.S. population and 58.7% of the civilian workforce aged 16 and older.

Introduction

Ra ne dc r euvi tei rnyg eamn dp lroeyt ae irn. Oi nngewwoamy etno edmo pt lhoayte iess taot faol lc ul esv eo lns ws hoomu ledn b’ se hae taol tphp. rI ni o frai tcyt , f o“ Cr oamn y- pb ea tnt ieers rtehtaetnot if of enr oc fo fme mp rael he eenms ipvleo ys eu epsp, oarnt df omr ows ot mi mepno’ sr thaenatl ltyh, thhaevye hhei lgph ei mr pp rr oo vd eu chtei va il tt yh, oEumtpcolomyeesrsfoCranwSoumpepno,”rtaWccoomrdeinng’stHoeaalHtha.rvard Business Review article titled How U.S. 1 The message may be getting through. During and after the pandemic, many employers began offering benefits like more childcare support and flexible time off to retain wom - ei nn .dWi v oe rms ietny, aerqeupi tlya cai nn dg ei nmc lpuhsai os ins aonnd waor er kci no mg fmo ri t toerdg at no i zmaat ikoi nn sg tshuarte vtahlaute eamn pd l oi nyveeesst’ day-to-day experiences are in line with their personal values and promote well-being. One place to start is cardiometabolic health, or heart, blood and blood vessel health. Cardiometabolic diseases include (but are not limited to) heart attack, stroke and di - abetes. This guide explores how being female impacts the incidence, prevalence and outcomes of cardiometabolic disorders.

1 https://hbr.org/2022/06/how-u-s-employers-can-support-womens-health

Cardiometabolic Disorders

Cardiometabolic disorders emerge from interrelated risk factors such as hypertension, elevated fasting blood sugar, dyslipidemia, abdominal obesity and elevated triglycerides that put people at increased risk for heart attack and stroke — forms of cardiovascular disease (CVD) that are the two leading causes of death in the U.S. 2 An estimated 47 million people in the U.S. are living with cardiometabolic disorders, putting them at an increased risk of developing heart disease or type 2 diabetes. 3 The prevalence of cardiometabolic disorders is increasing worldwide for both women and men, primarily due to increasing obesity and obesity-related risk factors. 4 Women-specific risk factors for cardiometabolic disease include pregnancy, gestational diabetes (which occurs during pregnancy), preeclampsia, polycystic ovary syndrome (PCOS) and menopause. 5

HEART DISEASE

TYPE 2 DIABETES

2 https://www.health.harvard.edu/blog/how-good-is-your-cardiometabolic-health-and-what-is-that-anyway-202208182803 3 https://www.acc.org/Tools-and-Practice-Support/Quality-Programs/CardioMetabolic-Health-Alliance#:~:text=Cardiometabolic%20disorders%20represent%20a%20cluster,abdominal%20 obesity%20and%20elevated%20triglycerides. 4 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8017169/ 5 https://www.mdpi.com/1422-0067/24/2/1588

Women and Cardiovascular Disease

In this guide, terms such as “women” and “females” are used. We recognize that people who identify as female may not experience the issues and outcomes described and people who don’t identify as female may experience them. Employers should consider the health and well-being considerations of employees who identify as non-binary or transgender or who may be affected in other ways. Cc oVnDd ii st i ao ng es nseurcahl taesr mc o tnhgaetsdt ievsec rhi ebaerst af adiilsueraes, ee on fdtohcea hr de iat ri st , ohr ebal rotordhvyet hs sme l sp raonbdl ei nmc sl uadneds coronary heart disease, all of which can lead to heart attack or stroke. 10 Diabetes and obesity are significant risk factors for CVD, 11 and obesity-associated type 2 diabetes accounts for 90-95% of all diagnosed diabetes cases in adults. 12 CcyV-Dreilsatthede ldeeaadtihnsg.cause of death in women (and men) and the leading cause of pregnan- 6 In 2021, heart disease was responsible for 1 in every 5 deaths among women but research has shown that only about half (56%) of women in the U.S. recognize that heart disease is their No. 1 killer. 7 Up to 90% of women in the U.S. have at least one cardiovascular risk 8 and nearly half— 4te4n%sio—n.who are 20 years old or older have some form of clinical CVD‚ including hyper- 9

6 https://www.ahajournals.org/doi/10.1161/CIR.0000000000000907 7 https://www.cdc.gov/heartdisease/women.htm 8 https://www.ahajournals.org/doi/10.1161/CIRCRESAHA.121.319876 9 https://www.ahajournals.org/doi/full/10.1161/CIR.0000000000000950 10 https://www.cancer.gov/publications/dictionaries/cancer-terms/def/cardiovascular-disease 11 https://www.heart.org/en/health-topics/diabetes/diabetes-complications-and-risks/cardiovascular-disease--diabetes 12 https://www.ahajournals.org/doi/10.1161/CIRCRESAHA.116.308999

In 2021, heart disease was responsible for 1 in every 5 deaths among women.

Douiatcboemteess, .obesity and CVD affect women differently than men and can result in worse • People with diabetes are 2-4 times more likely than others to develop CVD. 13 • Women with diabetes have twice as much risk for CVD as men. 14 • Women with diabetes are more likely to have heart attacks before menopause than those without diabetes. 15 • Women are more than twice as likely to die after a heart attack than men, and 3he4a%rtoafttwaockm, ecnomexppaerreidenwciethm2a0jo%r oafdmveernse. cardiovascular events within five years of a 16 • Women die more often than men from their first heart attack. 17 • Women are at higher risk of diabetes-related complications like blindness, kid - ney disease, and depression than men. 18 • Female gender is associated with twice the risk of being overweight or having obesity. 19 • Women are at higher risk for developing obesity-related comorbidities and have two times higher mortality risk than overweight men. 20 Diabetes, Obesity and CVD Affect Women Differently than Men and Can Result in Worse Outcomes Women are at higher risk of diabetes-related complications like blind- ness, kidney disease, and depression than men. 17 Women die more often than men from their first heart attack. 16

People with diabetes are 2-4 times more likely than others to develop CVD. 12

Women with diabetes have twice as much risk for CVD as men. 13

Women with diabetes are more likely to have heart attacks before menopause than those without diabetes. 14

Female gender is associat- ed with twice the risk of being overweight or having obesity. 18

Women are more than twice as likely to die after a heart attack than men, and 34% of women experience major adverse cardiovascular events within five years of a heart attack, compared with 20% of men. 15

Women are at higher risk for developing obesity- related comorbidities and have two times higher

mortality risk than overweight men. 19

13 https://www.hopkinsmedicine.org/health/conditions-and-diseases/diabetes/diabetes-and-heart-disease 14 https://www.heart.org/en/news/2019/05/14/why-are-women-with-diabetes-at-greater-risk-for-poor-heart-health 15 https://www.hopkinsmedicine.org/health/conditions-and-diseases/diabetes-and-heart-disease-in-women 16 https://www.escardio.org/The-ESC/Press-Office/Press-releases/Women-more-likely-to-die-after-heart-attack-than-men#:~:text=At%2030%20days%2C%20 11.8%25%20of,Dr. 17 https://www.heart.org/en/news/2019/05/14/why-are-women-with-diabetes-at-greater-risk-for-poor-heart-health 18 https://www.cdc.gov/diabetes/library/features/diabetes-and-women.html

19 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8409720/ 20 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8409720/

A • mong women, health disparities by race and ethnicity are significant. For example: Black women have higher CVD morbidity and mortality rates than women of other races and ethnicities. 21 • Black women have a 50% higher risk of heart failure compared with white wom - en. 22 • Younger Black women are 2-3 times more likely to suffer premature CVD death. 23 • Nearly 43% of Hispanic/Latina women had some form of CVD in 2017. 24 • Hispanic women are more than twice as likely to have diabetes as white wom - en. 25 • Black people — women and men — are twice as likely to die from diabetes as white counterparts and three times more likely to be hospitalized from diabetes com - plications. 26 • Black women have the highest rates of obesity and overweight compared to oth - er groups in the U.S. 27 • Nearly 79% of Hispanic women are overweight or obese compared with 64% of non-Hispanic white women. 28 • Asian American adults have a lower prevalence of overweight and obesity than aadt uthltessianmoethBeMr rIalceivaellgsr. oups, but higher rates of hypertension, CVD and type 2 diabetes 29 Black women have higher CVD morbidity and mortality rates than women of other races and ethnicities. 20 Black women have a 50% higher risk of heart failure compared with white women. 21 Younger Black women are 2-3 times more likely to suffer premature CVD death. 22 Among Women, Health Disparities by Race and Ethnicity are Significant

Black people—women and men—are twice as likely to die from diabetes as white counterparts and three times more likely to be hospitalized from diabetes complications. 25

Nearly 43% of Hispanic/ Latina women had some form of CVD in 2017. 23

Black women have the highest rates of obesity and overweight compared to other groups in the U.S. 26

Hispanic women are more than twice as likely to have diabetes as white women. 24

Nearly 79% of Hispanic women are overweight or obese compared with 64% of non-Hispanic white women. 27

Asian American adults have a lower prevalence of overweight and obesity than adults in other racial groups, but higher rates of hypertension, CVD and type 2 diabetes at the same BMI levels. 28

21 https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2022/10/26/14/41/eliminating-disparities-in-cvd 22 https://my.clevelandclinic.org/health/articles/23051-ethnicity-and-heart-disease 23 https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2022/10/26/14/41/eliminating-disparities-in-cvd 24 https://www.ahajournals.org/doi/10.1161/CIR.0000000000001139 25 https://my.clevelandclinic.org/health/articles/23051-ethnicity-and-heart-disease 26 https://www.heart.org/en/news/2021/07/13/the-challenge-of-diabetes-in-the-black-community-needs-comprehensive-solutions

27 https://www.minorityhealth.hhs.gov/omh/browse.aspx?lvl=4&lvlid=25 28 https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=4&lvlid=70 29 https://www.ahajournals.org/doi/10.1161/CIR.0000000000001139

Intersectionality: Gender, Race and CVD Risk “Intersectionality” reflects the importance of how gender, race and class experiences interact to produce health inequities and is relevant when considering CVD risk. 30 Being a woman and also being a Black woman presents unique experiences that influ- ence access to health, attitudes toward health and healthy lifestyle choices, all of which affect CVD risk. Women are not a homogeneous group. Racism is an established determinant of cardiovascular health outcomes that can’t be ignored when considering the health risks for women in minority populations. 31

SOCIAL DETERMINANTS OF HEALTH AND CARDIOVASCULAR DISPARITIES IN WOMEN: ACTIONS TO ADDRESS DISPARITIES

Education

Physical Environment Limited access to green space Housing instability Rurality Improve access and quality of built environment Telehealth

Low literacy Lack of higher education Educational policies Improved awareness and health literacy Vocational training

Health Care System Lack of health insurance Provider unavailability

Economic Stability Low income and debt

Unaffordability of quality food Economic policies Subsidized food options

Poor quality of care Health care policies Value based care Innovative health care delivery

Social Support Low community engagement

Sexual Orientation Sex and gender bias Discrimination and victimization

Poor social integration Promote social resilience and networks

High risk factors in LBGTQ+ Bias training Inclusion in trials

Cultural and Language Linguistic and cultural barriers Access to interpreter Cultural sensitivity training

Systemic Racism

Implicit and explicit bias Limited access to financial, health and physical environmental resources Bias mitigation Health care workforce diversity Apply social justice lens to policy and practice

Negative Impact

Positive Impact

Adapted from: Lindley, K.J. et al. J Am Coll Cardiol. 2021;78(19):1919-1929 | https://www.jacc.org/doi/10.1016/j.jacc.2021.09.011

30 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6286284/ 31 https://www.liebertpub.com/doi/pdf/10.1089/heq.2021.0077

Women and CVD Risk Factors Ihne aardt ddi itsi oe na steo atnrda dsimt i oo nk ai nl gr, i tshkefraec at or ress feoxr- sCpVe Dc i fliick be i od li oa bg iectaelsr, ios kb ef as icttyo, rfsa mf oirl ywhoims teonr .y o f 32

Risk Factors for Cardiovacular Disease in Women

SEX INFLUENCE Sex-specific risk factors Premature menopause Gestational diabetes Hypertensive disorders of pregancy Preterm delivery Polycystic ovary syndrome Systemic inflammatory and autoimmune disorders

GENDER INFLUENCE Under-recognized risk factors Psychosocial risk factors Abuse and intimate partner violence Socioeconomic deprivation Poor health literacy Environmental risk factors

WELL-ESTABLISHED RISK FACTORS Hypertension Dyslipidaemia Diabetes Obesity Unhealthy diet

Sedentary lifestyle Smoking or tobacco use

Source: Women and cardiovascular disease | https://www.thelancet.com/infographics-do/women-and-cardiovascular-disease Acknowledging the effects of these risk factors is crucial to understanding cardiovascu - ltaorCdVisDeapsreevinenwtioomn.en. Women have also been underrepresented in clinical trials related 33 Diagnosis, Treatment and Outcomes Women with CVD are more likely to report poorer patient experiences, lower health‐ related quality of life and poorer perception of their health compared with men. 34 Dr eedsupci tt ei ocna omf pCaVi gDnbs ut rodreani sfeo ar wwaorme ne ensos vaenrdt hi me pp raos vt ed ewcoamd ee nh ’asscsatradl li eodv .aIsnc uf al ac rt , hCeVaDl t hi s, tt hh ee leading cause of death in women. Cardiovascular disease in women remains under- studied, under-recognized, underdiagnosed and undertreated. 35

32 https://www.ahajournals.org/doi/10.1161/CIR.0000000000001139 33 https://pubmed.ncbi.nlm.nih.gov/20160159/ 34 https://www.ahajournals.org/doi/10.1161/JAHA.118.010498 35 https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)00684-X/fulltext

R—e saenadr cthh esnh odwi ssc ht haar gt ewdo—m ewnhairl ee isne vt he ne mt i mi desst mo foar eh el iakretlya ttthaacnk . m e n t o b e m i s d i a g n o s e d 36 Research shows that women are seven times more likely than men to be misdiagnosed — and then discharged — while in the midst of a heart attack. 35 ! PA hn yds ci cl ai as ns isc mmaeyd mi c ai sl st ehxet abrot oaktst ahcakvse bbeeceanu swe rwi t toemn ebna’ ss esdy mo np mt o aml es mc aond de il fsf eorf df rios me a sme .e n ’ s . 37

HEART ATTACK SYMPTOMS: MEN VS. WOMEN The most common symptom of a heart attack for both men and women is chest pain. But women may experience less obvious warning signs.

Men Nausea or vomiting Jaw, neck or back pain Squeezing chest pressure or pain Shortness of breath

Women Nausea or vomiting

Jaw, neck or upper back pain Chest pain, but not always Pain or pressure in the lower chest or upper abdomen Shortness of breath Fainting Indigestion Extreme fatigue

Source: American Heart Association’s journal, Circulation | https://www.heart.org/en/news/2020/01/21/get-familiar-with-signs-of-a-heart-attack-or-stroke

36 https://www.health.harvard.edu/blog/women-and-pain-disparities-in-experience-and-treatment-2017100912562 37 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6479531/

Physician bias can also play a role . A 2022 Kaiser Family Foundation Women’s Health Survey found that among women ages 18-64 who had seen a healthcare provider in the past two years: • 29% reported that their doctor had dismissed their health concerns • 15% said the provider did not believe they were telling the truth • 19% said the doctor assumed something about them without asking • 13% said it was suggested they were personally to blame for their health problem 38 Ians aa dg ed iat ni odnr teop dr oi fdf eurcet ni vcee ss tiangde i as es aws ee l pl ar es spesnytcaht oi osno caina dl f pa chtyosri sc iraenl abt ieads ,t oo tgheenr df ae cr tmo rasy saul cs ho contribute to differences in diagnosis, treatment and outcomes for women with CVD. Ft eermp aa rl et sp, awt iheinc ht s i os fnmo ta tl eh ec acradsiea cf oprhpyasti icei annt ss ohfafveemwaol er scea roduitocloomg ies st st. h a n t h e i r m a l e c o u n - 39 Gender and sex interact to contribute discrepancies in the diagnosis, treatment and outcomes for women with CVD. 40 GENDER AND SEX INTERACT, CONTRIBUTING TO DISCREPANCIES IN THE DIAGNOSIS, TREATMENT AND OUTCOMES FOR WOMEN WITH CVD. 39

SEX Menarche Reproductive endocrine disorders Pregancy complications CVD presentation Menopause

+ = GENDER Socialization of gender Personality traits Gender roles Caring responsibilities Psychosocial stress

INCREASES IN: Mortality Treatment delays Emergency response times

Interpersonal relationships Bias in medical treatment

Medical risk factors which impact women directly, e.g. diabetes

Reproductive Lifecycle and CVD Reproductive age (typically 15-49) Early first menstruation is associated with future obesity and metabolic syndrome and 15-30% higher risk of future CVD. 41 Polycystic ovarian syndrome (PCOS) affects 10%–13% of women of reproductive age and can worsen CVD risk. 42 38 https://www.kff.org/womens-health-policy/issue-brief/womens-experiences-with-provider-communication-interactions-health-care-settings-findings-from-2022-kff- womens-health-survey/

39 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6479531/ 40 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9399064/ 41 https://www.ahajournals.org/doi/10.1161/CIRCRESAHA.121.319895 42 https://www.ahajournals.org/doi/10.1161/CIR.0000000000001139

Obesity during pregnancy is associated with coronary artery disease, insulin resistance and a low-grade inflammatory state, all causing predisposition to CVD. 43 Gestational diabetes is an independent risk factor for developing CVD later in life. 44 Pre-term delivery is reported to increase future risk of CVD. 45 Menopause Transition (typically 40s-50s) 46 During perimenopause , higher risks for major depressive episodes and anxiety are strong - ly linked to increased CVD risk. Sleep disturbances are common and linked to greater CVD risk. Prevalence of metabolic syndrome increases with menopause and may increase type 2 diabetes risk. 47 Post Menopausal Transition (typically 50s+) Prevalence of hypertension increases beyond that of men after age 64 and affects women more severely than men. 48 Women have longer life expectancies than men , so are more likely to experience age-relat - etodemxpoerbriiednitcieess,tdroiskaebsilwitiythanwdodrseemoeunttcioam. Aess.women age, they are more likely than men 49 PCOS, Obesity, Diabetes and CVD: A Complex Relationship Polycystic ovary syndrome (PCOS) affects 10–13% of women and is one of the most common causes of infertility. 50 According to the CDC, women with PCOS are often insulin resistant and at increased risk for developing the following serious health problems, especially if they are overweight: 51 • Diabetes : More than half of women with PCOS develop type 2 diabetes by age 40. • Gestational diabetes : Puts the pregnancy and baby at risk and can lead to type 2 diabetes later in life for both mother and child. • Heart disease : Women with PCOS are at higher risk and risk increases with age. • High blood pressure : Can damage the heart, brain and kidneys. • High LDL (“bad”) cholesterol and low HDL (“good”) cholesterol : Increases risk for heart disease. • Sleep apnea : Causes breathing to stop during sleep and raises the risk for heart disease and type 2 diabetes. • Stroke : Plaque that clogs blood vessels (from cholesterol and white blood cells) can lead to blood clots that can cause a stroke. • PCOS is also linked to depression and anxiety though the connection is not fully understood.

43 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7478041/ 44 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7478041/ 45 https://www.jacc.org/doi/abs/10.1016/j.jacc.2020.04.072

46 https://www.ahajournals.org/doi/10.1161/CIR.0000000000000912 47 https://www.sciencedirect.com/science/article/pii/S0378512218305395 48 https://www.uspharmacist.com/article/selected-womens-health-disparities 49 https://www.commonwealthfund.org/publications/fund-reports/2020/jul/transforming-primary-health-care-women-part-1-framework 50 https://www.ahajournals.org/doi/10.1161/CIRCRESAHA.121.319895 51 https://www.cdc.gov/diabetes/basics/pcos.html#:~:text=Women%20with%20PCOS%20can%20develop,2%20diabetes%20by%20age%2040

Diabetes, CVD and Women

According to the U.S. Department of Health and Human Services’ Office on Women’s Health, 1 in 9 adult women in the U.S.—roughly 15 million— are living with diabetes , mostly type 2. 52 Diabetes affects the body’s ability tinotopreondeurcgey.or respond to insulin, and therefore how the body turns food Among both men and women, diabetes is one of the strongest CVD risk factors . Men generally develop heart disease in their 40s and 50s, about a decade before women. But for women with diabetes, CVD risk occurs ear - lier. Diabetes takes away much of the protection premenopausal women would normally get from estrogen. 53 A systematic review of 49 studies found that compared to men with diabetes, women with the same con- dition had 57% excess risk for coronary heart disease . 54

A systematic review of 49 studies found that compared to men with diabetes, women with the same condition had 57% excess risk for coronary heart disease. 53

52 https://www.womenshealth.gov/a-z-topics/diabetes 53 https://www.hopkinsmedicine.org/health/conditions-and-diseases/diabetes-and-heart-disease-in-women 54 https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-019-1355-0

In gestational diabetes , insulin production is not high enough to counter the insulin resistance caused by the placenta’s secreted hormones, causing blood glucose to rise. Women with gestational diabetes are more likely to develop preeclampsia and experi - ence an increased likelihood for pre-term birth. The baby is more likely to have exces - sive birth weight and low blood sugar. 55 Any woman can have gestational diabetes, but those at higher risk include women who are overweight or have obesity, are more than 25 years old, or have a family history of type 2 diabetes. 56 Differences in diabetes outcomes for women versus men include : 57 • Diabetes increases the risk of heart disease for women by 4 times • versus 2 times in men. Women with diabetes have worse outcomes after a heart attack. • Wasobmlienndnaeressa, tkhidignheeyrdriissekaosef oatnhderdedpiarbeessteiosn-r.elated complications such • • Yeast and urinary tract infections are more common. Blood sugar can be more difficult to control before a woman’s period and menstrual cycle changes can happen. For more information about diabetes including prevention, management and treatment, see the Resources section on page 37.

55 https://www.niddk.nih.gov/health-information/diabetes/overview/what-is-diabetes/gestational/definition-facts 56 https://www.cdc.gov/diabetes/basics/risk-factors.html 57 https://www.cdc.gov/diabetes/library/features/diabetes-and-women.html

Obesity, CVD and Women

Obesity is the most significant risk factor for development of diabetes. 58 In the U.S., 30% of women ages 18-44 are considered obese. 59 The Obesity Medicine As- sociation defines obesity as a chronic, relapsing, multifactorial, neurobehavioral dis - ei na saed vi ne rws eh imc he taanb oi nl iccr, ebai soemienc hb aondiyc af al ta np dr opms oy ct ehso saodci pi aol sheetailstshu ceodnyssefquunecnt icoens,. r e s u l t i n g 60 The in- flammatory nature of excessive adipose tissue—or body fat—is a critical risk factor for development of insulin resistance, type 2 diabetes and many other chronic diseases. 61 Obesity is associated with nearly 60 comorbidities. 62 Body Mass Index (BMI), waist cir - cduiamgnfeorseentcheeadnidsebaosdey. fat percentage are some of the most common methods used to BMI, Race and Medicine The American Medical Association (AMA) adopted a new policy 63 in June 2023 to clarify the use of BMI in medicine. The policy says that BMI is “significantly correlated with the amount of fat mass in the general population but loses predictability when applied on the individual level.” The AMA’s subcommittee acknowledges BMI’s “historical harm [and] use for racist exclusion” and its shortcomings due to BMI being based primarily on data collected from previous generations of non-Hispanic white populations. The new policy notes that “The current BMI classification system is misleading regarding the effects of body mass on mortality rates.” The AMA now suggests using BMI along with other measures and encourages physicians to understand the benefits and limitations of using BMI to determine the appropriate care for patients.

58 https://pubmed.ncbi.nlm.nih.gov/34749892/ 59 https://www.americashealthrankings.org/explore/measures/Obesity_women 60 https://obesitymedicine.org/definition-of-obesity/ 61 https://www.frontiersin.org/articles/10.3389/fphys.2019.01607/full 62 https://www.rethinkobesity.com/disease-progression/comorbidities-of-obesity.html

63 https://www.ihi.org/communities/blogs/the-risks-of-fatphobia-to-health-and-equity?utm_campaign=tw&utm_medium=email&_hsmi=264828051&_hsenc=p2ANqtz--Bl_ LAiGeABbYp80NDSioUCmb6zHIGfvZrbS3OJv5SB-NIjplaC8I0IMrr3g_suFntLcCCh5z7sJAxcYyX1ZKRbVOswTSGJaPgMGNcMXGJjAPrm7w&utm_content=264656423&utm_ source=hs_email

The science of obesity is clear: obesity is a disease and not an individual’s fault or mere - ly a product of individual lifestyle choices or environmental conditions. 64 Such miscon- ct he ep tdi oi snesa fsaei l atnodr ec coongt nr iibz ue ttihneg bt oi o ul ongdi cear lucsoe md pb ou nt eenf ftescot ifvoebme sei tt hy,osdt si g omf aatdi zdi rnegs tshi nogs ei twl iikt he the use of anti-obesity medications (AOMs) and surgical intervention. Obesity is a chronic metabolic disorder associated with CVD and increased mor- bidity and mortality rates . 65 A National Library of Medicine abstract states that “obe- sity contributes directly to incident cardiovascular risk factors, including dyslipidemia, tmy epne t 2o fd ci aabr de ti oe sv,ahs cyuplearrt edni ssei oa ns eaannddscl ea er dpi odvi saosrcduel ar rs . dOi sbeeassi et ymaol srot allei tayd isntdoe pt heen ddeenv et llyo po -f other cardiovascular risk factors.” 66 Weight Stigma, Healthcare and Women Healthcare is one of the most common contexts in which weight stigmatization occurs; isntigfamcta, apnhdysdicisiacrnismhinavaetiobne.en reported as the second most common source of weight 67 A nationwide survey conducted in 2014 by the Women’s Hp oe na er t aApl lhi ay ns iccei afno ua np dp ot ihnat tm4e5n%t uonft iwl looms ienng rwe epiog rhtte. dI ni tt hwi sa ss uc rovme ym, Co nV Dt owcaasn rcaetl eodr aps ot shte- top concern less frequently than weight issues by both women and physicians. Women reported being more apt to put off going to the physician (63%) than doing their taxes (27%). 68 Weight stigma is clearly an issue when it comes to women’s willingness to discuss heart health with their doctors.

64 https://nam.edu/clinical-perspectives-on-obesity-treatment-challenges-gaps-and-promising-opportunities/ 65 https://www.ahajournals.org/doi/10.1161/circulationaha.106.171016

66 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8493650/ 67 https://onlinelibrary.wiley.com/doi/full/10.1111/obr.13494 68 https://www.jacc.org/doi/10.1016/j.jacc.2017.05.024

OBESITY-ASSOCIATED METABOLIC DISTURBANCES Most prominent metabolic and psychological comorbidities associated with morbid obesity.

Malignant Several types of

Mental · Attention deficit diseases · Depression · Anxiety · Panic disorders

cancer · Colon · Breast · Pancreas

Cardiovascular · ASCVD · Hypertension · Atrial fibrillation · Heart failure

Pulmonary · Sleep apnea · Asthma · COPD

Coagulation · Thrombosis · Lung embolism

Metabolic · Type 2 diabetes · Fatty liver disease · Dyslipidemia · Gallstones · Gout

Skin · Psorias

Musculoskeletal · Osteoarthritis · Fatigue · Physical impairment · Backpain

Urogenital · Infections · Incontinence

Reproduction · Hypogonadism · PCOS

Adapted from: https://www.nature.com/articles/s41573-021-00337-8

Actions for Employers: CVD, Diabetes and Obesity in Women

Promote a Healthy Lifestyle By promoting healthy lifestyle behaviors, supporting mental health, addressing mod- ifiable risk factors and offering biometric screenings, employers can work toward im - provement in the overall heart health of their workforce. 69 S“iudrevaely”scahradvieovsahsocwulnarthhaetaflethw. U.S. adults—perhaps only 1% of the population—have 70 The American Heart Association has developed a pre- smc or itpi nt igo hn ecaarltl ehde a“ lLt ihf ea’ sn dS ismh op wl e sSae vpeant h” wt haayt f ol i rs tasc thhi ee vsi envgeind ema locsat ridmi opvoarst caunlta hr ahbeiat lst hp. r o -

Life's Simple 7 1. Stop Smoking 2. Eat Better

3. Get Active 4. Lose Weight 5. Manage Blood Pressure

6. Control

Cholesterol 7. Reduce Blood Sugar

Adapted from: https://playbook.heart.org/lifes-simple-7/

69 https://playbook.heart.org/lifes-simple-7/ 70 https://playbook.heart.org/lifes-simple-7/

Encouraging Healthy Eating and Physical Activity Wherever People are Working

ONSITE INTERVENTIONS

WORK-FROM-HOME (WFH) INTERVENTIONS

Increase availability of healthy foods and beverages and decrease availability of unhealthy foods and beverages in cafeterias, vending machines and other areas. Encourage selection of healthier foods and beverages through positioning them more promi- nently in cafeterias, vending machines and other areas. Positioning ideas: At eye level or just below eye level, in well-lit areas, next to cash registers, at the front of hot/cold food sections.

Provide employees with resources specific to eating healthy while WFH.

Offer virtual healthy cooking demonstrations . Utilize digital tools that provide healthy eating and nutrition recommendations. ( Excerpted from NEBGH's guide Workplace Weight Management in the New Normal, Sept. 2020 https://online.flippingbook.com/view/380866/) Provide coupons for specific foods or free or subsidized subscriptions for healthy meal deliv- ery services such as Green Chef, Home Chef, HelloFresh, Blue Apron, Daily Harvest, Freshly, Purple Carrot, Sun Basket, etc. Provide gift cards or discounts for healthy restaurants.

Encourage selection of healthier foods and beverages through reduced, subsidized or free pricing in cafeterias, vending machines and other areas.

Use promotional tactics such as pricing specials, offering samples and using attractive names for healthier options. Make healthy food and beverage options more convenient using tactics like express lines for healthy grab & go items, morning pre-orders for healthier lunch items and postings and promotions for healthy food places nearby.

Promote healthy themed days like Meatless Mondays or Fresh Fruit Fridays.

Promote access to healthy meal delivery services or even provide periodic deliveries. Online articles provide pros and cons for these services. Post lists of healthy restaurants and food places in areas where employees live.

Reduce default portion sizes and plate sizes for food and beverages.

Send out tips for measuring and controlling portion sizes.

Provide calorie and nutritional labeling at onsite food and beverage purchase areas. Labels can be plain text or include easy-to-interpret signals about the health of an item, e.g., traffic lights with green for healthiest, yellow for moderately healthy and red for least healthy. Educate food service professionals to ensure they understand, follow and promote healthier choices.

Offer mobile apps that have barcode scanners to scan food for nutritional content.

Send out healthy food recipes; ask employees to share their own favorites.

Offer only healthier options when catering events and meetings.

Send out tips and ideas for healthy snacking. Encourage employees to “bring” and show a healthy Zoom lunch.

Set up kitchen areas so employees can bring healthy lunches to work.

Send out easy-to-prepare lunch ideas for home.

Provide access to clean drinking water.

Remind employees about the importance of drinking water frequently throughout the day.

Provide access to fruits and vegetables through onsite farmers markets, employee gardens and farm-to-institution programs.

Provide lists of farmers markets in different communities. List of farmers markets in the U.S. Support and promote community and home gardens.

Create environmental prompts like signage that encourages healthy food and beverage choices.

Send emails , newsletters , videos and communications that promote healthy eating and showcase the benefit of doing so. Provide employees with resources specific to exercising while WFH. Utilize digital tools that promote physical activity. Offer live or taped virtual fitness classes . Offer generic fitness perks that employees can use as they see fit — reimbursement for at- home gym equipment, running shoes, bikes, fitness trackers, etc. Offer mobile applications for managing stress such as Happify; Sanvello; Calm; Headspace; Stop, Breathe & Think; etc. Offer free or discounted height-adjustable desks or other equipment that can be sent to employees’ homes.

Provide onsite exercise options such as gyms, indoor/outdoor walking trails, workout classes, group fitness activities, sports and physically active games, as well as other amenities. Centrally locate with convenient hours and low financial barriers.

Provide onsite destressing spaces for mindful meditation, resting and games.

Provide active furniture such as standing desks, treadmill desks, bicycle desks and un- der-desk cycles. Offer support for physically active commuting including walking or cycling — lockers and showers, secure places to store bikes, subsidies for leaving cars at home.

Schedule “active WFH commutes” and team breaks .

Make stairwells inviting , e.g., well-lit, visually appealing with art or photography displays.

Coordinate employee-wide step challenges .

Incorporate movement into work days with walking meetings and stretch breaks.

Provide guidance on incorporating movement into workdays with pacing phone calls, Zoom stretch breaks, desk exercises, stair climbing, etc. Facilitate virtual fitness events, clubs, weight management challenges and cooking demon- strations. Publicize employees’ wellness achievements. Send emails , newsletters , videos and communications that promote physical activity and showcase the benefit of it.

Facilitate social connections via fitness events, team-building exercises, games, walking/ running/sports clubs, cooking and exercise groups, lunch and learns.

Create environmental prompts like signage that encourages the use of stairs instead of elevators, encourages people who drive to work to park farther away, etc.

Educate and Inform Ewmithpleomyeprlsohyeaevse.an important role to play when it comes to sharing health information In fact, according to the 2022 Edelman Trust Barometer, employ- ers are one of the most trusted sources of information for both men and women across all ages and management titles. 71 That’s important because a global survey of over 9,000 healthcare consumers from the U.S., U.K., Germany, Brazil and Japan found that women don’t know what sources of healthcare information to believe. Of the women surveyed, 78% don’t fully trust their insurance provider, 83% don’t fully trust the pharmaceutical company that makes their medicine, 35% don’t fully trust their physician and 31% don’t trust online sources. 72 Tb rhoechheuarlet sh apnl adn oytohue wr ionrfko rwmi taht ii os nl i kaevlayi laa gbrl ee aot ns loi nu er c ae nodf hi ne apl trhi ni nt , f oa rnmd amt i aonny; ma lossot mm aa kk ee celviennictisa.ns and thought leaders available for webinars and other types of informational You can promote relevant messages and link them with the programs you offer by key - ing off health awareness months or weeks—American Heart Month (February), Wom - en’s Health Week (Mother’s Day week) and Diabetes Month (November), for example. The American Heart Association’s “Go Red for Women” signature campaign 73 offers lots of shareable information; the American Diabetes Association and the American Obesity Treatment Association are other important resources to mine for content. Implement Awareness Campaigns Lack of awareness among women about the risks of heart disease is an important issue. Recognition that heart disease is the leading cause of death in women declined tt oi o4n4a %l S ui nr v2e0y1. 9T hf reo m1 06- y5e%a ri nd e2c0l 0i n9e, ai nc caowr da irnegn teos sa w2 0a 1s 9o bAsme revr ei cda na mH oe na rgt aAl ls sr oa cc ii aa tl ,i oe nt hNnai c- and age groups except women ages 65 and older. 74

71 https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&cad=rja&uact=8&ved=2ahUKEwiMzY-QxL6AAxUflYkEHSXsCRgQFnoECBQQAQ&url=https%3A%2 F%2Fwww.edelman.com%2Fsites%2Fg%2Ffiles%2Faatuss191%2Ffiles%2F2022-08%2F2022%2520Edelman%2520Trust%2520Barometer%2520Special%2520Report %2520Trust%2520in%2520the%2520Workplace%2520FINAL.pdf&usg=AOvVaw0viVyKHMdDTr_Z-yn9tQ_9&opi=89978449 72 https://hbr.org/2015/05/the-health-care-industry-needs-to-start-taking-women-seriously 73 https://www.goredforwomen.org/en/ 74 https://newsroom.heart.org/news/heart-disease-awareness-decline-spotlights-urgency-to-reach-younger-women-and-women-of-color

Women and men benefit by learning about the risks of CVD—particularly since 80% of CVD is preventable. 75 For women, it’s critical to raise awareness about the dt hi frfeearte nf ocre tshienms y. Pmrpotmo mo tsi ntgh et hy embaeyn ee xf ipt se roifepnrceevaenndt i ot hneafna dc tt thheast tCe Vp sD tios taa ks eertioo uosp ht iema il zt he cAasr adliwo vaayss c, ua wl a ar rheenael tshs icsaema ps ya, i gg invse nn et he de mt o abney cf ul yl et ur sr aalnl yd si ennf os gi tri av pe hainc ds pt auibl ol ircel yd at ov asipl aebclief i. c* audiences. * See the Resources section on page 35.

SIGNS OF A HEART ATTACK Symptoms every woman should know and pay attention to: Women and men may differ in their experience of heart attack symptoms, as women are more likely to have unusual or "atypical" signs of a heart attack. Some of these may come and go before a heart attack occurs.

Fainting

Nausea or vomiting

Breaking out in a cold sweat

Shortness of breath with or without chest discomfort

Paleness or clammy skin

Dizziness or light headedness

Unusual fatigue

Pain in one or both arms, upper back, neck, jaw or stomach

Discomfort or pressure in the center of the chest. It often lasts more than a few minutes, or goes away and returns.

Inability to sleep

Source: https://myheartsisters.org/about-women-and-heart-disease/heart-attack-sign/

Design Women-Friendly Benefits Get Input from Women in Your Workforce Hwahvi cehy oo nu eassmk ei dg hwt or emael lny wh ehl apt i tnyaptet sr aocft pi nrgo ga rnadmr se taani ndi nb eg nveafliut se dy oeummp laoyy ebeesm? Ai sns ienfgf e? cAt invde way to explore these questions is by conducting surveys and leveraging employee re - spooupruclea tgi roonus p—s ( eEmR Gp sl o) y. Me easnoyf ecmo lpo lro, yLeBrGs ThQa +v ee EmRpGl os ydeeessi ,genxepde fcot ar nat vma roi teht ye ros f, cwaor rekg fi ov er cr es and employees dealing with mental health issues, for example. 75 https://world-heart-federation.org/what-we-do/prevention/

Employees are not expected to be experts on health issues like CVD, diabetes and obe - spirt oy vbi du et rt sh. eTyhceaynms ha ya rbee ehxepl eprf ui el ni nc ei sd ei nnct li uf ydi inngg h, foowr wb ioams —e ns, ehxo, gwe nt hdeeyr,’ vr ea cbee ae nn dt rwe ea it ge hd t b—y shows up in the workplace and suggesting ideas for organizational changes. Partici - pants in ERGs might express concerns about their benefits, offering insight into how and why they fall short of meeting their needs. Work with Your Health Plan to Mine Data Collaborate with your health plan and/or benefits consultant to examine your claims data. This can help you better understand which illnesses your female employees are dc oena dl i ni tgi own si t. hYoaunrd ddaet tae rc ma ni nael swo hheetlhpeyr otuh ef i nb de noeuf itt swyhoeut hoefrf eprr ai md eaqr yu actaerl ey —a dt hd er efsi rs stthloi ns ee ou fn dd ee freunsseed f oa rmpornegv ewnot imo ne ,nd. eNt ee ca triloyn2a0n%d mo fa anda ug letmweonmt oefnCrVeDp ,odr ita nb oe tt ehs aavni nd go ab epsri ti my —a ri ys health care provider. This rate is higher among some racial/ethnic minorities, including Hispanic (33%) and American Indian/Alaska Native (26%) women. 76 Promote the availability of primary care physicians in your health plan’s network and consider offering concierge-type primary care services if warranted. Tailor Your Wellness Programs Ee mmppllooyyeeres wa nedl l nc ae ns s b ep rhoegl rpaf mu l si nf opcruesveedn t ionng ahneda l mt hayn abgeihnagv Ci oVrDs , adri ea b ceot ems ma nodn oabme soint yg. You may wish to tailor some of your programs to meet women’s needs and interests, including: • Workout classes such as yoga, Pilates and Zumba ® • Women-only time periods for on-site fitness centers • Exercise classes for expectant mothers and postpartum women • Mmeedniotpataiuosnaal nwdommeinndfulness classes for perimenopausal and • Women-focused walking groups • Nutrition and cooking classes for expectant mothers Promote Self-Care Supporting a workplace culture where self-care isn’t seen as selfish is important. In our society, women may still feel obligated to act as caregivers, putting the needs of children, spouses, parents, coworkers, friends and even pets before their own. Stress c2adniainbcerteeasseansduswceepigthibtilgitayint.o colds, depression, high blood pressure, sleep issues, type 77 Employers can try to counter such stress by providing benefits that allow women—and others—flexibility to take care of themselves. Such

76 https://www.commonwealthfund.org/publications/fund-reports/2020/jul/transforming-primary-health-care-women-part-1-framework 77 https://health.clevelandclinic.org/why-self-care-isnt-selfish-advice-for-women/

ww oo mr ke- fnr-ofmr i e- hnodml y eb felne xe ifbi tisl i ti ny,c laundde fcehr itlidl ict ya raen, de l df aemr cial yr ep, lma nant ei nr ngi. t yA asnudr vpeayt errenpiot yr t el eda vbey, Sj oHbRqMu ailni tJiue sn ewionmd iecna twe da nttheadt i“nptehres oi rnnael xatnpdofsaimt i oi lny. n e e d s b e i n g m e t ” to p p e d t h e l i s t o f 78 Ensure Access to Women-Friendly Healthcare Providers Studies have highlighted the benefits of patients having culturally competent provid - ers. 79 And ample research shows that women are misdiagnosed, underdiagnosed and offered inappropriate treatments far more often than men. 80 Increasing the gender, ra- cial and ethnic diversity of network providers is critical to improving health outcomes as tnodo de ndsuurriinngg et ha caht wh eoaml tehnc a—r e iennc cl uoduinntge rw. Ao ms pe rne vo if ocuosl loyr n—o t ef ede, lf es ma f ea ,l eh epaart di e na nt sd ouf nmd ae lre- cthaerdciaascepfohryspiacitaiennstshaovfefewmoarlseecaorudticoolmogeissttsh. an their male counterparts, which is not 81 Weight bias among providers is another issue that affects the quality of healthcare received by patients. 82 Ac ocmc eps os nt eonht eoa fl t ha cna ri ne ctlhuas ti vree fwl eoc rt sk eemn vpilrooyneme se’ nnte. eCdosl laanbdo rpart ei nf egr eanncde sc oi sn tarna ci tmi npgo rwt ai nt ht health plans and other vendors that value and understand the unique needs of diverse employee populations is one way benefits leaders can intentionally build more equita - ble benefits. Here are some questions you can ask your vendors to assess adherence to inclusive practices: • Can you provide data on employee claims, engagement and/or oountlycoomnerseqbuyessetx?, race and/or ethnicity? Can you provide it regularly or • Wm ehtahtopdesr ac er en tyaogue uosf ipnrgotvoi daet trrsaicnt ydoi vuerr ns iet tyw? o r k a r e w o m e n ? W h a t • Hpoopwuldaotiyoonurelepardesbeynetxinamclupsleiv?iDtyo?es your own leadership and employee • Horogwandizoaetsioyno’usrinocrlguasnivizeasttiorant’es gwyo? rk align with and support our • How do you engage women in evaluating how well your offerings meet their needs?

78 https://www.shrm.org/resourcesandtools/hr-topics/behavioral-competencies/global-and-cultural-effectiveness/pages/what-women-want-from-the-workplace.aspx 79 https://npin.cdc.gov/pages/cultural-competence 80 https://www.cedars-sinai.org/blog/women-should-advocate-for-themselves.html 81 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6479531/ 82 https://time.com/6251890/weight-bias-doctors-how-to-overcome/

• What is your strategy for understanding those you’re not reaching? • Hquoawlitdaotiyvoeuanmdeqasuuarnetitthaetivsuecmceestshoodf sy?our offerings? Do you use both • Iwf hy ao tu er xotfef ne rt ihnagvsei nyvooul vl oe omk ea dc hai tn ien lheearrenni nt gb iaans di na rytoi fui rc iaallgionrt ietlhl img esn? c e , t o Make Sure Benefits Are Accessible at All Income Levels Many employers offer the same level of healthcare and other benefit choices to all em - ployees. That does not necessarily mean that benefits are accessible and affordable to aelrl-wemagpelopyoeseist.ioWnosm, en across all racial and ethnic groups are over-represented in low- 83 a consideration employers should keep in mind when assessing how equitable their offerings are. 84

EQUALITY VS. EQUITY IN EMPLOYER HEALTCARE BENEFITS

HEALTH AND WELL-BEING

BENEFITS

EQUALITY

EQUITY

Implement Digital Tools to Help Chronic Disease Management and Care Delivery Many employers have digital tools to help employees manage chronic illnesses like dia - betes and obesity, and to support mental health. Similar tools exist to help with cardio - vascular health, maternal health and healthy behaviors like smoking cessation. All such tools can be valuable. As u 2m0e1r6s fOo lui vnedr tWh ayt mwaonm/ Fe On ,RmT Uo rNeEt hKanno mw leend, gwe aGnrt oe ud pp rs ouvr ivdeeyr so ft hma ot roef f et hr ea dn t2e, c0h0n0o cl oogny- that streamlines care delivery. Examples include on-demand care that fast-tracks ac -

83 https://nwlc.org/resource/low-wage-jobs-are-womens-jobs-the-overrepresentation-of-women-in-low-wage-work/ 84 https://online.flippingbook.com/view/703279374/36/

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