When Samantha Dalby emailed us last month, she was frustrated and confused. The 50-year-old nurse practitioner from Ontario, Canada, had been eating a low-carb diet for more than five years. Originally she had done very well on it, keeping her weight at a healthy and stable 152 lbs (76 kg) on her 5'7″ (174 cm) frame.
But then, about 18 months ago, she went through menopause - her last period was 12 months ago. Suddenly the weight started creeping up. What had worked so well was no longer working for her. "It's a scary time because it feels like what is happening in your body is out of your control, on so many levels," Samantha says.
In her health clinic with her patients, and with friends, she has seen women gain a considerable amount of weight over the menopausal change and she did not want that to happen to her.
Nine months ago she decided to try the stricter keto diet and followed our advice to help support this way of eating. By testing her urine with keto stix she could see she was expelling ketones in the low to moderate range. But still her weight was increasing - she gained a total of 7 lbs (3 kg) over nine months of keto eating. And her clothes were feeling tight and uncomfortable. What was she doing wrong?
"I just seem to be gaining no matter what I do," she lamented in an email to us. "I accept that menopause will come with body changes, but I am frustrated that I can't seem to stop the weight gain."
A common problem
Samantha is not alone. Many women find in the years leading up to and after their final menstrual period that along with other symptoms like hot flashes, night sweats and sleep problems, their abdomens thicken and their weight increases. Some 40 million women in the US, 13 million in the UK, and many more millions around the world are estimated to be going through menopause, which usually occurs between age 49 and 52.
On Google, typing in "Weight gain in" the word "menopause" is what pops up as the most frequent search term to complete the phrase.
We'd like to help. Many of our readers are women over the age of 45, and we know that the keto low-carb diet for weight loss and improved health over the menopause years is of huge interest for a lot of people. Many women in this age group are happy with the results they have achieved by adopting the low-carb or keto way of eating. But what if you are not achieving the results you want?
Samantha described how she was eating low-carb, high-fat, exercising five times a week, snacking rarely on nuts or cheese, drinking about three to five glasses of alcohol a week (dry red or white wine, prosecco or vodka soda) and drinking bulletproof coffee in the morning. She had been tested for thyroid issues and was fine. What advice could we give her?
The response was to try intermittent fasting - and we go into more detail about that in tip #3 below. But to truly get to the bottom of menopausal weight stalls and challenges, we explored the medical literature about what is known about metabolism changes and physiological energy needs during menopause and also tapped the knowledge and experience of some of our stellar low-carb experts - Dr. Sarah Hallberg, Dr. Jason Fung, Dr. Eric Westman, Dr. Ted Naiman, and Atkins RN Jackie Eberstein. We have come up with nine other actions, along with intermittent fasting, that may help stop menopausal weight issues and to give a boost to weight loss if you are experiencing a plateau while low-carb keto eating.
We shared them with Samantha in advance of this post, and within a few days of adopting them, she saw the scale finally move downward 1.5 lbs (0.7 kg), the first time in months. She was delighted. Her ketones had increased from 1.5 to 4 mg/dl. "I really thank you for this. I am going to keep doing these tips. I will let you know how it goes!"
The ten tips can work, however, for anyone in a stall, not just for menopausal women. "Post menopausal women certainly can have problems with weight gain, but we see it in many others, too," said Dr. Jason Fung.
The weight-loss challenge in menopause
In fact, whether menopausal women have unique challenges for weight loss is controversial.
Some studies have proposed that women's weight gain in midlife is more a factor of aging - which impacts both sexes - than of menopausal changes in hormones. Other studies note, however, that declining estrogen (estradiol or E2) at menopause changes women's energy needs and metabolism, changes their location of body-fat accumulation from the hips to abdomen, and is associated with an increased rate of metabolic syndrome.
Dr. Wendy Kohrt, of the University of Colorado Denver, leads its IMAGE program (Investigation into Metabolism, Age, Gender and Exercise) and has been studying the impacts of menopause for more than 20 years. She has found that during menopause women's metabolisms slow by about 50 calories a day and that women experience more food cravings, less movement and more muscle loss, which together create a quadruple whammy for gradual weight gain over time. Kohrt notes, however, that menopause itself has been vastly under-researched over the years, a point shared by other commentators, considering the impact it has on the health and wellness of millions of women.
Dr. Sarah Hallberg notes: "Weight gain happens at menopause - we all know it - but research cannot yet fully explain why. It is not as universal an issue as generally perceived. Why menopausal women eating low carb or keto should stall or even gain weight is not really known either. We intend to try to understand this better."
Hallberg and colleagues are currently in the midst of a study in which ten overweight mostly menopausal women, who have been doing low carb keto eating but whose weight loss has stalled prematurely, will spend about five days in a monitored environment. During this time the women's food and activity will be observed and recorded and their metabolism analyzed. While studies like this have been done before, this is the first time the focus has been on women who have stalled in their weight loss on a low carb and high fat diet, Hallberg says. "Most of the other studies found it was overconsumption leading to the problem. We want to see what is happening for these women."
Results from that study won't be available for a number of months. Until then, here are our top ten tips from our experts to kick you out of a stall - which applies to women in menopause, or anyone experiencing a weight loss plateau or not having sufficient success on low carb keto eating.
1. Don't eat too much protein
Don't eat too much protein: "Number one issue for stalls, in my experience, is too much protein," says Dr. Hallberg. "Women need less protein and can much more easily over-consume protein compared to men. If you and your husband are eating the same size steak, you are consuming too much."
Drs. Fung and Westman agree. "Too much protein interferes with ketosis and fat burning," says Dr. Westman. He suggests testing your blood sugar after you eat protein to see if your blood sugar goes up. "If it goes up, some of that protein is being turned into sugar. And that can slow you down."
Dr. Naiman is less concerned with keeping protein intake modest. But apart from him, the general advice from our group of experts is to eat between 0.5 to 1.5 g of protein per kilogram of body weight per day. A 70 kg (154 lbs) woman would therefore eat no more than 105 g of protein per day, and perhaps significantly less.
If you're not really interested in counting grams, you may instead want to try a suggestion from Dr. Hallberg, to do a "mindful week" and retrain your feelings of hunger and fullness. Here's how Dr. Hallberg puts it:
The problem and the struggle for all the people we see, not just menopausal women, is they don't know what hunger and fullness really are. They come to us after years and decades of a low fat high carb diet. So they are used to a feeling of fullness that is fuller than full. So we need to retrain ourselves to understand that full enough is the way you should feel.
People always say: OMG I ate so much and I feel so full and disgusting. That is how they are used to feeling "full"... discomfort after eating. So retraining their sensory system to just accept full enough is something you have to work with people on.
So if we are having a plateau and we are struggling with this the first thing people say is "should I go back to counting calories." No, no, no! Have a mindful week. What that is, in my mind, is that patient is going to dedicate a week to this. They have to dedicate a week because it takes time.
So, if for breakfast they are used to having two eggs and two strips of bacon, during the mindful week you would only bring one egg and one piece of bacon to the table. And you would eat it. Then you have to wait 20 minutes - and that is where the time investment comes. And then ask yourself after 20 minutes, am I actually still hungry?
You have to give yourself time to learn how to feel if you are full or still hungry. And so you do that for each meal, for a week's time, you realize at some point that you are eating the right amount, you are eating too much, or you are eating too little. You will realize at some meals "I was eating too much. I didn't need that second egg or whatever." It is a way to do it without counting calories, to do it based on your body's need and for you to get in touch with your body's need.
2. Don't eat too much fat
A keto diet is not carte blanche to gorge yourself on fat...
Once fat adapted, cut back on extra fat: One of the great joys of low-carb keto eating is adding back fat into our bodies after denying them fat for so long. But a keto diet is not carte blanche to gorge yourself on fat, the experts note. If you want to lose weight, you have to burn your own fat stores for energy, not consume all the energy you need by eating fat. So stop the bulletproof coffee and fat bombs for now.Dr. Naiman notes that when people first start the low-carb keto diet, when they have previously been consuming lots of carbs and are very glucose dependent, he tells them to eat unlimited healthy fat until they are fully-fat adapted. "You will know you are fat adapted because you can go a long time without eating."
Once they are primed to burn fat, however, he then scales back on fat so that they will access and burn their own fat stores.
So if you are experiencing a weight-loss stall, our experts recommend you look at how much fat you are consuming and see where you might cut back without harming the tastiness or quality of your food or your feeling of fullness, and without bringing back the cravings and blood sugar swings. Don't starve yourself, but be mindful of excess fat for now. Samantha decided to cut out her bulletproof coffee for now.
Dr. Hallberg notes that it is easy to over-consume fat in liquids, especially full fat whipping cream. "Someone will come in and say they are in a weight loss plateau. We will look at their diet and see they are consuming six coffees, with two tablespoons of whipping cream in each one." Cutting back on the whipping cream can get them out of a stall.
"When you are at your ideal weight, you can add the fat back in and eat all the butter you want," Dr. Naiman says.
Dr. Fung discussed this concept of excess fat consumption, and how it applies to some people, in detail, including the role of leptin resistance in weight loss stalls in a popular earlier post.
3. Intermittent fasting
Add in intermittent fasting: Once you are fat-adapted, hunger pangs diminish and it is easy to go for longer periods without eating. Many people naturally stop eating breakfast - they just aren't hungry when they wake up. The number one rule of low-carb eating is "eat when you are hungry and stop when you are full." So if you are not hungry try fasting for 16 hours, and then eating just lunch and dinner in an 8-hour window, called a 16:8 fast. Or try eating dinner one night, than fasting until dinner the next night, doing a 24-hours fast.
Samantha added in a 24 hours fast on our advice and a couple of 16:8 fasts. "I was surprised how easy it was. I wasn't hungry."
For Ellen McCormick Martens, 71, of Houston Texas, adding in intermittent fasting, eating only between 11 am and 7 pm did the trick for her stubborn plateaus."Using IF, I have been able to keep my extra weight off for 1½ years. It is really simple and easy to incorporate [a short fast] into an LCHF lifestyle."
Dr. Fung suggests not doing the same fasting routine, day after day, but to "switch it up"; 16:8 one day, 24 hours IF the next, then a day of regular eating. That is because the body has a strong physiological drive to seek homeostasis - energy balance. "Whenever the body is exposed to a constant stimulus, it will become acclimated to it," he says.
Remember: eat when you are hungry and stop when you are full.
Hallberg suggests caution, however, around very long fasts lasting multiple days. "If you are skipping meals because you are not hungry from doing a proper low-carb, high-fat diet that is just fine." She is concerned, however, about very long fasts in which people are ignoring hunger signals and for the potential for a dangerous physiological fluid and electrolyte imbalance called refeeding syndrome that can arise after very long extended fasts, lasting many days, when normal eating is resumed.When people are doing low carb keto eating they are often not hungry for 16, 24 and even 36 hours. Such fasts are safe and healthy. Remember: eat when you are hungry (don't eat when you are not), and stop when you are full.
4. Watch out for the carb creep
Watch for carb creep: If you have been doing low-carb keto eating for a while, carbs can sneak back into your diet, particularly in the form of sauces, condiments, fruits, and nut snacks. If weight loss has stalled, closely examine what you are eating and cut back to under 20 g of carbs again. Nut snacks like cashews, almonds, and pistachios are easy to overeat and can contain enough carbs to contribute to a weight-loss stall. A cup of pistachios, for example, has 34 g of carbs. Avoid carb cycling or cheat meals, too, for now.
"For insulin resistant people, if they are in ketosis but eat one meal of carbohydrates, it can stop the ketosis in some people for up to three weeks," said Dr. Westman.
Keeping carbs below 20 g will maximize weight loss with more control over hunger and cravings, says Jackie Eberstein.
Samantha cut out her nut snacks and feels that, along with the IF, doing so contributed to getting the scale finally move downward.
5. Cut out alcohol
Cut out the alcohol for now: Many people love the fact that on a low-carb or keto diet you can have a glass of dry white or red wine from time to time. If you are experiencing a weight-loss plateau, or gaining weight, cut out all alcohol for now until weight loss starts again. Even a few drinks a week can cause a stall. "I love my Friday night glass of wine after a hard week, but I will cut it out for now," says Samantha.
6. Avoid sweeteners
Remove artificial sweeteners: If you have been including artificial sweeteners like aspartame or sucralose in your low-carb or keto diet, our experts recommend you wean yourself off them. "While there are not a whole lot of scientific studies, anecdotally we find when people get rid of artificial sweeetners, they were able to lose weight. Come off them as soon as you can," advises Dr. Westman.
More on artifical sweeteners and weight7. Do weight training
While you can't exercise your way out of a bad diet, adding in weight lifting will build muscle and increase your metabolism.
Lift weights: While you can't exercise your way out of a bad diet, adding in weight lifting will build muscle and increase your metabolism. "The more muscle you add, the better your insulin sensitivity, so any sort of resistant strain you can add to your muscle is great for weight loss," says Dr. Naiman. The weight lifting doesn't have to be a excessive - 90 seconds, twice a week can do it. But he notes it has to be a heavy enough weight that after about to 10 to 15 lifts (reps) you cannot do another rep. That is called lifting to muscle failure. "It is only if you go to absolute failure that you convince your body that you're not strong enough. Your body won't add muscle unless you send the message that it needs more," Dr. Naiman says. Squats, push-ups and other body resistance methods are just as effective as hand held weights or weight machines.Dr. Westman never brings up exercise as a first step in weight loss. He wants patients to focus on the diet first. "But later on, if things are no longer working well and there is still significant weight to lose, I bring up the E-word, exercise. But I try to get them back to things that are fun for them. Exercise will help you get through a plateau."
Dr. Hallberg notes that vigorous exercise can sometimes create a false weight plateau. "If you are exercising to the point of getting sore, you are tearing muscle - which is a good thing, that is how we build muscle, by micro-tears." But in order to deal with that, the body sets off a small inflammatory response, which causes people to retain fluid. "So after a vigorous workout you can jump up a few pounds overnight. It is not a real plateau, it is a pseudo plateau."
Make sure you have rest days between heavy exercise for the body to recover.
8. Get enough sleep
A good night sleep reduces stress and cortisol, the stress hormone that when raised hangs onto abdominal fat.
Get a good night sleep: During menopause, many women find their quality of sleep sharply deteriorates, often because of hot flashes and night sweats. Drs. Fung and Hallberg really recommend that women in weight loss plateaus aim to improve their sleep. A good night sleep reduces stress and cortisol, the stress hormone that when raised hangs onto abdominal fat.Tips for better sleep include:
- Sleep in a cool, dark room.
- Wear ear plugs and eye shades.
- Limit screen time and blue light before bed (or try the glasses that block blue light).
- Go to bed and get up at the same time each day.
- Stop drinking coffee by noon and limit caffeine consumption in all forms.
- Avoid alcohol before bed.
- Get exposure to natural daylight each day.
Read more here: National Sleep Foundation: Sleep Hygiene
This advice struck home for Samantha: "My sleep has been impaired for the last five years because of peri-menopause."
9. Reduce stress
Try stress reduction techniques: Examine the stresses in your life and see if you can do anything to alleviate any of them. Stress increases cortisol release. But don't stress about stress - that is no win. Many women during menopause find they are caught in the sandwich of still dependent children but aging or ill parents. Death of loved ones and loss are common during the menopausal years.
"When we see people struggle and hit a plateau, or completely fall off the wagon, the number one cause is a life crisis of some sort," says Dr. Hallberg. "We all have life crises, men and women - all our lives are managed chaos. We recommend people plan coping mechanisms to deal with stress."
Stress can cause emotional eating, too, another cause of stalls or weight gain, Dr. Fung notes.
Try yoga, meditation and mindfulness techniques, relaxing walks or other pleasant diversions and hobbies. Dr. Hallberg recommends a week of slow and mindful eating, where you really pay attention to taste, textures, and hunger cues. Eat slowly, deliberately and mindfully.
Dr. Westman notes that even worrying about your weight can be a stressor. While monitoring one's weight and food intake is usually helpful, if it becomes too stressful, Dr. Westman suggest not monitoring it for a while and just going by how you feel.
10. Be realistic
Some women are aiming for an arbitrary number on a scale... a number that has no real bearing or relationship to their actual health and wellness.
Set realistic expectations: Both Dr. Hallberg and Jackie Eberstein note this tip is particularly important for women, of all ages. Some women are aiming for an arbitrary number on a scale, perhaps from a long time ago or an idealized weight they have never achieved - a number that has no real bearing or relationship to their actual health and wellness."This is one of the really big issues I see for women - it is so much entwined with psychology, self-esteem, and societal pressure, and in many ways outside of women's control, "says Dr. Hallberg. "They succumb to ways they think they need to be, rather than what is healthy for them. If you see victory as only a number on a scale, you are going to sabotage yourself."
Jackie Eberstein agrees: "Measure your success by a loss of inches, rather than the scale." She advises that you accept that weight loss in middle age will be slower than when you were younger. "Remember that you are in this for the long haul. It is an investment in your health as you get older. Have patience. Your long-term goal is to make a permanent lifestyle change as well as lose the excess fat."
For Samantha, this last tip makes perfect sense.
"In all of this I really try to enjoy the body I'm in. I celebrate my muscles and skin and good hair; that I am healthy and that I look healthy," she says.
"I feel great on LCHF and keto, with whole food eating - great energy, GI tract, focus. So I'm happy to eat this way regardless of the scale. I really do feel that for women in menopause this is the crux of the issue - balancing the desire to lose (or not gain) weight with a focus on physical and mental health. To age with grace and vitality."
