Women’s lifestyle and sexual function
Karsten, Matty
DOI:
10.33612/diss.125792427
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Karsten, M. (2020). Women’s lifestyle and sexual function: the effects of a preconception intervention in
women with obesity. University of Groningen. https://doi.org/10.33612/diss.125792427
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CHAPTER 1
General Introduction
1
This dissertation consists of two parts: the first part is focussing on women’s lifestyle and the
second part on women’s sexual function.
P A R T I – W O M E N ’ S L I F E S T Y L E
Overweight and obesity: worldwide trend and causes
Overweight and obesity are increasingly prevalent and lead to chronic non-communicable
diseases around the globe.
1To date, nearly one third of the world’s population is either
overweight or obese.
2Overweight in Western societies is typically defined as a BMI (weight
divided by height squared) of 25 to 30 and obesity is defined as a BMI of 30 or higher.
3The prevalence of overweight and obesity is generally higher in women than in men.
2The mean
BMI of women is shown in Figure 1.1.
4Although the Netherlands has lower rates of overweight
or obesity than other European countries and the United States
5, the rates are alarmingly high.
6With nearly one in three women of reproductive age being overweight (24.6% in women aged
20 to 29 years and 30.1% in women aged 30 to 39 years in 2018) or obese (7.9% in women
aged 20 to 29 and 13.7% in women aged 30 to 39 in 2018).
6Causes of overweight and obesity
Overweight and obesity are the consequence of a positive energy balance between the intake
of calories and calories expended, leading to an excess of energy that is stored in in adipose
tissue.
7The cause of overweight and obesity is multifactorial, the interaction of several genetic,
behavioural, socioeconomic and environmental factors attribute to their development.
8Global
economic growth has led to rapid changes in the environment due to: increased portion sizes,
intake of energy-dense foods and a decrease in physical activity due to sedentary lifestyles in
terms of work, modes of transportation and increasing urbanisation
1, which led to the so called
‘obesogenic environment’.
9The obesogenic environment has been defined as the ‘sum of
influences that the surroundings, opportunities, or conditions of life have on promoting obesity
in individuals or populations’.
9Excess adiposity is not only linked with an increased body size, but also leads to metabolic
consequences.
10Overweight and obesity increase the risk of many non-communicable
diseases such as cardiometabolic diseases, type II diabetes mellitus,
1,11some forms of cancer
12,
and mental health problems such as depression.
13In women of reproductive age obesity leads
to longer time to pregnancy
14,15, higher chances of infertility
14,16and an increased risk for
pregnancy complications
17,18. The offspring of obese mothers have a higher risk of becoming
obese themselves
19–21, with higher blood pressures
22, an increased risk of cardio metabolic
1 1975 2014
18.5 25 30 35 kg/m2
FFiigguurree 11..11.. Age-standardised mean BMI in women by country from 1975 to 2014 Adapted from: NCD Risk Factor Collaboration. Lancet. 2016; 387(10026):1377-1396. 4
Figure 1.1. Age-standardised mean BMI in women by country from 1975 to 2014
Adapted from: NCD Risk Factor Collaboration. Lancet. 2016; 387(10026):1377-1396. 4
Lifestyle change as first step in the treatment of overweight and obesity
Improving lifestyle, through a healthy diet and increasing physical activity is recommended as
a first step in treatment of overweight and obesity.
25–27Dietary intake and Physical activity
Both dietary intake and physical activity are daily recurring lifestyle behaviours as part of
our inherent physiological humans needs. Dietary intake refers to an individual’s daily eating
pattern, including the number of calories, the specific foods and beverages and the relative
quantities consumed
28. Physical activity includes all bodily movements produced by our
skeletal muscles that require energy expenditure
29, including bodily movements performed
while working, playing, active transportation, and during household- and recreational
activities. Exercise is not the same as physical activity, but can be considered as the part of
physical activity that is planned, structured, repetitive and is done with a certain purpose (e.g.
to maintain a certain level of fitness).
29Both reducing dietary intake and increasing physical activity can contribute to weight loss
if more energy is expended than consumed, resulting in a negative energy balance. These
changes in lifestyle, however, require behaviour change, which is often very difficult
30–33since
lifestyle behaviours are intertwined with many aspects of our daily living and involve a high
percentage habitual actions
31,34,35. Most lifestyle interventions often result in modest short term
1
term lifestyle changes
35,39,40. A systematic review showed that, in most studies, dietary changes
returned to baseline after 12 months of follow-up unless the intervention program remained
highly intensive.
41Since lifestyle change is difficult, not all individuals participating in a lifestyle intervention
programs will achieve the intended goal
38,42,43, and 10 to 80% of all participants will not
complete the intervention at all, depending on duration and intensity of the program.
44,45It
is unclear which factors relate to successful lifestyle change, to date, insufficient research
attention has been paid to the aspects that determine whether someone succeeds in changing
lifestyle.
46,47Studies have investigated psychological and behavioural factors, such as
self-efficacy, goal setting, social support and motivation
43,48as determinants of lifestyle change.
In a review, the most consistent determinants of lifestyle change were: a higher autonomous
self-motivation, a high self-efficacy level and self-regulation skills (such as self-monitoring).
48Identifying determinants of a successful lifestyle change in participants of lifestyle intervention
programs will provide tools to improve interventions for women with overweight, obesity or an
unhealthy lifestyle. If we know the determinants of success, it will be possible to personalise
interventions and increase effectiveness of interventions. In chapter 3 of this dissertation we
therefore aimed to identify biopsychosocial determinants of successful lifestyle change and
program completion of a preconception lifestyle intervention in women with obesity.
Intervening during the preconception period
Although changing and maintaining lifestyle is difficult, the period before and during pregnancy
may be an optimal period in which women are receptive to dietary and lifestyle advice, and
can therefore be seen as a an optimal time window to intervene.
49,50During this time period,
besides their own health, women also feel responsible for the health of their child.
50Intervening
in the preconception period may benefit both the woman and her future child. Moreover,
interventions in smoking- and alcohol cessation for example, are therefore particularly
successful in pregnant women or women with a wish to conceive.
49,51,52In chapter 2 and 4 of
this dissertation, we therefore aimed to investigate the immediate short-term and sustainable
long-term effects of a preconception lifestyle intervention on women’s dietary intake and
physical activity patterns.
P A R T I I – W O M E N ’ S S E X U A L F U N C T I O N
Sexual function
Sexual function is the way in which the body and mind respond to sexual stimulation and the
various stages of sexual response.
53These stages can be seen in the Human Sexual Response
Cycle (Figure 1.2).
54Female sexual dysfunction refers to an impaired ‘ability to respond
sexually or to experience sexual pleasure’
55and can take different forms of impairment to
the stages of sexual response, such as a decreased sexual interest, desire or arousal, the
inability to achieve orgasm, genito-pelvic pain during sexual activity, penetration disorder,
substance or medication-induced sexual dysfunction, a decreased sexual satisfaction, or a
combination of these problems (Diagnostic and Statistical Manual of Mental Disorders (DSM),
5
thEdition
55). Generally, more sexual dysfunctions are reported in women than in men in
the few studies that include both sexes
56, noting that fewer studies have been performed in
women.
56,57Female sexual function can be understood through a biopsychosocial model,
which is biologically driven, but is experienced through a complex interplay between (neuro)
biological, sociocultural, psychological- and interpersonal factors.
55,58,59Sexual function and obesity
Sexual function seems decreased in women with obesity
60compared to normal weight
women
61,62and weight loss can improve sexual function.
63,64The association between obesity
and sexual function in women is complex, at least three different pathways can explain
their relationship: direct effects from excess adipose tissue, co-occurring pathophysiological
conditions and mediating effects of psychological factors.
65Pathophysiologic comorbidities of
obesity such as metabolic syndrome
66,67, dysregulation of oestrogen and androgen levels
68,
and a poorer endothelial function that is important for vaginal lubrication
69–71, can all have a
negative effect on sexual function in women with obesity. Moreover, women with obesity are
more often dissatisfied with their body, and this can lower sexual desire and arousal.
72,73There is some evidence that weight loss increases female sexual function
56,65, especially in
women who had been diagnosed with sexual dysfunction prior to the start of the intervention.
74,75In chapter 5 of this dissertation, we therefore aimed to study the effects of a lifestyle intervention
on women’s sexual function.
1
Figure 1.2. Human Sexual Response Cycle.
Once sexual desire is accessed, receptivity to sexual stimuli increases, and proceeding of these stimuli in the mind is more likely to lead to further and more intensive arousal.
Adapted from: R. Basson. Journal of Sex & Marital Therapy, 2001;27(1):33-43. 54
Mental health and sexual function
Mental health and sexual dysfunction are intertwined, as mental health problems can be seen
as the most important risk factor for sexual dysfunction
76, even to a higher extent than physical
function.
76,77Depression is linked to a low sexual desire
78, sexual arousal and sexual pleasure
79and sexual dysfunction in general.
80A negative mood, apart from depression, has also
been linked to a decreased sexual function.
80Furthermore, anxiety has been linked to a lack
of subjective arousal
76, pleasure and orgasm.
81In anxiety the physical sensations of sexual
arousal can get neurologically linked to fear rather than pleasure.
82,83Medications such as
antidepressants wherein the reuptake of serotonin is blocked resulting in receptor inactivity
84,85,
can induce sexual dysfunction leading to a suppression of sexual desire and a delay or absence
of orgasm through inhibiting dopamine signalling in brain circuits.
84–86Furthermore, traumatic
experiences
83,87–89, relationship difficulties
90–93and stigmatisation
94–96as social aspects of
mental health can also contribute to a decreased sexual functioning.
Traumatic events and Post-Traumatic Stress Disorder
Worldwide, it is estimated that 70% of men and women experience at least one traumatic
event during their lifetime.
97Although most recover, a minority suffers from enduring severe
psychological and emotional distress resulting in post-traumatic stress disorder (PTSD).
98The
gender and trauma type.
99Women are more likely to develop PTSD than men, when exposed
to the same kinds of trauma.
100Furthermore, individuals with interpersonal traumas have the
highest risk of developing PTSD, especially following exposure to rape and sexual assault (19%
and 11% respectively).
100Furthermore, women who experienced trauma are more likely to be
obese
101and adverse experiences seem to be related to binge eating and the development of
obesity
102, mainly when PTSD symptoms are present.
103Traumatic events and sexual function
Of all types of trauma, sexual trauma types have been studied most in relation to female sexual
dysfunction and often show a profound effect.
87,88Traumatic experiences other than sexual
trauma, such as non-interpersonal trauma, have hardly been addressed in relation to sexual
function.
87,88A recent review proposed that the relationship between sexual trauma and sexual
dysfunction is mainly driven by PTSD symptoms.
83It is thought that physical sensations of sexual
arousal during sexual activity can be misinterpreted as threat rather than pleasure during
heightened arousal states in PTSD.
82,83The type of traumatic event in this regard may therefore
be less important, suggesting that also after other than sexual trauma types, a relationship
between trauma exposure and sexual dysfunction may occur.
Pelvic floor overactivity and sexual function
The function of pelvic floor muscles is critical to sexual function, as a normal tonic pelvic floor
seems to be associated with better sexual function.
104The pelvic floor is involved in stress
response and emotional processing, and is neuronally linked though the central nervous system
to the limbic system.
105,106Trauma- and stress-related disorders can lead to an overactive pelvic
floor, as part of a trauma-related defence mechanism.
107Pelvic floor overactivity can lead to
physical symptoms, such as micturition complaints, defecation problems, and sexual problems
including pain during sexual intercourse.
107–109Furthermore, almost half of the women with
chronic pelvic pain as part of an overactive pelvic floor reports a history of either sexual or
physical abuse, and a quarter of them screens positive for PTSD.
110The association with pelvic
floor overactivity may therefore be due to the development of PTSD resulting from trauma.
110In chapter 7 of this dissertation we therefore aimed examine the effects of lifetime traumatic
experiences and subsequent PTSD symptoms on sexual function and pelvic floor activity.
Polycystic ovary syndrome
Polycystic ovary syndrome (PCOS) is a common chronic heterogeneous disorder in women
of reproductive age worldwide.
111The three main characteristics of PCOS are: anovulation,
hyperandrogenism and the presence of polycystic ovaries.
112Features of appearance in
1
though loss of their feminine identity and may account for emotional distress.
113–115Furthermore,
clinical features such as: infertility, obesity, insulin resistance, type II diabetes, dyslipidaemia,
hypertension and metabolic syndrome
116are a risk factor for cardiometabolic disease in
women with PCOS.
117PCOS and its associated symptom profile can have an negative effect
on sexual function
118and mental health.
119Higher rates of depression and anxiety
120,121, and a
lower quality of life
122have been found in women with PCOS compared to a healthy controls.
121However, studies investigating the effects of PCOS on mental health and sexual function mostly
do not match the PCOS and control groups in characteristics, such as infertility status and the
degree of obesity, this may lead to confounding. In chapter 6 of this dissertation we therefore
aimed to investigate if mental health and sexual function differed in women with and without
PCOS with a comparable BMI and fertility characteristics.
The LIFEstyle study
This dissertation is based upon the data of two studies: the LIFEstyle study and the WOMB
project; a follow-up of women and children of the LIFEstyle study. The LIFEstyle study is a
multicentre randomised controlled trial including 577 women of reproductive age (18 to
39 years) with infertility, a BMI ≥29 kg/m
2and a wish to conceive. Women were asked to
participate in one of the 23 medical centres in the Netherlands between 2009 and 2012.
Women were then randomised into the intervention- or control group of the study. The women
in the intervention group received a six-month structured preconception lifestyle intervention
program. The main outcome of the study was a healthy at-term born singleton.
The lifestyle program consisted of a combination of dietary counselling, recommendations
to increase physical activity, and behavioural counselling. Within the intervention period, six
individual face-to-face consultations and four telephone or e-mail consultations were planned
with a trained intervention coach. Women were advised to eat a healthy diet
28with a caloric
restriction of 600 kcal per day compared to their habitual intake, but not below 1200 kcal per
day. Furthermore, women were advised to be moderately physically active for at least 2-3
times per week with a minimum of 30 minutes per day. And they were advised to increase
their physical activity by taking at least 10.000 steps per day, which was monitored by a
pedometer.
The main goal of the intervention was a preconception weight loss of at least 5% of their
original bodyweight. When the target weight reduction was met or BMI decreased to below
29 kg/m
2, women could proceed with fertility treatment. When a women became pregnant the
intervention was discontinued and women could re-enter in case of a miscarriage. The women
in the control group received immediate fertility treatment, irrespective of their BMI.
The WOMB project
Between 2015 and 2017, on average five and a half years after randomisation in the LIFEstyle
study, women were asked to participate in the WOMB project. WOMB is an acronym for
Women, their Offspring and iMproving lifestyle for Better cardiovascular health of both.
During this follow-up, data was gathered on a broad spectrum of outcomes directly- or
indirectly related to cardiometabolic health, obesity, and infertility, both from the women that
participated in the LIFEstyle study and the children that were conceived within the LIFEstyle
study and born up to 24 months after randomization.
Part I of this dissertation focuses on both the short term effects of the preconception intervention
during the LIFEstyle study on women’s lifestyle and the long term effects of the preconception
intervention on women’s lifestyle during the WOMB project. Part II focuses entirely on the
outcomes studied within the WOMB project.
Within this thesis, the following hypothesis was examined (Figure 1.3): Women with obesity
and the wish to conceive, who participated in a preconception lifestyle intervention program
to reduce weight, improve their short- and long-term lifestyle, mental health, quality of life and
sexual function.
Obese & wish to conceiveImproving
lifestyle before
pregnancy
• Lower cardiometabolic risks • Higher chances of getting
pregnant Long-term improved lifestyle Better mental health Better sexual function Better quality of life
1
O U T L I N E O F T H I S D I S S E R T A T I O N
Part I of this dissertation evaluates the effects of a preconception lifestyle intervention in women
with obesity on short and long term diet and physical activity. Furthermore, we evaluated
determinants of successful short term lifestyle change.
Chapter 2 of this dissertation reports the effects of a preconception lifestyle intervention on
short-term diet and physical activity in the LIFEstyle RCT.
In
chapter 3 the demographic, (bio)physical, behavioural and psychological determinants
of short-term successful lifestyle change and program completion are investigated in the
intervention arm of the LIFEstyle RCT.
In chapter 4 the effect of a lifestyle intervention on long term energy intake, diet quality and
physical activity are examined in the WOMB project follow-up.
Part II of this dissertation evaluates whether a lifestyle intervention improves sexual function
on the long term. Furthermore, the mental health and sexual function in women with obesity
and PCOS is compared to controls with a comparable BMI and evaluates the relationship
between traumatic life events, subsequent PTSD symptoms and sexual function and pelvic floor
overactivity.
Chapter 5 reports the effects of a lifestyle intervention on sexual function 5 years after inclusion
in the LIFEstyle RCT.
In chapter 6 we investigated whether women with PCOS and obesity differ with respect to
controls in the domains: anxiety and depression, quality of life and sexual function.
In chapter 7 we examined the effects of traumatic life events and subsequent PTSD symptoms
on pelvic floor overactivity and sexual functioning.
In
chapter 8 the results and implications of this dissertation are discussed and put into a
broader perspective.
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