Beyond the Scale: Metabolic Health

Metabolic health is more important than your weight.

There, I said it.

As a physician, I care much more about your blood sugar, insulin resistance, cholesterol, blood pressure, and muscle mass than the number on your scale. And yet, I hear so much frustration from women about their weight. "I weighed 130 pounds when I was 20, and I can't seem to get back there, even though I'm counting calories and exercising." I understand. 

That quote is from me!

But I'm not 20 anymore. And when I think back, I didn't particularly like my body then, either. Isn't it interesting how we spend so much of our lives wanting to return to a body we didn't appreciate when we had it? Our lives have changed. We move differently, we're often overworked and stressed, and our eating habits aren't always what they used to be. I used to prepare home-cooked meals with a salad almost every day. Now I'm lucky if that happens three times a week.

But something else is happening in midlife that deserves more attention than those extra ten or fifteen pounds. Our metabolic health is changing, often without us realizing it. I have thin patients with insulin resistance, elevated blood sugar, fatty liver disease, and unhealthy cholesterol levels. I also have patients in larger bodies whose metabolic markers are quite good. Your weight tells me something about your body, but it doesn't tell me how healthy your metabolism is. And during the menopause transition, metabolic changes can accelerate.

What Is Metabolic Health?

Metabolism is the collection of processes that allow our bodies to convert food into energy, regulate blood sugar, store and use fat, maintain muscle, and support the functions that keep us alive. When I assess metabolic health, I want to know how efficiently your body regulates glucose, how sensitive your cells are to insulin, where you carry body fat, how much muscle you have, and whether your blood pressure and cholesterol are changing. These systems are interconnected, and when one begins to struggle, others often follow.

Metabolic dysfunction can develop quietly over many years. You may feel perfectly healthy while your fasting glucose gradually increases, your triglycerides rise, or fat begins accumulating around your internal organs. By the time someone develops type 2 diabetes, the underlying metabolic changes may have been present for a decade or longer. This is why I want us to pay attention long before we develop a disease that can damage our hearts, kidneys, nerves, eyes, and brains.

What Happens to Metabolism During Menopause?

Estrogen does much more than regulate our reproductive system. It influences where we store fat, how our muscles respond to insulin, and how our bodies regulate energy. During our reproductive years, women tend to store more fat beneath the skin around our hips and thighs. This is called subcutaneous fat. While we often think of body fat as something undesirable, this type of fat provides a relatively safe place to store excess energy.

As estrogen declines during menopause, our fat distribution begins to change. We tend to accumulate more fat around our abdomen, particularly deep inside the abdominal cavity, surrounding our organs. This is called visceral fat, and it behaves differently from the fat we can pinch beneath our skin. Excess visceral fat is associated with inflammation, insulin resistance, abnormal cholesterol levels, fatty liver disease, and increased cardiovascular risk. What's especially interesting is that these changes can happen without a dramatic increase in weight.

As I discussed in last week's article on bone health, we also lose muscle and bone as we age. We can lose muscle while gaining fat, and the scale may barely change. Add the natural effects of aging, disrupted sleep, changes in physical activity, genetics, and declining estrogen, and we have a period of increased metabolic vulnerability.

At this year's Menopause Society conference, researchers discussed how the menopause transition represents an important period of cardiometabolic change. Cholesterol levels, particularly LDL cholesterol and the number of cholesterol-carrying particles measured by ApoB, can rise around the final menstrual period. Body fat distribution and insulin sensitivity may also change. This means that a woman whose metabolic health looked excellent at 45 may have a very different risk profile at 55, even if she weighs exactly the same. We need to pay much closer attention to what is happening inside our bodies during these years.

Insulin Resistance: When Your Cells Stop Listening

Insulin is a hormone produced by the pancreas. One of its main jobs is helping glucose move from our bloodstream into our cells, where it can be used for energy or stored for later. Think of insulin as a messenger telling our cells that glucose is available. When our cells become less responsive to insulin, the pancreas compensates by producing more of it. This is called insulin resistance, and for many women, it may be one of the earliest signs that their metabolic health is changing.

For years, the pancreas may produce enough extra insulin to keep blood sugar within the normal range. So you could have a normal fasting glucose and hemoglobin A1c while your body is working increasingly hard to maintain those numbers. Eventually, the pancreas may no longer be able to keep up. Blood glucose begins to rise, and prediabetes or type 2 diabetes can develop. Insulin resistance is influenced by genetics, visceral fat, physical inactivity, sleep, medications, and dietary patterns. It is not simply the result of eating too many carbohydrates, and it can happen to women who aren't overweight.

From Insulin Resistance to Prediabetes and Diabetes

Prediabetes means that blood glucose is higher than normal but hasn't yet reached the threshold for diabetes. A hemoglobin A1c between 5.7% and 6.4% is considered prediabetes. An A1c of 6.5% or higher, confirmed when appropriate, meets a diagnostic threshold for diabetes. I consider prediabetes an opportunity because we still have time to change the course of the disease. Improving nutrition, increasing physical activity, building muscle, addressing sleep, and sometimes using medications can substantially reduce the likelihood of progressing to diabetes. Estrogen may be supportive, but using it just for this has not yet been justified. Some people can return their glucose levels to the normal range by lifestyle changes alone.

Why am I so concerned about preventing diabetes? Because persistently elevated glucose can damage blood vessels and nerves throughout the body. We call this end-organ damage. The kidneys can gradually lose their ability to filter blood. The tiny blood vessels in the retina can become damaged, threatening vision. Nerves can become injured, causing numbness, burning, or pain, particularly in the feet. Diabetes also increases the risk of heart attack, stroke, and peripheral arterial disease. These complications don't happen to everyone, and good treatment can greatly reduce the risks. But I'd much rather identify metabolic dysfunction early than wait until someone develops complications.

There is also growing evidence connecting insulin resistance and impaired glucose regulation with cognitive decline. Our brains require a reliable energy supply, and metabolic dysfunction is associated with an increased risk of cognitive impairment. The relationship is complex, and we are still learning how much of that risk can be modified through treatment. But it reinforces something I believe strongly: we cannot separate brain health, heart health, and metabolic health into unrelated conversations.

How Do I Assess Metabolic Health?

I don't rely on weight or BMI alone. I look at several measurements together and, importantly, how they change over time. I want to identify early signs of metabolic dysfunction, ideally before someone develops diabetes or cardiovascular disease. Not everyone needs every test, but there are several measurements I think women should understand.

Hemoglobin A1c gives us an estimate of average glucose exposure over approximately three months. Below 5.7% is generally considered normal, 5.7% to 6.4% is prediabetes, and 6.5% or higher is in the diabetes range. A1c doesn't show the daily fluctuations that contribute to that average, and certain conditions, including iron deficiency and changes in red blood cell turnover, can affect its accuracy. Fasting glucose measures blood sugar after an overnight fast. Below 100 mg/dL is considered normal, 100 to 125 mg/dL indicates prediabetes, and 126 mg/dL or higher is in the diabetes range when confirmed appropriately.

Fasting insulin can sometimes provide additional information about insulin resistance. I find it useful, particularly when other metabolic changes are developing. It needs to be interpreted alongside glucose, other clinical findings, and the laboratory's reference range. A higher insulin level can suggest that the pancreas is working harder to maintain normal glucose, but one number alone cannot establish the diagnosis.

Triglycerides and HDL cholesterol provide additional clues about metabolic health. Elevated triglycerides and low HDL frequently accompany insulin resistance. I also evaluate LDL cholesterol and ApoB and lipoprotein(a), which I'll discuss in more detail next week. Blood pressure is another essential measurement because hypertension frequently accompanies metabolic dysfunction and increases the risk of cardiovascular and kidney disease. These are relatively simple measurements that can tell us a great deal about someone's long-term health.

I also pay attention to waist circumference and waist-to-hip ratio because where we store fat can be more informative than how much we weigh. A waist circumference above 35 inches is a commonly used risk threshold for women in the United States, although risk can increase at lower measurements, particularly in some ancestry groups. A waist-to-hip ratio above approximately 0.85 in women is another marker of increased abdominal adiposity and metabolic risk. To calculate this, divide your waist circumference by your hip circumference, using the same units for both measurements.

In my practice, we use Styku, a three-dimensional body-scanning system that estimates body measurements, shape, and body composition. I appreciate being able to follow changes in waist circumference and body shape over time rather than relying entirely on weight. Styku is a tracking tool, not a direct measurement of visceral fat. When more precise information is needed, DEXA can estimate fat and lean tissue distribution, and certain systems can estimate visceral fat. No single measurement is perfect, but following changes over time can help us understand whether our interventions are working.

I also use continuous glucose monitors, or CGMs. These devices allow us to see how glucose changes throughout the day in response to meals, exercise, sleep, and stress. For some women, seeing their own glucose patterns can be educational. They may discover that a short walk after dinner changes their glucose response or that a night of poor sleep affects their fasting glucose the next morning. CGMs aren't necessary for everyone, and we don't yet have well-established CGM targets for people without diabetes. My goal isn't to give women another collection of numbers to criticize themselves over. I want us to understand our bodies so we can make informed decisions about our health.

What About Your Thyroid?

I can't discuss metabolism without mentioning the thyroid. Thyroid hormones help regulate energy expenditure, temperature, heart rate, and many other metabolic processes. Hypothyroidism can contribute to fatigue, constipation, cold intolerance, changes in cholesterol, and modest weight gain. Some of these symptoms overlap with perimenopause and menopause, which can make it difficult to distinguish what's causing them. They also tend to show up during the menopausal transition. 

I always check thyroid functions, including a TSH, Free T3 and Free T4. Sometimes I will also check for thyroid antibodies if I am suspecting autoimmune issues. I do want to be clear that thyroid disease is not responsible for most midlife weight gain. And giving thyroid hormone to someone whose thyroid function is normal is not an appropriate weight-loss treatment. Our thyroid deserves attention when symptoms or clinical findings suggest a problem, but we shouldn't assume it's the explanation for every change we experience during menopause.

Muscle Is One of Our Most Important Metabolic Organs

Our muscles are essential to metabolic health. Skeletal muscle is one of the primary places where glucose is taken up and used, especially after meals and during physical activity. When muscles contract, they can increase glucose uptake through pathways that don't depend entirely on insulin. This is one reason walking after a meal can help lower the post-meal glucose rise. The more functional muscle we maintain, the greater our capacity to manage glucose and remain physically capable.

Beginning in midlife, women gradually lose muscle mass and strength, especially if we aren't doing regular resistance training. This process can accelerate with inactivity, illness, inadequate nutrition, and advancing age. When muscle declines while body fat increases, our metabolic health can worsen even if our weight stays the same. This is why I pay attention to body composition rather than simply what someone weighs.

I want women to become stronger, not simply lighter. Muscle allows us to climb stairs, carry groceries, hike, travel, get up off the floor, and remain independent as we age. It also helps our bodies regulate glucose. When we talk about longevity, I believe preserving muscle and strength deserves much more attention than achieving a particular number on the scale.

Nutrition: More Than Eating Less

One of the most persistent messages women receive about weight is that we simply need to eat fewer calories. Energy balance is part of weight regulation, but our bodies are more complicated than a calculator. Appetite, satiety, sleep, genetics, hormones, medications, food environment, and the body's adaptations to weight loss all influence how much we eat and how much energy we expend. I don't believe most women need another restrictive diet. I'd rather focus on the quality of our food, whether we're eating enough protein, and how our meals support our energy, muscle, and glucose regulation.

Protein becomes increasingly important as we age because preserving muscle becomes more challenging. For many active midlife women, approximately 1.2 to 1.6 grams of protein per kilogram of body weight daily can be a reasonable goal, adjusted for activity level, health conditions, and kidney function. Fiber is another important part of metabolic health. Vegetables, legumes, whole grains, nuts, seeds, and fruit support digestive health, satiety, cholesterol regulation, and glucose control. I generally encourage women to work toward around 30 grams of fiber daily, increasing gradually and adjusting to what their digestive system tolerates.

A Mediterranean-style eating pattern, emphasizing vegetables, legumes, whole grains, olive oil, nuts, fish, and minimally processed foods, has strong evidence supporting cardiovascular and metabolic health. I also encourage women to pay attention to how they combine foods. Eating carbohydrates with protein, fiber, and healthy fats can produce a different glucose response than eating refined carbohydrates alone. And please, don't be afraid of carbohydrates. Our bodies can use carbohydrates effectively, especially when we're physically active. We don't need to turn every meal into a mathematical exercise or feel guilty about enjoying food.

Exercise: Why Walking Is Good, but Strength Training Is Essential

Physical activity improves insulin sensitivity even without significant weight loss. In fact, exercise isn't a particularly effective weight-loss strategy on its own. You can become much stronger and healthier while the scale barely moves. I love walking, hiking, dancing, cycling, and anything else that keeps us moving. Aerobic exercise supports cardiovascular health, endurance, and glucose regulation. But we also need resistance training because maintaining muscle becomes increasingly important during and after menopause.

Lifting weights, using resistance machines, or doing appropriately challenging body-weight exercises helps preserve and build muscle. Current physical activity guidelines recommend at least 150 minutes of moderate-intensity aerobic activity each week, along with muscle-strengthening activities on at least two days. A combination of aerobic exercise and progressive resistance training is generally more effective for overall metabolic health than either alone. And if you haven't exercised regularly in years, you don't need to begin with an intense program. Start where you are and gradually build your strength and endurance.

I also encourage what I call exercise snacks. Dance to one song. Do 20 squats. Walk around the office. Take the stairs. Get up and move between meetings. These little bursts of movement throughout the day can help interrupt prolonged sitting and improve glucose regulation. Someone can exercise for an hour every morning and still spend most of the rest of the day sitting. Our bodies benefit from movement throughout the day, and these small opportunities can be especially helpful for women who struggle to find time for a formal workout.

You don't exercise for weight loss. You exercise for life gain. I want us to enjoy moving our bodies because it helps us feel strong, capable, and alive. Exercise should support the life you want to live, not become punishment for what you ate.

Sleep, Stress, and the Metabolic Changes We Overlook

Sleep is one of the most underappreciated influences on metabolic health. Even short periods of insufficient sleep can reduce insulin sensitivity and change appetite regulation. Chronic sleep disruption is associated with an increased risk of weight gain, insulin resistance, and type 2 diabetes. This becomes particularly relevant during perimenopause and menopause, when night sweats, insomnia, anxiety, and changes in sleep can interfere with restorative rest. We can eat well and exercise regularly, but if we're consistently sleeping poorly, our metabolic health may still suffer.

Stress also influences metabolism. Cortisol helps mobilize energy during periods of physical or psychological demand. But chronic stress can contribute to poor sleep, changes in appetite, and difficulty maintaining healthy behaviors. I want to address something that's become popular on social media: the idea that all abdominal weight gain is caused by cortisol. It isn't. Abdominal fat accumulation involves a complicated interaction between sex hormones, insulin, stress hormones, brain signaling, genetics, and lifestyle. Blaming everything on cortisol oversimplifies what is happening in our bodies.

And during midlife, our hormones are changing while life keeps demanding more of us. We may be caring for aging parents, supporting children, managing careers, navigating relationships, and trying to find time for ourselves. Sometimes the most useful metabolic intervention isn't another supplement or a more intense workout. It's treating night sweats, improving sleep, addressing sleep apnea, reducing chronic stress, or creating enough space in life for genuine recovery. We need to acknowledge how much our daily lives influence our health rather than expecting ourselves to overcome everything through willpower.

Where Do GLP-1 Medications Fit?

Medications such as semaglutide and tirzepatide have changed how we treat obesity and metabolic disease. They work through hormonal pathways involved in appetite, satiety, and glucose regulation. Semaglutide activates the GLP-1 receptor, while tirzepatide activates both GIP and GLP-1 receptors. For appropriately selected patients, these medications can produce substantial weight loss and improve glucose regulation. Some also have demonstrated cardiovascular and other clinical benefits in specific populations.

I prescribe these medications in my practice, and I've seen how helpful they can be. But they aren't magic. I've also seen patients lose significant weight without making meaningful changes to their nutrition, physical activity, or overall metabolic habits. The medications themselves can improve important metabolic markers, but they don't automatically create the habits that will support someone's health over the coming decades. We need to think beyond what happens while someone is taking the medication and consider how they will maintain their strength, nutrition, and metabolic health over time.

We also need to talk about muscle. When someone loses a substantial amount of weight, they generally lose both fat and some lean tissue. Bone health also deserves attention during significant weight loss, particularly in postmenopausal women. This is why I emphasize adequate protein, resistance training, and monitoring body composition when patients use these medications. I want my patients to lose excess fat while preserving as much muscle and physical function as possible.

I don't believe every woman who gains ten pounds during menopause needs a GLP-1 medication. For some women, these medications are an important treatment for obesity, diabetes, or other metabolic complications. For others, changes in nutrition, physical activity, sleep, and stress may be enough. Treatment should be based on medical indications, metabolic health, risks, and personal goals, not simply frustration with a changing body.

Can Menopausal Hormone Therapy Improve Metabolic Health?

Because estrogen influences fat distribution and insulin sensitivity, it's reasonable to ask whether menopausal hormone therapy can help protect metabolic health. Research suggests that hormone therapy may modestly improve some aspects of body fat distribution and glucose regulation in certain women. It can also improve sleep and quality of life when menopausal symptoms interfere with daily functioning. These benefits can indirectly support healthier behaviors, particularly when a woman is finally sleeping well enough to exercise, prepare nutritious meals, and feel like herself again.

But menopausal hormone therapy is not a weight-loss treatment, and I would never promise that an estrogen patch will eliminate abdominal fat or reverse insulin resistance. For women who are appropriate candidates and experiencing menopausal symptoms, these possible metabolic effects can be part of our discussion about treatment. We also need to assess cardiovascular risk before prescribing hormones, particularly as women get older or further from menopause. Hormone therapy should not be prescribed for the purpose of preventing heart disease.

At the Menopause Society conference, the importance of understanding each woman's cardiovascular risk when making decisions about hormone therapy was an important part of the discussion. We need to understand the whole woman, including her metabolic health, cardiovascular risk factors, symptoms, and personal goals. Just as with brain health, I don't want us to turn estrogen into either the villain or the solution to every change women experience during menopause.

Metabolic Health Is About the Future You Want

I believe cardiometabolic health in midlife women has been overlooked for far too long. We spend so much time talking about hot flashes, weight gain, sleep, and hormone therapy, while metabolic changes that influence our health for decades may be developing quietly. You may leave your annual appointment with a prescription for an estrogen patch but without a meaningful conversation about your rising blood glucose, changing cholesterol, increasing abdominal fat, or loss of muscle. These changes deserve our attention, and I hope to help you feel comfortable asking your clinicians to evaluate your metabolic health as part of their menopause care.

When I care for a woman in her 40s, 50s, or 60s, I'm thinking about the decades ahead. I want us all to have the strength and energy to hike, travel, dance, carry groceries, enjoy our sexuality, and remain physically independent. I want us to reduce our risk of diabetes, heart disease, stroke, and other conditions that can interfere with the life we want to live. And I want evert woman to stop measuring her health, or her worth, by the number on a scale. 

So along with the estrogen patch your primary care clinician or gynecologist may be prescribing, I encourage you to ask about the rest of your health. Know your blood pressure, glucose, A1c, and cholesterol. Ask whether additional testing for insulin resistance or cardiovascular risk would be useful. Have your thyroid evaluated when your symptoms suggest a problem. Pay attention to your waist circumference, strength, and body composition. You don't need to measure everything or turn your health into a full-time project, but you deserve to understand what's happening inside your body.

The goal isn't simply to weigh less. It's to build a body that can support the life you want to keep living.

Coming Next Week: Your Heart Health After Menopause

Next week, we'll talk about something I believe deserves far more attention in women's healthcare: cardiovascular health. Heart disease remains the leading cause of death among women, yet too many women enter menopause without a meaningful assessment of their cardiovascular risk. I'll share some of the research discussed at this year's Menopause Society conference, including why our cholesterol can change around menopause, why a standard cholesterol panel may not tell the whole story, and which additional tests can help us better understand our risk.

We'll also talk about coronary artery calcium, ApoB, lipoprotein(a), and why knowing your cardiovascular risk before starting hormone therapy is important. Some of this information may be new to your primary care clinician, and I want you to feel comfortable asking questions and participating in decisions about your health. I want us to spend less time worrying about whether we can fit into the jeans we wore at 25, and more time protecting the health that will allow us to live fully for decades to come.