Why Does Menopause Treatment Always Include a Diet?

Time​ Magazine

2 days ago

We are finally, as a culture, having conversations about menopause. What was once spoken only in whispers, if at all, by our mothers and grandmothers, is now trending on TikTok. There is an abundance of books on the topic by everyone from physicians to researchers to Naomi Watts; emerging research, and concrete information to help women navigate the often sudden, severe, and frequently misdiagnosed physical, emotional, and mental health symptoms that go along with it. This is progress.
Unfortunately, like so much in the women's health space, a disproportionate amount of the advice is weight loss-related, involving food restriction, fasting, and exercise. This is especially concerning, since according to experts in the field, women approaching menopause—a process known as 'perimenopause'—may be at an elevated risk for developing an eating disorder. Deprivation, along with a preoccupation with food, our bodies, and working out, only increases that vulnerability.
Beginning in your 30s, 40s, or 50s, perimenopause can last anywhere from a few months to eight years. Twelve consecutive months without a period means you've entered menopause, but until then, there's an 'are we there yet?' quality. There are no concrete tools for diagnosis apart from the symptoms themselves.
I'm in it now—I think. I'm around the 'right' age, and after decades of regular periods, sometimes I miss one. I don't (yet?) have any of the classic hallmarks like hot flashes, which is sort of the 'Born to Run' of perimenopause symptoms, and if you get that reference, you're probably in perimenopause, too. But I'm bracing for any others to come—the list is long and runs the gamut—insomnia, anxiety, brain fog, incontinence, high cholesterol, dental problems, and so many more. All the results of declining estrogen, a group of hormones which, in addition to sexual and reproductive health, impact bone density, metabolism, cholesterol, and just about every organ system in the body.
Read More: 8 Signs You're in Perimenopause
Weight gain happens, too, along with changes in shape, as fat redistributes around the mid-section of the body. It's often the first symptom that women notice, and the first thing we try to 'fix.'
'I think the unrealistic expectations for aging has led to much more of a consumer demand for advice and treatment about weight loss for women going through menopause,' said Jessica Baker, PhD, and senior research manager for Equip Health, which offers virtual eating disorder treatment. 'Of all the bodily changes that happen during this period of time, weight gain is the most talked about, publicized, and advertised.'
The messages are everywhere. 'One of the main reasons people visit my office is this unwelcomed and often unexpected change,' Mary Claire Haver, MD, wrote in her best-selling book, The New Menopause, referring specifically to weight gain. Haver's book is groundbreaking in its outlining of the wide range of symptoms and compassion for those who are suffering. But it happens to also be filled with weight loss advice, including a nutrition tracking app, weight lifting, and intermittent fasting. Companies like Noom and Hers now offer menopause-specific weight loss programs. Recently, on the Today Show, Halle Berry's personal trainer demonstrated exercises for 'combatting' menopausal weight gain.
But depending on a woman's history, all of this advice could encourage behaviors that push her toward the first steps of an unhealthy relationship with food and her body, says Cynthia Bulik, founding director of the University of North Carolina Center of Excellence for Eating Disorders, and one of the leading researchers in the field. ''You must eat at minimum 1200 mg of calcium per day and 1.0 g per kg of protein per day. You must take 12,500 steps per day to improve health and fight impending obesity.' All of these things, if rigidly adhered to, can be a trap and an entrée to an eating disorder or at least eating disorder behaviors,' Bulik says.
Haver posted on Instagram that those who may be vulnerable to an eating disorder should not fast. What complicates the matter, though, is that many people with an eating disorder may not know they have one, and will never be properly diagnosed.
I know this personally. I've struggled on and off for much of my life with eating disorders until, after multiple rounds of treatment and too many relapses to mention, I finally found something that worked. I was fortunate. By some estimates, only 20% of people with eating disorders get treatment, relapse rates are high, and most people never even get properly diagnosed. There is no standard of care for eating disorders in the U.S., despite the fact that they have among the highest mortality rates of any mental illness.
Read More: What Recovery Looks Like When You Have an Eating Disorder
Eating disorders are complex, often life-threatening illnesses that even experts in the field don't fully understand. Contributing factors include genetics, stress, trauma, and a culture that prizes thinness. Dieting is the most important predictor of developing an eating disorder, according to one of the largest studies done on the subject.
All the focus on weight neglects the very real risk for developing an eating disorder during this phase of life, in part because eating disorders are still so often inaccurately stereotyped as only a teenage affliction. But about 60% of women with an eating disorder in midlife have had a previous one that was perhaps less severe, but reemerged during perimenopause.
'I consider puberty and menopause to be reproductive and metabolic bookends,' said Bulik. 'Both are marked by prolonged shifts in the hormonal milieu.' Hormone shifts affect mood, appetite and cravings. In addition to weight, menopause often brings changes in hair texture, thinning of skin, and vaginal dryness. 'All of these things can lead to intensified body dissatisfaction and even worse, body disgust and body hatred,' Bulik added.
Personally, I feel solid in my own body acceptance (today, at least), but I want to be healthy, and it's so easy to conflate health with weight. Reviewing the protein recommendations in Haver's book— a certain number of grams per pound you weigh in order to maintain muscle mass—I found myself opening up MyFitnessPal, an app I haven't looked at since my own recovery from anorexia many years ago. My password, skinnybitch, was still saved. I told myself I wouldn't track calories—only protein.
After three days of protein tracking, I quickly realized how easy it would be to go back down that obsessive road, and I stopped. Yes, I want to be strong as I age, but that includes mental health, too. Revising a preoccupation with food and my body would erode my hard-won recovery.
While women lose muscle mass and bone density during the menopausal transition, and many have concerns about visceral fat, commonly called 'belly fat,' which resides in the abdominal wall, here is where our behaviors matter more than results. As one public health researcher told me when I was writing my book: You can control your behaviors. You can't control your weight.
We would be well-advised to carry that guidance into menopause. Exercise benefits our health and reduces the risk of chronic diseases, whether we lose weight or not—a vast body of research supports this. Same for quitting smoking, getting a good night's sleep, limiting alcohol, and adding foods rich in omega-3s. Not to mention, people who eat a plant-based diet may have fewer hot flashes than those who do not, according to a recent study in Menopause, the journal of The Menopause Society.
Most weight loss advice during this period, however, is not evidence based, Bulik pointed out. 'So often PCPs will say, 'It's going to be a lot harder to work off that hamburger at your age than it used to be,' (and) yes, there are some data behind those comments,'' she says. 'It is easier to gain weight when you are older, and your caloric requirements do go down. But the delivery is so negative and focuses on the loss of the previous self. How about, 'What are you planning to do nice for yourself with the money you save on tampons and pads every month?'' In The Menopause Brain, neuroscientist Lisa Mosconi also cautioned against intermittent fasting, encouraging instead eating mindfully, reducing stress, and practicing yoga.
In so much of the new writing and advice on menopause, authors open with some version of: You're not crazy, and it's not in your head, validating women's symptoms, which for centuries, and even today, still often go undiagnosed. I wish they would extend that compassion to the way our bodies look, too. And for menopause to be the time in a woman's life where—finally—her body is just fine the way it is.