Charting the Path to Health in Midlife and Beyond: The Biology and Practice of Wellness

Abstract

Charting the Path to Health in Midlife and Beyond: The Biology and Practice of Wellness was a Translational Science Symposium held on Tuesday, September 21, 2021. Foundational psychosocial and behavioral approaches to promote healthy aging and strategies to disseminate this information were discussed. The following synopsis documents the conversation, describes the state of the science, and outlines a path forward for clinical practice. Wellness, in its broadest sense, prioritizes an orientation towards health and an embrace of behaviors that will promote it. It involves a journey to improve and maintain physical and mental health and overall well-being to fully engage and live one’s best life. It is more about recognizing and optimizing what one can do than what one cannot do and emphasizes the individual’s agency over changing what they are able to change. Wellness is therefore not a passive state but rather an active goal to be sought continually. When viewed in this fashion, wellness is accessible to all. The conference addressed multiple aspects of wellness and embraced this philosophy throughout.

The Tao of Wellness.

A Tao may describe a path, a holistic belief, or a way of being. All three definitions can describe wellness. Much of medicine operates on a disease-based model in which ‘wellness’ is described as the absence of disease. The scientific models we use focus on the ‘what’. However, if we are to address wellness as a concept, we must also address ‘why’. For example, patients with obesity know what methods to use to lose weight but without identifying and addressing the psychological and even spiritual barriers to behavior changes, sustained weight loss will be unsuccessful. The transformational process of creating and aligning a new reduced body weight, a positive and emotionally resilient mindset and one’s bigger purpose/spirit with a new way of living and being results in sustained weight loss and life satisfaction. Domains of wellness typically consider physical—which we dwell on in the medical model of illness—emotional, mental/intellectual, and spiritual. However, occupational, social, financial and environmental domains also need to be considered in order to take into account health wellness in its broadest sense¹.

Biomarking the Tao.

Are there ways to measure wellness? A good place to start is with markers that predict a long and healthy life. We have many measurements in daily medical use that provide indicators of health: body mass index, blood pressure, heart rate, cholesterol levels², and more. Since cardiometabolic health is a powerful predictor of longevity, among the most useful measures are hemoglobinA1c and low-density lipoprotein cholesterol. Markers of well-being also include aspects of physiology that may be sensitive to physiological processes, such as heart rate variability (HRV). HRV is a measure that indicates parasympathetic nervous system influence over the heart and can be increased with exercise and meditation³. HRV is now a component of many wearable devices, among them the Apple Watch, and allows users to monitor this aspect of their physiology. Other markers, such as sex hormone binding globulin (SHBG) are not in use in clinical practice but may be helpful in the future⁴. Healthy aging is a matter of resilience, and measurement of markers of ‘allostatic load’ can also help an individual estimate their success in coping with the stresses of life⁵. Markers of allostatic load are described in Table 1.

Table 1.

Markers of allostatic load

Allostasis Cut Points
System	Marker	High Risk	Moderate Risk	Low Risk
CV	SBP	≥150 mmHg	120-149	<120
	DBP	≥90 mmHg	80-89	<80
	TC	≥240 mg/dL	200-239	<200
	HDLC	<40 mg/dL	40-59	≥60
	TC/HDLC	≥6	6-<6	<5
Metabolic	HgbA1c	≥6.5%	5.7-<6.5	<5.7
	WHR	≥0.85	>0.8-<0.85	≤0.8
	BMI	≥30 kg/m2	25-<30	18-<25
	Albumin	<3%	3-<3.8	≥3.8
	Cr Clearance	<30 mL/min	30-<60	≥60
Inflammatory	CRP	>3 mg/L	1-3	<1

CV=cardiovascular; SBP=systolic blood pressure; DBP=diastolic blood pressure; TC=total cholesterol; HDLC=high-density lipoprotein; HgbA1cc=hemoglobinA1c; WHR=waist-hip ratio; BMI=body mass index; Cr clearance=creatinine clearance; CRP=C-reactive protein

The Role of Social Connections.

Social connections are essential for health and well-being and a key component of wellness. Social connection is a strong protective factor for chronic disease and mortality and an important dimension of wellness that is often left out of a medical model that focuses on disease. Loneliness increases earlier death by 26%, social isolation increases earlier death by 29%, and living alone increases earlier death by 32%⁶, numbers that are on a par with and even exceed the effect of typical risk factors for disease (Figure 1)⁷. Loneliness is estimated to affect 3.4 million people worldwide. Improved social connection can lead to an astonishing 50% increase in survival⁸! The National Academy of Science, Engineering and Medicine’s recent report on Social Isolation and Loneliness in Older Adults—recommended a strategy called EAR: Educate, Assess and Respond⁹.

Figure 1.

Comparison of odds of decreased mortality across several conditions associated with mortality (effect size of zero = no effect). Social indicators of health are shown in orange bars and other leading health indicators in blue. From reference 8.

Health is Where the Heart is.

Cardiovascular (CV) health is a major underpinning of wellness. Whether one is working, exercising, relaxing, or even just sleeping, their heart keeps on beating. This amazing organ works non-stop to keep the rest of the human body regulated and well-maintained. As such, it is critical to preserve excellent heart health for continued physical health and overall wellbeing. The American Heart Association’s Life's Simple 7 (Table 2) lists seven modifiable risk factors that can be managed behaviorally to achieve ideal heart health¹⁰. It is especially important for midlife women to address Life’s Simple 7 because the process of menopause leads to multiple adverse changes in cholesterol, body fat composition, weight, blood pressure, glucose, and insulin, all markers of the metabolic syndrome. Additionally, increases in arterial stiffness and carotid artery thickness and narrowing of the adventitial diameter accompany the menopausal transition¹¹. Therefore, assessing and addressing cardiovascular disease (CVD) risk at midlife can have a major impact on a woman’s physical wellness and future health. Overall population adherence to Life’s Simple 7 is far from optimal. Clinicians should closely monitor women's heart health during midlife and promote lifestyle modifications as a vital approach to help counteract the consequences of the menopause transition, which would ensure better future heart health and physical wellness.

Table 2.

American Heart Association’s Life’s Simple 7

Stop smoking

Eat better

Get active

Lose weight

Manage blood pressure

Control cholesterol

Reduce blood sugar

Lifestyle—The Silver Bullet.

If the term silver bullet is a metaphor for a simple, seemingly magical, solution to a difficult problem, then lifestyle may indeed merit that moniker when targeting health and longevity. As ‘portal to the second half of life,’ the menopause transition provides a critical window to adopt a proactive approach to future wellbeing¹². Preventive measures—particularly lifestyle—promote cardiovascular, cognitive, bone and emotional health, while combatting obesity and associated disorders, including cancers. Lifestyle optimization is endorsed by the National Institute on Aging⁹ and the National Academy of Medicine¹³ to promote healthy longevity.

Two decades ago, The Women’s Healthy Lifestyle Project confirmed the benefits of lifestyle—primarily increased exercise and limitation of dietary fat—initiated in women before transitioning to menopause. Women can ‘pay it forward’ and stave off weight gain, waist gain, deterioration of lipids, and progression of subclinical atherosclerosis¹⁴. In addition to Life’s Simple 7, described above, the AHA recommends physical activity as a critical component of first-line treatment for elevated blood pressure or cholesterol¹⁰.

Healthy lifestyle reduces mortality risk, as shown in a large follow-up study of over 123,000 women¹⁵. Those who adopted a healthy lifestyle (never smoking, maintaining a healthy BMI, engaging in ≥ 30 minutes/day moderate to vigorous physical activity, moderating alcohol intake, and ingesting healthy foods) had a substantial reduction in all-cause (74%), cancer-associated (65%), and CVD (82%) mortality^15,16. Better yet, if all five low-risk factors were practiced at age 50, life expectancy was extended 14 additional years to age 93¹⁵.

Cognitive health is supported by cardiovascular health. Regular exercise, maintenance of a healthy weight, regulation of blood sugar levels, and keeping cholesterol within recommended limits, while giving up unhealthy habits (alcohol and tobacco) are all recommended by the WHO¹⁷. A UK Biobank program study implied that optimizing lifestyle could reduce the risk of cognitive decline even in those at high genetic risk for dementia¹⁸. Recent identification of exercise-induced circulating factors, or exerkines, may be a mechanistic link between exercise and improved neurogenesis and neuroprotection¹⁹.

Surprising to some, common risk factors for CVD are also risks for breast cancer²⁰. In the Women’s Health Initiative Observational Study, weight loss was associated with a 12% lower risk of new breast cancers²¹. For women with existing breast cancer, a 35% reduction in mortality was observed with weight loss²²; after 19.6-year follow-up, a 15% reduction in breast cancer deaths persisted²³. A healthy lifestyle also lowers endometrial²⁴ and colon cancer risks²⁵.

To address the challenges involved in encouraging and adopting a beneficial lifestyle, the 2019 American College of Cardiology/ AHA Guideline on primary prevention of CVD suggests team-based care that takes into consideration social determinants of health²⁶. The powerful incentive to reduce CVD expands exponentially when additional benefits are anticipated: life extension, preservation of cognition, cancer prevention, and improved bone health. Importantly, it is never too late to take up healthy behaviors: in a motivating report, women started competitive running after age 50 managed to be as swift and well-muscled as lifelong runners²⁷.

The Role of the Environment in Estrogen Action and Cardiovascular Effects.

Discrepancy between the association of exogenous estrogen with favorable cardiovascular outcomes in observational studies and the failure of randomized clinical trials to find similar effects^28,29 has led to a re-evaluation of the role of estrogen, its receptors, and its possible environmental mimics (endocrine disruptors). The G-protein coupled estrogen receptor (GPER) is of particular recent interest in vascular function, as it is widely expressed in vascular smooth muscle and endothelium³⁰. Biological aging, underlying disease, and endocrine disruptors may all contribute to wellness, and their impact on estrogen receptor expression was examined mouse models. Estrogen loss induces arterial stiffening before increases in blood pressure are observed, suggesting that arterial stiffness may be a better indicator of cardiovascular risk in postmenopausal women³¹. Aging, the endocrine disruptor Bisphenol A, and angiotensin II-induced hypertension all significantly downregulate estrogen receptors and decrease the vasodilatory response to estrogen³². Other xenoestrogens, acting through GPER, may modify signaling of this receptor and thereby alter its inherent physiological activity³⁰. Understanding the impact of the environment on estrogen receptor location, density and subtypes appear critical for resolving the apparent paradox of estrogen’s effects on vascular health, a crucial component of wellness.

Addressing the Lifelong Challenge that ACEs Pose to Wellness.

Adverse childhood (ages 0-17 years) experiences (ACEs) are reported by almost 60% of US adults³³. There is a graded association between ACEs and risk for physical and mental health conditions across the lifespan; including CVD, autoimmune, endocrine and metabolic disorders, migraines, loss of first pregnancy, depression, anxiety, post-traumatic stress disorder, psychosis and suicide. Females compared to males carry a greater disease burden associated with many of these conditions, highlighting the importance of considering ACEs in the women’s healthcare setting.

ACE exposures are associated with greater risk for first onset of depression during the menopausal transition³⁴. Women are already at 2-3 times the risk of experiencing a major depressive episode during the perimenopause compared to premenopause, however those reporting two or more (2+) ACEs are at even greater risk of first-onset depression, suggesting that ACEs create a vulnerability to depression that is unveiled by the dynamic hormonal milieu of the perimenopause.

Similarly, functional magnetic resonance imaging research has demonstrated that postmenopausal/hypogonadal women who experience 2+ ACEs (high ACE) compared to those reporting 0 or 1 (low ACE) show a differential brain response during performance of a standard working memory task,³⁵ with those in the high ACE group demonstrating greater blood oxygen level dependent (BOLD) signal in the dorsolateral prefrontal cortex (DLPFC) than those in the low ACE group. This finding suggests that women in the high ACE group must recruit greater DLPFC neuronal activity to perform just as well. Interestingly, administration of estradiol (100 ug/d) eliminated the difference in DLPFC activation between the two ACE groups by reducing DLPFC activation among high ACE women. Thus, exposures to ACEs appear to have an enduring impact on brain regions critical for executive cognitive functions that could impact women negatively as they become postmenopausal. Whether excessive DLPFC activation during working memory has long-term negative effects on cognition and whether estradiol treatment should be initiated in menopausal women with high ACE exposures requires further investigation. However, these data support clinical recommendations to screen for not only mental health issues such as depression during the peri and early postmenopause, but also to consider the risk for cognitive symptoms among women with higher ACE exposures.

Screening for ACEs is simple to incorporate into practice with the 10-item Adverse Childhood Experience Questionnaire³⁶. Considering their negative impact on women’s health will not only advance the science but will hopefully motivate women who have suffered ACEs to undertake health promoting behaviors before the menopause transition ensues.

Undermining the Power of Hot Flashes to Disrupt Sleep.

VMS, or hot flashes and night sweats, are the hallmark menopause symptom experienced by a majority of women during the menopause transition³⁷ and are frequent or severe in 30% of women. Newer data indicate that frequent or severe VMS persist for 7-10 years, and milder symptoms persist for much longer³⁸. In the US, VMS are most prevalent among African American women and least prevalent among Asian women, although most women experience them across all racial/ethnic groups³⁷.

In addition to VMS, up to half of midlife women report sleep problems³⁹. All three major types of sleep problems (trouble falling asleep, waking during the night, early morning wakening) worsen during the transition, with more than double the odds of sleep challenges during the late perimenopause and early postmenopause relative to the premenopause. Nocturnal VMS can exacerbate sleep problems for many women.

VMS and sleep problems are linked to poorer mental health and worse quality of life. Notably, VMS have been linked to increased depressive symptoms and persistent sleep problems are established risk factors for a wide range of mental health disorders⁴⁰. VMS and poor sleep have also been linked to increased physical health problems, such as CVD risk. There is evidence of a synergy between VMS and sleep, such that women with VMS and short sleep are at particularly increased cardiovascular risk⁴¹.

Multiple empirically-supported behavioral approaches to managing VMS and poor sleep that do not require pharmacologic intervention are available. For VMS, cognitive behavioral therapy (CBT), mindfulness-based stress reduction (MBSR), and clinical hypnosis have been shown to reduce the occurrence of VMS (clinical hypnosis) or the bother and interference associated with VMS (CBT, MBSR)^42-44. For sleep, behavioral approaches are more effective, safe, and durable for treating sleep problems than pharmacologic methods. CBT for insomnia (CBT-I) and brief behavioral therapy for insomnia (BBT-I)^45,46 are both effective methods that are increasingly incorporating mindfulness.

VMS are prevalent, sleep problems are common, and both symptoms can erode wellness in midlife. Effective behavioral approaches delivered by experienced clinicians trained in how to deliver them provides the best results. Providers and patients should be aware of the prevalence and implications of these menopausal experiences and management options.

Fortifying Oneself Against Sadness and Worry.

Mental illness is the leading burden of illness in women. Poor mental health in midlife erodes well-being at a time when women are at their most productive in the workplace, shoulder family responsibilities, and are adapting to changes in their physical health. Neuropsychological aspects of wellbeing are therefore especially important for midlife women to monitor. While clinical depression is less prevalent, subsyndromal depressive symptoms, anxiety, and irritability affect a large proportion of women in the perimenopause and early postmenopause. Some women with a history of depression are specifically susceptible to endocrine changes across reproductive transitions that precipitate depression or may have accumulated health conditions that predispose them to recurrence of depression in midlife⁴⁷. However, not all affective symptoms occurring during the menopause transition are attributable to menopause. Nonetheless, the indolent biological processes underlying and the protracted time course of the perimenopause may each contribute to depression risk.

Leveraging resources that derive from the brain/mind, from the body/systemic factors, and also the exposome that surrounds women can improve well-being in this population. Understanding the mind-body connection and taking into account central and systemic hormone changes, symptoms and environmental factors provides insights into therapeutic strategies to counter these pressures and improve mood. Intersections between midlife, the menopause transition, and mood are complex to disentangle. Protecting mental health and improving emergent distress and depression symptoms require a causal attribution in order to select the most specific treatment approach(es). To best protect the mental health and wellbeing of our midlife patients, we must take this broader view to consider the full range of contributing factors, which will then point toward specific modalities for prevention and/or treatment. Take-home messages for clinicians are that: 1) the human brain and experience are complex; 2) collaboration with the patient and other clinicians and monitoring over time are key aspects of any treatment; and 3) many resources for treatment that derive from the brain (e.g., antidepressants), the body (e.g., hormonal therapy), and the exposome (e.g., cognitive behavioral therapy) are available. Midlife women should be encourage to ‘eMPoweR’ themselves by Monitoring, Protecting, and Relieving depression when present.

Validation: The Clinician’s Superpower.

A patient’s emotions, experiences and communication of health-related information all benefit from validation by women’s health providers.

Clinician functions can be both task-driven and relational. Task-driven functions focus on exchanging information, implementing accepted health-promoting guidelines, addressing physical complaints, engaging in shared decision-making, enabling self-management, and managing uncertainty. Relational functions focus on fostering healing relationships and validating and responding to information patients provide about emotions and experiences. Clinical validation strategies help health care providers communicate with patients in ways that make them feel understood⁴⁸. These include recognizing patients’ feelings and opinions as understandable in the current context and legitimizing and conveying acceptance of patient’s reports of their feelings and experiences. The desired outcome is for patients to feel heard, understood and supported.

Validation strategies include “being present” by listening carefully to emotions and experiences, accurately reflecting what the clinician has heard without judgement, and asking clarifying questions i.e. restating a person’s perspective, giving a person an opportunity to correct or affirm. The strategy of matching feelings by sharing the clinician’s own feelings or experiences is described as “radical genuineness”^49,50. Two data-based strategies for clinicians are normalizing thoughts and feelings patients express while emphasizing how they make sense given the patient’s past history or present context and validating experiences by sharing information about other women. Normalizing is especially important to women during the transition to menopause, when many may wonder if what they are experiencing is “normal.”.

Participants aged 35-55 in the Women Living Better Survey identified validation efforts as leading to satisfaction with clinical encounters⁵¹. Clinician behaviors that led to participants expressing dissatisfaction with their care included: dismissing complaints (concerns not taken seriously, not listening to, brushed off) or failing to acknowledge feelings expressed, and invalidating explanatory models for their symptoms, e.g. being told their concerns were unrelated to menopause because they were “too young” or still having regular periods.

Anticipatory guidance about the broad range of symptoms that occur on the path to menopause provides a foundation for a strong patient-provider relationship, and validating patients’ experiences and information builds a trusting relationship which in turn enables health and wellness promotion. A health care provider who will collaborate, listen to and validate, and share information about the transition is a powerful prescription for wellness through the transition to menopause.

Becoming the Exercise Enthusiast You Always Hated.

Over 60% of U.S. women do not engage in ideal amounts of physical activity, more than a quarter are not active at all, and physical inactivity is more common among women than men ⁵². Women’s health providers are well positioned to help patients initiate, increase, and sustain physical activity throughout their mid-life and beyond, given its numerous benefits for physical, cognitive, emotional and sexual health.

Exercise habits are highly impacted by income, ethnicity, education, employment, children, gender beliefs, relational and cultural context, among other factors⁵². Asian-American, Hispanic and African-American women are less likely to engage in physical activity than non-Hispanic white females during midlife^53,54. Social determinants of health (e.g., income, living environment) impact access to childcare, gyms/recreational centers and safer areas for walking and biking. Employment and childcare demands can sabotage attempts to increase physical activity for women who return home from work to caregiving responsibilities. Individuals may carry gender-based beliefs about exercise and live with cultural messages and power dynamics that reduce their control over their own health decisions including engagement in physical activity.

Clinicians can support their patients by asking direct and detailed questions about physical activity. Review the type, frequency, and intensity of exercise, and consider motivational interviewing to explore how women feel and function when they are active. Discuss barriers to and need for support to initiate and sustain self-care including physical activity. Invite women to view exercise as an essential contributor to their health and well-being, negotiate short-term, realistic physical activity goals, and write a prescription for personalized exercise with the dose and frequency – just as you would for other treatment recommendations. Consider asking members of your practice team to follow-up with patients about their fitness goals by EMR, phone or letter.

Many women will engage in alternative forms of physical activity such as destination walking or hiking, dancing, skating, Thai Chi/Qi Gong, team membership and fitness challenges, heavy gardening, using a desk treadmill, etc. rather than structured types of exercise. Women with physical challenges may benefit from regular seated movement with strengthening and stretching. Engage mid-life women in discussions about their support needs to initiate, increase, and sustain physical activity. Encourage women to meet family members, neighbors, friends, and co-workers at specific times for walks, fitness programs, team sports, etc.

The Role of Movement.

The Diabetes Prevention Program (DPP) study showed that under ideal conditions a lifestyle intervention with goals of 7% weight loss and 150 minutes/week of moderate intensity physical activity can reduce risk for type 2 diabetes by 58% and the metabolic syndrome by 41% in high-risk individuals when compared to a control group. The DPP showed that the lifestyle arm initially became more active and maintained a higher activity level over the study period of more than 10 years when activity was measured subjectively and objectively. Post hoc analyses showed that over the ~12-year follow-up physical activity level was related to lower risk of diabetes development⁵⁵ with a particularly strong relationship observed in participants with lower baseline physical activity.

The Diabetes Prevention Support Center (DPSC) was formed at the University of Pittsburgh by members of the DPP lifestyle intervention core group to help guide community translation efforts in a similar manner to the guidance provided for the DPP. The DPSC (under the larger umbrella of the CDC Diabetes Prevention Program) developed a 12 month in-person group-based version of the DPP, the Group Lifestyle Balance Program (GLB), to use in the community setting. The GLB program demonstrated excellent attendance and clinically relevant improvements in weight, self-reported physical activity levels, and cardiometabolic risk factors in several different settings. The GLB-Sedentary program was devised as an alternative version that might be more acceptable for participants who would benefit from a more modest goal to reduce sedentary behavior before adding the standard physical activity goal of 150 minutes/week of moderate intensity physical activity. Preliminary results show excellent attendance and participant satisfaction with significant improvements in weight, self-reported physical activity, and step counts for participants in the GLB-sedentary program.

The Power of Culinary Medicine.

Using food as medicine is a powerful tool to help women lose weight and enjoy better health throughout the life span, including during menopause. Women gain an average of five pounds over the menopause transition and often report that losing weight becomes more challenging. 43-45% of perimenopausal and menopausal age women in the US are obese,⁵⁶ putting themselves at risk for diabetes, cardiovascular disease, and cancer. 80% of women over 55 have at least one chronic disease and almost 70% have 2 or more⁵².

Aging, ethnicity, hormonal changes, reduced physical activity, disease, poor nutrition, sex steroid changes and poor sleep all lead to weight gain, loss of muscle (fat-free) mass, and an increase and redistribution of fat (also known as “belly fat”). Obesity and most chronic diseases induce an inflammatory response that damages healthy tissue. Healthy foods rich in antioxidants, many of which are included in the Mediterranean diet, reduce inflammation.

Culinary medicine

is an emerging practical discipline that integrates the art of food and cooking with the science of medicine. It’s a treatment strategy designed to empower people to think of and use food as medicine and help them make good personal medical decisions about accessing and eating high-quality meals that help prevent and treat disease and restore well-being⁵⁷.

Evidence consistently demonstrates the effectiveness of the Mediterranean diet in reducing cardiovascular and other chronic disease⁵⁸. One in five deaths can be prevented by improving eating habits. The Standard American Diet (SAD) is suboptimal and as a risk factor is responsible for more deaths than any other risk factor. Patients should be encouraged to fight menopausal weight gain using Culinary Medicine Principles. Small, sustained changes should be encouraged, as a sudden major overhaul may lead to binge eating and failure. Swapping out less healthy food choices with healthier options, and adoption of a Mediterranean or plant-based diet are all wellness-promoting strategies with evidence of benefit for managing weight, lowering risk of chronic disease, and living longer. Referral to a registered dietitian to provide accountability and support can help keep patients on track and create sustainable change. More health systems and insurance companies are providing specialized nutrition resources, including classes and apps.

Triangulating Weight Loss: Behavior, Medicine, and Surgery.

The menopause transition is characterized by distinct changes in circulating hormones, energy balance, and body composition that contribute to weight gain and increased cardiometabolic risk⁵⁹. The hormonal changes of menopause are associated with well-documented increases in energy intake (EI; calories consumed from food). More recent controversy focuses on whether there is a distinct, menopause-associated decrease in energy expenditure (EE; calories expended from metabolic rate plus physical activity and exercise)^60,61. At any rate, a positive energy balance will lead to weight gain. This weight gain is primarily in the form of increased fat mass, and in particular increases in abdominal fat deposition^61,62, which are linked with metabolic disturbances such as hypertension, insulin resistance, and type 2 diabetes⁶³.

Behavioral modification, the first line of treatment to combat weight gain, is appropriate for all levels of disease severity, and achieves approximately 5 to 7% weight loss. Cardiometabolic benefits begin at ~3 to 5% weight loss, with even greater benefits observed with higher degrees of weight loss^64,65. Importantly, reducing EI appears to be imperative for weight loss success. Adding in physical activity or exercise on top of an ongoing dietary weight loss intervention can modestly increase weight loss by 1 to 3% over the course of 1-year (compared to diet alone), but relying on increased physical activity and exercise alone to lose weight is not effective⁶⁶. Physical activity and exercise will promote cardiovascular health and retention of fat-free (muscle) mass⁶⁷. Encouraging healthier food choices, physical activity and exercise, and sleep quality, as well as establishing formal in-person weight management sessions (≥14 counseling sessions across 6 months is recommended⁶⁸) increases adherence to behavioral modification.

Adjunct pharmacotherapies may be indicated if the person has a BMI≥30 kg/m² or BMI≥27 kg/m² with obesity-related complications or advanced cardiometabolic risk⁶⁸. Weight loss medications have enormous variation in response, with 20 to 40% of patients not achieving weight loss of even 5% at 6 months. Additionally, only 1.3% of eligible persons are prescribed anti-obesity medications⁶⁹. Older medications (including phentermine, lorcaserin, and bupropion) relied on targeting monoamines for drug development or simply coincidental observation of weight loss with a drug (topiramate). Greater knowledge of food intake biology has led to emergent medications with potential to far surpass the results from first-generation agents. Glucagon-like peptide 1 (GLP-1) receptor agonists (e.g., liraglutide, semaglutide); setmelanotide (a melanocortin 4 receptor agonist); and single molecules with dual or triple targets around GLP-1, glucagon, and gastric inhibitory polypeptide (GIP), target pathways more prominent for appetite reduction. Semaglutide, tirzepatide, and bimagrumab can elicit 15 to 25% weight loss, approaching the results seen with surgical methods⁷⁰. Hopefully, these options will become more affordable and easier for physicians to prescribe. Meanwhile, metformin remains the most commonly used weight management agent, with patients adhering to a 1750 mg/day dose achieving 4 to 5% weight loss sustainable for 10 years⁷¹. Women with BMI≥40 kg/m² or BMI≥35 kg/m² in the presence of obesity-related complications are most effectively treated with bariatric surgery⁶⁸. The timing, order, and combination of weight loss modalities should be individualized to maximize efficacy.

How to become the meditation enthusiast you always hated.

Meditation and mindfulness practices are increasingly foujnd to have salubrious effects on well-being with few negative side-effects. The techniques are easy to learn from videos, workshops, behavioral health providers, certified coaches and in many yoga classes. Food, sleep, and a meditative mind are key sources of energy, but the most important source of energy for meditation is our breath. While many of us strive to drink at least 3 liters of water daily, we are actually breathing in about 10,000 liters of air! However, since breathing is automatic, most of us do not pay attention to it, until we are out of breath. When we’re stressed, our breath can become shallow and heavy, and we might hold our breath. When we’re under chronic stress, our built-in fight/flight response can also become over-activated and trigger a host of negative effects. Every emotion has a particular rhythm in the breath, and through skillful use of the breath, we can influence our emotions.

A beneficial impact of yoga and meditation-based interventions has been demonstrated in veterans recently returned from Iraq and Afghanistan with trauma⁷². Veterans in the study sample had gone through regular courses of therapeutic or pharmacological treatment without improvement. Using the Sudarshan Kriya (SKY) Breath Meditation protocol, anxiety was normalized as rapidly as within one week. Benefits persisted one year later, suggesting permanent improvement. An 8-week pilot study of the SKY protocol in 25 patients with major depressive disorder refractory to 8 weeks of antidepressant treatment demonstrated substantial reductions in depression and anxiety scores compared to waitlist controls⁷³. These studies, combined with its inherent lack of side effects, support the clinical use of breathing meditation as a means to assist women transitioning into menopause and through the postmenopausal years.

Organize Menopause Care the Implementation Science to Promote Wellness.

Implementation research can evaluate a menopause care model to understand how to better deliver it, improve its spread and demonstrate health benefits. This approach to evidence-based practice of medicine relies on rating the clinical research on potential model components and choosing those which have enough evidence that there is certainty about the magnitude of benefits. Typically, this requires a systematic review to address the services, conducted using rigor, informed by decision-makers, and finalized for public presentation. Many groups follow this type of process to develop practice guidelines.

The components of a menopause care model should include the ability to evaluate women, provide treatment for menopause-related symptoms, and promote health and prevent disease. Initial components could be 1) evaluation and medical management of menopausal symptoms; 2) age- and gender-appropriate clinical preventive services to promote health and prevent disease; 3) personal planning and other activities to reduce stress, prevent symptoms or otherwise enhance quality of life.

Implementation science can evaluate potential methods to spread evidence-based menopause care more widely to practitioners and patients. Techniques to increase this type of care include: reminder systems or other use of health information technology; feedback of provider assessment; removal of economic barriers such as co-payment. Most implementation strategies combine several of these proven interventions.

Evidence for menopausal symptom management needs to be enhanced through clinical trials of treatment strategies. Clinical preventive services recommended for women about age 50 years by the United States Preventive Services Task Force (USPSTF) include cancer and cholesterol screening (every 2-5 years) and a flu shot (annually). A menopause care model should track that women remain up to date on those services. Health promotion activities should focus on screening for risk factors, followed by counseling and appropriate behavior modification. Current risk factor surveillance by CDC indicates that there are many gaps, with great potential for improvement of the health of peri- and postmenopausal women.

Insurance payment is another important way to ensure that a transformed model of menopause care gains widespread use. Although symptom evaluation and care is typically paid by insurance plans, preventive services are covered without cost-sharing if hey are rated A or B by the USPSTF, such coverage was mandated by the Affordable Care Act.

Innovators are needed to develop and evaluate a proposed menopause care model. The needed implementation research could address health care priorities articulated by stakeholders and federal funding agencies. Insurance and managed care could potentially widely cover the elements of menopause care with minimal to no cost to the patient.

Summary and Conclusions

Midlife is an inflection point that marks a period of risk for changes in health that can accumulate and progress into later life. As such, it remains an ideal time to initiate a broad wellness promoting strategy for women, as many will engage with clinicians during this time due to symptoms. In this respect, it is a golden opportunity to optimize clinical care. It is critical to reframe midlife care from symptom or problem-focused to wellness oriented. Establishing a relationship in which patients feel heard, orienting patients to a wellness mindset, and emphasizing the power of behavior all contribute to a strong patient-provider bond that can continue to promote optimal health for all through the second half of life.