Obesity, sexual orientation, and getting to a "healthy weight"

When a group of researchers supported by the HHS Office on Women's Health set about designing a weight-loss intervention for lesbian and bisexual (LB) women, they ran into a challenge: Many lesbian and bisexual women are averse to the idea of weight loss. Although LB women are more likely to be overweight or obese than their heterosexual counterparts, they are less likely to consider themselves overweight. The researchers conducted focus groups with LB women (some involving only overweight participants), and learned that participants often didn't prioritize weight loss, but did want to be feel healthy and be more active. So, the researchers set primary objectives that emphasized physical activity and nutrition, with weight loss as a secondary objective.

The "Healthy Weight for Lesbian and Bisexual Communities: Striving for a Healthy Community" (HWLB) study involved five different programs in 10 cities across the US. The programs all lasted 12 or 16 weeks and involved weekly group meetings, nutrition education, and physical activity for overweight lesbian and bisexual women age 40 and older. Each program also used pedometers, gym membership, or a mindfulness approach to health improvement. The results have just been published in a supplement to the journal Women's Health Issues (disclosure: I'm the journal's managing editor). Researchers found that of the 266 participants, 95% achieved at least one of the health objectives; that included 57% of participants increasing their total weekly minutes of physical activity by 20%.

Health focus, safe environments, local norms

"We found we had very clear messages from the community that they did not want to focus on weight loss -- they wanted to focus on being healthy," explains Jane McElroy of the University of Missouri in a video about the study. McElroy ran the "Living Out, Living Actively" (LOLA) program in St. Louis and Columbia, Missouri, and served as first author of the paper reporting the study's main findings. In addition to focusing on health rather than weight loss, the programs all partnered with local LGBT organizations and worked to provide safe and welcoming environments for LB women. In the same video, LOLA participant Hudson Giles Lavender explains the importance of an intervention specifically tailored for LB women: "When I'm working on something that's really personal, the closer I get with people I identify with, the safer I feel."

Outside of such safe environments, lesbian and bisexual women of larger sizes may face bias and discrimination -- including from healthcare providers. As part of the HWLB study, Natalie Ingraham of Lyon-Martin Health Services, a program of HealthRights360, and colleagues designed and tested two trainings to help healthcare providers better serve LB patients who are overweight or obese.

Partnering with community organizations also helped researchers tailor their programs to local norms. "In some parts of the country, lesbian and bisexual women are more accepting of mainstream health interventions, whereas in the Bay Area, women were much more suspicious of mainstream approaches to health," says Michele Eliason of San Francisco State University, who led the "Doing It For Ourselves" (DFIO) program in the Bay Area and served as first author of the paper on sexual identities. "We were successful in recruiting women to our program because we culturally tailored the approach to community norms." The two Bay Area programs used mindfulness approaches; DIFO used an "intuitive eating" approach that emphasized body positivity and learning to assess one's own body cues, while Women's Health and Mindfulness (WHAM) used mindfulness stress reduction and mindful eating tools.

A comparison group of 67 participants did not receive an intervention. When McElroy et al compared each of the the three component groups (pedometer, gym membership, and mindfulness) to the comparison group, they found that the pedometer and mindfulness groups were more likely to increase their physical activity minutes by 20%, and the gym membership group was more likely to achieve a 5% reduction in the ratio of waist circumference to height -- and important indicator of metabolic health. Among all the intervention participants, the authors found:

• 57% increased their physical activity minutes by 20% or more;
• 51% increased their fruit and vegetable consumption by 10% or more;
• 28% decreased their waist-to-height ratio by 5% or more; and
• 19% decreased their weight by 5% or more.

Lessons for future research and practice

This is the first large-scale US study to focus on healthy weight for lesbian and bisexual women. McElroy and colleagues found the culturally tailored approach to be effective, and encourage other researchers to "replicate the models with longer follow-up in different geographic areas, urban and rural, and in different racial/ethnic groups with the ultimate goal of achieving healthy weight in all LB communities across the country."

In an article about recruitment and participation in the study, Susan Wood and her co-authors report that researchers found flyers and web posting to be less helpful for recruitment than "word-of-mouth participant referrals, emails to LB participants' social networks, and use of electronic health records (at the two clinic-based programs)." Despite special efforts to recruit underrepresented populations, the final sample had a high rate of college completion and employment. "Developing effective strategies for recruiting LB women with lower incomes, who are less educated, and who are from underrepresented populations should be a focus for future interventions," Wood et al write.

"We are hopeful that these results will motivate other communities to develop tailored interventions to support lesbian and bisexual women achieving the active healthy lives they desire," McElroy said. Program materials are online and available for use by other organizations. Study articles are available on the Women's Health Issues website.

Liz Borkowski, MPH is the managing editor of Women's Health Issues and a researcher at the George Washington University Milken Institute School of Public Health.