“It just seems like people are talking about menopause, but nobody has a solution”: A qualitative exploration of menopause experiences and preferences for weight management among Black women

Abstract

Objectives:

A qualitative study was performed to characterize experiences of women going through menopause, as well as to identify barriers and facilitators for participating in a lifestyle program targeting weight management during menopause.

Study Design:

Perimenopausal and postmenopausal Black women with a self-reported desire to lose or maintain weight during menopause participated in a total of six focus groups.

Main Outcome Measures:

Women were asked about their past experiences with diet, exercise, and weight management; their menopause experiences; as well as specific components and considerations for developing a lifestyle program for weight management. Thematic analysis was conducted on coded transcripts and four main themes emerged, each containing three to seven subthemes.

Results:

Twenty-seven Black women (age 54±4 years, BMI 35.1 ± 9.0 kg/m²) were enrolled. Overall, women felt unprepared for the changes they experienced during menopause and had difficulty maintaining or losing weight. While women were receptive to trying different diets and exercises, they wanted a diet that was flexible with their lifestyle and exercises that considered their existing health status. Women were also interested in learning about menopause alongside other women, stating that medical professionals did not provide them with adequate information or help. Social support, accountability, and seeing results were perceived critical to achieve long-lasting behavioral change.

Conclusions:

Women were interested in receiving menopause information and improving their overall health as part of a lifestyle program during menopause. Associating with other women affected by menopause will allow for the creation of more sustainable lifestyle programs during menopause.

Clinicaltrials.gov identifier:

NCT04487782.

1. Introduction

The menopause transition is characterized by changes in hormones, energy balance, and body composition that contribute to increases in cardiovascular disease risk, the leading cause of death in postmenopausal women [1]. Changes in hormones, particularly the decline in estradiol, are associated with reductions in energy expenditure and increases in energy intake [2-5]. This positive energy balance leads to weight gain and increased adiposity, namely in the abdominal region [2-4]. Common menopause-related symptoms (e.g., vasomotor symptoms, sleep disturbances, etc.) can also exacerbate cardiovascular disease risk and metabolic dysfunction during menopause [6-9]. Opportunities to mitigate these negative effects caused by menopause would help to promote healthy aging in women.

Despite our current understanding of the cardiometabolic consequences of menopause [10], many women are not prepared for menopause and how its associated symptoms will impact their lives. In a cross-sectional study of 1611 perimenopausal and postmenopausal women, most women (65%) felt unprepared for menopause and many women (70%) wanted help managing their weight during the menopause transition [11]. Specifically, 83% of women were interested in dietary and exercise guidance to help them control their menopause symptoms and weight gain, as well as menopause-specific education to address the changes they experience [11]. These findings are supported by other observational studies that weight gain during menopause is a major concern for menopausal women [2-5,12]. Still, some women choose not to discuss menopause with a medical professional. It is possible that women may not speak to medical professionals about menopause-related changes due to feelings of embarrassment when discussing menopause with a stranger or due to the underlying social stigmatization of menopause and aging [13,14]. Taken together, women are interested in receiving guidance about managing their menopause but may not be receiving the guidance needed.

Another consideration when addressing the needs of menopausal women and their symptoms is that women of different races and ethnicities experience menopause differently. Compared to White women, Black women typically have a longer menopause transition duration; have a higher prevalence and longer duration of bothersome vasomotor symptoms (i.e., hot flashes and night sweats); have shorter sleep duration and less efficient sleep; and have lower energy expenditure and physical activity [5,6,13,15-17]. Black women are also less likely to experience increases in depressive symptoms or declines in sexual function over the menopause transition compared to White women [5,6,15,16]. Additionally, there may be certain systemic barriers for Black Women to receiving guidance from their medical professional compared to White women.

When developing pragmatic lifestyle programs during menopause, it is important to incorporate the perspectives of women affected by menopause in order to create lasting behavioral change [18]. To develop a successful lifestyle program targeting weight management, additional investigation into women’s experiences, as well as barriers and facilitators to participation in such a lifestyle program within specific races may help tailor future programs and improve health-related outcomes and overall quality of life during menopause. Therefore, the objective of this qualitative research study was (1) to characterize the personal experiences and perspectives of Black women during menopause; and (2) to identify key components of a lifestyle program targeting weight management strategies during menopause.

2. Methods

2.1. Study design and setting

A cross-sectional, qualitative study was conducted to characterize past experiences of women going through menopause, as well as identify barriers and facilitators to participating in a pragmatic weight management program (WISE Study: NCT04487782). Using participatory research strategies, we partnered with women directly affected by menopause to inform the design of this program [18]. This study was conducted at the Pennington Biomedical Research Center (PBRC) between February 2020 and March 2021. The entire study included 55 perimenopausal and postmenopausal women between 45 and 60 years of age, who were a part of 11 focus groups. All women resided in Southeastern Louisiana.

Eligibility criteria included: (1) having experience of menopause, i.e., women currently experiencing or having previously experienced menopause-related symptoms or irregular menstrual cycles; (2) having self-reported a desire to lose (or maintain) weight during menopause; and (3) identifying as Black or White race. An equal distribution of Black and White women stratified by socioeconomic status (SES) was targeted to ensure different racial and household backgrounds were represented. Both Black and White women were enrolled based on previously observed differences in their weight trajectory [5] and menopausal symptoms [6,13,19-22] across menopause. Furthermore, women of different SES were enrolled to capture menopause experiences that may vary by different social determinants of health (e.g., household income, employment and housing status, food insecurity, etc.) [20,23]. Low SES was defined by a poverty-to-income ratio (PIR) <2.25, and high SES was defined by a PIR ≥2.25 based on previous studies [24,25]. The study was approved by the PBRC Institutional Review Board. Women provided their informed consent (written or verbal) prior to commencing the focus group. The present analysis details the results from the Black women who participated (n = 27). Results from our White cohort of women will be published in a forthcoming paper.

2.2. Recruitment

Women were recruited via online advertisements and health promotion events to participate in focus groups held either in-person or virtually. A saturation sampling strategy was used for recruitment, whereby we continued to recruit until themes were repeated across multiple groups. After reaching an a priori amount of six focus groups for Black women (n = 27; range of 4–6 women per focus group), it was determined that saturation was reached, and no additional women were recruited. Due to safety concerns surrounding the SARS-CoV-2 virus (i.e., COVID-19) from March 2020 to March 2021, all six focus groups were held virtually using a videoconferencing platform.

2.3. Data collection

Two focus group moderators [authors JSR (lead) and JCH (assistant)] trained in qualitative methods conducted the focus groups in a private setting. As part of an online web screening process, women self-reported their age, race, ethnicity, height, weight, annual household income, and household size. Body mass index (BMI) was calculated (kg/m²). Using national standards for poverty level published in 2018 by the United States Census Bureau [26], PIR was calculated by dividing the annual household income by a defined weighted average threshold. Following verbal consent, women participating in the focus groups were asked the same questions with flexibility following each question so that moderators could probe and seek further clarification. The focus group script was structured to help the investigators tailor a lifestyle program for weight management during menopause, thus included questions about women’s experiences with menopause; past experiences with diet, exercise, and weight management; as well as specific components of a lifestyle program for weight management (Table 1). Focus group questions were informed by a prior investigation, which explored women’s interest in a lifestyle program containing weight management strategies during menopause [11].

Table 1.

Focus group script on menopause experiences and preferences for a lifestyle program for weight management during menopause.

Component	Questions
1. Lifestyle Program Components	What components of a lifestyle program during menopause are most important to you? (e.g., diet, exercise, or menopause education)
2. Duration & Time Commitment	How long would a structured lifestyle program have to last to affect change and teach you how to be successful on your own? (e.g., weeks, months, years) How many times (i.e., days per week) would you be able to participate in this program? How much time each day (i.e., minutes, hours) would you be willing to participate in this program? Is there an ideal time of day?
3. Motivation	What would help get (and keep) you motivated to participate in (and continue) a lifestyle program? (e.g., group sessions, individual coaching, incentives, or accountability partner) What components of a lifestyle program would need to be done with other women? What components of a lifestyle program would need to be in-person or virtually?
4. Diet Interests	What are your thoughts on diets? What types of diets have you tried before that you want to do again? (e.g., ketogenic, intermittent fasting, etc.) Are there any diets you do not want to try?
5. Exercise Interests	What types of exercises do you like to do? What exercises would you like to see be included in a lifestyle program? What exercises helped you with your weight or lower your blood sugar?
6. Menopause Education Topics	What menopause topics would you like to see discussed in a lifestyle program? (e.g., symptom management, mental health, sleep health, etc.) How would you like to receive this menopause information? (e.g., group setting, individually, written/electronic form, or a phone app)
7. Location	Are you comfortable with coming to Pennington Biomedical for this lifestyle program? Would you prefer the program take place at a local gym or community center? (e.g., YMCA)
8. Barriers	Are there any barriers you experience to being part of a lifestyle program? (e.g., work, family, injury) Are there any barriers that you experience when trying to maintain regular exercise or a healthy diet?
9. Other Comments	Any other comments that we did not cover within the interview?

Each focus group lasted approximately 90 min (range: 60–120 min). One focus group was not recorded due to technical error and handwritten notes from this focus group were transcribed and used for a limited part of analysis. Each woman received $25 for participating and was referred to free online resources containing relevant menopause-specific health information following participation.

2.4. Data analysis

Interviews were transcribed from the audio files and were checked for accuracy after transcription. Two authors (CLK [collaborator] and KLM [principal investigator]) trained in qualitative analysis and first reviewed transcripts independently to create an initial codebook using the focus group questions as a guide. This codebook was then refined through a second review of transcripts to create a final codebook. To determine themes, selected codes were read independently by the authors (CLK and KLM) using a grounded theory approach in thematic analysis [27,28]. The research team allowed themes to emerge from the women’s responses to open-ended questions, thereby “grounding” the determined themes in the beliefs and explanations of the women [29]. It was determined a priori that codes must be mentioned by at least two across women within one focus group, and repeated in another focus group, to ensure translation across women. Saturation was reached when themes repeated across multiple focus groups. The two authors then coded one transcript independently, compared coding for discrepancies, and then coded the remaining transcripts independently. After the transcripts were coded, any disagreements were discussed until consensus was reached.

Next, the coded interviews were analyzed for themes by the research team (CLK and KLM). The finalized themes were informed by the aims of the study and reviewed one final time. It was determined that an emergent theme could be considered when at least 20% of focus group women provided relevant comments, including women across multiple focus groups [30]. Any coding disagreements were discussed and incorporated into themes and results. These analysis steps have been previously used by other focus group investigations of barriers and facilitators to behavior change [31]. The final themes were compared to the handwritten notes of the focus group that was not recorded to ensure these themes were repeated. All data analysis occurred using NVivo software (Version 12, QSR, Victoria, Australia).

3. Results

Twenty-seven perimenopausal and postmenopausal Black women participated in focus groups (Table 2). On average, women were 54±4 years of age, had a BMI of 35.1 ± 9.0 kg/m², and a majority (89%) had overweight or obesity. By design, there was an even split between those of low SES (n = 14) and high SES (n = 13). Emergent themes were similar across the low and high SES groups and as such, the responses from all women were evaluated together.

Table 2.

Characteristics of Black women participating in focus groups (n = 27)^a.

	All Black Women	Low SES	High SES
Sample size, n	27	14	13
Number of focus groups, n	6	3	3
Age, years	54 (4)	54 (4)	54 (3)
BMI, kg/m2	35.1 (9.0)	36.8 (10.7)	33.4 (6.7)
BMI categories, n (%)
Normal (18.5 - 24.9 kg/m2)	3 (11.1%)	2 (14.3%)	1 (7.7%)
Overweight (25.0 - 29.9 kg/m2)	5 (18.5%)	3 (21.4%)	2 (15.4%)
Obese (30.0+ kg/m2)	19 (70.4%)	9 (64.3%)	10 (76.9%)
PIR Ratio	2.53 (1.56)	1.27 (0.55)	3.88 (1.06)
[min, max]	[0.61, 6.30]	[0.61, 1.90]	[2.50, 6.30]

Abbreviations: BMI, body mass index; PIR, poverty-to-income ratio.

^aData are presented as mean (SD), unless otherwise noted as a sample size (n) or percentage (%). The range [min, max] for PIR are provided.

Four main themes emerged: (1) past experiences; (2) menopause experiences; (3) lifestyle program components; and (4) lifestyle program development and considerations. The major themes are presented in Table 3 with illustrative quotes (identified by focus group and participant number within that group). Our findings are presented as a graphical illustration in Fig. 1.

Table 3.

Thematic findings and quotes related to menopause experiences and a lifestyle program for weight management among Black women.

Theme	Subthemes:	Quotes representative of subtheme:
1. Past Experiences	Menopause is one of the most impactful events on weight, including gaining weight and difficulty losing weight	“It drives me crazy that I can’t get rid of this weight that I’ve gained.” (Group 1, Person 3) “I’m also concerned I guess about the weight at this time, the weight gain and just having a difficult time, you know, losing it.” (Group 3, Person 2) “A couple of years ago I did lose 50 pounds which seemed relatively easier than I’ve been trying to do over the last 6 months or so. And this weight settling in the mid-area and I didn’t have weight that settled there before so I figured that’s got to be a side effect of menopause.” (Group 3, Person 3)
	There was a spectrum of diet experiences, from none to many, but all women were open to new diet ideas	“I would be open to try anything because I’ve never had to diet, never had to hold myself accountable to sticking to one. I have a child who’s a fitness trainer, he’s tried to get me to do things like this, I look at him like he’s crazy, (laughs) so you know. I’d be willing to try just to see.” (Group 1, Person 3) “Well, to be honest, I haven’t tried any of those diets. I think my weight gain has been within the last year, so I just really hadn’t had to diet at all. I tried the cabbage soup once and I lost a few pounds, but I figured that was just more water than anything so I haven’t tried anything. So I really don’t know what would work.” (Group 3, Person 1) “I’m open to trying anything. You know, I’m open to it, if it’s something that I can enjoy, then I’m willing to try it.” (Group 4, Person 2)
	Successful exercise and diet experiences were social and enjoyable	“I have gone to the Women’s Fitness Center before and I like the environment where it’s mostly a lot of women in there to feel a lot more comfortable. But yes, in a situation like that with other women working out and different things, it does make you more accountable. You also kind of look forward to going to workout.” (Group 1, Person 1) “But when I was younger and my friends and I would workout you know it was fun when you went with a friend. So I guess a partner is better than a group, I don’t know.” (Group 2, Person 2) “Right, that’s what me and my co-worker did and we did wonderful. Not anything hard competitive, but just we’d weigh in once a week and report our results, kind of like Weight Watchers. You know, where you got to share your success. And you got to cheer each other when you weren’t so successful.” (Group 3, Person 3)
2. Menopause Experiences	Women felt unprepared and overwhelmed at times by changes from menopause	“So it’s a number of things that are happening and I don’t have the answers, I don’t know what to do. Because it’s bothersome.” (Group 1, Person 4) “I [have] so many symptoms, and I don’t understand all of it you know. I just would like to learn more about it.” (Group 5, Person 3)
	When seeking help from medical professionals for menopause, women were not given adequate attention or the information they wanted	“…I asked my doctor and the first thing she said is there’s not a whole lot you can do during menopause. That just threw me off…” (Group 1, Person 2) “I don’t know if this would matter or not but this discussion this evening is with strictly African American women and I know we’re often overlooked just for regular medical things, and so even for things related to what we’re discussing this evening you’ve heard our honest opinions on what we experience individually. You know, I don’t know if that would matter or not, that those things are real things because we’re always looked at as that’s not a real thing. Or we’re lying about what we say. And so I don’t know if it matters that we’re making, that I’m making, that distinction that we are all African American women and all we are saying is true things we experience. It can be a racial issue but also at the same time it can be just a woman issue so thank you so much we appreciate it.” (Group 2, Person 1) “I was told with the hot flashes and stuff that they could give you something that will help that. But my doctor wouldn’t. They said they didn’t believe in that, that they didn’t think it made a difference. So they wouldn’t put me on it. So I was like, oh well, ok. So I just, I would like to know if really that would help or not help because I mean if it will help I’ll be willing to go to somebody else. (laughs) To try to get some help.” (Group 5, Person 3)
	Women had less energy and motivation to change diet and exercise during and after the menopause transition	“Right now, my only barrier outside of motivation would be depending on my emotional state or my psyche at the time. (Focus Group #1, Person #3) “I’ve been so in a rut, I don’t know, it’s part depression, part a lot going on, I’m in graduate school, I just got a lot, and stress at work,…my motivation just fizzled out and I’ve been trying—every week I tell myself I’m going to go walk in the park. I tell myself that. And then I go buy some chips and I start eating chips and I was like ok, next week. So it’s always next time, it’s always I’m going to do it, but it’s next week. And so I just need to put it in myself that I need to just get it going myself.” (Group 4, Person 2)
3. Lifestyle Program Components	Women were interested in an intensive lifestyle program that can be transitioned to their daily life	“Three months would give me a good foundation and from there you could give us the tools we need to continue on.” (Group 1, Person 3) “Let’s say everything that we plan to do works. How do we sustain this? Because I mean I’ve lost weight before and it just comes on back. And I know I mess up my habits but how can I sustain this as I move into my 60s?” (Group 3, Person 5) “I would think 6 months, like the first lady said, because I’ve, on occasion I’ve done like a month or two then I just go back to my old routine. I think 6 months is probably better.” (Group 4, Person 1) “I am so jealous. All of these ladies got their stuff together. Honey I know me, I need something that would be, I gotta be on it, so I say for me 6 months to a year. So I can get it down. Because I know me.” (Group 4, Person 4)
	Women wanted flexibility in the sessions offered	“So I’m definitely always looking forward to something and I’m sure others do also that’s in the afternoon you know 5/6:00, you know after traffic, something like that. …but I would dedicate 3 days out of the week but for me the biggest issue is the time. The time that it starts.” (Group 1, Person 1) “I’d love to be able to come. Again, my time, my distance commitment is still there, but I would be comfortable with video maybe coming here or there. It would depend on what the schedule would be.” (Group 3, Person 3) “It’s not like I couldn’t make the trip there, it’s just when. You know what I mean, I have to put all the things into consideration.” (Group 4, Person 2)
	Virtual platforms could be used to deliver information, though some women still preferred other methods of delivery	“I don’t really have a problem receiving [menopause education] in an app, something in written documentation, or some type of a newsletter to read or something but I do kind of feel like sometimes I’d like to pass questions by someone so having a follow up with someone that maybe I’ve gotten the information from just to be able to—similar to a doctor you know, I can read the information that’s given to me or for meds or anything that a doctor may give but I feel comfortable also being able to ask follow up questions. To make sure that I’m addressing something in the proper way so that’s usually also helpful to me.” (Group 1, Person 1) “I think maybe a support group, an app where you have women talking about their experiences.” (Group 1, Person 5) “[Receiving diet or menopause education through video] would be fine. But for the exercising I need to be on site. I’m not going to be trusted.” (Group 3, Person 4) “Or it could be by email or you video chat or it really doesn’t matter, but 1-on-1 or even in a group setting you get to ask questions because everybody is different and nobody may be experiencing the same things. That way we could get input.” (Group 4, Person 3)
4. Lifestyle Program Development & Considerations	Existing health problems may limit women’s participation in a lifestyle program	“[I am interested in] anything that would allow me to still preserve my knees, because I do have arthritis in one of my knees. So that is something that I take into consideration also.” (Group 1, Person 1) “I do have a little problem with my lower back. You know, I can do all the exercises but sometimes my back will start hurting, I just won’t do as many.” (Group 2, Person 3) “I’m kind of limited with the exercise because I’ve had 2 back surgeries, so there are a lot of exercises that I can’t do…” (Group 4, Person 1)
	Women were interested in a diet that was flexible with their lifestyle	“Right, right, right. And that’s pretty much how we do everything in Louisiana, everything is surrounding food. I love bread. So [keto] is not going to work for me…I will feel like I fail before I even start because I know I may want a ham sandwich or something or I might want a roll.” (Group 1, Person 1) “I’m not on anybody’s diet. I’m trying to learn how to get on a diet that works for me.” (Group 5, Person 4)
	Younger family members were seen as a positive influence on women’s health behaviors	“I have a child who’s a fitness trainer. He’s tried to get me to do things like this, I look at him like he’s crazy, (laughs) so you know. I’d be willing to try just to see.” (Group 1, Person 3) “My sister and I used to go to the gym, we used to do the treadmill, and the elliptical.” (Group 5, Person 5)
	Women were open to many different types of exercise	“I really can, I mean, I’m ok with treadmills, I’m ok with circuit training, I’m ok with doing weights, I just need to get back into it. The only thing I probably hate to do is a burpee. That’s the only thing I hate to do…” (Group 4, Person 2) “So I would like to branch out and do more exercises that are geared at increasing more muscle, toning up, meaning I would like to eventually get into the gym and be able to utilize the equipment to get the results that I want.” (Group 5, Person 1)
	Women were interested in learning more about menopause	“I guess I know I’m going through menopause, but I don’t exactly know where I’m at, what phase of menopause I’m in. So, I guess maybe what to expect, whether it’s premenopause or post or, I don’t know the different types but maybe like what we could expect at these different levels.” (Group 4, Person 3) “I would like anything that I need because it’s a lot of stuff I’m not aware of, you know just because I’m 56 doesn’t mean I know it all. I just don’t.” (Group 4, Person 4) “I got so many symptoms, and I don’t understand all of it you know. I just would like to learn more about it.” (Group 5, Person 3)
	Social support and accountability were desirable aspects of an ideal lifestyle program	“Barriers for me would include just not staying focused. I might come up with something to do, I might get started but just not sticking with it, that’s why I’m thinking being accountable to someone else might keep me motivated and stick with it.” (Group 3, Person 2) “I was actually going to shout out an accountability partner, that is the best way I lost weight before, just motivating each other and a little tiny competition. You know, not with any incentives, just kind of feeding each other and keeping our spirits up.” (Group 3, Person 3) “[I need] a small group [to be successful]. An accountability group. Don’t let me get away with anything. (Group 3, Person 4) “Yes, I can. I just like being around people. And would do something, because I’m a little lonely old lady. So uh that’s what I would like.” (Group 4, Person 4)
	Women were motivated by seeing results and by other women, namely changes in weight	“I think it’s more of a group effort if you know you have like-minded people that are interested in what you’re interested in and they have the same goals that you have then that helps for me at least.” (Group 2, Person 1) “If I see the scale go down 1 pound, I’m happy. Or if I can tell that my clothes fit a little differently, I’m happy.” (Group 2, Person 2) “I was going to say I could do it myself, especially if there is structure; however, I think the better thing for me would be something, some sort of partnership or some sort of check in so that I can kind of have accountability to someone other than me. And seeing other people’s progress would probably motivate me to get myself going too I think.” (Group 4, Person 5)

Fig. 1.

Four Emergent Themes Among Black Women.

3.1. Past experiences

Menopause is one of the most impactful events on weight, including gaining weight and difficulty losing weight.

Most women described menopause as a significant disruption to their daily lives and their weight. Many described having trouble losing weight or gaining excess weight during the menopause transition and into the postmenopausal years. Some women experienced substantial weight gain of ~7 to 9 kg (i.e., 15–20 pounds) over the last three years and an inability to lose this weight.

There was a spectrum of diet experiences, from none to many, but all women were open to new diet ideas.

There were a variety of answers related to past experiences with diet, as well as the types of diets they have tried or would like to try. While some women had never experimented with different diets, others reported trying numerous types of diets in the past (e.g., ketogenic, Weight Watchers (or recently named WW), and intermittent fasting). Overall, all women were interested in trying new diets.

Successful exercise and diet experiences were social and enjoyable.

Most women enjoyed the social aspects of dieting and exercising. These social aspects included doing the activity with a partner or having it as part of a friendly competition. Examples included dancing, participating in activities with a friend or co-worker, or attending an all-women’s fitness center. Women reflected on when they were younger and more recent experiences with trying new exercises and diets.

Overall, women mentioned that menopause had a large influence on their weight and felt that menopausal weight gain was incomparable to any of their past experiences with weight. There was a variety of answers about previous diet and exercise experiences, though all were interested in trying new diets as part of a lifestyle program. Most women noted that their most enjoyable diet and exercise experiences were those including other people.

3.2. Menopause experiences

Women felt unprepared and overwhelmed at times by changes from menopause.

Most women stated they did not anticipate menopausal symptoms or that they had limited information on how to mitigate symptoms. The overwhelming symptom that women experienced was hot flashes, which frequently interrupted their daily and nightly routines. Other symptoms, including weight gain and a slowing metabolism, sleep disturbances, memory problems, mood shifts, and vaginal dryness, were also disruptive and not anticipated as a part of menopause. Women did not feel these physical and emotional changes were ever discussed or mentioned in informal conversations with others. As one woman expressed, “It just seems like people are talking about [menopause], but nobody has a solution (laughs). (Group 1, Person 4)”

When seeking help from medical professionals for menopause, women were not given adequate attention or the information they wanted. Women expressed that the main medical professional they spoke with about these concerns was their obstetrician-gynecologist (OB-GYN). Many women felt their OB-GYN did not provide them with guidance (i.e., verbal or handouts) to navigate the menopause transition. Women often stated that their OB-GYN did not believe their symptoms were as severe as described, or their OB-GYN did not appear to know how to adequately support them. Importantly, the topic of racial disparities in healthcare practice was discussed without prompting. Women stated that they believed their health concerns were overlooked and not believed by healthcare providers (e.g., OB-GYN or other) because of their race.

Women had less energy and motivation to change diet and exercise during and after the menopause transition.

Women expressed that they experienced a lack of energy and overall motivation to change their lifestyle behaviors due to their current emotional state (e.g., depression), busy schedule, and stress level. These concerns were related to their menopause transition rather than the COVID-19 pandemic. Having an established schedule and plan to diet and exercise alongside other women was a favored technique that women felt would combat this lack of motivation.

Overall, women did not feel prepared for menopause. Women stated that they did seek out information and advice from other women, family members, and their OB-GYN or medical professionals about how to navigate menopause. However, women expressed the sentiment that every individual woman had different menopause experiences (e.g., medical histories and symptoms) and a one-size-fits-all approach to navigating menopause did not exist. When speaking to medical professionals, women did not feel that they were provided with the information or knowledge they were hoping to receive.

3.3. Lifestyle program components

Women were interested in an intensive lifestyle program that can be transitioned to their daily life.

Most women were interested in a lifestyle program that lasted 3–6 months. Women stated that this amount of time would allow them to create a new routine and consistent change as part of their daily routines. Some women came up with this length based on their past experiences with diet or exercise.

Women wanted flexibility in the sessions offered.

Women had differing day-to-day work schedules, traffic and commute times, and distance they would need to travel to participate in any lifestyle program. Women expressed that flexibility in the time of day (morning vs. evening) and days of the week (weekday vs. weekend) was important. These concerns were similar between women of low and high SES.

Virtual platforms could be used to deliver information, though some women still preferred other methods of delivery.

Women were comfortable receiving some of the lifestyle program sessions on a virtual platform (e.g., Zoom meeting, phone app, and video), particularly menopause education and dietary guidance. Regardless of platform, women wanted the ability to ask questions of the session moderator, as well as hear what other women were experiencing during menopause and discuss among themselves. Women also wanted to exercise with other women for social support and accountability and did not want to exercise exclusively on their own.

In summary, women wanted to participate in a lifestyle program that was long enough in duration (3–6 months) and that would give them the proper tools and resources they needed to sustain these behavioral modifications after the program ended. Flexibility in the sessions (e.g., time of day, day of the week, etc.) was also important. While women were comfortable with using virtual platforms to receive menopause education and dietary guidance, women expressed wanting to exercise in-person with other women to keep them accountable and motivated.

3.4. Lifestyle program development and considerations

Existing health problems may limit women’s participation in a lifestyle program.

When asked about prior exercise experiences or exercises women would be interested in, women stated that existing health problems from menopause or other comorbidities would pose various physical limitations when exercising. Examples of these limitations included back and knee pain, prior surgeries, and obesity or diabetes-related challenges.

Women were interested in a diet that was flexible with their lifestyle.

Regarding previous dieting experiences, women did not want a diet that was too restrictive and wanted flexibility in their diet options. One example of diet flexibility that fit their lifestyle was the format of Weight Watchers (or WW). One woman said, “About 10 years ago or so I tried Weight Watchers and I found that I actually enjoyed Weight Watchers and I think it was because it was unrestricted in the sense that you could eat whatever you wanted to eat but you could only eat, you had to stay within a certain amount of points. (Group 1, Person 1)” Another woman said, “Like with Weight Watchers, it helped going to the meetings and everything. Getting new recipes and getting input from other people. To see what worked for them. (Group 4, Person 3)” Women described an interest in this style of dieting because it encouraged them to eat healthy, while allowing them to also enjoy large family meals and other events where a healthy option may not be available for that setting (e.g., backyard barbeques, family get-togethers, etc.).

Younger family members were seen as a positive influence on women’s health behaviors.

Several women expressed that their children or family members (e.g., sister) had a positive influence on their behaviors. Women mentioned that their children, some of which were health professionals themselves, often encouraged them to eat healthy and exercise. Women also mentioned positive experiences with sisters or other health-conscious family members, namely those that were younger than them (rather than parents or their partner).

Women were open to many different types of exercise.

Women mentioned they were interested in trying different exercises, including both aerobic and strength training options, though most women noted they currently performed more aerobic activity (e.g., walking, running, and water aerobics). While some women already incorporated strength training into their daily lives, other women had not. Nonetheless, all women were interested in adding in exercises that strengthened their core, increased muscle tone (e.g., weight-machines), and increased flexibility (e.g., yoga). Similar contextual considerations in other previous themes, including social support and physical limitations, were mentioned when considering new exercises.

Women were interested in learning more about menopause.

Many women stated that they did not know what to expect of menopause and wanted more information on menopause to feel more prepared. While some women wanted specific information on how to manage their hot flashes or sleep disturbances, most women wanted to receive any (or all) menopause information that was possible. Women mentioned they were interested in knowing what menopausal phase they are in (e.g., perimenopausal vs. postmenopausal), what they can expect as they progress through menopause, and how they can best prepare for each part of the menopause transition.

Social support and accountability were desirable aspects of an ideal lifestyle program.

Social support and accountability were mentioned as important components for a lifestyle program to be successful. Women expressed that participating in a lifestyle program alongside other women like them would help them stay focused and allow them to motivate each other, while also building camaraderie.

Women were motivated by seeing results and by other women, namely changes in weight.

Women mentioned they were primarily motivated by seeing results, including weight loss and better sleep. They were also motivated by seeing other women’s progress in a program and succeeding in the program together. Social support and seeing results were mentioned together often and tended to have a positive influence on one another.

4. Discussion

The purpose of this qualitative research study was to explore personal experiences and perspectives of menopause among Black women, interest in a lifestyle program for weight management, as well as define enablers and barriers to a healthy lifestyle among women affected by menopause. Most women stated that menopause was a significant event in their life, which impacted their physical and mental health. Women received little support during menopause and welcomed a lifestyle program for weight management (i.e., weight loss and weight maintenance) that can be transitioned to their daily life. While their existing commitment and current health status may hinder participation, women felt a supportive and flexible lifestyle program may help them achieve their goals for a healthier life during menopause and beyond.

Weight gain and difficulty losing weight were major concerns for women. These findings align with previous longitudinal studies that observed weight gain and increased abdominal adiposity across the menopause transition and into the postmenopausal years [2-5,12]. These changes in body composition are partially caused by reductions in energy expenditure [2], which may be explained by reduced physical activity during the peri menopausal years [17,32]. Most Black women in the present study referred to past exercise experiences in their younger years, rather than current physical activity. Decreases in physical activity may be expected as increased daily life demands (e.g., job-related responsibilities, caregiving for grandchildren and/or parents, etc.) during the menopausal years may leave women with less time for regular physical activity [33]. Furthermore, women within this study stated that enjoyable experiences with diet and exercise were often social, and that social support led to increased accountability in maintaining their existing dietary and exercise regimens. This finding is important, as one study within the rural Deep South found that Black women received little social support from family and friends surrounding healthy eating and exercise [34]. Online platforms (e.g., private Facebook group) may also be appropriate to foster social support and maintain motivation.

When asked about their menopausal experiences, many women mentioned that hot flashes and night sweats, sleep disturbances, memory problems, and mood swings, interrupted their daily lives. These menopausal symptoms may further exacerbate weight and abdominal fat gain by increasing energy intake [7,35,36]. Supportive data from the Study of Women’s Health Across the Nation (SWAN) indicate that Black women have a higher prevalence and longer duration of vasomotor symptoms [6,16], as well as experience shorter sleep duration and poorer sleep quality [6,16] compared to White women. Women mentioned that these menopausal symptoms persisted and that they were unable to find long-term remedies. Furthermore, women mentioned a lack of motivation or energy to make consistent lifestyle changes during this time, which may be due, in part, to these symptoms. As a result, treatment of bothersome menopausal symptoms should be a part of any comprehensive lifestyle program during menopause.

None of the women in any focus group reported a positive experience when talking to medical professionals about menopause. Racial disparities in healthcare practice are known to exist and structural racism has been cited as a reason that Black women receive less validation (e.g., feelings of not being listened to or believed [37]), which may deter Black women from seeking medical guidance for their menopause altogether. Black women’s descriptions of their symptoms may differ from ‘textbook’ presentations which are based on the experiences of White women [38]. While it is also possible that few Black women may have discussed their menopausal symptoms with a medical professional, it is concerning that no woman mentioned a positive encounter with a medical professional. Therefore, more attention and training are needed in this area to engage and validate Black women who are having a symptomatic menopause. The themes in the current study are unfortunately common ones, including anticipation that complaints will not be believed, symptom severity will be minimized, and appropriate treatments will simply not be offered [39]. Utilizing supplemental sources that are trusted and accessible (e.g., health educator, community centers, etc.) may be appropriate for future menopause programs among Black women if helpful menopause treatment plans are lacking from medical professionals.

Women were interested in learning about menopause and its related symptoms alongside other women. Women expressed comfort and feelings of support when discussing their menopause experiences with other women and were receptive to trying new diets and exercises. While women wanted to perform in-person exercise alongside other women approximately 2 to 3 times per week, women were comfortable receiving menopause education and dietary guidance on a virtual platform as long as they can ask questions and discuss their experiences with one another. It is unclear if these preferences in virtual platforms are due to the increase in technology use with the COVID-19 pandemic [40]. Nonetheless, changes in infrastructure and engagement platforms could provide an opportunity to bring evidenced-based menopause education to women no matter where they live.

Women also wanted flexibility in their diet and exercise regimen. Specific to dietary intake, the flexible format of Weight Watchers was considered a positive of any forthcoming lifestyle program [41]. Regardless of program format, women were motivated by seeing changes and results in the form of weight loss, symptom relief, or improved sleep. Though meaningful weight loss may take several months to achieve, opportunities to focus on short-term changes, such as improvements in sleep, may help women stay motivated. Finally, although the ability to participate in such a lifestyle program may be different among low and high SES communities, we did not observe a difference in our cohort of women. The lack of difference among women of different SES may speak to systemic problems for Black women seeking help for menopause.

There were strengths and limitations of our study. Strengths include the enrollment of Black women and inclusion of women from both low and high SES groups. Recruiting racially diverse populations in studies is often challenging. The inclusion of low and high SES also allows us to evaluate facilitators and barriers from women of different financial backgrounds. Another strength of our study is that a trained team of researchers performed all qualitative analysis, including independent review and creation of codes and themes. A limitation of this study is that our findings may not be generalizable to all women. Even though enrolled was not restricted to a geographic location, all participating women lived exclusively in the Southeastern United States. Another limitation is that the overall study was confined to women who were White or Black. Exploration of barriers within other ethnicities is warranted as all women are affected by menopause and may have differing experiences. Additionally, all focus group moderators were White, which may contribute to possible censored responses. Our study was designed to separate focus groups by race to eliminate feelings of discomfort when discussing their menopause. Finally, height and weight were self-reported, and we did not measure dietary intake or habitual physical activity. Opportunities to examine objectively measured anthropometry, dietary intake, and physical activity with barriers and facilitators may provide additional context to current lifestyle behaviors.

Opportunities for future intervention and behavioral change engagement across menopause are evident. First, menopause-specific treatment plans utilized by medical professionals may need to be more comprehensive (e.g., more educational information provided to women) and individualized. Menopause education resources from the American College of Obstetricians and Gynecologists (ACOG) or referencing the 2020–2025 Dietary Guidelines for Americans (specific to older adults) may be appropriate, and recommended for medical providers to use in their practice [42,43]. Addressing knowledge gaps in the proper care of menopausal women that exist among medical professionals is an important first step [44]. Second, exploring lifestyle preferences and menopause experiences among women of other races and ethnicities (e.g., White, Asian, etc.) can help further tailor lifestyle interventions and programs to enhance success. Third, working alongside professionals beyond the medical community (e.g., community centers and other trusted partner sites) to provide menopause education to women before menopause may help promote women’s short- and long-term health. Incorporating the key constructs of social cognitive theory may help inform the theoretical framework of future lifestyle programs for menopausal women looking to improve their health through behavioral change.

Despite personal experiences and the many barriers to obtaining menopause-specific information, Black women were interested in receiving this information and improving their overall health. Creating an intensive lifestyle program with behavioral change components (e.g., diet, exercise, menopause education) that is both flexible and feasible may increase adherence and enjoyment among women within such a program. These program components may help Black women sustain and translate these changes to their everyday lives beyond the program itself, leading to reduced weight gain and promoting healthy weight management as well as symptom relief for long-term health benefit.