Weight Gain in Middle Age: Why It Happens, How to Stop It

One thing women should know about midlife weight gain: The struggle is real.

As women age, they are likely to burn fewer calories because of a reduction in physical activity and a decrease in lean body mass and muscle mass. On top of that, the drop in estrogen levels that happens during perimenopause and the menopause transition can redistribute fat that was previously stored in the hips or buttocks, moving it to the waistline and belly.

Research shows that most midlife women (between the ages of 40 and 65) gain weight. In the study of women across the nation (SWAN), women added an average of 1.5 pounds per year during midlife. Similarly, in the Nurses’ Health Study, midlife women gained an average of 7 pounds over 8 years of follow-up.

But there are interventions, both lifestyle and pharmaceutical, that can help women manage weight during midlife, says Maria Daniela Hurtado, MD, PhD, an endocrinologist who is part of the Mayo Clinic Precision Medicine for Obesity program in Jacksonville, Florida.

Dr. Hurtado outlined strategies for preventing weight gain and shedding excess pounds in a presentation, “The Skinny on Weight Management in Midlife,” at the 2023 annual meeting of the Menopause Society, in Philadelphia.

Hormone Changes Around Menopause Are Just 1 Factor in Weight Gain

Midlife comes with physical, psychological, and social changes that can be related to aging, menopause, or both, says Hurtado. “It can be challenging to discern the effects of aging from the effects of menopause on weight gain in midlife women, as these two life events overlap,” she says.

The abrupt change in hormone levels that occurs during the menopause transition can predispose women to quicker weight gain, says Rekha Kumar, MD, an endocrinologist at Weill Cornell Medicine and NewYork-Presbyterian Hospital in New York City.

“Although we mostly focus on the decline in estrogen, other hormones are impacted as well, such as progesterone and testosterone,” Dr. Kumar explains. “It is not always the absolute level of hormones that might lead to a change in body composition but the balance between certain hormones.”

External factors can contribute to weight gain, too, says Hurtado. “People are likely to engage in less physical activity as they age. This, coupled with the decrease in lean mass or muscle mass, can potentially decrease energy expenditure and predispose women to weight gain,” she says.

Weight Gain Is Not Just About Appearance: There Are Health Consequences

Accumulating excess fat tissue has multiple consequences for health.

“The most important health risks associated with midlife weight gain, especially gaining abdominal fat, would be the risk of insulin resistance, diabetes, and heart disease,” says Kumar.

Excess fat, especially in the belly area, is linked to several types of cancer, including breast, endometrial, ovarian, esophageal, gastric, colorectal, liver, gallbladder, pancreas, and kidney cancers, says Hurtado.

Additionally, carrying extra pounds can lead to mechanical complications that can include obstructive sleep apnea and joint pain and damage, such as osteoarthritis, and acid reflux, she explains.

“Finally, excess adiposity [fat] has been linked to worse hot flashes and night sweats early in the menopause transition; increased vaginal, genital, and urinary symptoms of menopause; and sexual dysfunction,” Hurtado adds.

Work Out to Combat Muscle Loss and Belly Fat

It should come as no surprise that experts recommend exercise to prevent changes in weight. “Activity is considered of moderate intensity when people are working hard enough that they are able to talk but cannot sing a song,” Hurtado says.

If women are already getting that kind of exercise but are still gaining weight, they may need to change up the type of activity. Kumar recommends trying a new (but safe) fitness challenge.

“If my patients are not following an exercise routine at all, I develop a plan taking into consideration their fitness level and other health problems that may affect their capability of exercising,” says Hurtado.

Women should aim for 20 to 30 minutes of aerobic exercise most days, plus resistance or strength training, such as lifting weights, yoga, and Pilates, two or three times a week, advises Karen Adams, MD, a professor of obstetrics and gynecology and the director of the menopause and healthy aging center at Stanford Medicine in California. “Women who do both strength training and cut back on calorie intake will lose more fat than those who only cut back on calories,” she says.

The experts agree that women who do resistance training and aerobic exercise before menopause hits will reap the advantages later. “The more muscle you have going into menopause, the better you’ll be able to withstand the natural loss that happens during the menopausal transition. And exercise is good for so many reasons: It improves mood, helps sleep, benefits sexual functioning, and decreases fall risk,” says Dr. Adams.

Keep Track of Your Calories and Try the Mediterranean Diet

To prevent weight gain during menopause, Hurtado recommends monitoring and decreasing caloric intake by about 10 to 20 percent from the amount you consumed before the transition. So, if you ate 2,000 calories per day in your premenopausal world, that means trimming it down to 1,800.

Adams recommends a Mediterranean-style diet. “It’s mostly fruit, veggies, whole grains, plus legumes, nuts and seeds, and olive oil. It’s best to minimize all types of meat, but if we do eat meat, make it mostly chicken or fish — red meat is pro-inflammatory and associated with higher rates of heart disease and cancer,” she says.

If you want to consume more protein, remember there are many great plant-based protein sources such as nuts, legumes, and whole grains like quinoa, adds Adams.

“I’m not saying you can never have a burger! If you want it, have it and enjoy it. But if you have a burger three times a week, you’ll be increasing your risk for chronic illness, plus making it harder to lose weight,” she says.

And whenever possible, Adams advises women to focus on eating whole foods, not “foods where you have to tear open the package or open the box. Those are highly processed foods, and they typically have loads of sugar, salt, and fat,” she adds.

Make Sure Your Medications Aren’t Causing Weight Gain

Hurtado reviews health records to make sure her patients aren't using weight-promoting medications.

“Unfortunately, this is a common side effect to frequently used medications. When possible, I discontinue these medications or try switching to weight-neutral (or even weight loss–promoting) medications to treat the underlying disease,” she says.

Manage Menopause Symptoms to Support Your Efforts to Maintain a Healthy Weight

Although menopause hormone therapy isn’t indicated for weight loss, it can help support efforts to shed pounds, says Hurtado.

“Untreated vasomotor symptoms like hot flashes and night sweats can have negative consequences in quality of life and health. The use of hormone therapy to treat vasomotor symptoms has been shown to improve sleep, activity, and quality of life, all factors that can mitigate weight gain in midlife women,” she says.

In a small study presented at ENDO 2021, the yearly meeting of the Endocrine Society, the authors concluded that helping women sleep better during menopause may prevent weight gain.

If there are medical or other reasons not to use hormone therapy, alternative treatment options may help, including nonhormonal treatment options (avoiding those that promote weight gain) and cognitive behavioral therapy, notes Hurtado.

Make Sleep a Priority

“Poor sleep is associated with weight gain, mood disturbance, and brain fog, Adams says. “Managing sleep disturbance is the first thing I would advise if someone is having difficulty maintaining a healthy weight.”

Her advice on sleep hygiene: Get up at the same time every day, go to bed only when you're sleepy, and no naps. Keep the bedroom dark and cool and get treatment for any conditions that can interrupt sleep, such as sleep apnea or restless legs.

Weight Loss Medications or Surgery May Be Appropriate

Weight gain in midlife is a common concern, says Hurtado. But people tend to blame themselves and feel that it shows a lack of self-discipline, and so may be reluctant to bring up their concerns with their doctor.

“This is just part of the highly prevalent weight stigma and bias, the belief that problems with weight are a ‘character flaw’ or the result of lack of willpower or self-restraint. Women should feel that they can mention this issue at their appointment without feeling stigmatized,” she says.

It’s a damaging myth that all it takes is “eating less and exercising more,” to lose weight, says Hurtado. “While a caloric deficit is needed for weight loss, patients should know of the existence of tools that can help achieve this negative caloric balance and that can be used to mitigate weight gain or to treat [people who are] overweight and obese,” she says.

Obesity needs to be accepted as a disease with a biological basis that, if left untreated, can lead to serious health problems, according to Hurtado. “We must amplify the message that overweight and obesity can be effectively treated with evidence-based tools that include antiobesity medications, bariatric endoscopic procedures, and bariatric surgery.”

Prescription weight loss drugs like Wegovy are very popular right now, and for some women they may be a good choice, says Adams. “The patient who might consider them is someone with a BMI in the obese range who has been unsuccessful in losing weight with lifestyle changes,” she says.

To meet the FDA-approved criteria for use, a person must have a BMI of 30 or greater or 27 or greater with a weight-related medical complication, says Kumar. “Many women who have menopausal weight gain don’t meet these criteria, so the medicines would be considered off-label use. We do see these medicines leading to great benefit in some cases of menopausal weight gain, and so hopefully studies can be done on this specific population in the future,” says Kumar.

Because drugs like Wegovy are relatively new, there’s a lot about them we don’t know, says Adams. “It also seems that people regain about two-thirds of the weight they lost within a year if they go off those drugs, so it’s a long-term commitment to start those drugs. In general, it’s best to focus on lifestyle and behavioral changes, not drugs,” she says.

Remember: You Can Do This!

“Focusing on what’s called ‘self-efficacy’ is really important. It’s telling yourself you can do this,” Adams says. You don’t have the body of a 20-year-old any longer, but you have so many other things, especially confidence in who you are, she points out.

Kumar believes that while maintaining a healthy weight is essential, there needs to be some reasonable amount of acceptance that bodies change over time. “We should focus on our functionality and maintaining fitness. How we look is important, too, but shouldn’t be the only focus,” she says.