Clinicians should discuss obesity prevention strategies with all women aged 40 to 60 years even if they are not overweight, according to a new clinical guideline by the Women’s Preventive Services Initiative (WPSI) published in Annals of Internal Medicine.

The recommendation was made based on the balance of benefits and harms found in an accompanying systematic review of women at midlife. Normalizing counseling about healthy diet and physical activity by providing it to all women at women “may also mitigate concerns about weight stigma resulting from only counseling women with obesity,” the guideline authors noted.

The WPSI recommends counseling women aged 40 to 60 years with normal or overweight body mass index (18.5-29.9) to maintain weight or limit weight gain to prevent obesity. Counseling may include individualized discussion of healthy eating and physical activity.

Obesity affects approximately 43% of American women aged 40 to 59 years. Weight gain at this age may be related to physiologic changes related to aging, menopause, reduced physical activity, and changes in body composition. Previous clinical recommendations have not specifically addressed obesity prevention in women at midlife with normal or overweight BMI. The WPSI recommendation addresses this gap. The WPSI is a national coalition of women’s health professional organizations and patient advocacy representatives.

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Evidence Review

The systematic review included 7 randomized control trials (RCTs) that included a total of 51,638 participants, most of whom were between 40 and 60 years of age with BMIs in the normal to obese categories. Five of the trials focused on counseling participants, with clinicians offering advice or specific recommendations on behavior change, such as weight monitoring, dietary changes, or physical activity. Two trials focused on exercise: 1 evaluated medically supervised exercise and 1 evaluated both exercise and counseling.

Four of the 5 counseling trials showed statistically significant differences in weight loss (1.9 to 5.5 pounds) favoring moderate- to high-intensity counseling interventions versus control interventions. The 2 exercise trials did not show a significant effect on weight loss. No adverse psychological effects associated with counseling interventions were reported, and 1 trial found an increased incidence of self-reported falls with an exercise intervention for previously inactive women who were overweight (37% vs 29% with control intervention).

The findings are limited by the limited number of high-quality research studies on this topic. The studies reviewed were of short duration and evaluated different interventions. 

Some forms of behavioral counseling approaches to prevent weight gain among women at midlife may result in modest weight loss without causing harm, the study authors concluded. Further research is needed to identify optimal behavioral interventions that are effective, feasible, and sustainable, and can be implemented in primary care settings among diverse populations, according to the guideline authors.

Tips for Counseling Women on Preventing Weight Gain at Midlife

“The most important thing is to not deliver passive messages” and to empower women, said Zhaoping Li, MD, PhD, in an interview. “I am often very frustrated with primary care clinicians, including my own, who say that the weight gain is a fact of menopause and there is not anything you can do about it.” Dr Li is director of the Center for Human Nutrition and Chief of the Division of Clinical Nutrition at David Geffen School of Medicine at UCLA.

Zhaoping Li headshot
Zhaoping Li, MD, PhD

Many women lack adequate protein intake that is essential to counteract the decrease in muscle mass that occurs as estrogen levels decrease during perimenopause and menopause. Also, women’s bodies “are less efficient at using this macronutrient” as they age, she said. “It is even more important to increase daily activity or start an exercise program to help our bodies best use protein and other nutrients.”

Decreasing carbohydrate intake is also important. Women at midlife need approximately 8 grams of carbohydrates per hour if they work a sedentary job, she said, adding that 1 slice of bread contains 30 grams of carbohydrates and would take 4 hours to burn.

Women also need to increase their intake of phytonutrients such as lycopene, lutein, and resveratrol, which are found in a plant-based diet, she said. She educates all of her patients including menopausal women to replace refined starches with vegetables.

In the Women’s Health Initiative Observational Study, postmenopausal women (n=88,805) with the greatest level of adherence to a reduced-carbohydrate diet had the lowest risk for weight gain compared with those following a Mediterranean-style diet or Dietary Guidelines for Americans diet. A low-fat diet was linked to the greatest risk of weight gain.

Dr Li emphasized that a one-size-fits all diet for women at midlife is not realistic and that as many as 50% of women may not respond to a low-carbohydrate, high-protein diet. These women may need to use different strategies such as intermittent fasting, reducing stress levels, improving sleep, and working more resistance training into their day. 

“We are learning more and more about individual differences in metabolism as we age,” Dr Li said. “That is why the National Institutes of Health launched the Nutrition for Precision Health study that will develop algorithms to predict individual responses to food and dietary routines. In another 5 or 10 years, we will have more knowledge on how to individualize management.”


Chemlow D, Gregory KD, Witkop C, et al. Preventing obesity in midlife women: a recommendation from the Women’s Preventive Services Initiative. Ann Intern Med. doi:10.7326/M22-0252.

Cantor AG, Nelson HD, Pappas M, Atchison C. Preventing obesity in midlife women: a systematic review for the Women’s Preventive Services Initiative. Ann Intern Med. doi:10.7326/M22-0160.

This article originally appeared on Clinical Advisor