Menopause and Weight: There is No Code to Crack
A personal reflection
One of the most common questions I get asked is about menopause and weight gain. So it’s no surprise that there is a lot of predatory misinformation out there, either about weight loss “codes to crack” or about hormone therapy and weight loss.
First off, there is no code to crack. The very language is ridiculous and borders on conspiracy theory thinking. There is no mysterious weight loss hack known only to a few people who sell books and coaching about this so-called secret.
Secondly, hormone therapy doesn’t help with weight loss. Just look at this predatory marketing from Winona, an on-line hormone business (not sure what else to call them). This is just one of several reasons why I advise against using this service. We know that hormone therapy in menopause does not rev up your metabolism or lead to weight loss, so they are either making it up or don’t know the literature. It also doesn’t treat brain fog or reduce bloating. But what are facts anyway?
Despite what many people think, menopause is not associated with a major change in metabolism and does not lead to weight gain. We know this because of studies that have looked at metabolism and because of the Study of Women’s Health Across the Nation which compared the effects of aging versus the effects of menopause on weight. We all age together, but we don’t all enter the menopause transition and stop menstruating at the same time, so researchers were able to look at changes in weight trajectory over time and in relation to the menopause transition and final menstrual period. The conclusion was menopause and hormone changes are not associated with a change in weight, but over time, in America anyway, we tend to gain weight as we age. For those in their 40s and 50s it was about 1-1.5 pounds per year. So if your menopause transition starts at age 45 and ends when you are 52, you could gain 5-10 lbs during that time.
What does happen with menopause is that the weight we gain tends to accumulate around the waist, and so if it seems like you are gaining fat where you didn’t have it previously, that is true. We also lose muscle mass. Why the hormone changes of the menopause transition cause the weight to be deposited around the middle isn’t known, but there are medical implications, because a waist circumference of 35 inches or more for women is associated with an increased risk of cardiovascular disease and is also one of the five criteria for metabolic syndrome, and having three or more is associated with an increased risk of cardiovascular disease, diabetes, and stroke. Basically, fat gained around the middle has more health implications than fat gained elsewhere.
When I was 45 years old I had a major reckoning with myself about my health. My incredibly stressful pregnancy when I was 38 (triplets born prematurely and one dying at birth, the other two on oxygen for a year and with years of health issues is the short story) meant I did not care for myself for about seven years. Like at all. In addition, my marriage was falling apart and I was eating my feelings. I was out of breath doing light exercise, I was obese, and my cholesterol, triglycerides and LDL were all rising.
I filed for divorce and embarked on getting in shape. While a “revenge” body for my unhappy marriage was part of my initial motivation, and not one that I am proud of, I also wanted to be healthy so I could enjoy my kids for as long as I could. I knew what the medical evidence showed for weight loss, a calorie deficit is key, and that exercise is great for my heart and bones and could be helpful for weight maintenance. I planned every meal, tracked calories, joined a boot camp three days a week and started running. I went from someone who despised exercise in all of its forms to someone who appreciated what it did for me.
I lost 60 lbs, but more importantly my cholesterol, triglycerides and LDL plummeted, my waist circumference dropped below 35 inches, and I was strong. And all of this happened while I was going through my menopause transition and without hormone therapy (I started that a few years later).
And this is how it went for several years. I planned meals and tracked my calories and went to the gym four days a week where I ran on the treadmill and did weights. I even entered some races. I was fifty years old and the fittest I had been in my life. I was proud of my muscles and strength, and considering my strong family history of osteoporosis, I felt comfort in the fact that I was working my bones.
And then I started writing The Vagina Bible while I was also working full time. The hours it took to write the book had to come from somewhere, so I exercised a little less and became less rigorous about planning meals. And then there was a book tour, and I told myself I would get back into exercising and meal planning when it was done. But then I started writing The Menopause Manifesto, and had some major, but very common, life stress related to kids and High School. And then the pandemic hit. Over time I stopped exercising, tracking calories, and planning meals. Honestly, in the first few months of the pandemic I barely moved. I mean, there was nowhere to go.
When I decided to take stock, I had gained 20 lbs, and it seemed like almost all around my waist, my cholesterol, triglycerides and LDL had risen again, and I was out of breath climbing stairs.
I didn’t gain weight because dieting had “wrecked my metabolism” or because I was eating carbs (I ate carbs when I lost weight the first time), or because of menopause. I gained weight because I stopped doing the things that worked. And it’s hard to do those things day in and day out. And the more stress one has, the harder it is.
Weight loss isn’t about hormone balancing and cracking a code, what it is really about is having a plan and being consistent with that plan. And so I am back to tracking calories, planning my meals, exercising and this time I am working remotely with a trainer (the fantastic Kim Schlag). My weight loss is slower than when I was 45, and no, not because of my metabolism. It’s because I'm having trouble being consistent with my plan. I am not upset with myself, rather, I’m just trying to focus on ways to be more consistent. And I am reminding myself that weight loss isn’t the real goal here, it’s my health. My waist circumference is back under 35 inches, my cholesterol, triglycerides, and LDL are heading black down, and I am much stronger.
One thing that helps me eat the way that I want to eat is meal planning. And if you are like me, it can get tedious to find meals that are nutritious and higher in protein and fiber (I’m aiming for 100-120 g of protein a day and 35 g of fiber). And so I want to leave you with some day-to-day recipes, meals that for me live at the center of the Venn diagram of taste, ease to make, and nutrition. There is minimal prep time, and these meals are big on flavor, and have no fancy ingredients so you can get everything you need at Safeway or Trader Joe’s.
Salmon and Salad
This is my favorite no recipe-recipe. I sear salmon and make a salad. This is 20 minutes from start to finish. You need the following (for two):
Ingredients:
Two 8 ounce filets of salmon
3 tbsp olive oil
4 tbsp lemon juice (Meyer is preferred, but any lemon is fine)
Salt
1 clove garlic, minced or crushed
2 tbsp Dijon mustard (I love Trader Joe’s)
Lettuce (I use almost the whole bag from Trader Joe’s) and any other salad fixings you like. I like some diced red onions, cherry tomatoes (about 8 ounces), a sliced cucumber and some diced avocado.
Preparation:
Heat a non stick skillet on medium high.
Salt the salmon.
Add 1 tbsp oil to the pan, when it’s sizzling add the salmon skin side UP. Cook for 4-5 minutes and then flip to skin side DOWN, turn the heat down to medium, and cook for another 4 minutes. If your salmon is really thick you may need to cook for longer or cover to help it cook through (if that is what you want).
While the salmon is cooking, add the other 2 tbsp of oil to a big bowl, and then add the garlic, Dijon mustard, and lemon juice. Mix well. Add all the salad fixings and toss.
Put one filet and half the salad on each plate and voila!
Honey chipotle chicken tacos in the slow cooker. Here is the recipe from the New York Times and it takes 5 minutes to assemble, and yes, make the pickled red onions. They also take 5 minutes. Buy the tortillas or your choice and serve with sliced avocado and sprigs of cilantro. Serve with a side salad (you have the recipe above!). This is a crowd pleaser.
Turmeric and Black Pepper Chicken, also from the New York Times. You can find the recipe here. This is 20 minutes from start to finish. I serve it with quinoa. To make the quinoa, I use this recipe and it is perfect. Chop the chicken, start the quinoa, then finish the chicken recipe. It will all be ready at once. If you are vegan, I am bet you could substitute tofu and alter the cooking times just a little.
Chrissy Teigen’s skillet charred fish tacos. They are amazing and they take 6 or 7 minutes to make. I serve with corn tortillas, but I don’t make the cabbage slaw, instead I make a mango salad with 2-3 mangoes, chopped red onion, chopped cilantro, and a diced jalapeño and the juice of half a lime. I serve it with tomatillo salsa, sliced avocado, and cilantro. And the salad from the first recipe and you’re good to go.
Chicken and lentil soup. My partner, Dr. Jen Adjacent (not his real name) turned me on to this recipe (and it has stovetop, Instant Pot, and slow cooker variations!). Serve with some avocado, cilantro, cheese, and a spritz of lime juice. My kid who dislikes lentils even loved it. The next day when the leftover soup has soaked up the liquid, you can either reheat it with more broth or some water, or use it as filling for chicken lentil quesadillas! That’s what my kids do.
Oh boy. OK, Dr Jen, I love you, you are often a voice of sanity in the wilderness but this is a top to bottom 'no' from me, and I'm feeling sick as I write it because I hate contradicting even people I hate but when it's someone I like...ouch. I am so so sorry but this is all coming from a place of antifat, thin, white, rich privilege and nowhere is that acknowledged, and I know that is so, so triggering for people because it is so horrible to think we might be insufficiently kind or compassionate, especially when we are 'just' looking out for people's health, but this is not kind, not at all. Talking about 'doing the things that worked' is so horrible for people for whom it does NOT work, and talking approvingly about tracking calories and exercise is beyond triggering for people with all sorts of eating disorders and it is particularly problematic when you are talking from a position of authority as a medical professional. You may talk about how it's not about losing weight but the first metric you cite in all these instances is the amount of weight gained or lost. I confront this constantly with people who profess to love me and then talk about my imminent death because I am not trying hard enough to do the things 'that work'. And I'm actually really healthy! How the hell must it feel for people who aren't doing the exercise, aren't eating 'correctly' and are consequently the authors of their own downfalls? And the thing is, you could take the weight conversation out and still have a really valuable post - for people who can do it, exercise can be incredibly valuable and helpful in changing the metrics NOT to do with weight. Eating protein and fibre can be very helpful, without reference to restriction. I know you will not agree with me and feel fully justified in placing this piece here unquestioned, and I'll probably get a ton of pushback on this but this really needs to be called out wherever it appears, even if it is on the publication of a tremendously helpful, kind, empathetic practitioner. Perhaps especially then. And again, I know you might feel comfortable in stating these positions because you operate in an evidence-based paradigm and the 'science' is 'on your side' (sorry, I'm not setting up strawmen here, this is the response I get whenever I try to challenge my friends on these positions). I've gone on way too long so I won't get into it too much here but I'm afraid the science is way more fraught than is generally assumed, and I'm particularly alarmed by the 'a waist circumference of 35 inches or more for women is associated with an increased risk of cardiovascular disease and is also one of the five criteria for metabolic syndrome, and having three or more is associated with an increased risk of cardiovascular disease, diabetes, and stroke', where the word 'associated' is doing a HELL of a lot of work. I'm not a medical professional myself and you could probably destroy me in debate but the work of people like Regan Chastain, Sonya Renee Taylor, Jessican Wilson, Asher Larmie, Lucy Aphramor, Aubrey Gordon, and and and... demonstrates that this kind of presentation of health as equated with thinness (and I'm sorry, also whiteness and wealth - we'll just sail past the bit about having a trainer, an option obviously available to everyone, everywhere, at no cost. Sorry, that was really snide but it's a little grating) is really unhelpful and actively dangerous to fat bodies. I don't expect to change any minds here but it's important to call this stuff out when you encounter it. Diet and exercise are not the universal panaceas they are so uncritically presented as, and 'fat people are worthy of respect, safety, and dignity' (https://pipewrenchmag.com/dismantling-medical-fatphobia). This piece perpetuates antifat harm, however kindly, however well-meaning. Ohhh, it hurts to write this, I feel sick.
I appreciated your recognition that “weight loss isn’t the real goal here, it’s my health.” As someone with a history of disordered eating and exercise, who has worked very hard to place my emphasis on health and not weight loss (and certainly not using the flawed indicator of BMI), I’d value more content that takes into account those of us in perimenopause and menopause with these histories. For many of us, daily tracking is contraindicated and a sure fire way to trigger unhealthy behaviors.