The question of weight gain is consistently one of the most common complaints, and is often difficult to address. To solve this frequent dilemma in our Spectrum Health Midlife and Menopause Clinic, I had to come up with a plan, especially for the times when the question of "why am I gaining weight?" is followed by "I have not done anything different!" Weight gain, of course, can contribute to chronic health conditions such as diabetes and cardiovascular disease, but also can lead to a sense of helplessness. When women do not see any result from their best efforts, often the reaction is to give up. Nothing makes my day more than seeing a woman regain hope.
In such a visit when weight gain is a main issue, I ask what weight gain means to her, how excess weight affects her life and self image, and how she defines her weight goals. I ask her about a time in her life when she was at her goal weight, and what that felt like. I ask if she has a picture of herself at that weight, and to come up with a word to describe how she feels at the present moment as compared with the feeling of her ideal weight. A recent patient said she felt "anchored," and when 20 pounds lighter, she felt "free." I then ask if she is willing to do the work, and if the answer is yes, I say "then let's get started."
As in all such visits, it is invaluable to review and catalog an inventory of the common midlife and menopause symptoms including hot flashes, mood changes, sleep disturbances, and changes in libido or physical comfort with sex. The next step is to review the frequency of the seven daily habits I call the SEEDS, or Seven Essential Elements of Daily Success -- including water intake, restful sleep, vitamins, fiber, exercise, food intake, and practice of gratitude and metered breathing, In terms of food, I ask the patient what she eats for breakfast, snack, lunch, snack, dinner, and snacks, as well as her average weekly alcohol intake. At the end of this discussion, I have a good idea of her challenges and barriers, and know where we are headed. Taking a thorough medical history is key as well, especially having a history of gestational diabetes, pre-eclampsia, irregular periods, and hirsutism, and a family history of obesity and diabetes. I ask about food mentors, dietary restrictions, food budget concerns, and the habits of her family and peers.
After any necessary physical exam, we then bring all the puzzle pieces together by using an explanation of the pathophysiology of weight gain in midlife. Unexplained weight gain in the midlife years and menopause is usually central, and related to increasing insulin resistance with loss of estrogen, loss of lean body mass, and incremental events of weight gain. I explain that even if the individual's exercise is unchanged, and food choices also the same, these same habits are not conducive to avoiding weight gain with aging. To lose weight in perimenopause and beyond requires smarter choices and maintenance of muscle mass with resistance training. I draw my explanation on paper as a vicious cycle: lower estrogen leads to insulin resistance to slightly higher blood sugars, leads to greater insulin response to sugar cravings and increase in central obesity, leading to increased insulin resistance. Associated symptoms of poor sleep and chronic stress are also associated with increased insulin resistance and craving of simple carbohydrates, leading to more central obesity from even too many potatoes at dinner. Women are smart and deserve explanations, which give them power to make better choices.
Along these lines, I recommend such books as "Sugar Busters" to teach glycemic index, and based on the person's lifestyle, cultural preferences, and schedule, I draw out a sample food plan. I make it simple to start: sprouted grain bread with an egg or peanut butter and a bit of honey at breakfast, and whole wheat or brown rice crackers with two cheese sticks or a low sugar whole grain "'bar" at snack. For lunch I recommend salad, leftover protein such as chicken or a veggie patty and brown rice or roasted sweet potato, and an afternoon snack of a low glycemic fruit such as apple, together with nuts or natural peanut butter. Dinner can be left as a no- or low-carb meal with the focus on salad, green vegetable, and protein (with enough left over for lunch the next day). Many women are surprised to hear this -- "but I thought I had to avoid carbs!" -- and then we review the need for steady blood sugar to avoid insulin surges as achieved by complex carbs. Such a diet is necessary to maintain an energy source for muscle and brain cells, and to avoid excessive hunger and cravings.
"Mary" (not her real name) is a patient who stands out in my mind: She was frustrated to tears about weight gain at her preop for a D&C to evaluate heavy perimenopause bleeding. She followed the dietary suggestions for 3 weeks, and on her day of surgery, she reported a weight loss of five pounds, and was grateful her body changes finally made sense. The pathology report showed simple hyperplasia, which I had assumed, and placed a Mirena IUD (off label) at the time of D&C for control of her perimenopausal bleeding. With her newfound knowledge, she would be able to reduce both her risk of diabetes and uterine cancer. Three months later she was down another 12 pounds and her A1C had dropped from 6.1% to 5.8%.
I love my job, and having a plan for the most difficult questions is the solution to a good day at work and helping our patients age as they wish, instead of by default.
"Lady Doc" is Diana L. Bitner, MD, NCMP, director of Women's Health Network at Spectrum Health in Grand Rapids, Mich. After 20 years in obstetrics and gynecology, Bitner wrote I Want to Age Like That! Healthy Aging through Midlife and Menopause (2014), an educational tool for patients and providers. Check out previous Lady Doc posts about menopause and weight gain and polycystic ovarian disease.