Women in perimenopause are faced with a catch-22 situation: they need to limit weight gain and central adiposity at the same time as their estrogen levels are plummeting, which reduces their ability to burn fat and build muscle. The menopause-related changes in body composition, fat distribution, and metabolism are well documented in the literature. Counseling women on diet and exercise at this time of life is essential but can be tricky.

In honor of National Nutrition Month, we spoke with Zhaoping Li, MD, PhD, on how clinicians can help empower women to take charge of their health during this time of transition. Dr Li is Director of the Center for Human Nutrition and Chief of the Division of Clinical Nutrition at David Geffen School of Medicine at UCLA.

Q: How should primary care clinicians counsel women about preventing weight gain during perimenopause or menopause?

Dr Li: The most important thing is to not deliver passive messages. I am often very frustrated with primary care clinicians, including my own, who say that the weight gain is a fact of menopause. The message should be “yes, this is a physiologic process, but it is a time for us to refocus on how we take care of our body. There are many things we can do about it.” That is a very different message from, “oh sorry, yes that is menopause.”

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Zhaoping Li headshot
Zhaoping Li, MD, PhD

Women need to be actively managed and empowered. Women in mid-life are mature and have life experiences. If we can bring our kids from infancy to adulthood, we can manage our bodies. You have to respect women’s power.

Women are living to a hundred years old and 50 years is a mid-point checkup. Women need to learn to invest in themselves and not consider it selfish to take time to exercise and meal plan. Many women at this age are transitioning from caring for their children to caring for their aging parents and they have to be told to put on their masks first in order to help others. If you are not there for yourself, you cannot be there for your kids, your spouse, your parents, your loved ones. And, more importantly, you won’t need others to help you later in life.

Q: What are the essentials of diet during the menopause transition?

Dr Li: Adequate protein intake is essential. If women don’t have good quality protein every day, the decrease in muscle mass that occurs as estrogen levels drop is accelerated. And women need even more protein during menopause as their bodies are less efficient at using this macronutrient. In addition to skeletal muscles, research is starting to show that our heart and other organs also need better protein support as we age.

Decreasing carbohydrate intake is also important. Most Americans have more carbohydrates than we need. Women in particular only need approximately 8 grams of carbohydrates per hour if they work a sedentary job. One slice of bread is 30 grams of carbohydrates, which would take 4 hours to burn. And menopausal-related muscle loss causes decreased metabolism, which means they need even less sugar per hour.

Another message that is frequently missed in studies on metabolic changes with aging and the menopause transition is the need for other nutrients beyond macronutrients and micronutrients. Women need to increase their intake of phytonutrients such as lycopene, lutein, and resveratrol, which are found in a plant-based diet. I educate all our patients including menopausal women to replace refined starches with vegetables. This allows people to decrease their carbohydrate intake, not feel deprived, and add more nutrients to serve their bodies.

Q: What about exercise during perimenopause and menopause?

Dr Li: Women need to be educated to look beyond their weight. We also need to pay attention to body composition. Even if a woman’s weight has stayed the same, with estrogen loss during menopause, they are losing muscle and replacing it with fat.

Thus, engaging in physical activity is equally as important as diet during the menopause transition. Hiking is an example of a great exercise as it is a combination of aerobic and resistance training. Physical activity also boosts our mood.

Q: What if women exercise and eat a healthy diet and still gain weight during perimenopause and menopause?

Dr Li: We are learning more and more about individual differences in metabolism as we age. That is why the National Institutes of Health launched the Nutrition for Precision Health study that will develop algorithms to predict individual responses to food and dietary routines.

The diet and exercise solutions we are talking about probably work for approximately 50% of menopausal women. Thus, I don’t want women to focus on one strategy for preventing weight gain; they should check on their results and communicate with their clinicians to determine the best diet and exercise program for their body. In another 5 or 10 years, we will have more knowledge on how to individualize management. Women need to hear the message that “If something does not work out for you, there is nothing wrong with you. You just need to find what does work for you.”

The next layer of management is to help women re-evaluate their lives to see if there is a force driving their weight gain such as their work environment, stress, sleep issues related to hormonal change, or gut microbiome abnormalities. Maybe this is a time that they need to try a type of intermittent fasting. Maybe it is not feasible for a woman to go to the gym but she could start squatting at intervals during the day. Maybe their gut microbiome requires a greater vegetable intake, which will improve their metabolic rate. Maybe women have friends or partners who are younger or have faster metabolisms and they now need to modify what they eat when they are at social gatherings.

Instead of struggling on their own, women need to talk to a dietician, clinician specializing in nutrition, or primary care clinician for other solutions. Women should not hold on to the belief “It worked for my friend. It has got to work for me.” We are all different.

Q: As a busy physician and a working mother, what did you eat for breakfast today?

Dr Li: This morning, I needed to grab something quick on my way out so I put a scoop of pea protein powder in my tea and had an orange. It was fulfilling.