You’re listening to Burnt Toast! Today, my guest is Mara Gordon, MD.

Dr. Mara is a family physician on the faculty of Cooper Medical School of Rowan University, as well as a writer, journalist and contributor to NPR. She also writes the newsletter Your Doctor Friend by Mara Gordon about her efforts to make medicine more fat friendly. And she was previously on the podcast last November, answering your questions on how to take a weight inclusive approach to conditions like diabetes, acid reflux, and sleep apnea.

Dr. Mara is back today to tackle all your questions about perimenopause and menopause!

Actually, half your questions—there were so many, and the answers are so detailed, we’re going to be breaking this one into a two parter. So stay tuned for the second half, coming in September! As we discussed in our recent episode with Cole Kazdin, finding menopause advice that doesn’t come with a side of diet culture is really difficult. Dr Mara is here to help, and she will not sell you a supplement sign or make you wear a weighted vest.

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And don’t miss these:

• Healthcare is Ground Zero for Fatphobia

• Is Dr. Mary Claire Haver Making Menopause a Diet?

Episode 203 Transcript

Virginia

When I put up the call out for listener questions for this, we were immediately inundated with, like, 50 questions in an hour. People have thoughts and feelings and need information! So I’m very excited you’re here. Before we dive into the listener questions, let’s establish some big picture framing on how we are going to approach this conversation around perimenopause and menopause.

Mara

I should start just by introducing myself. I’m a family doctor and I have a very general practice, which means I take care of infants and I have a couple patients who are over 100. It’s amazing. And families, which is such an honor, to care for multiple generations of families. So, perimenopause and menopause is one chunk of my practice, but it is not all of it.

I come from the perspective of a generalist, right? Lots of my patients have questions about perimenopause and menopause. Many of my patients are women in that age group. And I have been learning a lot over the last couple of years. The science is emerging, and I think a lot of practice patterns amongst doctors have really changed, even in the time that I have been in practice, which is about 10 years. There has been a huge shift in the way we physicians think about menopause and think about perimenopause, which I think is mostly for the better, which is really exciting.

There’s an increased focus on doctors taking menopause seriously, approaching it with deep care and concern and professionalism. And that is excellent. But this menopause advocacy is taking place in a world that’s really steeped in fatphobia and diet culture. Our culture is just so susceptible to corporate influence. There are tons of influencers who call themselves menopause experts selling supplements online, just selling stuff. Sort of cashing in on this. And I will note, a lot of them are medical doctors, too, so it can be really hard to sort through.

Virginia

Your instinct is to trust, because you see the MD.

Mara

Totally. There’s a lot of diet talk wrapped up in all of it, and there’s a lot of fear-mongering, which I would argue often has fatphobia at its core. It’s a fear of fatness, a fear of aging, a fear of our bodies not being ultra thin, ultra sexualized bodies of adolescents or women in their 20s, right?

This is all to say that I think it’s really exciting that there’s an increased cultural focus on women’s health, particularly health in midlife. But we also need to be careful about the ways that diet culture sneaks into some of this talk, and who might be profiting from it. So we do have some hearty skepticism, but also some enthusiasm for the culture moving towards taking women’s concerns and midlife seriously.

Virginia

The cultural discourse around this is really tricky. Part of why I wanted you to come on to answer listener questions is because you approach healthcare from a weight inclusive lens, which is not every doctor. It is certainly not every doctor in the menopause space. And you’re not selling us a supplement line or a weighted vest, so that’s really helpful. So that’s a good objective place for us to start!

Here’s our first question, from Julie:

It’s my understanding that the body naturally puts on weight in menopause, especially around the torso, and that this fat helps to replace declining estrogen, because fat produces estrogen. I don’t know where I’ve heard this, but I think it’s true? But I would like to know a doctor’s explanation of this, just because I think it’s just more evidence that our bodies know what they’re doing and we can trust them, and that menopause and the possible related weight gain is nothing to fear or dread or fight.

Mara

Oof, okay, so we are just diving right in. Thank you so much for this question. It’s one I get from many of my patients, too.

So I looked into some of the literature on this, and it is thought that declining estrogen—which happens in the menopausal transition—does contribute to what we call visceral adiposity, which is basically fatty tissue around the internal organs. And in clinical practice, we approximate this by assessing waist circumference. This is really spotty! But we tend to think of it as “belly fat,” which is a fatphobic term. I prefer the term “visceral adiposity” even though it sounds really medical, it gets more specifically at what the issue is, which is that this particular adipose tissue around internal organs can be pathologic. It can be associated with insulin resistance, increasing risk of cardiovascular disease, and risk of what we call metabolic—here’s a mouthful—metabolic dysfunction associated steatotic liver disease, which is what fatty liver disease has been renamed.

So I don’t think we totally understand why this happens in the menopausal transition. There is a hypothesis that torso fatty tissue does help increase estrogen, and it’s the body’s response to declining estrogen and attempts to preserve estrogen. But in our modern lives, where people live much longer than midlife, it can create pathology.

Virginia

I just want to pause there to make sure folks get it. So it could be that this extra fat in our torsos develops for a protective reason —possibly replacing estrogen levels—but because we now live longer, there’s a scenario where it doesn’t stay protective, or it has other impacts besides its initial protective purpose.

Mara

Right? And this is just a theory. It’s kind of impossible to prove something like that, but many menopause researchers have this working theory about, quote—we’ve got to find a better term for it—belly fat. What should we call it, Virginia?

Virginia.

I mean, or can we reclaim belly fat? But that’s like a whole project. There is a lot of great work reclaiming bellies, but we’ll go with visceral adiposity right now.

Mara

Anyway, this is an active area of menopause research, and I’m not sure we totally understand the phenomenon. That being said, Julie asks, “Should we just trust our bodies?” Do our bodies know what they’re doing? And I think that’s a really philosophical question, and that is the heart of what you’re asking, Julie, rather than what’s the state of the research on visceral adiposity in the menopause transition.

It’s how much do we trust our bodies versus how much do we use modern medicine to intervene, to try to change the natural course of our bodies? And it’s a question about the role that modern medicine plays in our live