Review: Weight Regulation in Menopause
Key findings
- In an invited review, Fatima Cody Stanford, MD, MPH, MPA, MBA, and colleagues review the prevalence, pathophysiology and management of obesity in postmenopausal women
- Postmenopausal women often lose weight more slowly than other adults, so they should be counseled that there are numerous health benefits from even 5% to 10% loss of total body weight; a reasonable goal is "metabolically healthy" obesity
- Four weight loss medications are FDA-approved for the treatment of obesity (and treatment of patients with overweight who have at least one of certain obesity-related diseases) but they are underutilized, particularly for older adults
- Metabolic and bariatric surgery, particularly Roux-en-Y gastric bypass, can be effective in older women; in one study postmenopausal women lost 60% to 70% of excess body weight within 12–24 months after gastric bypass
- Peri- and postmenopausal women are predisposed to gain weight, so even normal-weight peri- and postmenopausal women should be encouraged to increase their physical activity and make long-term dietary changes
Despite ongoing public health initiatives and the efforts of health care professionals, obesity continues to be one of the largest epidemics in the world. There is no significant sex difference in its prevalence overall, but severe obesity is more prevalent in women.
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The editors of Menopause invited Fatima Cody Stanford, MD, MPH, MPA, MBA, an obesity medicine physician-scientist at the Massachusetts General Hospital Weight Center, and colleagues to review the prevalence, pathophysiology and management of obesity in postmenopausal women. This summary presents highlights.
Obesity Prevalence in Postmenopause
Approximately 70% of U.S. women of perimenopausal age have overweight or obesity, and the incidence reaches a peak of 76% before declining after age 75. A sub analysis of the Women's Health Initiative cohort, published in the American Journal of Epidemiology, showed that body mass index (BMI) ≥35 kg/m2 is associated with increased mortality in postmenopausal women.
Assessment and Diagnosis
Screening for eating disorders is paramount. In a large online survey reported in the International Journal of Eating Disorders, 13% of women over age 50 endorsed at least one current symptom of an eating disorder, and 62% said concerns about their eating, weight or shape negatively affected their lives.
In the general population of adults seeking treatment for obesity, 30% report an eating disorder. Common abnormal patterns are binge eating, purging, ignoring satiety, food-seeking behavior and night-eating syndrome.
Identifying weight-promoting medications improves obesity management. Many postmenopausal women use beta-blockers, psychotropic medications or sleep medications, which are associated with weight gain and metabolic dysfunction.
Weight Loss Targets
Weight loss in postmenopausal women is often slower than in other adults and requires sustained effort. Women should be counseled that there are numerous health benefits from even 5% to 10% loss of total body weight.
A reasonable goal is moderate weight loss with a transition to "metabolically healthy" obesity, where the risk of adverse health outcomes is reduced. This target can be set while continuing to pursue normal weight.
Pharmacotherapy
Weight loss pharmacotherapy is recommended for patients with obesity (BMI ≥30 kg/m2) or patients with BMI ≥27 kg/m2 who have associated conditions such as type 2 diabetes, hypertension or hyperlipidemia. Currently, five weight-loss medications are approved by the FDA for long-term use in conjunction with diet and exercise:
- The combination of phentermine, an anorectic, with extended-release topiramate, an anticonvulsant that has an anorectic effect and prolongs satiety (phentermine monotherapy is approved for short-term use)
- Orlistat, which decreases intestinal fat absorption
- The combination of naltrexone and sustained-release bupropion, which is thought to have anorectic effects and modulate reward behaviors such as food intake
- Liraglutide, a glucagon-like peptide-1 agonist that is self-administered daily by subcutaneous injection
- Semaglutide, a glucagon-like peptide-1 agonist that is self-administered weekly by subcutaneous injection
Despite the effectiveness of weight loss medications, few clinicians prescribe them, and prescribing rates are even lower for older adults. Concerns about the risk of adverse effects should be balanced against the harms of progressive cardiometabolic disease.
Surgery
Metabolic and bariatric surgery is generally recommended for patients with a BMI ≥40 kg/m2 or BMI of 35–40 kg/m2 with an obesity-associated condition such as type 2 diabetes, heart disease or obstructive sleep apnea. Some experts also recommend surgery for patients with a BMI of 30–35 kg/m2 and type 2 diabetes.
A study reported in Obesity Surgery demonstrated that bariatric surgery was effective in postmenopausal women, with 60% to 70% of excess body weight lost 12–24 months after Roux-en-Y gastric bypass. Women ages 55–65 lost less weight than those ages 20–45 during the first two years after bariatric surgery, especially after gastric banding.
Normal-weight Women
Peri- and postmenopausal women are predisposed to gain excess weight because of an increase in fat mass, decrease in lean muscle mass and the effect of medications used to combat the hormonal and physical changes of menopause.
Even normal-weight peri- and postmenopausal women should be encouraged to increase their physical activity and make long-term dietary changes to avoid a host of cardiometabolic diseases.
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