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Obesity- A Malediction In Menopause

Introduction:

Midlife, a phase marked by considerable hormonal shifts and lifestyle changes, presents unique challenges for women, particularly in terms of health and wellness. Obesity is one of the most significant concerns, affecting not only physical health but also mental well-being and general quality of life. among this essay, we will look at the intricacies of obesity among women in their midlife, including its causes, effects, and possible solutions.

Menopause is a seminal event produced by the decrease of ovarian follicular activity and is diagnosed retrospectively 12 months after the permanent cessation of menstruation. The average age is 46 years. At 44.69 ± 3.79 years, Indian women enter the perimenopausal stage, characterized by irregular periods. The menopausal transition period is characterized by a variety of metabolic changes, including increased body weight, total body fat, and loss of lean body mass. These changes result in central obesity, dyslipidemia, and insulin resistance in postmenopausal women.

Obesity has been a growing epidemic for decades. It is a well-known cause of numerous medical issues, including type 2 diabetes, hyperlipidemia, arterial hypertension, cardiovascular disease, osteoarthritis, depression, and multiple cancers, to name a few.

The World Health Organization defines overweight and obesity as follows:

Overweight is defined as having a BMI of 25 kg/m2 or higher.

Obesity is defined as a BMI more than or equal to 30 kg/m2.

Morbid obesity is defined as BMI greater than or equal to 40 kg/m2.

Asian population:

• Overweight -BMI between 23 and 24.9 kg/m2

• Obesity – BMI greater than 25 kg/m2

BMI is the most useful population-level metric for both sexes and all age groups of adults. Children's age must be taken into account when defining overweight and obesity.

Classification and Calculation of BMI

This is a graph of BMI categories based on the World Health Organization data. 

Limitations of BMI

BMI is a commonly used and helpful predictor of healthy body weight, however it has limits because it does not account for body composition. The wide range of body types, as well as the distribution of muscle, bone mass, and fat, should be considered in addition to other parameters when calculating a person's healthy body weight. BMI is also influenced by parameters including age, gender, ethnicity, muscle mass, body fat, and exercise level, among others. BMI is not completely correct because it measures extra body weight rather than excess body fat.

In adults:

For example, an elderly person who is deemed a healthy weight but is entirely sedentary in their everyday life may have considerable quantities of excess body fat despite not being overweight. This would be regarded unhealthy, whereas a younger person with a higher muscle composition and the same BMI would be deemed healthy. Athletes, particularly bodybuilders, who are deemed overweight because muscle weighs more than fat, may actually be at a healthy weight for their body type. Generally, according to the CDC:

• Older persons typically have greater body fat than younger adults with the same BMI.
• Women typically have greater body fat than men with an identical BMI.
• Muscular people and highly trained athletes may have higher BMIs due to their increased muscle mass.

The risk of obesity skyrockets during the menopausal transition era. It is unclear whether this connection is due to diminishing ovarian hormone output or age. Preclinical data show that disrupting estradiol (E2) signaling via estrogen receptor (ER) deletion or ovariectomy (OVX) promotes fat formation, supporting the causal link with estrogen insufficiency. Current evidence from multiple large and long-running cohort studies, such as the Study of Women's Health Across the Nation (SWAN) and the Women's Health Initiative (WHI), suggests that the peri-menopausal increase in obesity, as assessed by body mass index (BMI), is caused by aging.

Obesity and menopausal transition

Menstrual abnormalities precede the final menstrual period, which is caused by a dwindling pool of ovarian follicles and variations in reproductive hormones. The Stages of Reproductive Aging Workshop +10 (STRAW+10) criteria, which are based on menstrual bleeding patterns, reflect a consensual staging scheme developed by field researchers.

The menopausal transition has four stages: late reproductive (−3), early menopausal (−2), late menopausal (−1), and early postmenopausal (+1). During the menopausal transition, ovarian sex steroids continue to reduce; inhibin B gradually decreases, contributing to the relaxation of negative feedback inhibition on pituitary follicle stimulating hormone (FSH) synthesis. In stage -3, FSH may be normal or occasionally raised, but it continues to climb and remains persistently elevated by early menopause.

Effect of obesity on vasomotor symptoms

The link between obesity and the severity of vasomotor symptoms is debatable. There are two opposing explanations that explain the relationship. The "theromoregulatory" model proposes that higher BMI and adiposity are associated with a higher prevalence of hot flashes because body adipose tissue acts as a thermal insulator, impeding heat dissipation, and the "thin hypothesis" proposes that women with excess body weight experience fewer VMS because the cytochrome P450 aromatase enzyme in fat tissue converts androgens to estrogens. increased BMI is connected with a lower incidence of hot flashes during menopause due to increased levels of estrone, which may lessen hot flash frequency.

Effect of menopause on obesity

Obesity is associated with a decrease in circulating estrogen (i.e., estradiol) levels during menopause. Among premenopausal women, estrogen levels are inversely related to obesity. E2 influences many energy homeostasis pathways, including central nervous system (CNS) control of food intake and energy expenditure, regulation of lipid storage and metabolism in adipose tissue, and insulin sensitivity.  Experiments with laboratory animals (e.g., estrogen receptor knockout and knock-in models, as well as ovariectomy with and without hormone supplementation) have shown that, in the absence of estrogens, a general mechanism for fat gain operates by lowering metabolic rate at rest, decreasing spontaneous physical activity, and increasing caloric intake.

Not only does the menopause facilitate weight gain, it modifies the pattern of fat distribution. Ovarian estrogens promote peripheral fat storage in the gluteal and femoral subcutaneous region, whereas androgens (mainly bioavailable testosterone) stimulate visceral abdominal fat accumulation. This is irrespective of age, race, total fat mass, and other cardiovascular risk factors and changes following the menopause.

Menopause and cardio-metabolic risk

Abdominal fat is recognized as a metabolically active endocrine organ that secretes numerous adipokines and substances linked to insulin resistance, type 2 diabetes, and metabolic syndrome. Alterations in adipokine release from visceral fat initiate inflammation and play a role in insulin resistance, leading to elevated levels of circulating insulin .

Because most VAT is drained by the portal vein, the hyperlipolytic state of large (hypertrophic) adipocytes associated with visceral obesity exposes the liver to high concentrations of free fatty acids and glycerol, leading to several impairments in liver metabolism, such as reduced hepatic extraction of insulin (exacerbating hyperinsulinemia) and increased production of triglyceride-rich lipoproteins, as well as increased production of hepatic glucose, which explains the link between visceral obesity and glucose intolerance and type 2 diabetes .

Obesity and osteoporosis:

The notion that obesity has a protective effect against fractures has influenced clinical practice, with BMI being a component of the Fracture Risk Assessment Tool (FRAX). Research has shown a positive correlation between bone mineral density (BMD) and BMI, as well as a lower incidence of hip fractures in adults with obesity . A systematic review and meta-analysis of 121 studies found higher BMD in the lumbar spine, total hip, femoral neck, and radius in men and women with obesity compared to their counterparts with normal weight.

Menopausal obesity and risk of cancer:

Obesity after menopause, particularly visceral adiposity, increases the risk of developing breast cancer. Many studies have revealed that postmenopausal women who accumulate abdominal fat tissue are more likely to develop breast cancer. The risk of postmenopausal breast cancer rises by 11% for every 5 kilograms added as an adult. Overweight or obese women have a 1.5-2 times increased risk of postmenopausal estrogen receptor positive (ERþ) and progesterone receptor-positive breast cancer, with an increase of 70% for ER þ breast cancer.

Management of menopause and related obesity:

Obesity management consists of lifestyle changes, as well as pharmaceutical and nonpharmacological interventions. Non-pharmacological treatments for managing grade I obesity include a low-calorie diet and increased physical exercise. Pharmacological therapy is indicated for patients who are unable to meet their weight loss objectives using these methods. Indications for grade II and grade III obesity include personalized pharmacological and surgical recommendations.

Lifestyle changes and exercise:

Lifestyle changes, such as regular physical activity and dietary management, have a positive effect and prevention of metabolic diseases. Intensive lifestyle changes leading to weight loss have been shown to reduce various menopausal symptoms.

Recommended activities for menopausal women

Step I: Aging makes the body less flexible. Start with warm‑up exercises such as full body stretches, walking for 10 min on the treadmill, suryanamaskar, etc. Warming up helps to prepare the body for exercise by gradually increasing physical activity, joint mobility, and stretching.

Step II : Aerobic exercises help to burn calories and provide cardiometabolic benefits to older women. Aerobic exercise can be initiated by walking for a short duration at a comfortable pace.

Step III : Short bouts of resistance exercise and strength training can also be incorporated using resistance bands, weight resistance, or utilizing one’s own body weight. It is recommended that these exercises can be incorporated on every alternate day focusing on the abdomen, arms, legs, shoulders, and hips.

Step IV: Practicing yoga and stretches help to maintain flexibility in older age women to perform daily chores. These light intensity exercise do not spike the vasomotor symptoms and help to ease the psychological symptoms.

Step V : Balance exercises help in postural and gait control to prevent falls in menopausal women. Practices such as tai chi, pilates, and some functional exercises Can help to maintain balance

Step VI :The exercise session should conclude with cooling down exercises such as walking a few minutes and muscle relaxing postures and stretches which will ease the pain. Regular exercise has both short‑term and long‑term benefits in menopausal women .

Strength training: Due to the strong influence of aging and the menopause on body composition, including the loss of lean mass, exercise designed to improve and maintain muscle mass is critical. In this regard, strength training has been the focus of some studies examining how exercise may mitigate metabolic dysfunction following the menopause. A study investigating the association of resistance training exercise frequency and volume with changes in body composition among postmenopausal women found that resistance training was successful in preventing weight gain and deleterious changes in body composition.

High-intensity interval training: The metabolic benefits of high intensity interval training (HIIT) are well established. A recent meta-analysis concluded that HIIT is a time-efficient, feasible, and effective intervention to modify body composition by reducing abdominal and visceral fat mass . Lean mass increases the basal metabolic rate and total energy expenditure, so the combination of HIIT and resistance training may be an equally beneficial exercise modality for postmenopausal women .

v  Dietary strategies for weight loss:

        1.Based on amount of food intake :

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