Why Can't I Lose Weight?

Are you noticing that the numbers on the scale are slowly starting to creep upward? Is your clothing not fitting quite the way it used to? Or has your 'winter weight' decided to stick around all year? Your once lean belly started to big as big as some of the men in your life.

Maybe you have noticed this. So you did the things that used to always work - reduced some sweets, moved a little more... but this time, it's not having the same effect. When you were younger, it was more predictable that you would lose weight when you stuck to your plan. Now that you are in your 40's or 50's this is not the case and it's beyond frustrating! Why is this happening?! Not only does this affect our self-esteem but more 'android' or torso fat also has negative cardiovascular outcomes for women.

It's not in your head and it's not due to a lack of willpower. Some research shows that in the 8 years before your last menstrual period you may start to notice annual weight and fat mass increases. These changes will slow after you become post-menopausal (the FMP or final menstrual period in the graph below from the SWAN study).

SWAN study showing weight related to final menstrual period

When we are younger than our 40's, we kind of know that the below items can impact our weight:

Resting Energy Expenditure (or your base metabolic rate): what you burn just by eating, breathing, and non-exercise being.
Daily energy expenditure (physical activity)
Energy intake
Sleep & Stress (have their own metabolic effects, mostly relating back to numbers 1-3 on this list)
Unavoidables - medications, genetics, age, race.

How does Menopause affect these things?

I consider the following the main culprits in weight management issues in those 40 years old and older:

Age itself - man or woman, age is affecting your weight gain.
Activity level
The hormones, of course, have an impact here.

Let's talk about each one in more depth, and their influence on Energy Intake and Energy Expenditure.

How Age Impacts Weight Gain

Aging itself has a huge hand in weight changes. Our metabolisms do slow down as we get older

Our bodies also get worse at using protein from our diets. In research this is called "anabolic protein resistance". This relative deficiency lowers our daily energy expenditure as well as increases our energy intake due to less satiety cues. We also start to naturally lose muscle mass as we age, at a rate of 3-8% per year from your 30's and onward. Lean muscle mass has a big impact on our base metabolic rate (BMR). So we aren't as good as building muscle with the same amount of nutrients in our diets, and we are better at breaking down muscles (catabolism). You may look the same, or a little softer from the outside but this is a big change to your body from the inside perspective.

How Activity Level is Impacting Your Weight Gain

For most women we are at a point in our lives where we are not as physically active as we used to be. It's just how it goes. We are less likely to be chasing after small children and more likely to be sitting at a desk, or keeping our typical daily movement to a minimum. Even though playing with an active child is not a cardio workout, that type of constant activity impacts your energy expenditure. Eating the same thing today that you would have eaten 10 years ago may net you more calories because of this type of change in lifestyle.

How Menopausal Hormonal Changes Impact Weight Gain

Alright this is the big one and the one you may have scrolled down the previous part of the post for. And it's a big one. Estrogen really does have some impacts on how and why we gain weight. To start off with, estrogen inhibits hunger signals which prevents excessive caloric consumption. Estrogen also has a hand in insulin secretion and energy usage by the body. When estrogen is high (like in your 20's in the follicular phase of your menstrual cycle) your body is really good at burning fat at lower intensity exercise and burning sugar at higher intensity exercise. I thought this was really interesting. Lower estrogen leans the body toward more insulin resistance - you aren't as good at fat burning and your body preferentially stores fat. If you've increased your walks or jogs in hopes that this would positively impact your weight and you have not found that then this could be why. Longer duration cardio training is less beneficial here because your body prefers to burn sugar instead of fat and your body is more catabolic.

Estogen also naturally impacts your resting energy expenditure in its own way thereby a decrease in estrogen causes a decrease in your BMR, leading to about a 220 kcal difference. This may be due to lowered estrogen leading to an increase in muscle breakdown. This is specific to menopause and really compounds the age related muscle catabolism I mentioned above. Increased muscle breakdown will therefore yield a higher need for MORE protein, which your body will interpret as a hunger cue. In today's world it's very easy to satisfy a hunger pang with taste fat and carbs instead of protein (or if you do look for something higher in protein, it often comes along with those taste fats and carbs). So your body ends up with a full stomach and an unsatisfied need for more protein, and it will likely try again with the hunger pangs as well as continue down the lowered BMR pathway. This easily can lead to increased total calories. What your body needs NOW is a larger proportion of your calories to come from protein and not fat and carbs. A good goal is about 1.2 g/kg of your body weight daily for protein intake.

For those that may wonder, there are currently no clinical trials that support a ketogenic diet for weight loss in women that are perimenopausal/menopausal.

You need to run to stay in place.

The Bottom Line

As we age, we quite literally need to run to stay in place. We need to start/increase our activity level and be on top of our food consumption to just maintain our weight. I have patients that are extremely frustrated by this fact. I'm sorry I don't have a magic pill to help with these crumby changes that we experience.

There is some evidence that menopause hormone therapy (MHT) can help a bit with the weight changes - that's actually where the resting energy expenditure value of 220 kcal that I quoted above came from. Weidlinger et. al (2023) found that women who used MHT had an increased energy expenditure of 222kcal per day. When you've been on a treadmill, you can understand the value of this number!

Recommendations for Menopausal Weight Gain

Exercise recommendations

Increasing your muscle mass will have the biggest impact on weight management. More lean muscle mass = more energy expenditure. You need this. You can't skip this step. If you feel like you've done the typical caloric pinching you used to do and are frustrated that you aren't losing weight like you used to, this may be the step you need. This means:

Strength training: 2 times per week MINIMUM. Lift Heavy Things!
4-5 days metabolic conditioning - mixed cardio and weight interval training (HIIT)
Resources:
- Check out researcher Dr. Stacy Sims as she focuses specifically on women and exercise. She also has a book you may enjoy.
- Youtube Channels:
  - MrAndMrsMuscle - various muscle groups/length videos, using free weights
  - Zuzka Light , about 20 min workout
  - YogaWithAdrienne - gentle yoga for stretching, great for post-workout or on a 'rest'day. Tons of different types of videos here.
  - Kayla Itsines
  - Barre3 - especially for pelvic floor and abdominal muscle recovery

Dietary Recommendation Summary

increase your protein to 1.2g/kg/day. So if you are 160 lbs, that's about 72.5 kg. If you take that and multiply it by 1.2, you get 86.4. This means that a 160 lb woman should strive for 86.4 g of protein daily.
Salculate your BMR and see if you are able to calorically reduce your total by about 250 calories or so
- be mindful of how this is going. It's very easy to reduce calories but also reduce protein and that's not the recommendation i'm making here at all
- if you find that you stick to this most of the time and then over-fuel later, that's not going to help long term either. It may be easier to first increase your protein, and see how this naturally effects your satiety, and then incorporate some level of caloric restriction if it isn't happening organically and you are still struggling with weight.
Mediterranean Diet is a fantastic one to strive toward as it's nutrient dense and limits refined carbs