COMMON SCENARIO FOR POSTMENOPAUSAL WOMEN
A 52-year-old, recently postmenopausal woman is having some bothersome hot flashes and night sweats. But she's telling me the real reason why she's here in my office is, in her own words, she is devastated and depressed by the recent weight gain of 15 pounds, which seems to go in the wrong area, which is the belly area. And she's never seen this before.
She continues to watch her diet closely and is walking one to two miles a day, something she's done over the years. And she's like, all of a sudden, it doesn't seem to work anymore. She's asking me these difficult questions: why am I gaining weight despite doing everything right or the same anyhow as I have over the years? Is there anything I can do to prevent it? And then the bombshell question: should I be on estrogen to get rid of this fat?
So, I'm sitting in my chair, and I'm trying to come up with some good explanation for her question. What do I tell her? This is an aging effect. Not much you can do about a not very intelligent response, definitely.
WATCH OUT FOR DAIRY AND STRESS EATING
You're probably underestimating your dietary intake. Need to watch it better and exercise more. The standard recommendation, she probably knows better than that. This happens to all menopausal women. Is there any stress eating going on? Or what do I tell an estrogen for weight loss? That's an interesting thought.
When it comes to weight gain in midlife women, it's a rather common occurrence, more than 2/3rd of women greater than 40 years of age are overweight or obese. And more than 3/4th of women who are greater than 60 years of age are overweight or obese in this country. A whopping popping number, as I said, that this turns out to be one of the most bothersome symptoms for my midlife patients.
So even though hot flashes and night sweats are classically considered the most common symptoms in the perimenopausal period, the two most common complaints that I hear in my office when I take care of these patients are rigging and sexual dysfunction, even though these symptoms are far more common.
INCREASED ABDOMINAL FAT IN MENOPAUSE – IT’S NOT WEIGHT GAIN
The other issue that one needs to talk about, and I make a big deal about because it needs to be thought of distinctly from weight gain, is the increase in abdominal fat that occurs in women going through menopause.
Very menopausal women or women who are post-menopausal undergo body fat distribution changes such that they see more fat in the abdominal area, more than the subcutaneous and visceral distribution. And that's a direct consequence of lack of estrogen. Every now and then, you will see a woman who has normal weight, as defined by the BMI criteria, but she still has an elevated waist circumference.
We are paying more and more attention to these women from a health standpoint because there is a big study that recently came out which confirmed our fears: these patients who have an elevated circumference, despite having a normal BMI, believe it or not, had equivalent cardiovascular risk and risk of dying as obese patients with elevated base circumference.
So that's why we have to really get away from this practice of just measuring BMI as a measure of obesity and really paying attention to body fat distribution changes, and weight circumference measurement would be a starting point for that.
IS IT OLD AGE OR IS IT MENOPAUSE?
Unfortunately, after menopause, there’s upper-body fat distribution. So then one has to wonder: “OK, these changes are happening in midlife women. Is it because of aging? Is it because of menopause? Or is it both?” Not to say that that distinction is really important from a management standpoint, but it still helps to know what is causing these changes.
As we get older, all of us have a reduction in lean body mass, meaning our muscle mass, and that's mostly because of the hormonal changes that we are experiencing.
HOW HORMONES AFFECT OUR MUSCLE MASS
What does that mean? As you know, muscle is our powerhouse, meaning that's where we burn most of our calories when we are sitting and doing nothing. So the resting energy expenditure is mostly because of the calories that are being burned in muscle. As we get older, there are subtle changes in physical activity. Patients don't even perceive the speed at which they move around the rate of physical activity.
So all those things change and patients tend to spend less time in moderate to high-intensity exercise. So what does that mean? We're burning fewer calories at rest. We're burning probably fewer calories with activity. So we are in an energy surplus state, if we’re are not changing our diet to match those changes in energy expenditure.
CAN DIETING HELP MENOPAUSAL MUSCLE CHANGE?
Now, when it comes to dieting, the data are really variable. Some people tend to be better as they're getting older. Some people stay the same, some people eat worse. So there is a more uniform trend there. But one thing is for sure that we are burning fewer calories as we are getting older. So if a patient comes and tells you that they haven't changed anything and are still gaining weight, the response that I have in my head is that something needs to change.
WHY WE MUST MAKE CHANGES FOR PATIENTS IN MENOPAUSE
And some of the unique challenges in midlife women that need to be paid attention to are motor symptoms, hot flashes, night sweats, disturbed sleep, mood problems, joint aches, and pains. As you can imagine, a woman who is suffering all these changes is very unlikely to engage in lifestyle interventions. Therefore, adequate attention to these things.
And managing these problems becomes very important for weight management programs. How does estrogen play into it? What does menopause do not believe it, or not, menopause or C does not lead to weight gain, even though it’s very common thinking that menopause causes the increase in body weight.
WHAT CAUSES BODY FAT DISTRIBUTION CHANGE IN MENOPAUSE? ESTROGEN
It's not so much menopause, and it's not the lack of estrogen. But estrogen is directly responsible for body fat distribution changes. Why is that? Our estrogen receptors on fat cells and, depending upon where those fat cells are, lower body versus upper body estrogen has a differential effect on them.
Very simply stated, estrogen causes melting, if you will, of the belly fat. So, when you lose that estrogen after menopause, there is an increased tendency for women to deposit that fat in the wrong area, if you will.
In summary, what are the changes in women that will lead to an increase in total body fat? As I stated, there'll be a decrease in lean body mass, which is muscle and bone. There'll be an increase in visceral fat, maybe even in the absence of weight gain. Therefore, we need to measure waist circumference even in patients who have normal BMI.
HOW TO HELP YOUR MENOPAUSAL PATIENTS MANAGE WEIGHT GAIN
So then, let’s switch gears to talk about management issues. Recognition and validation of these changes are very important for women who are trying to talk about weight gain and are devastated and are depressed by it. These issues need to be addressed very aggressively, even in that patient who's not really coming to you with a complaint or weight gain.
The practice has to be to get the BMI and waist circumference in every patient. And if they are found to be overweight or obese, we must address it appropriately. We did a small study in internal medicine at the Mayo Clinic where we asked: How often did the diagnosis of overweight or obesity make it to the list of diagnoses for patients that were being seen in general medicine?
And, more than half the time, if the patient didn't bring it up, it did not show up in the diagnosis. So that's a whopping number, and it's really concerning. This is obesity being the epidemic that it is. We really have to change the way we practice medicine and be aggressive about management counseling these patients. And then again, midlife women pay specific attention to barriers to the adoption of a healthy lifestyle.
HOW TO TREAT THE BMI IN YOUR MENOPAUSAL PATIENTS
So, hot flashes, night sweats, not sleeping well, mood problems – these issues need to be addressed aggressively. What BMI thresholds do we use for recommending specific treatment approaches for obesity? So obviously, everybody gets counseling regarding diet, exercise, and behavioral therapy. I think it would make sense that this is something everybody needs, even for people who are normal weight in order for them to stay normal weight. This is something that needs to be reinforced to them also.
What about medications for weight loss? I can give you blanket advice: eat healthily, exercise daily. But does that mean anything? I think the important message really is in the details and making a customized program for each patient that fits their unique situation. So diet, physical activity, the core piece, which is a behavioral modification, has actually become the most important piece in weight management in the last decade because we have an increasing recognition that obesity is a psychological problem. It's a behavioral problem.
TREATING WEIGHT GAIN AND WEIGHT LOSS FOR BEHAVIORAL MODIFICATION
If you want to really make a difference in society, you have to encourage people to change their behaviors and change the behaviors long term. That is why in all our obesity programs at the clinic, we engage with psychologists because it's about breaking those vices. What keeps the patients from doing the right things?
I often tell my patients that they can probably tell me better as to what it takes to lose weight, what kind of diet they should be following. They are living that life, but something is keeping them from doing the right thing. So that's where a behavioral modification program comes in. How do we encourage and engage the patients to do the right stuff? As you can imagine, if you want to be doing all of this, it has to be a team-based approach.
So, you have to have a dietician, exercise physiologist, and, very importantly, a psychologist as part of the program. Talking about diet is this information explosion when it comes to which sort of diet works for weight loss. It’s all about caloric restriction. The prescription to the patient has to be 1200 to 1500 calories per day, which for an average woman, is a caloric deficit of 500 to 750 kilocalories this year. The weight loss of about a pound a week.
TEACHING YOUR PATIENT HOW TO MONITOR WEIGHT OBJECTIVELY
OK, now the other important thing to stress to the patient is that monitoring, again, brings in the piece of behavioral modification monitoring is very important. That whole approach of trying to do it in my head doesn't really work. If you ask me what I ate last night for dinner, I probably couldn't tell you everything that I did. As human beings, we tend to underestimate our dietary intake and tend to overestimate our physical activity. That's just how we are wired.
Therefore, there is the importance of objectifying. What is it that we are doing? And when we have a log, how can we change this? How can we do things differently? What did we do wrong in the last week? The importance of monitoring this could be a traditional measure. There's an explosion of apps that one can use for monitoring purposes.
Then, the other age-long debate has been which type of diet works: low carbohydrate, low fat, low protein, high protein, etc. So what I tell my patients is that, when it comes to just weight loss, not cardiovascular risk reduction, the micronutrient composition of the diet does not matter. What really matters is caloric restriction. You follow the diet that you are likely to adhere to.
WHAT WEIGHT PROGRAMS TO RECOMMEND TO YOUR MENOPAUSAL PATIENTS
If you want a very extreme diet, you're not likely to be compliant. So, the most important pieces are caloric restriction and long-term adherence. Any dietary plan you can stick to long-term will work for you.
Now, having said that, the U.S. News came out with rankings for the best diets for weight loss in 2019, and the Weight Watchers diet was ranked number one. On the basis that there were no foods that were considered off-limits. It gives patients the flexibility of choice. And as you know, they use the point system. Weight Watchers is pricey, though. The Vegan Diet, which is filling, has environmental benefits, but it can be fairly restrictive and can be onerous for planning purposes.
The third on the list, which actually was a close second, was the Volumetrics Diet. Again, no foods are off-limits. It's filling, but meal preparation can be rather lengthy. Patients will ask about this, so it’s a useful piece of information to discuss. But at the end of the day, again, there are three important things: caloric restriction, adherence, monitoring.
HOW INTERMITTENT FASTING CAN HELP MENOPAUSAL WOMEN
Intermittent fasting has been talked about in recent times, but what makes it important or more interesting now is that it probably has benefits with respect to delaying aging, decreasing cardiovascular risk, and other health benefits. It’s receiving more and more attention, and there are several different ways of doing it.
16-hour fasting, 18-hour fasting. There is a beautiful review in the NEJM that is very nicely written and talks about the benefits, that you know, how fasting really makes you eat like your ancestors and puts the body in that stress mode, which we previously thought was harmful, but now it potentially has health advantages. Go ahead and read it if you haven't already.
DOES EXERCISE HELP MENOPAUSAL PATIENTS?
Physical activity, that's another interesting one, I make sure to tell my patients that if you are planning to lose weight just by increasing your physical activity and want to keep eating at 3000 or 4000 your locality diet, you're going to need to exercise 48 hours in a day. It just does not happen with physical activity alone.
It's all about caloric restriction, particularly initially. But having said that, exercise, regardless of whether or not it results in weight loss, improves cardiorespiratory fitness, improves blood pressure, lipids, glycemic control, and reduces visceral fat.
In terms of which exercises I recommend to my midlife women, some brisk walking or similar aerobic exercise. The goal really is 151 to 180 minutes per week, and short bouts throughout the day versus one consolidated exercise have been shown to be similar strength. Building exercises are very important in my post-menopausal women because it helps them maintain their lean body mass. Even if it doesn’t help them build it up, the health maintenance of it helps.
BEHAVIORAL MODIFICATION FOR WEIGHT GAIN IN MENOPAUSAL WOMEN
And like I said, behavioral modification, just this is an important take-home message that has to be the core of any lifestyle programs, a lot of handholding. Teaching patients these strategies which they can use in their day-to-day life, fighting temptations. So monitoring goal setting, Problem-Solving stimulus control, stress reduction, mobilizing social support structures, and motivational interviewing are just some of the strategies we use in these behavioral programs.
MEDICATIONS FOR WEIGHT GAIN IN MENOPAUSAL WOMEN
Medications: this comes up all the time. Everybody wants that fantasy. “Give me that one pill that'll get me down to the normal weight!” But this is obviously a nuanced thing. These are the five FDA-approved medications for weight loss. That has been a declaration from the FDA that lorcaserin should be taken off the market because there is some increased risk of cancer. And those data, I have to confess, are a little iffy.
Now, when do you add an appetite suppressant? So, like I said, BMI greater than 27 with weight-related morbidity or BMI greater than 30. But when you start somebody with an appetite suppressant, the understanding is that the patient is already doing things to improve their diet on their own. They are already physically active, and they are motivated.
So, the first time I see somebody for weight management, I do not send them home with a prescription. I want to see what they are doing on their own. Three months, six months down the line is when we start talking about prescription medication. And again, these are important counseling points for patients.
WHY YOU SHOULDN’T RUSH TO PRESCRIBE
What are the real-world issues with medication? They are not the permanent solution for weight loss. Cost becomes the big one in my practice. Actually, the insurance companies are still not doing a good job of covering this stuff, but that is the deterrent.
Number one, the cost of these medications, side effects, like with any medications, are potentially teratogenic. So, using in younger women can be a problem. The other important thing is, if you think about it, obesity management is like hypertension management. If I start somebody on this medicine, it's not like I can take them off of it in 6 months or even 12 months. We're looking at long-term therapy. Do we know that these medicines are effective long term? No, they haven't been studied long term. So I don't know. There will be a plateauing effect when the patient starts regaining the weight.
And the other big issue is long-term toxicity. That's what is happening with lorcaserin. Now, they're concerned about cancer risk. So what about the other meds out there? Have we studied them long enough? We haven't. So, all these things need to be discussed with patients when we are prescribing medications. Estrogen has no direct effect on weight itself, but if you think about it, you put a woman who is going through a life change on estrogen. Manage her hot flashes, manage your sleep, manage her mood, and she's more likely to engage in behavioral interventions. That's number one.
Number two, if you are starting out on estrogen for a different reason, she's likely to experience favorable body fat distribution changes. But then again, I don't give estrogen to patients just to improve their body fat distribution.
CONCLUSION – FOLLOW THIS PROTOCOL FOR MIDDLE-AGED WOMEN WITH WEIGHT GAIN
So, someday in midlife, women will gain weight and have a greater tendency to accumulate visceral fat, so please measure their weight circumferences even if they have a normal BM. Lifestyle interventions really are the core principle here. They're the mainstay of prevention and management.
Perimenopausal women who exercise regularly and enter menopause at a normal weight are more likely to maintain their weight after menopause. Estrogen therapy decreases abdominal fat, but is not approved for this purpose, obviously. So, going back to my patient, I would tell her that this is, to some extent, an aging effect. But there are things we can do about it.
I don't know whether she's underestimating her dietary intake or not, but something needs to change there if you want to prevent further weight gain. This happens to a lot of menopausal women, but it's not something we just sit and watch. We can be proactive about it. But estrogen for weight loss – that's a bad idea.