[INTERVIEW]
Ronda Nelson: You know, she’s been doing everything right. She eats clean, she’s cutting her calories, she’s walking every morning, and she’s still gaining weight around the middle, and it will not come off. This is the number one complaint we hear from menopausal women, and one of the most — in my opinion — mismanaged. The standard advice is to eat less, move more, exercise, but not only does it not work, it often makes it worse.
Belly fat in menopause is not a willpower problem. It is a physiology problem, and today we’re gonna talk about the actual mechanism — why it happens, and what to do about it.
Well, hello and welcome back to the show. Today we’re gonna be talking about menopause and belly fat, and if you have been around for any amount of time, I am pretty certain that you as a provider have met these women that come in and they just can’t get rid of that belly fat. It is a stubborn, stubborn problem.
And yes, there are aesthetic things that they could do, but what if we took the approach that it’s fixable? I would argue that it could be. That fat doesn’t have to be stubborn. But for these women that come in, it’s a big deal for them. I mean, they are… They’re struggling. They are on the struggle bus, and they’re gaining weight. It won’t come off, doesn’t matter what they do — diet, exercise, none of that works. So I wanna talk to you today a little bit about why that happens and what we can do about it.
So first, we have to talk about — now we’re talking about menopausal women here, right? Okay, so we gotta be clear about that. Sometimes it’s in that perimenopause window, you know, that little window — five to 10 years before they actually have that last period and their 12 months with no menstrual cycle. But during that perimenopause period through menopause and even post-menopause, that’s when we start to see this happening.
So let’s talk a little bit about why it happens and what’s going into this — what’s causing the problem, so to speak. First of all, I think that we all know that estrogen is dropping, right? That’s clear. So the estrogen is dropping because she’s in menopause. She doesn’t have that E2. What happens is she ends up with more E1. Now, E1 is the post-menopausal or menopausal hormone. E3 is the estrogen that is predominant during pregnancy. Clearly, she’s not pregnant. So we need to think about E1.
Well, let’s — before we get there, let’s kind of back it up a little bit and let’s talk about estradiol or E2 and insulin sensitivity, because any time we have fat, we know that there is probably some dysregulation in the glucose, insulin, and how those two are working together. So estradiol plays a role in maintaining insulin receptor sensitivity, especially in skeletal muscle and adipose tissue. Estrogen, E2, actually upregulates a transporter protein called GLUT4 in the muscle cells. And what that does is it actually pulls the glucose out of the bloodstream after meals. That’s what it does.
But when estrogen declines, GLUT4 declines as well, so the cells become less responsive to insulin, glucose stays longer in the bloodstream after meals, and insulin remains high to try and compensate. It’s trying to help because the GLUT4 isn’t working to pull the glucose into the muscle. And that’s the estradiol-insulin-glucose piece.
But before she hits menopause, you have to remember, too, that estrogen is going to naturally direct a little bit more fat storage towards the hips, the thighs, and the glutes. That’s that pear-shaped body type, right? We know this. But after menopause, when we’re through with this menopausal transition, the estrogen influence changes. We change from E2 to E1, and the fat storage then shifts. Important to note that the body is still storing fat during reproductive years — it’s just storing it differently. Now, that doesn’t mean that a woman who is running and exercising can’t keep those fat stores down a little bit on her hips and thighs. But in menopause, that’s not as likely to happen. In fact, because that estradiol starts to drop, the fat storage starts to shift to the abdomen and the tissue surrounding the abdominal organs, and then that adipose tissue releases those fatty acids back into circulation — which can drive some hepatic insulin resistance and cause some inflammation.
But the adipose tissue — I think this is the key — the fat cells are the body’s backup hormone system. And if you’ve been hanging around with me any amount of time, you know this. The adipose tissue is absolutely central to her backup hormone system, and this is the part that we forget to tell them. The body wants to store or hold onto that adipose tissue after menopause because the adipose tissue is the primary production site of estrogen via the aromatase enzyme. That’s where it comes from. And so that aromatase enzyme converts the androgens — mostly androstenedione, some DHEA, et cetera — down into E1, and that’s the compensatory mechanism. The ovaries stop with E2, and then we go into E1, which is our menopausal hormone, and the aromatase enzyme keeps converting it. But the body goes, “Yeah, I can’t trust that that’s always gonna be there. I need to make sure I’ve got extra fat so that I have estrogen — E1 specifically — when I need it.”
So if the body is actively trying to store fat, why does it store more in one woman than another? You’ll have one woman that had a flat, flat, flat belly, and then boom — she’s got a nice little roll around the lower abdomen. Why does that happen in one woman, but not another?
So what we often tell them to do, which doesn’t always work out well, is “just do intermittent fasting.” Well, wait a minute. When you do intermittent fasting, what’s happening is we could, in some women, actually make the problem worse because we’re calorie restricting when her body just wants those calories to make sure it feels stable — there’s enough glucose, we’ve got everything we need to be able to create these hormones. So I don’t know that calorie restriction in women is necessarily a beneficial thing. I think the body senses the threat of low calories. It protects that backup hormone factory and holds fat even more tenaciously. That’s what I believe happens. So the belly fat isn’t the body being stubborn — it’s just the body’s strategy. It’s holding on to its only remaining estrogen source. The clinical question becomes: how do we support the transition so the body doesn’t feel like it has to hold on so hard? That’s our job.
So there’s also the adrenal connection, and this is the one that most patients can understand. We can’t talk to them about GLUT4 and their muscles and all that — no, no, no, that’s not gonna work. What we wanna talk to them about is how the HPA axis responds during menopause. Because the adrenal glands are that backup hormone system. But are the adrenal glands involved in blood sugar regulation? Yes. So could we blame this fat accumulation on excess glucose in the bloodstream and poor insulin response? It’s a contributing factor for sure. But I think at the end of the day, we have to be aware that the adrenal glands and relative dysfunction play a bigger role than we think.
Because if you think about it — I’m in menopause, and I wouldn’t say that my life has been without stress. In fact, I’ve had a lot of years of some pretty dang stressful periods of time. And as we get older, that HPA axis becomes more and more dysregulated. Whether it’s just dysregulation in the HPA or you actually have a frank issue with the way that cortisol is produced from the adrenal glands — i.e., they’re kinda tired, they’ve just become really dysregulated, whether that’s because of poor signaling or because you’ve just used them up and burned them up because the stress has been so high — regardless of where it happens, when we get into menopause, the more insufficient the adrenal glands are in regulating cortisol, in other words, the more chronic stress there’s been in her life, the body’s gonna prioritize cortisol every single time versus prioritizing sex hormones.
And if you remember, that sex hormone pathway starts with cholesterol to pregnenolone. Pregnenolone diverts over into 17-hydroxypregnenolone or DHEA. One is the cortisol pathway down. The other is the sex hormone pathway down. Progesterone kinda links them together at the bottom. So if she’s under high stress, those sex hormones aren’t gonna get what they need — and the body will always prioritize cortisol production. And cortisol opposes insulin. Cortisol promotes gluconeogenesis, and it contributes to central fat accumulation and deposition. There it is.
So what if the only thing we did for her was just start to work and support her adrenal glands? Could we make a difference? I would say yes. Now, I’m not saying we don’t need to address diet and get the sugar and the carbs out — all that’s obvious. But if we’ve got high cortisol, if there’s a stress response in menopause or the years leading up to it, that is going to end up creating higher fat deposition in that lower belly.
And so I’ve always kind of said that it’s normal for a woman to gain around five pounds or so when she goes into menopause — this is normal. But I’ve kind of used a clinical test where I will say: if she has gained more than five pounds — let’s say it’s 10, or 15, or 20 pounds — I use that as an indicator to me as to how dysregulated those adrenal glands are. I think the more weight she gains, the more likely it is that those adrenal glands are involved. It’s kind of a big Las Vegas neon flashing sign saying, “Look here, look here, look here,” pointing right at those adrenal glands.
And then you get the 2:00 AM cortisol surge — that’s just liver and adrenals. And so that can be a clinical sign too that can point you back toward those adrenal glands. And then you’ve got the hot flashes — the adrenal glands and cortisol are contributing to those as well.
So if we ever had a starting place for a woman in menopause… Again, I started this episode by talking about lower belly fat, but my point is it’s never just that. It’s not just diet. It’s not just exercise. It can’t be. There are too many other things going on. What we have to realize is that this whole process of her going through menopause is — I’ll call it a multidisciplinary exercise. This is special forces all together times 20. There are a lot of things happening in the body, and managing the symptoms one by one by one isn’t always going to get you where you need to go. Because then it’s like playing Whac-A-Mole at Chuck E. Cheese. The mole pops up and you just whack it. Oh, hot flashes — here you go. Something else — here you go. Oh, something else — here you go. We’re just playing Whac-A-Mole, but we’re not addressing the system, the underlying cause, a system that is actually dysfunctional.
And then we might tell her, “Well, just restrict your calories.” First of all, that creates physiologic stress when we don’t eat — raises cortisol, lowers blood sugar, increases insulin. Insulin is a fat storage hormone. Cortisol contributes to fat storage, and if she’s already under some HPA axis stress, this is the definite wrong direction to go. She needs less cortisol pressure, not more. We need to calm her down. We need to reset that HPA axis so that she can get energy back, she can feel better. She should not be restricting her calories, in my opinion.
So let me kind of walk this through with you. I know I just kinda dropped a lot on you, but this is on my mind lately. So first of all, she has declining estrogen — specifically estradiol. Her estrogen’s going down. That’s going to cause reduced sensitivity to insulin because E2 and insulin, they work together. So her E2 goes down, insulin goes down, her fasting insulin can maybe go up a little bit. If it does go up, it is going to cause some central fat storage. That’s gonna happen.
If she has adrenal stress, that adrenal stress is causing elevated cortisol. That cortisol is causing gluconeogenesis to happen. We get higher blood sugar, and then we have higher insulin, and then that can lead us to more central adiposity. Now we’ve got more aromatase activity, and we end up with more E1 — and we end up really with an estrogen dominance. And people throw that term around, and it’s always kind of made me crazy. I’m like, estrogen dominance relative to what? The moon? You have to have estrogen dominance in relationship to something. What are we in relationship to?
So if we have a relative estrogen dominance — and remember, E1 and E2 are not the same — what kind of estrogen are we talking about here? Even though E1 is a weaker estrogen, it still binds to the receptors, and it can drive those symptoms. So we have to look at what this ratio is between some of these hormones.
Then insulin goes up because we’ve done intermittent fasting, or we’ve got this low E2, and we’re working on the E1. When we get elevated insulin, that tends to suppress sex hormone binding globulin. So now we have all these hormones — they don’t have a protein to bind to, so we have more free hormones available, and that worsens the estrogen dominance symptoms. Because even though we have low estradiol, she feels worse because we have low sex hormone binding globulin. And then top all that off with poor sleep because she’s having hot flashes every night, so her cortisol’s up — and it just becomes a super vicious cycle.
So what is it that we’re going to do? Are these separate problems, is my question — or are they the exact same problem running through different systems? I would argue that it’s the one problem, and it’s running through different systems. Because if we chase the symptoms, we’re not going to be able to effectively address the system that’s causing the issue.
So now — what do we address? Okay. I like to ask a few questions. First question I’m gonna ask is: where do you normally carry your weight, and has that weight changed in the last five years? Is this normal for her? Most of the time, these menopausal women are gonna say, “No, I’ve never had this before.” Second, I’m gonna ask her what happens between about 1:30 and 3:00 in the morning, and is there associated sweating or anxiety around that time? My friend, that is a key question, because that tells you cortisol is involved. If she wakes up and has a hot flash, or wakes up and there’s anxiety, that is adrenals — that’s cortisol right there.
I would also ask how her energy is sustained throughout the day. Is she pretty level? Does she crash in the mid-afternoon? Does she have to go to bed by eight o’clock because she’s worth nothing, or does she get that cortisol bump in the evening? And then for sure, you wanna ask about diet. What are you eating? When are you eating? Are you skipping meals? Are you living on coffee in the morning only? Are you doing low fat? Are you a vegetarian? What’s happening with your diet? You’ve gotta get a diet log, because blood sugar becomes absolutely critical — and I cannot underscore that enough in this population of women.
And then we wanna know what her stress history looks like. Has stress always been high? Have you had a pretty stress-free life? What was happening in your 30s and 40s? Because remember, those are the years prior to perimenopause, and that’s where a lot of this starts. I always say the stage is being set in your 30s, and in your 40s is when you’re having to live in the stage you set in your 30s — which is giving rise to what your experience is gonna be in your 50s, in your menopausal years.
So I’ve always said you have to start supporting menopause in your 30s. But you say the M word to a 30-year-old, and they will punch you in the throat. I can’t tell you how many patients I’ve had that say, “I don’t wanna talk about it. I don’t wanna talk about it.” I’ve had a couple of people who start crying. They’re like, “No, I don’t wanna be in menopause.” I’m like, “I’m not saying you are. I’m just saying when you get there.” “I don’t wanna talk about it.” Okay, great. No problem. We can just let this one ride, but it isn’t gonna work out well if we don’t prep them in their 30s.
Think of it like a theater. In the 30s, we’re bringing in all the props. We’re making sure the lights are good, everything is good, so that in the 40s she can be on her stage. Because if we don’t set that stage, then when she moves into her 50s, it’s just chaos. The lighting people don’t know what they’re doing. The prop people don’t know what they’re doing. Back of the house doesn’t know what they’re doing — it’s chaos, and her symptom experience becomes chaos. So you wanna ask about stress history during the 30s and 40s.
Metabolically, I would definitely look at glucose, fasting insulin, A1C, triglycerides. A saliva test is good to map out that cortisol — it gives you that whole diurnal curve, morning, noon, afternoon, and evening, rather than just taking it with serum, which only gives you one snapshot into the day.
So what are we gonna do with her? First — and I’ve been saying this for 20 years, I don’t even know how I figured it out, but it still sticks — the PFC: protein, fat, carbohydrate with every single meal or snack. That’s it. And I would now add fiber because it helps stabilize glucose, especially in this case. Protein and fat slow gastric emptying and help moderate the glucose response, and they give satiety — mostly the fat, but it will give satiety. The carbohydrates do not give satiety like that.
The goal with her is to keep her blood glucose as stable as we can. No high spikes, no low dips, no living off caffeine — none of that business. We are gonna keep it steady, steady, steady Eddie. This reduces cortisol, it’s gonna help her sleep better, and we’re also going to reduce that central adiposity by stabilizing her blood sugar.
She really, really needs protein. In menopause, it’s natural that we have some muscle loss, right? And that skeletal muscle is the primary site of glucose disposal, even with the reduced GLUT4. So when we lose muscle, we’re also not able to buffer that glucose, pull it out of the bloodstream, and insulin can go high.
So our target — in order to increase satiety, elongate that glucose, make it really work for us — I really think that women should be shooting for 25 to 30 grams of protein per meal. Not per day, per meal. And especially breakfast. We know when mom said breakfast is the most important meal of the day, she was right — I’ve seen it over and over again. Women that don’t eat a good breakfast tend to have trouble with weight and difficulty maintaining good glucose balance throughout the day. They get cravey. They get those sugar cravings. That’s no good. We have to get that breakfast, get them off to a good start. And often, with a good breakfast, I’ve found that they’ll eat less during the day — it can actually stabilize glucose, and they tend to eat a little bit less.
And then before bed — if you have that woman that wakes up in the middle of the night, between 1:30 and 3:00, maybe has a hot flash, a little bit of anxiety or something — you can try giving her a little bit of protein, fat, and carbohydrate. I usually say protein, fat, fruit, or veggie. I don’t want them thinking carbohydrate means a piece of toast. What we wanna do is give the body just enough substrate to maintain blood glucose through the night. That’s all. It could be a hard-boiled egg with some olives. Doesn’t have to be much. It could be full-fat Greek yogurt with some nuts. Just a small bedtime snack makes a big difference.
And then, as we wrap up, I wanna talk about a few herbs that you can also add in. Cinnamon is always a good thing — get a good quality cinnamon. You can use it as a liquid. There’s a lot of supplements you can get that have cinnamon and other things in them. I put cinnamon in my smoothie — whenever I make a smoothie, I just put a whole bunch of cinnamon in. It helps support insulin receptors and also improves the GLUT4 pathway. See how this ties in? Gaia has a cinnamon bark — I think it’s a PhytoCap. And I think Doctors Research has something with cinnamon in the glucose-sugar-balance formula, though I’m not positive on that.
Another one is berberine. Berberine’s always good. Standard Process has one, or MediHerb — and Gaia has one as well. There’s lots of berberine products available. This is one of the most well-researched compounds for helping with insulin sensitivity, especially because it activates what’s called AMPK — the cellular energy regulator. It improves glucose uptake, so think about it like a little motor. If you can improve AMPK, it’s like getting the RPMs up. The cells start to use the glucose faster. Gaia has one called AMPK Activator, and I’ve used that with a lot of women who’ve needed to lose weight, and it works well. It’s not gonna take 10 pounds off in two weeks — it’s not gonna do that. But it does work, very, very well.
Another one is gymnema. That’s always kind of been my favorite, because it helps sensitize insulin receptors, and it also anesthetizes sweet taste perception and reduces glucose absorption in the intestine — so it works sort of like the GLP in that manner. But it does support beta cell function in the pancreas, which is great, so it’s safe for type 2 diabetics. I use it quite often with type 1 as well. I would give gymnema if sugar cravings are part of their issue. If they don’t have high sugar cravings, then berberine and cinnamon — or some combination that has those two — is amazing.
Now what are we gonna do with adrenals? Well, that’s easy. If you’ve been hanging around any amount of time, you know I’m gonna say: start with adaptogens. You can use withania, you can use Gaia products — Gaia’s got some great adrenal support products. Daytime HPA is kind of their flagship. You can use any adaptogen. Rhodiola is a great one. Holy basil is also good for cortisol modulation and blood sugar support in general. If they have high, high cortisol, you could even use phosphatidylserine — sometimes I’ll give that at night if they have higher cortisol in the evening. Chromium is the mineral for the pancreas, so you can use that. Alpha lipoic acid can sometimes help too — when you have people that are kind of resistant, sometimes I’ll give them a little ALA, and it will improve that glucose uptake in the muscle cells through the GLUT4 as well.
So there’s lots of things you can do here, but the key is: we wanna make sure we’re getting those adrenals supported and helping with the blood sugar system. I’m not talking about managing a symptom. If she wakes up, my question is: well, why is she waking up? What are the other things that are going on? She’s complaining about lower abdominal fat — I’m like, hmm, and you’re in menopause, okay. And you’ve had some high stress, okay. And you’re not sleeping, okay. And the list goes on and on. I’m probably gonna start with those adrenal glands, because I really believe that stress is a big driver with this central adiposity. And then you pack or layer on glucose dysregulation — and the adrenal glands, cortisol, and glucose dysregulation, they all kind of go together. And then declining estradiol. We just tell her to exercise more, intermittent fasting, et cetera — but I think there’s a lot better way to manage these types of patients.
Everything I shared with you — the adrenals, the glucose — and we’ve got mood and libido, and all the other symptoms that come with this — but all of them are part of a bigger picture. Belly fat is just one part of a potential metabolic dysfunction or an adrenal dysfunction. These symptoms don’t exist in a vacuum. They all connect. They connect to adrenals. They affect sleep. They’re involved with liver and bile function — which I talked about in a recent episode. They’re connected to hot flashes and vaginal dryness and loss of libido and brain fog and cardiovascular risk. All of those things can manifest as symptoms. And it’s so easy for us to just go, “Oh, symptom — here’s a supplement. Oh, there’s this — let’s give this herb. Oh, here’s one, let’s try this one.” When really what we want to do is rethink this and approach it from a systems perspective rather than a symptom perspective.
[CLOSING]
Ronda Nelson: Now, I have to say — the reason I’m talking about this specifically is because it’s been on my mind a lot lately. I’m teaching a menopause seminar on May 30th. It’s called Understanding Menopause: Supporting Women Through Those Transitional Years — premenopause, perimenopause, menopause, postmenopause — and there are a whole bunch of changes that happen in there. I’m teaching a six-hour seminar on Saturday, May 30th, and you can register for it in the show notes. All you have to do is go to rondanelson.com/meno2026. This is through May 17th — this week only. It ends on May 17th. There is early bird pricing, and you can use code EARLY50 and get $50 off. It’s $249, and if you register this week, you get it for $199.
I highly recommend it. What I’m going to do is provide for you and teach you a brand-new framework that I’ve put together on how to work with these menopausal women in a very structured, strategic way so that we’re not playing Whac-A-Mole for weight gain, we’re not playing Whac-A-Mole for fatigue, we’re not playing Whac-A-Mole for hot flashes. With this framework, I’m giving you all the resources to do it, plus a quiz — you’re gonna have to get on the seminar to find out more about that. But for everyone who shows up, I actually have something that’s going to be a tool you can use with your patients to find out which system is under the greatest stress. Yes, I’ve got that for you.
So this is a brand-new framework. I’ve never taught it before. It’s not inside Clinical Academy. If you want it, register. The seminar is on the 30th of May. If you can’t join live, no problem — all you have to do is register and you’ll get the notes. I have a menopause kit for you that has a whole bunch of resources and frameworks and images and diagrams, a whole bunch of stuff, as well as access to the replays. So even if you can’t make it on Saturday, register — because you can get access to all the things afterwards.
Go to rondanelson.com/meno2026. Use the code this week only — EARLY50, E-A-R-L-Y-5-0 — and that will give you $50 off. Go grab your spot. I will see you next week on the show — the podcast, now on YouTube. I’m loving this — it makes me so happy. Grab a cup of coffee if it’s morning and you’re listening. Go exercise. Go do something wonderful for yourself today, and I’ll see you next week on the podcast. Take care.
[END]