Weighing options for mid-life women
Talking about diet and exercise habits in mid-life can help guard against incremental weight gain.
The seemingly inexorable weight gain that many women face during mid-life shouldn't be viewed as inevitable. Physicians can play an influential role in staving off extra pounds, advises a recent recommendation from the Women's Preventive Services Initiative (WPSI).
All women ages 40 to 60 years should be counseled on strategies to prevent weight gain, even when they haven't been diagnosed with obesity, according to the recommendation, published in September 2022 in Annals of Internal Medicine. Once they reach mid-life, women typically gain an average of 1.5 pounds annually, according to research cited.
Talking with mid-life women about their diet and exercise habits, even if they do not carry excess weight, helps to normalize the discussion and ideally guard against incremental gain, said Kimberly D. Gregory, MD, MPH, who chairs the advisory panel for the WPSI, a national coalition of women's health professional organizations and patient advocacy representatives.
“It's a great opportunity to do some primary prevention,” said Dr. Gregory, also vice chair of women's health care quality and performance improvement in the department of obstetrics and gynecology at Cedars-Sinai Medical Center in Los Angeles. Without being proactive, it's easy for those pounds to sneak up, she said.
“I think women recognize it and frequently associate it with perimenopausal hormonal changes, and not necessarily paying attention to how sedentary we're becoming over time,” Dr. Gregory said. “Bringing to the forefront the importance of healthy eating, lifestyle, and exercise, it's a good time to revisit that.”
Over the last two decades, more Americans have been diagnosed with obesity. By 2017-2020, 41.9% of adults had a body mass index (BMI) of at least 30 kg/m2 compared with 30.5% in 1999-2000, according to CDC data. Among women ages 40 to 59 years, 42.8% were classified as having obesity by 2017-2020. This latest recommendation by WPSI, which joins other guidance from the organization focused on contraception, anxiety screening, and other recommended preventive care, enables obesity prevention counseling to be a covered service under the Affordable Care Act, beginning in 2023.
Laura Davisson, MD, MPH, FACP, who directs the medical weight management clinic at West Virginia University in Morgantown, embraces the guideline's approach. “Once someone has gained weight, it's harder to lose than to prevent that in the first place,” she said.
Women with a normal BMI can benefit if physicians take a few minutes to suggest periodic weighing to catch any weight gain, along with a few reminders about habits that accumulate calories, such as eating too many meals outside the home or consuming sugary beverages, Dr. Davisson said.
“It is very difficult to maintain weight,” she said. “Most people are gaining weight. A lot of this is being driven by the environment. If we don't actively focus on trying to avoid weight gain, for almost all of us it will happen.”
The WPSI recommendation, based on a systematic evidence review, found that the research wasn't sufficiently robust to recommend a particular counseling approach. Four of the five included studies that focused on behavioral counseling—including weight monitoring, changes in diet, and more physical activity—found clinically significant weight loss. The other two studies, which involved either medically supervised or prescribed exercise, found no significant benefit.
Among the four studies that found benefit versus a control group, the average number of pounds lost ranged from nearly 2 pounds to 5.5 pounds, according to the systematic review, which was also published in September 2022 by Annals.
Research has identified health benefits from even modest weight loss, according to the recommendation's authors. Losing 3% to 5% of body weight has been associated with reductions in cardiovascular risk factors like hyperlipidemia and hyperglycemia, according to a 2013 guideline the authors cited, which looked at the management of overweight and obesity in adults and was developed by several groups, including the American College of Cardiology. It was published in the June 24, 2014, Circulation.
Shedding some weight “is clinically meaningful when you are looking at maintenance and loss and sustainability over time,” said Amy G. Cantor, MD, MPH, lead author of the systematic evidence review and an associate professor of family medicine at Oregon Health & Science University in Portland.
Women at all weight ranges can benefit from brief counseling, Dr. Cantor said. Someone who has maintained a normal weight could be reminded about the difficulties of sustaining that through menopause. Another patient might have a BMI below 25 kg/m2 but unhealthy eating habits, she said.
“I think that normalizing counseling about healthy diet and physical activity by providing it to all mid-life women can help mitigate concerns about weight stigma,” Dr. Cantor said.
And the role of exercise shouldn't be ignored, despite the lack of available data when looking at research focused on this specific population, Dr. Cantor said. Only one in five women, she noted, meet the federal recommendations to complete at least 150 minutes of moderate physical activity or 75 minutes of vigorous activity each week along with two days of strength training. “We really need to get this population moving,” she said.
Still, these are highly individualized conversations, and physicians should keep in mind everything from cultural considerations to patients' ability to access healthy food and safe places to exercise, Dr. Cantor said.
While weight counseling could be incorporated into the annual well woman's visit, it might fit better at other times, Dr. Cantor said. For instance, “When a patient is coming in for a visit about managing their hypertension or their diabetes, that is another opportunity.”
Despite the reliance on BMI in various preventive guidelines, it remains a crude metric of someone's overall health, said Fatima Cody Stanford, MD, MPH, MPA, MBA, FACP, an obesity medicine physician scientist at Massachusetts General Hospital and Harvard Medical School in Boston. One woman might be categorized as normal weight but have metabolic disease, while another might meet the cutoff for mild obesity but show no signs of metabolic issues, she said.
But women do often struggle with adipose weight gain as they approach menopause, amid hormonal changes and decline in estrogen, Dr. Stanford said. That central adiposity “leads to a deleterious metabolic profile,” she said, boosting the risk of related diseases, including type 2 diabetes and nonalcoholic fatty liver disease.
When raising the subject of weight, physicians should be cautious about the language they use with patients and strive to approach the conversation without built-in assumptions, said Dr. Stanford, who has written about weight bias in medicine. “One of the key things that women tell me is that they feel accused by their doctor of not doing the right thing when they start to gain weight,” she said.
Approach the subject in an open-ended way and ask permission from women first, Dr. Stanford said. Then ask them to reflect on what's difficult about maintaining their weight before making any suggestions.
“We have to tailor our recommendations based upon what they say,” she said. “You wouldn't tell a marathon runner, ‘Hey, you need to increase your activity to 300 minutes a week.’ Because they're probably doing significantly more than that and may still be struggling with weight.”
Promoting small changes
While the WPSI doesn't recommend exercise in and of itself as a weight maintenance strategy, Laura Q. Rogers, MD, MPH, FACP, credits a downshift in mid-life activity as a contributing factor for weight gain, based on stories that women share with her. “I wouldn't disregard exercise outright,” said Dr. Rogers, a professor of medicine at the University of Alabama (UAB) at Birmingham, who sees patients at the UAB Weight Loss Medicine clinic.
In mid-life, women might be juggling work along with caring for children or aging parents and put their own health, including sufficient exercise, on the back burner, Dr. Rogers said. Or, she said, they might need to have their knee replaced or have a fall and related fracture.
“Something happens, and they're suddenly not very mobile and they are not physically active,” she said. “Oftentimes they will attribute that event as a reason for some weight gain.”
Women also might not realize their vulnerability to gaining 1.5 pounds annually if physicians don't share that data, Dr. Rogers said. “If someone is normal weight and age 50, you can say, ‘Hey, over the next 10 years you could potentially gain 15 pounds.’”
Another strategy: Recommend that all women weigh themselves regularly, Dr. Davisson said. She suggests once or twice weekly, so they don't worry about minor fluctuations. “What that allows you to do is that if you notice [you're] a couple of pounds up, you can jump on that right away,” she said.
Starting a food diary enables patients to identify hidden calories over the course of the day, such as how often they snack between meals or indulge in beverages, both alcoholic and nonalcoholic, Dr. Davisson said. “They don't count that in their heads unless they're doing the food tracking.”
Physicians can recommend free apps, she said, such as MyFitnessPal or Lose It! This fall, ACP and two other organizations launched an online app library that has compiled free, effective weight management apps that physicians can recommend to patients.
Women might recognize that eating out can drive up calories, but perhaps not to what extent, Dr. Davisson said. “When you look at the calorie counts, they are astonishing.” She suggests the Center for Science in the Public Interest as an online resource for some restaurant calorie counts, as well as strategies to eat healthier and still enjoy a meal out.
Even in time-pressed visits, physicians can ask patients to suggest one or two dietary changes they can make, Dr. Davisson said. The goal is to encourage patients to identify sustainable changes, which will make it more likely that they'll follow through, she said. Since dietary preferences can vary between cultures, one tool is a series of healthy eating guides published recently by the Obesity Medicine Association, she said.
Regarding exercise, mid-life women tend to focus on cardiovascular activities and skimp on strength training, which limits muscle loss at this stage of life, Dr. Davisson said. “Women are maybe somewhat intimidated by weightlifting,” she said. “Once they do it, they really like it more than they'd think.”
Alternatively, women can be encouraged to add squats, push-ups, sit-ups, planks, and other strength-training activities to their weekly regimen, Dr. Davisson said. For added motivation, physicians can remind them that building muscle can boost metabolism, making it easier to maintain weight, she said.
Addressing weight gain
Along with checking in on diet and exercise, be sure to review other changes that might have influenced weight gain, such as starting a medication, Dr. Cantor said. Ask patients about their sleeping habits and if they've coped with any recent mental health or other challenges that might have altered their eating or exercise habits, she said.
Avoid inflammatory or stigmatizing language, including in the medical notes, which the patient might read later, Dr. Stanford said. Jettison terms like “obese,” “fat,” or “morbid,” she said. Instead, use language that focuses on the disease, such as “a person with excess weight” or “a person with excess adiposity.”
Dr. Stanford avoids any mention of physical aesthetics, such as how great the patient looks, which implies that they didn't in prior visits, she said. But she does highlight promising lab results. “I will say, ‘Wow, your cholesterol was stunning today,’ or ‘This is gorgeous blood pressure.’”
Physicians should also watch out for signs of a history of eating disorders, Dr. Davisson said. If someone describes losing a lot of weight in their teens or if they appear very focused on their body image, that might be a flag, she said.
In cases where a history of eating disorders is known, those patients should guide the physician about how they prefer to approach their weight, Dr. Davisson said. They might want to avoid food logging or weighing or prefer to take pictures of their food rather than using an app, she said.
For some mid-life women, diet and exercise changes might not be sufficient and primary care physicians might need to refer them for medication or surgical treatment, Dr. Stanford said. They can help patients identify experts in their community, she said, by referring them to a searchable online directory from the American Board of Obesity Medicine.
At a minimum, if a woman is interested in addressing her weight, it's likely a complex medical challenge that will require time to address, Dr. Stanford said.
“One of the key things for primary care providers is don't try to do this in one visit,” she said. “It may take a series of visits to come to an understanding of how you can best assist this individual.”