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Obesity is prevalent, complex, progressive and a relapsing chronic disease, characterised by abnormal or excessive fat (adiposity) that impairs health. It is a complex and multifactorial disease. Increased palatability or pleasure (hedonic input) and inactive lifestyle, smoking cessation, psychosocial factors (environmental factors) all play a role.

Weight gain in adulthood

Women gain 0.7kg/year during midlife (5th and 6th decades of life), independent of their initial body size or ethnicity. An extra 100 kcal/day is all that it takes to steadily increase weight.

Is weight gain at midlife a consequence of menopause or ageing? From what we currently know, it seems as though weight gain in midlife women is primarily the result of ageing and lifestyle change (and not menopause per se). Oestrogen deficiency leads to an increase in total body fat and a decrease in lean body mass = little net effect on weight.

What does ageing do?

• Decreases lean muscle mass and resting metabolic rate
• Decreases physical activity – this is often subtle, which leads to a further decrease in muscle mass. This is the most important environmental factor.
• Decrease in basal and total energy expenditure. Unless caloric intake is reduced, weight gain will result.
• Sleep disturbances, exacerbated by:
  • Vasomotor symptoms
  • Mood disorders
  • Obstructive sleep apnoea
  • E2 deficiency.

However, BMI does not tell us the full story. Menopause causes central fat distribution. Visceral fat depots may increase by 15% to 20% of total body fat (cf. 5% to 8% in premenopausal women). BMI is therefore not an accurate predictor of cardiometabolic risk.

SWAN study

The SWAN: study included 1246 women. Fat mass and lean mass increased prior to the menopause transition (MT).
At the start of the MT, the rate of fat gain doubled, and lean mass declined. Gains and losses continued until two years after the final menstrual period. After that, the trajectories of fat and lean mass decelerated to zero slope.

Menopause transition

Perimenopause is associated with a more rapid increase in fat mass and redistribution of fat to the abdomen leading to android pattern of body fat distribution.

Cardiovascular disease is the most common cause of death in postmenopausal women. Abdominal fat is an endocrine organ. The risk of cancer (breast, uterine, colon and renal cell) and death from cancer is significantly increased. Mortality is 62% higher in women with BMI >40.

Mechanisms of disease

There is an increased production of aldosterone and an enhanced mineralocorticoid receptor signal. There are also increased androgen levels and aberrant oestrogen signalling.

Obesity and menopausal symptoms

Obesity is an independent risk factor for more severe menopausal symptoms. It has a significant impact on mood and quality of life. Vasomotor symptoms (VMS) and chronic diseases impact menopausal women. VMS are associated with increased risk of metabolic syndrome, insulin resistance, nonalcoholic fatty liver disease, osteoporosis, and cardiovascular diseases in menopausal women.

Prevention

Prevention is based on:

• Reduction in caloric intake:
  • Daily caloric deficit: 500 to 750kcal/day
  • Mediterranean diet for CVS health + metabolic risk.

• Regular physical activity:
  • At least 150 min/week (brisk walking or similar aerobic exercise)
  • Resistance training to improve lean body mass. This improves body composition by decreasing abdominal fat and preserving lean body mass.

The 5A approach to obesity management

• Ask permission: “Would it be alright if we discussed your weight?” Asking permission shows compassion and empathy and builds patient-provider trust.
• Assess their story. Discuss goals that matter to the patient, obesity classification (BMI and waist circumference) and disease severity (Edmonton Obesity Staging System).
• Advise on management. Medical nutrition therapy should include personalised counselling (with a registered dietitian) – looking at healthy food choices and evidence-based nutrition therapy. Recommend 30-60 minutes of exercise (moderate-vigorous activity) most days. In terms of psychological aspects, look at the cognitive approach to behaviour change. Manage sleep, time and stress. Recommend psychotherapy if appropriate. Look at medications for weight loss and to help maintain weight loss. Consider bariatric surgery if necessary.
• Agree on goals. Collaborate on a personalised, sustainable action plan.
• Assist with drivers and barriers.

Initial assessment of the patient living with obesity

Thou shalt not do:

• Insulin assays
• Thyroid autoantibodies
• A random cortisol
• Reverse T3.

Thou shalt do:

• Take blood pressure in both arms
• Waist circumference/WHR
• Fasting blood glucose/HbA1c
• Liver function tests with or without abdominal ultrasound
• Consider a sleep study.

Can you outrun your fork?

In the diet wars, there is no clear winner. For longevity, the Mediterranean diet and the DASH diet for hypertension are the only two with evidence.

What is the role of MHT in weight management?

Menopause hormone therapy (MHT), is weight neutral but favourably alters body composition. There are improvements in:

• Lean body mass
• Insulin resistance
• Lipids
• Decrease in central adiposity.

These changes may explain the lower CVS mortality in young, recently menopausal women receiving MHT. However, MHT use is not recommended for prevention of chronic disease or prevention of weight gain.

What keeps weight off?

• Long-term pharmacotherapy
• Exercise: 200 to 300 minutes per week (weight maintenance)
• Behavioural interventions
• Bariatric surgery.

Conclusion

Weight gain is a major health concern for women at midlife. Weight gain per se does not appear to be affected by the hormonal changes of the menopause. However, the fall in oestrogen at menopause favours central fat distribution. Other factors that may contribute to obesity in women include a low level of activity, parity, lower level of education, a family history of obesity, and use of certain medication. This has adverse physical and psychological outcomes. These patients are at risk of more severe vasomotor symptoms. MHT may ameliorate accumulation of abdominal fat. Management is based on calorie restriction, increased physical activity and pharmacotherapy or surgery.