In this DrTalks, we are going to be talking about comprehensive obesity medicine, comprehensive weight loss, especially for perimenopausal women. I have with me Dr. Sejal Desai.

She is a family medicine and obesity medicine physician in Houston, Texas. She’s been practicing for more than 20 years, specifically working with women who are struggling with weight and other symptoms around perimenopause.

And she has a comprehensive, evidence based approach to weight loss. And she’s going to share some of that with us today. Welcome, Dr. Desai. Thanks so much for having me.

I’m excited to have this conversation with you. Let’s start off generally, can you tell us when you talk about comprehensive and evidence based approach to weight loss?

What does that mean? What does that look like? Broadly? Yeah. So that’s a great question. When when we look at anything in medicine, right. We’re looking at the whole patient.

We really, want to focus on more than just one aspect of the patient. If a patient comes, for me specifically, yeah, if they come for weight loss, we are not just looking at the number on the scale. Right?

We’re looking at that whole patient. We’re looking at their family history, their lifestyle. We’re taking into account, you know, everything that’s currently going on with that patient.

And and then we’re, you know, coming up with a comprehensive plan. And the plan can include lifestyle modifications. And it may include, anti-obesity medications because we know obesity is a chronic disease.

Right. That’s the the crux of all of this. We have to treat obesity. And no matter what stage somebody is in, you know, it may be different if we’re if I’m treating obesity and a perimenopausal woman, it might be different than treating obesity in someone who’s 20 years old.

So we take all of those factors into consideration when we come up with our diagnosis and treatment plan. Yeah, I think that’s really powerful to emphasize that everyone is an individual.

Right. And if you work with someone who’s an expert, they’re going to be able to hear your story. Look at your age, your gender, your medications, your health history, and figure out a plan that’s really makes sense for you.

And so in the course of this summit, we’re hearing from lots of different experts, lots of different strategies. And at the end of the day, sometimes having someone who can look at the big picture and figure out what makes sense for you is really helpful, because it’ll be hard to figure that out for yourself.

Absolutely. I think that’s very hard. I think, you know, for most of most people, you can’t just, think about it again. When you think about your own health, it is very hard to come up with a treatment plan that that’s why we’re here.

That is, you know, why do we want to have these conversations, you know, so I encourage patients to have those conversations with your doctor because it is important for them to know everything, including, you know, what current medications you’re taking, what supplements you’re taking.

That stuff plays a role, right? So absolutely. Well, let’s start off talking about what perimenopause is. I feel like this is a term we didn’t hear that much until recently.

And now it’s finally getting a little bit of attention. But what is it? How does someone know if they’re in perimenopause? Why is it important? Yeah. So, we all hear about menopause, right?

And, perimenopause is actually the period that comes before that. It can last anywhere between four to like eight years. This is when our ovaries stop modulating.

There is no more eggs to release each month. So there’s big fluctuations in our hormones. Right. And that’s what causes all of this. So estrogen, progesterone as well as other hormones, when you stop having periods for 12 consecutive months, we call that menopause.

And in the United States that’s usually on average, it’s about the age of 51 for most women, but it can be anywhere from their early 40s to late 50s. It can or any of that can be normal.

And so if you think about 4 to 8 years prior to that, you can see perimenopause can actually start in our, you know, 30s for a lot of people. And it may it’s not always just related to, you know, related to the periods.

There are many symptoms that are related to perimenopause as our, estrogen is fluctuating. It affects everything from head to toe. So it could be, you know, things like, of course, we hear about hot flashes and night sweats, mood swings, but it could be, you know, brittle nails or hair loss or, you know, headaches that are worsening.

It can be bloating and gas. So some of these changes that are occurring as we’re going through, you know, our late 30s to 40s, if you’re noticing some of these changes, it may be related to perimenopause.

And then specifically related to weight and metabolic health. What do we start seeing in terms of the hormonal fluctuations during perimenopause that affect weight?

Oh yeah. So there’s so many changes that happened during this time for women. And you know, definitely there are, weight gain and especially weight gain around the midsection.

I think that’s kind of what most people are worried about during this time. There are a lot of different, you know, factors that can cause that. But first I want to, you know, just kind of define weight gain around the midsection, right?

Because, there’s a difference between, just what we call subcutaneous fat or visceral fat. Right. And I want to give that distinction because it’s very important to know that difference.

Subcutaneous fat is just the fat that’s stored around the skin. It’s visible. It’s the fat. You can pinch visceral fat. This is the deeper, you know, fat that lies in the body.

It’s stored around those internal organs. All right. This is what we worry about. Stored around your liver or your intestines or even your heart. It’s inflammatory.

So it increases our risk for things like diabetes and heart disease and all of these things. And this is why we worry. Because during this time, because of the hormonal fluctuations, we’re getting more fat storage in the around our organs, the visceral fat storage around our midsection.

So that’s the fact that we’re really worried about. So, so I think a good question then, which I would imagine people have is how do you know which one it is?

You kind of mentioned there’s the fat you can grab. Is is there a way that, like, we can know if we have more visceral fat? So, you know, there absolutely is when we when we, you know, look at a lot of these factors, especially as an obesity medicine doctor, you know, it’s important for me that we’re looking at your entire body composition.

And there are ways to check for visceral fat. Right. And getting your body composed and done, you know, there are many different ways to check body composition, and different doctors have different machines.

But in general, you need to get that full body composition checked to see if you have, you know, visceral fat, how much visceral fat you have, and muscle mass, body fat percentage.

All of these numbers are important, not just the number on the scale. Easy way at home to check is is doing a waist circumference or, you know, you can you can kind of see what your waist measurements are and, you know, and, and use that as a reference as well.

So there’s definitely ways to measure. Measure the fat. So when it comes to this perimenopausal time period, are there like specific nutritional or dietary strategies use that are most effective in this time period.

Yeah. So you know, there are many different things that we can do with our nutrition that can help, a lot of, a lot of our symptoms. And, you know, it actually, you know, maybe I can go back and talk just a little about what is exactly causing it, because that leads to the dietary, dietary, you know, treatment basically for it because, you know, there are several, as you mentioned earlier, metabolic things that are going on in our processes that are going on in our body that causes that weight gain around the waist area.

Right? So there’s big things that, that do cause that. And one is that we’re more prone to insulin resistance during this time of our life. Right. And, and insulin resistance, is really kind of that precursor to diabetes.

You go through this pattern of insulin resistance and then prediabetes and diabetes. So our insulin levels are higher during this time. Our cells are not responding to the insulin as well.

And so it’s just pumping out more insulin. And so we are more prone to developing, prediabetes and diabetes during this time, which definitely leads to certain, nutritional, you know, think factors that we can, we can do, and, and then sleep disturbance is the second thing.

So, you know, really big fluctuations in sleep during this time may be due to, due to night sweats or urinary frequency, you know, can cause some of those.

And the third thing is loss of muscle mass, which really makes, makes us gain more weight around the waist area as well. And depression and anxiety can worsen.

So those are kind of the four big things. And we can certainly dive deeper into those as well. That when you ask about nutrition, I like to mention those initially because, nutrition plays a big role.

So as because insulin resistance is increasing, we want to be really cautious with, you know, simple and refined carbohydrates like white bread, pasta, rice, cookies, candies, you know, all of those types of things and drinks.

Don’t forget those sugary drinks. Alcohol, can all play, you know, play a role in worsening all of that. And, and we want to and, and also saturated fats.

This is a time where our LDL cholesterol may be increasing as well. So we really want to watch those saturated fats, fried food, and processed food intake.

And we want to increase our fruits, vegetables, especially leafy greens, whole grains, and, and lean proteins. Right. Because of that muscle mass loss, we really want to increase our protein intake.

That could be beans, lentils, legumes, fish, lean turkey, chicken, eggs, lots of different ways. But really prioritizing our protein intake because of the loss of muscle mass.

I love how consistent the messaging from all of our experts has been so far about nutrition. You know, I mean, like everyone has emphasized that eating more plants is, you know, a really important strategy.

So and that decreasing processed food is an important strategy. So, you know, once again, even for perimenopause, like an important strategy. But you mentioned some of the other health changes that happen in this time period.

So how do we address those? Is there any underlying thing we can do for all of those, or what are some other solutions to those many, medical changes that are happening in this time period?

So I think first, it’s really important to identify those changes, right? And know that it’s a change. So many times we just tend to pass it off as, oh, it’s just, you know, because I’m more stressed or because of this is going on in my life or whatever, but really taking this time to take stock in what is going on with our health is important.

So, you know, and I think addressing each one separately is important for treatment. So if sleep disturbance is something that is happening because of night sweats or urinary, you know, frequency, we need to treat those night sweats and urinary frequency right.

So working on our sleep hygiene in that case is incredibly important. You know, making sure the room is dark and, and, prior to going to bed at the same time, waking up at the same time, avoiding some of the triggers for night sweats and hot flashes like alcohol, caffeine, spicy foods.

I think some of that is important. And, you know, also talking, to your health care providers because if you’re you’re trying all of these, you know, lifestyle treatments and it’s not helping, really don’t shy away from hormone replacement therapy because we know now that it is for sleep, especially for night sweats and hot flashes.

Hormone replacement therapy is fantastic, and you can can actually have a lot of protective benefits. There’s also non-hormonal treatments. Oxybutynin is one of those that now, we use for, as a non hormonal treatment for hot flashes.

And it can also help the urinary symptoms as you know. So there are both hormonal and non hormonal treatments. But regardless treat treat the underlying cause of of the sleep disturbance.

And same with all of the other things. So you know depression and anxiety can really worsen during this time. In fact during menopause our risk for depression goes up by 2 to 5 times compared to what we were free menopause.

Right. And in one study, that was done recently in 2021, showed that 59% of women experience depression at, at menopause. That’s a significant amount of us.

And so, you know, it’s important to, to notice that because it could be new onset or it could be worsening from what you had previously. Either way. So, you know, it can it can manifest as symptoms of lack of motivation, low energy, lack of concentration, sleep disturbance, all of these things then elevate our cortisol levels, which, you know, is our fight or flight response and can lead to fat accumulation around the belly area, especially that visceral fat.

So don’t ignore these symptoms of depression and anxiety. Get that treated and treatment can, you know, involve many different things. Again, it can involve lifestyle modifications, improving your sleep habits, working on lowering stress through meditation, yoga, you know, all these different ways.

It can involve counseling and therapy. Cognitive behavioral therapy can certainly help with a lot of this. And it can also involve, medications to help as well.

So the the treatment of course has to be individualized again to the person. But there are many different, you know, ways to treat it. And so we definitely want to you know, take, take take all of that into account.

And then we can’t forget weight loss because weight is very, very closely tied in to menopausal symptoms. And a lot of people don’t realize that, but it really is.

And it doesn’t actually take a whole lot of weight loss. So there were two studies done, and one of them showed that just an 8% weight loss can improve your hot flashes and night sweats by like 74%.

And another study, done a few years ago, 2019, showed that 10% weight loss can improve it by 50%. So somewhere between even just an 8 to 10%, right. For a person who weighs 200 pounds, that’s like about 20 pounds can really make a difference in your symptoms of hot flashes and night sweats.

So, you know, working on weight loss. And then as you know, we talk about with weight loss, there are many different ways. There’s the lifestyle that definitely we have to incorporate lifestyle, with medications if you’re a candidate and if that is something that your doctor, thinks is appropriate for you.

There are many wonderful medications for weight loss as well. So I think it has to be individualized and tailored to your needs. Yeah. And I think that’s so powerful to recognize, you know, that lifestyle is going to be part of this no matter what.

A lot of times I talk about that as the foundation, right? No matter what, we’re going to try to improve the balance of what we’re eating, trying to get exercise, reduce stress, sleep.

Those are important no matter what. If you’re already doing those, or you keep finding you can’t do those things because the medical problem, the depression and the anxiety, the insulin resistance is too much and it’s keeping you from successfully doing that thing, then there’s treatment, right?

And meeting with a physician will allow you to figure out, do you need hormone replacement to get things going? Do you need a little bit of maybe metformin to help with insulin resistance?

Do you need one of the more powerful injectable medications like govi or zap bone, and like what is going to make sense for you, your goals, your health risks?

And if you’re struggling to lose that 8 to 10% that we know can help, then like, let’s figure out what the solution is to that, because we know an 8 to 10% weight loss helps with most medical conditions.

It sounds like including perimenopause and menopause. But you also explained to us earlier that it’s a time where it’s easy to gain weight. And so it’s like a double edged sword, right?

Where we’re saying weight loss can help, but this is also a time in your life where you’re more prone to gain weight. And so if you’re stuck in that chicken and egg situation, we have a lot of obesity expert colleagues, including ourselves, but others as well, that can help you figure out, you know, what the solution there is.

Yeah. And I think that’s why it is important to see an obesity medicine specialist, because this is our area of specialty, right? This is this is what we do all day.

And I think that’s really important. As you mentioned earlier, it’s comprehensive care. So you need somebody who’s not just going to prescribe a medication but who’s actually going to help guide you through, you know, the nutritional, you know, changes that need to be made, your physical activity, help you improve your sleep and help you work on stress reduction, because all of that has to be done together.

This is how we, you know, make sure that your, medications aren’t causing side effects or, you know, that you’re not losing too much weight, right? We need somebody has to be watching this, following this, very closely.

It is not one of those situations where I can just give you an antibiotic for your sinus infection and say, see you later. Right. This is definitely something that we have to follow closely.

And, you know, an obesity medicine doctor, you we’re following those body composition metrics more than we are. The number on the scale again. So it’s we’re looking at your muscle mass.

We’re especially perimenopausal women as I talked about earlier, we’re losing muscle mass. It increases during, you know, this perimenopausal time we start in our 30s and then it continues to increase.

So we really want to be gaining muscle mass during this time. So your weight loss, it’s not exactly, you know, huge numbers all the time because we’re looking more at your body fat loss, your visceral fat loss, weight around the waist and increase in that muscle mass through body composition testing.

So, That number on the scale is just one number, right? We might be looking at your bloodwork. We’re looking to see are you gaining muscle. Are you losing fat.

It’s not just about the number on the scale. And then of course how do you feel. Right. If you’re losing weight and you feel terrible, that’s not a good sign.

We want your your sleeve to be better and your energy to be better, and you to feel good. And that’s like a super important part of all this as well, especially during perimenopause.

Absolutely. I just had a patient the other day and she was he had lost about 20 pounds and she was just bummed. She said that I wanted to, you know, I had this number in my mind and this is what I wanted to lose.

And and she was upset and I and we took a step back and I was like, so what’s going on with your blood pressures? I know all this, right? But I needed her to realize.

And she said, oh, I’m, you know, they’re totally normal and I’m off my medications. I was like, what about your pre-diabetes? Oh, it’s gone now. Oh, what about, you know, how are you feeling?

How’s your energy levels? Oh, I wake up and I’m so energized. Right. So there’s all these other improvements that are happening. So what is the number on the scale really. Right.

Even her muscle mass, we we always grab it and our muscle mass has been going up. And she was almost 60. So to have almost a 60 year old female with muscle mass going up right is is incredible.

And it is possible, for all this to happen. So focus I it’s really I think and I know, you know, Carolyn, you’re on the same page like focus on, on these other factors.

So you know. Yeah I love that story. I had someone last week where she, you know, was very menopausal and she had had a lot going on in the last month.

She had a sick family member, a really sick family member. She had quit vaping. So she had done that stress at work and she was upset she actually hadn’t lost any weight.

And I said, okay, but you are going through a really stressful time period. You quit smoking, which is often a time when people will gain weight and you didn’t gain any weight, and you said your cravings are under control and they’re eating a pretty healthy, balanced diet like that is a win, right?

Like most people would have gained weight when they quit smoking and, had a loved one in the hospital dying, right. And like you maintained. And so I think we have to look at that big picture of like, what are your goals?

It’s not just all about the scale, that’s just the number. And, thank you for sharing that, because I think that those are good signs of things we can look for, like, how do you feel?

How are you doing? The scale is just one tiny piece of that. Yeah. Non scale victories is what I said. You know I always like you know make a list for them too and try to keep a running list because I want to you know it’s an a motivational factor as well right.

Like focus on the good that’s already been done. You know, and focus on those small little goals like you said. So yeah, my mission has always been to help people live longer and live better.

Right. That feels like my job as a physician. And that’s why I help people lose weight. And so can we look at a list and say, are you living longer? Are you living better based on the changes we’ve made?

Because that’s all that really matters, right? And we can all be healthy at different weights. That’s right. Absolutely. So I find that especially around this topic of perimenopause and menopause, there are some there’s lots of misconceptions, maybe even myths out there in the world.

What are some of the myths and misconceptions that you see, that you would want to clear up? Yeah. So one of the biggest things that I see is women just think that this is, you know, menopause is inevitable.

Yes, menopause is inevitable. But the symptoms of menopause are not inevitable, right? So, we don’t have to experience all of these symptoms that are making us feel bad because we have treatments for them.

If you are experiencing them, you know, take, take, take stock in what’s going on and treat those underlying causes so that you aren’t feeling miserable during this time.

It is not a time where we should be feeling miserable. And we can absolutely, you know, help treat with lifestyle and or medication. We’re combination, you know, really help all of these symptoms, no matter what it may be.

You don’t have to just live with hot flashes, live with, you know, insomnia or depression or, you know, any of these symptoms, the GI symptoms that can happen around, perimenopause, any of this, talk, talk to your doctors because we’re here to to listen and help you through this.

So I think that’s a big one. Yeah. I think sometimes what I’ll hear, people wonder is it is inevitable. Right. But. So why would this happen to women?

Like, why, why do all these things happen? And isn’t it natural? Right. Like, why are we fighting this? Why are we using hormones? Why are we using meds?

Isn’t this a natural process for women? Why do we need to treat it? Yeah, it’s so good. Well, you know, first and foremost, you know, we know that around this time, perimenopause and post menopause, we are at higher risk for heart disease.

And a lot of these, you know, bigger chronic medical conditions. And so one of the reasons to treat is to prevent, you know, a lot of those, you know, getting a lot of those chronic medical conditions.

So that’s a big reason to treat. And also just because we don’t feel good if we don’t treat it right, we have more fatigue and we’re tired because we’re not sleeping well.

And how can we function. And this is a time where for a lot of women, we have children, we may have spouses, we may have aging parents we’re taking care of.

We’re working. We have a lot going on in our lives. We need we need our brain to be focused and concentrate. And in order to take care of everybody else, we have to take care of ourselves first. Right.

So I think it’s I think, you know, we absolutely have to have to treat it. And we have a lot of safety information. We have a lot of evidence based information.

So I’m never saying do something that, you know, doesn’t have safety or evidence, or efficacy behind it. Right? We want to do things the right way. You don’t want to just take a hormone over the counter, you know, you want to talk to your doctor who’s going to prescribe you something that has safety and efficacy behind it, so we know if it’s safe to do, then we do it.

And you may be at the age where, you know, you you don’t need hormone replacement therapy, or you may have some, you know, contraindications to something like hormone replacement therapy or weight loss medications.

But for those that don’t, it can certainly help you live and feel better. So, I think that’s that’s really powerful, right? Like just because something might be a normal process doesn’t mean we can’t treat it.

And then sometimes I’ll hear people also say like, yes, but our life expectancy wasn’t like 85, you know, for most of human history. So a lot of us didn’t make it to, you know, menopause if we look historically.

And so now that we can live, you know, into our 80s and 90s, like we need estrogen longer in our life, right. And otherwise, you know, we do have this increased risk of heart disease and bone loss and muscle loss and fatigue.

And, if we want to live longer and live healthier, like, maybe we need to treat that so that we can be 90 year old women. That’s right. And live a healthy life.

Like you said, healthy span, not just the lifespan. Right? Yeah. Right. Right. Who wants to live to 90 if we don’t feel good? That’s right. And most people, I think, sometimes think that hormones were the only reason for, you know, the weight gain and some of these symptoms were feeling and stuff and, and you know, I think it’s kind of a myth or misconception too, because we mentioned earlier, you know, that there are a lot of things that are going on in our bodies metabolically, during this time.

Yes. Hormones do play a role, but, you know, they cause other symptoms. So I think it’s important to remember that, you know, not just I think a lot of women feel sometimes, you know, especially as family medicine.

I’m sure, you know, you see this. I don’t practice family medicine anymore, as I only do obesity medicine. But when I was family, everybody wanted me to check their hormones.

Right? And even now I get patients saying that. So it’s there’s not a hormone, you know, you can’t really check during perimenopause your estrogen progesterone levels.

They’re all over the place. Right. So what it’s going to be one day is not going to be, give us any type of answer. So it’s not really a great idea to check your hormones.

It doesn’t really tell a whole lot. You gynecologist may need it for other reasons, but usually not for perimenopause or menopause. When you do know hormones play a role and they affect all of these other areas, so you know, pay attention to all of that.

It’s not just all about hormones. Yeah, I think that’s really powerful information because I get that very, very frequently from my patients asking to check hormones.

And sometimes we will. But most of the time we’ll talk about they were really treating your symptoms right. Like if the story all adds up, that’s really you know, we can tell that this is perimenopause or menopause based on the symptoms.

We don’t necessarily need blood tests for that. Sometimes if I have a patient who’s really young, they’re in their 30s, I’m like, ooh, like, let’s see.

Because this would be early but possible. Like let’s see if we can find signs of it. But if you’re 48 and you’re having these symptoms like it’s probably perimenopause, right.

And we can usually get that from history and check off other other things that could be going on. And so I think, yeah, that’s actually a great point that like we don’t necessarily need like hormone tests.

And I think there’s a lot of myth around that right now that, that, you know, if you buy these really expensive tests or do these really, you know, specific tests that maybe you’ve seen someone on the internet recommend that, that that’s what you need to do and we’re just not there yet.

Like maybe someday we’ll have good hormone testing where we can dial in and really treat to that. But we’re just we’re really just not there. We don’t have the science for that as of 2024. No.

And we don’t have the studies that show that it’s beneficial. Right. So we don’t have the evidence for it. And so that’s why it’s it’s, you know, and it’s a clinical diagnosis.

You don’t need to, you know, you don’t need to spend all that money. You know, getting all of that stuff done. So but what is important, what tests you do need to get done.

Because I’ll always be a family medicine doctor at heart. Is your is your physical with your primary care doctor right. Please, please, please get your physical every year.

And some women think that they can see the gynecologist. And I love my gynecologist counterparts, but they’re they need to focus on your breast and pelvic health and and your primary care doctor focus is on everything else.

So once a year physical with your primary care doctor, many people say I don’t need a physical because I’m healthy. No, that’s why you need a physical is when you’re healthy.

We don’t do a physical if you’re sick, that’s called a sick visit, right? Your physical is for prevention. And so it is critically important and especially around the time of perimenopause and menopause.

Please go in and get your yearly physical done. This is how we pick up on, you know, certain things that might just be maybe your agency is just a little bit higher, your blood sugar, maybe your LDL cholesterol is a little bit higher.

Let’s pick it up now before it causes some major, you know, concerns later on. So I think that’s super powerful. Yes. Because at this time we’ll often see, like you said, those changes in blood sugar.

Let’s find them early. The changes in cholesterol sleep apnea can start sneaking in high blood pressure. And so like if you can find those things when they’re just sort of peeking their head out, and work on addressing them as opposed to waiting ten years and now they’re, they’re really big deal.

They’re a problem. I think that’s amazing advice to, like, make sure you’re seeing the whole care team. Okay. Any final thoughts for, our audience about perimenopause or weight loss in general?

Yeah. You know, I think the biggest thing is, you know, use this opportunity, you know, that you have during this perimenopausal time to really take care of yourself.

I mentioned it earlier, but self-care is not selfish, right? We want to reflect on our health during this time, make some positive changes, because I really do truly believe that this can be the best time of our lives.

So, you know, talking about. What a way to end. So if people want more information or to connect with you, where can they find more information? I can go to, my website at www.tulawlw.com Or you can also find me on Instagram and Facebook, @tulamedicalweightloss I love it. Thank you so much for joining me.

Thanks for having me.

Sejal Desai, MD

How To Manage Weight Gain In Perimenopause