How can menopausal and perimenopausal women exercise to avoid "middle-age spread?" We talked with physician and triathlete Dr. Tamsin Lewis to find out.
A while ago, a listener wrote to me asking a question that was decidedly beyond my area of expertise. It was a question about menopause. Seeing as I am neither a doctor nor a woman, I decided I needed to call in an expert to tackle this one.
The question was:
"I have just started the menopause and would really like to keep trim and lean and keep my muscle tone up. Is this realistic, or is middle-aged spread inevitable, and I should just accept that I will have a rounder, softer, body than I used to? I have noticed there are very few women my age in the gym lifting weights."
I met my podcast guest, Dr. Tamsin Lewis, when she was racing (and winning) Ironman triathlons. She has since become an expert in the field of aging and hormones, making her the perfect guest for this topic.
About Dr. Tamsin Lewis
Dr. Tamsin Lewis (or Dr. Tam) is an Ironman athlete and an MD who trained at King's College in London. She first became interested in the role of hormones in health and disease as well as in their optimization while she was competing as an athlete. In 2014, she completed her athletic career after becoming pregnant, and soon after dove into the field of endocrinology and the role of hormones. Dr. Tam began working at a clinic in London called the Center for Health and Human Performance, which worked closely with a bioidentical hormone clinic. It was there that she truly started to understand how impactful hormones were in terms of both physical and mental aspects of health and wellness.
When I reached out to Dr. Tam and asked her if she would be willing to join me on the podcast to discuss this topic, she immediately and wholeheartedly responded saying that "... there is a dearth of information around menopause and the menopausal athlete, and the role of hormones more specifically on health and longevity, and health outcomes."
A three-pronged strategy for the fit menopausal woman
In our conversation, we broke down the most important and actionable tips into to three buckets:
- Nutritional strategy: Reducing simple carbs and increasing protein intake.
- Supplementary strategy: Discussing with a trusted physician the possibility of introducing bioidentical hormone replacement.
- Lifestyle strategy: Increasing the amount of resistance or strength training (specifically in the larger muscle groups), choosing physical activities that are enjoyable and contribute to your happiness and lower stress, sleeping well, and focusing on a restorative practice (yoga, pilates, and breath work).
Here is a transcript of my conversation with Dr. Tamsin Lewis. The text is verbatim, so it's much easier to listen to than to read. So, as always, I encourage you to listen to the audio so you don't miss out on any of the subtleties.
Exercise for Menopause
Brock: I'm going to harken back to a question that I received specifically from one of the listeners. I guess a good place to start would be to answer her first question because I think we can answer that quite quickly. Is she right? Is this middle-age spread inevitable?
Dr. Tam: I don't think anything in life is inevitable, is it? Apart from death and taxes. Who was it that said that? I think it's certainly more common, and it's certainly [something] that people come to me to help explore in terms of if there's any answers for why I'm suddenly gaining weight. I haven't changed what I'm eating. I'm mostly doing the same exercise. But certainly, once you approach that menopausal transition, the shift in the hormones absolutely makes you more prone to storing weight. So there are two things there. You can either adjust the way you exercise, or you should adjust the way you exercise, and we'll come back to that. And also you can alter this hormonal milieu as they call it by three strategic dietary approaches, and also potentially using in a safe and medically guided manner, hormones, bioidentical hormones. So effectively replacing what your body is running out of, or is imbalanced in. Talking more about the perimenopausal state, which can certainly be from anything from mid-thirties onwards, where you become this ratio of estrogen and progesterone changes.
Dr. Tam: Estrogen tends to make you store fat. It tends to make you more prone to being, this is when you have excess estrogen, it tends to make you feel bloated. It can make you store fat specifically in the female-dominant shape so around the hips and the waist and the breasts. So I mean, I could explore the chemistry all day, but I guess we need to look at the answers here. And I think for the menopause when the timing is important. So classically, medically, menopause is defined as the absence of menstrual cycles for a period of one year. But the perimenopause is that years before, perhaps even up to 10 years, classically around five years, of hormonal changes. And that's as I've said, usually characterized by this fluctuation of estrogen levels, either in an estrogen-dominant picture or in a low estrogen and progesterone picture. So once you reach the menopause, if you've been characterized medically or by yourself as not having any menstrual cycles for approximately one year, then you could probably make the decision, which means you will have categorically very little estrogen circulating, estrogen and progesterone.
Theoretically, [during menopause], your body does become more prone to storing weight around the middle.
Dr. Tam: Now that can lead to a situation in the body, which changes up its preference for fat storage. And it also changes the function of cortisol. So theoretically, I know we're going into a lot of detail here, but your body does become more prone to storing weight around the middle. I've mentioned a few things here. I've mentioned the role of estrogen in its being dominant and in its problems with high estrogen. So in the menopause, there'll be very low estrogen. You've gone through the ovarian senescence, as we call it, which is where the ovaries stop producing estrogen. So estrogen levels would be low. Estrogen is such an important hormone, but it needs to be at the right level. In the menopausal, levels are going to be too low. So we need a certain amount of estrogen to drive a healthy fat metabolism. And also it's protected to the brain, to the cardiovascular system, and to bones. So I guess if we just back up a little bit and to answer the question here, is it inevitable that your body shape changes?
Dr. Tam: In most cases it is inevitable. There are things you can do to make that inevitability less pronounced. So for example, she mentioned that very few people as she sees in the older ladies lifting weights, and there are two reasons behind that, one, I feel, and you can disagree or agree here that one needs to feel strong in order to lift weights to start with it. It's like it precludes you, I go to the gym or I feel a bit too weak to do that, and therefore I'll avoid it. So there needs to be a graded approach to weights. Also, I don't like the word lifting, but weights—
Brock: Yeah, it sounds like bodybuilding or something. But resistance training, how about that?
Dr. Tam: Resistance training. So I think there's got to be a balance between some intensity, some weight training, or resistance training. So anything that puts the muscles under strain, and encourages a strengthening response so that the cardiovascular endurance in stroke intensity and then the resistance. And then also restorative exercise, which is often neglected, and that's more of the yoga, Pilates, breath work, et cetera. I think there needs to be a balance of all three. Now, I'm trying to get this into a system whereby your listeners can understand, because it's complex.
Brock: It is. It's very complex.
Dr. Tam: It's complex in terms of the physiology, and then it's complex in terms of the individual's response to the shifts in physiologies. And that depends on genetics. It can depend on obviously environment. The healthier you are in terms of eat, sleep, move, relax, the less likely you are to suffer from the consequences of fluctuating estrogen, which is characteristic in the perimenopause. So there's the period around the medicals, as I said few times, and then there's the menopause, which is the decline in hormone levels. You are less likely to respond to an exercise stimulus in a low hormone milieu. So if you're in the menopause, you have less of the driving molecules, hormones, which augment the adaptation to the exercise.
Dr. Tam: So we know testosterone is one in men and women, you do retain some degree of testosterone in the menopause because the adrenals produce it, but levels tend to decline, and that's why measurement and understanding your levels of hormones are important. Estrogen levels definitely drop, and estrogen is important, like I said, in excess, it enhances fat storage, but even when it's too low, that also affects metabolism via a number of [nuance] pathways. So having some estrogen is definitely beneficial to muscle strength, and body composition, which is why I often advocate for bioidentical hormone replacement.
Brock: Would you suggest that that's the first thing that people should focus on? In terms of if you start to notice this change, obviously you want to do it quickly.
Dr. Tam: I think you need to make a decision quite early on, like where you stand ethically on using hormone replacement therapy. So understand, or speak to someone that you trust to explore that with you. The other way to look at this is to obviously look at ways to improve other hormone systems in the body to kind of take over the role of estrogen, for example. We know that protein intake is important if you're looking to retain muscle mass, and if you retain muscle mass, this is lean body composition. You're retaining insulin sensitivity, which is going to directly help with fat accumulation around the abdomen. So methods to improve insulin sensitivity, time restrictive feeding, cycling periods of low carbohydrate. So improving insulin sensitivity is one big factor, and one of the ways you can do that is by the dietary specialist, but also doing the lifting and the gym specifically for the quads, which are one of the biggest muscles in the body.
You go from having hormones to not having hormones, and therefore the drivers of strength and a lean body composition have fallen off a cliff.
Dr. Tam: Having good form, doing deep squats, doing functional movements, using the functional movements, lunges, et cetera. That definitely helps. So it's a cause and effect here. It's almost like if your hormone levels are low, or your hormone levels have shifted, which is what happens in that transition. You go from having hormones to not having hormones, and therefore the drivers of strength and a lean body composition have fallen off a cliff. So you have to work harder to maintain the body composition that you had in the presence of hormones. Make sense?
Brock: Yes. I got it.
Dr. Tam: Not to say you can't do it, your body shifts to a more prone to fat storage, more prone to a lower muscle mass. And the ways to overcome that are actually doing the weight training, doing periods of ensuring you have enough protein intake because the protein is the precursor to driving the muscle growth. And this is where aiming at the sort of one to 1.2 grams per kilogram is probably more than you think sometimes. You must have a view on this, though Brock, this is your area.
Brock: Well, the nutrition side of things I dabble in a little bit, but I know that on our Quick and Dirty Tips network, we have the Nutrition Diva, who's talked about the protein intakes and the benefits, but I'd like to go back to, you mentioned something earlier on about getting your quads involved in the exercise that you're doing, because they're one of the biggest muscles in the body, if not the biggest muscle in the body. Why is that important to be concentrating on using those big muscles?
Dr. Tam: Because they're so metabolically active. The stronger they are, the more mitochondria they have, the denser they are, the more metabolically active they are. That helps clear glucose from the system quicker. That's about the level of detail that I know, but I know that working on the quad muscles, and the glutes and the lower body muscles means that muscle bulk is protecting us from, it has a longevity benefit for a number of reasons, but one is because the high metabolic activity of the muscle helps clear glucose out of the blood, and therefore it's not able to have adverse effects. It's more prone to going in and being stored as glycogen. Secondarily, the stronger your leg muscles are, the less prone you are to frailty generally. So this is two of the mechanisms.
Brock: A lot of the stuff that you just mentioned there in terms of the benefits of that, I've also heard benefiting diabetics, as well. Especially Type 2 diabetics, getting those big muscles working harder, increasing the insulin sensitivity. So it's interesting that the same things that can benefit somebody who's in menopause also can work for diabetics as well.
Dr. Tam: Well I think it's a general ... physiological probably isn't the word here, but it's a principle, right? I mean blood glucose regulation is one of the main drivers of dysfunction and disease as we age, and diabetes is just an exacerbated form of that, accelerated form of that. And so insulin sensitivity, ability to clear glucose from the blood is a key determinant of body composition and healthy ageing. So strengthened and size of those muscles in the legs we know is protective. It's definitely an interesting principle, and it's one that I've become more aware of as being important, the hardest part is actually enforcing it.
Dr. Tam: Not enforcing it, that's too harsh a word, but enabling people to do it, to actually do the exercise necessary to have longer-term benefits, because it doesn't feel good, whatever reason you come up with, but getting people to squat to lift is definitely helpful. And if they're embarrassed to be in the gym, then using more functional metrics or methods to gain muscle strength in the lower limbs is good. I often do step-ups in the park on a log or bench or things like that. Things that people perhaps wouldn't find as intimidating as getting into the gym and doing barbell presses, et cetera.
Brock: Yeah. Near the beginning of this conversation we were mentioning that in the question that came from the listener, very few women her age are lifting weights in the gym and that one of the things that may be contributing to that is that sort of fear, or that feeling of being too weak to go and do that. And then you used the word "frailty" just in the last couple of minutes.
Brock: One of the side benefits of doing some of this work that we were talking about—doing some of this resistance training or strength training or weight lifting or whatever you want to call it—definitely contributes and alleviates two of those problems, that feeling of frailty definitely is something that I've heard reported from a lot of my clients and friends who were in a perimenopausal or menopausal state, and it really becomes sort of a self-fulfilling prophecy I guess at that point, you feel more and more frail, less and less able to go and do that stuff, so you don't do it, and then you get less able and you don't do it, so you get less able. What would be the remedy for that?
Dr. Tam: It is a loop. It's a loop of if you feel better, you're more likely to make healthy food choices, and therefore that you're more likely to go and do the exercise, and then it becomes a positive feedback mechanism. But often if you don't, if people just, not just, but if people are on the decline, I think that this ancestrally, that menopausal time, everything kind of shrinks, everything kind of senescences and you are on a downward trajectory to frailty, and then dysfunction, and then my interest is how can you invest reverse engineer that, and it's multifactorial as we've pointed out many times here. I think improving the mood, I think there are ways to improve mood, which can therefore directly affect motivation, irrespective of whether you use hormonal precursors or hormones. And that can be light, it can be meditation, it can be improving the quality of your relationships, it can be looking at your sleep, and diet quality obviously. But again, mood impacts that. So, sorry if there are no easy answers here.
Brock: Yeah, for sure.
Dr. Tam: There's a multifactorial network here of benefit cause and effect.
Brock: Well, so to sort of boil down what I'm hearing is:
- The first thing would be to work with a physician to determine whether or not you want to pursue the bioidentical hormone replacement, which may be right for some people and may not be for others.
- Then the second thing would be to make sure your diet is supporting things, so increasing your protein, maybe decreasing your carbohydrate intake, your simple carbohydrates especially to help with that insulin sensitivity that you were talking about, and the protein to help slow down the loss of muscle and hopefully actually aid in increasing muscle.
- And then, to that same point, getting some strength training into your exercise program, not necessarily going and lifting weights and trying to be a bodybuilder of any sort, but doing things like you were saying, step-ups, squats, using those big muscles and developing more muscle as you said, having more muscle in your body actually helps with that insulin sensitivity.
Brock: It also then feeds into that mood portion, which I guess would be the next thing, the sort of mental wellness aspect of it. If you're stronger and feeling more capable, then your mood increases, it makes it easier to make better dietary choices. It makes it easier to go out and do the workouts. And it seems like everything just sort of, it really does, you said a snowball effect and I think that's very apt, that each one of those aspects would definitely aid the other one, and make everything easier and just sort of spiral into a positive overall functional effect.
Dr. Tam: Correct. Yeah. Awesome.
Brock: Did I sum that up right?
Dr. Tam: Yeah, that's definitely good. We should say that I do use strategic supplements have been proven to help because as I said, that mood pillar is very important. Mood and sleep, and often the sleep goes in the menopause, and then obviously you have the knock on effects of that. So there are strategic things you can do to improve brain health, which because as estrogen levels drop, estrogen is brain protective. And if you've gone through the menopause and estrogen levels drop, we do feel that estrogen can be protective. So that's what the studies show. So there are other ways of improving brain health that perhaps you should touch on another podcast because brain health determines mood, which determines motivation, which determines libido, which determines all of it. So I think that looking at these different pillars is really important.
Brock: You're no stranger to the gym, or to exercise programs in general. So I feel like you probably have some good advice for the women out there in terms of a workout routine they might be able to start working into their lives.
Dr. Tam: Yeah, absolutely. I mean I'm not a fan of the gym, generally. I'd much rather be outside, even if it's raining. I think there are additional benefits, and the studies say this, from exercising outdoors. In terms that they, the cortisol response to exercise, and also the benefits from light and nature, blah, blah. And I feel like the gym environment isn't potentially that conducive to that. But needs must. Can we add in the sauna? I love the sauna. It's so wonderful.
Brock: Of course, yeah. If your gym or your community center or whatever has a sauna, take full advantage.
Dr. Tam: Definitely. We know that it enhances any exercise benefits and acts as what they call an exercise proxy. So you're getting effects on the cardiovascular system and brain with the caveat that if you've got high blood pressure and all the other medical and tendon issues that you should probably ask your doctor first. But yes, saunaing, definitely a big fan. I also liked the idea of people dancing, especially the older age group, if you haven't grown up through an era of athleticism, going to the gym can be daunting. So I encourage doing things in the community, whether it's hiking, whether it's dancing, all of these things have such a positive impact on emotional and physical health, which will then have an impact on your body composition. It all works as one big engine.
Brock: All right, so we've got maybe a sauna or hot baths even will help.
Dr. Tam: I say chuck some Epsom salts, some magnesium salts in the bath because that will help with muscle relaxation and it's a good source of magnesium, which we're all low on.
Brock: Yeah, absolutely. And then we've got what might be categorized as cardio exercise perhaps like you mentioned hiking, you mentioned dancing, which are also as you said, good for the mood, and then to just improve quality of life and connectivity with other people. Yeah, that's great. Okay. So we've got those two, then we've already mentioned in terms of like strength training and doing some functional movement kind of stuff. Like maybe taking the stairs more often at work.
Dr. Tam: Taking the stairs ... without holding onto the handrails. It's one of my bug-bears, because it's almost like as people get older, their posture changes, and therefore they then hold onto things and they're all like, my balance is going. And they don't challenge the system. And if you don't challenge the system, your body, your brain, your nervous system, then it will inevitably decline. And people slowly, slowly go on that trajectory downwards. So try and challenge the system, don't hold onto the handrail, go up the stairs two at a time, if you can, take time to stretch and get out of your desk so that your posture is more open, crunch down, twist, all of those things. These little things really do add up to have a benefit over time.
Brock: Yeah. So the mobility type of stuff?
Dr. Tam: Mobility, but it's mobility posture, which then have an impact on almost all the body composition because posture is related to the strength of the postural muscles. I'm trying to get people to understand that how you move, how you do things, not just when you're in the gym, but in your day-to-day really do have an impact on body composition, because it changes the way you breathe. It changes the way you stand, it changes the way different muscles are activated.
Brock: Yeah. Yeah. Okay. So we've got some things you can throw into the day and concentrate on when you're just moving through the world. And earlier on you mentioned something about like doing some Pilates, doing some yoga, not only for flexibility and mobility, but you mentioned breathing as well.
Dr. Tam: Breathing is such a huge component of our nervous system. And we often under breathe, we hold ourselves in this kind of chronic state of tension, because we breathe with our upper chest, and our upper neck muscles, and we don't actually get a full lung. So I think just being aware of your breath and actually just spending a couple of minutes at your desk, something I quite like to do is the four, seven, eight, which some people find quite hard, and it might be the first time you do it. Breathe in for four, hold for seven and then out for eight. So a long out-breath. And you just repeat that five times.
Dr. Tam: And that enhances mental clarity, mental calm. It also sort of resets the nervous system, right? So when I talk about the nervous systems, I'm talking about adrenaline, cortisol, those stress hormones, which we haven't spoken about much here, because we were focused on sex hormones. But there is obviously an interplay. So the higher your adrenaline, your fight or flight, and your medium-term stress hormone, the cortisol, the more likely or the more prone you are to storing fat as a kind of reserve. So anything you can do like breath work, nature bathing is one other way. Anything that stimulates the vagal nerve does help produce that tension and those levels of stress hormones, which means slimmer, healthier, happier.
Brock: The other interesting thing about doing deep breathing is that it's very cooling to the body. And I know one of the symptoms that most people complain about with menopause is the hot flash. So using the breathing in terms of helping mitigate those hot flash moments could be very helpful, and it sort of becomes a win-win-win situation in this case.
Dr. Tam: Yes, absolutely. Those hot flashes are really difficult, but definitely breathing will reduce them, because it's not just the hot flash comes, and it's the hot flash and then the response to the hot flash, which is like, oh this is embarrassing. Oh, this is like, and so you get a stress response to the hot flash, which actually if you'd have just let the hot flash pass, it wouldn't have been such a big deal. But your body then overreacts each time it gets it. So rewiring that part is definitely helpful. So breathing through your hot flash, four, seven, eight.
Brock: And one thing we didn't mention at all yet, but I think would go really well with the whole idea of getting some resistance training or strength training is bone density. As I know osteoporosis often happens in the same demographic of people who are going through menopause. So that's definitely a potential issue that you could mitigate by maintaining that activeness, and whether it's the dance classes that we were talking about or doing the yoga or the Pilates and definitely from doing the strength training, whether it's actually lifting weights, or doing bodyweight or elastic band resistance or anything like that.
Dr. Tam: Absolutely. I would advocate more people to have bone density checks earlier on as it were, in your forties, for looking after your nutrition, and you have good hormonal health throughout your 20s and 30s, and your bone density is protected. So look at this not as a drop off the cliff, but also it's a period of time when you need to consider your brain health.
Brock: Before I let you go, Dr. Tam, can you let people know where they can find you if they want to reach out or just want to follow your good work?
Dr. Tam: So I'm about to launch, Wellgevity, a company in the UK that does essentially a lot of what we've talked about in terms of this holistic health management, but mostly aimed at enabling the individual to understand and advocate for their own health as opposed to relying on doctors. So really giving you the tools and techniques and insights in order that you can make better changes on the day-to-day. So that's Wellgevity.Co.UK. You can go there or you can follow me on Instagram when I occasionally get up there. SportieDoc is my Twitter and Instagram handle. And I have a Sportie Doc website too, which chronicles my athletic history, which I'm no longer competitively involved in, but I learned a lot from, as you know.
Brock: Yeah. I think both of us have a history of learning a lot from things that we did right and things that we did wrong in our competitive racing careers.
Dr. Tam: Yeah. Really well.
Brock: Well thank you so much for coming on the Get-Fit Guy podcast.
Dr. Tam: Absolutely. I think that just the takeaways are finding a support system that you can get good advice from, and then deciding on a nutritional strategy, a supplementary strategy, and then a lifestyle strategy just to put them in those three buckets.
Brock: Awesome. Thank you.
Dr. Tam: Thank you.
ABOUT THE AUTHOR
Brock Armstrong is a certified AFLCA Group Fitness Leader with a designation in Portable Equipment, NCCP and CAC Triathlon Coach, and a TnT certified run coach. He is also on the board of advisors for the Primal Health Coach Institute and a guest faculty member of the Human Potential Institute. Do you have a fitness question? Leave a message on the Get-Fit Guy listener line. Your question could be featured on the show. Stay in the fitness loop! Listen and subscribe to the Get-Fit Guy show on Apple, Spotify, or wherever you get your podcasts.