The Midlife "Middle", belly fat, visceral fat and a Dose of Self-Acceptance!

"How do I get rid of this belly fat?"

As yoga teachers, this is probably one of the most common questions we hear from women in midlife. Nearly every woman going through menopause notices her body changing in ways that feel completely unfamiliar. The jeans that always fit suddenly don't, without changing what we eat or how we move.

Restricting food might not even shift the weight, but it will heighten the risk of fractures which is linked to some terrifying stats: approximately 20-25% of people die within 12 months of a hip fracture. So please don’t do it. As we explore below, there is another issue- this type of abdominal fat can be a warning sign.

The Two Types of Belly Fat

Not all belly fat is created equal, and understanding the difference matters.

Subcutaneous fat sits just beneath your skin. You can pinch it. While this might affect how your jeans fit, it's relatively metabolically inactive and less concerning from a health perspective.

Visceral adipose tissue (VAT) is the one we need to understand better. This fat wraps around your internal organs deep in your abdominal cavity. It's metabolically active and inflammatory, releasing substances called cytokines that increase your risk for cardiovascular disease, type 2 diabetes, insulin resistance, high blood pressure, and certain cancers.

Research shows that visceral fat can double during menopause, from 5-8% to 10-15% of total body weight. We cannot always tell who has more VAT as it can hide even inside more slim bodies. 

Why This Happens: The Hormonal Story

Your body is following a predictable hormonal script, and understanding this helps explain why hormone replacement therapy (HRT) can be effective for influencing body composition during menopause.

Estrogen decline is the primary driver. Estrogen directs where fat is stored in your body. Before menopause, it encouraged fat storage on hips and thighs. As estrogen declines, fat redistributes to your abdomen instead. Estrogen also affects insulin sensitivity, inflammation in fat tissue, and how fat cells metabolize energy.

This is why HRT (which restores estrogen) is associated with less visceral fat accumulation. It literally addresses the hormonal shift that's driving the fat redistribution.

Hunger hormones change. Leptin (your appetite suppressant) decreases, while ghrelin (your hunger signal) increases, especially if you're not sleeping well.

Metabolism shifts. Studies show a 32% decrease in fat oxidation after menopause. Your sleeping energy expenditure (the calories you burn just lying in bed) decreases 1.5 times more after menopause.

Muscle mass declines. After age 50, we lose approximately 1-2% of muscle mass per year. Since muscle is metabolically active tissue, this loss affects overall metabolic rate.

The Inflammatory Piece

Here's something fascinating: after menopause, fat cells themselves change. They get larger (adipocyte hypertrophy), more inflamed, and less healthy. This inflammatory fat tissue is linked to insulin resistance and metabolic dysfunction.

This helps explain why the same approaches that worked before menopause often don't work now. The tissue itself has been hormonally reprogrammed.

How to Tell if Belly Fat is Visceral or Just “Surface Fat”

1. Look and Feel

• Subcutaneous fat: This is the soft fat you can pinch just under the skin. Think about the “squish” around your hips or thighs. Not as risky for your health.
• Visceral fat: This is deeper, around your organs. Your belly might feel firm or hard, even if you’re not very overweight. It can make your stomach stick out in a rounded way, like a small ball inside.

Example:

• You pinch your belly and it’s soft – mostly subcutaneous.
• Your belly feels firm and sticks out a bit even when standing straight – could be visceral fat.

2. Measure Waist Size

• Use a tape measure around your waist, just above your belly button.
• Guideline for women:
• Less than 31.5 inches → lower risk
• 31.5–34.5 inches → moderate risk
• Over 35 inches → higher risk

Example:

• Waist = 36 inches → higher risk, even if hips are wide.

3. Check Waist-to-Hip Ratio (WHR)

• Measure hips around the widest part of your buttocks.
• Divide waist by hip:

• Interpretation:
• ≤ 0.80 → lower risk
• 0.81–0.85 → moderate risk
• 0.85 → higher risk

Waist measurement: 36 inches for both women

Woman A (wider hips):

• Hips = 42 inches
• WHR = 36 ÷ 42 = 0.86 → moderate risk
• Belly may be softer and more “distributed” → more subcutaneous fat

Woman B (narrower hips):

• Hips = 38 inches
• WHR = 36 ÷ 38 = 0.95 → higher risk
• Belly more protruding and firmer → more visceral fat

Key point: Even with the same waist, hip size matters. Smaller hips relative to waist → higher visceral fat risk.

Key Takeaways

• Firm, protruding belly = likely visceral fat
• Soft pinchable belly = mostly subcutaneous fat
• Waist Hip Ratio gives more info than waist alone because it considers body shape.
• Track measurements to see changes over time 
• Get medical advise to see if it is of concern or just normal fatty tissue that we all have.

What Actually Helps: Evidence-Based Strategies

1. Resistance Training: Why It Works

Resistance training is the most critical intervention for menopausal body composition changes. Why? Because it maintains and builds muscle mass, which is metabolically active tissue. More muscle means better metabolic rate, improved insulin sensitivity, and healthier body composition overall.

The research shows that resistance training in menopausal women:

• Maintains and builds muscle mass
• Improves metabolic markers including glucose control and inflammation
• Supports healthy body composition changes over time
• Improves bone density (crucial for fracture prevention)

But what about yoga asana?

This depends entirely on how you practice. Traditional asana where we tend to repeat the same poses weekly and have long slow holds, doesn't provide the progressive resistance needed. Dynamic asana like ashtanga or vinyasa flow might offer some more chances for bone and muscle strength but not in a systematic way, targeting different muscle groups. It was never designed for that. However, more gymnast type practices- handstands, “drop backs” etc. definitely meet the criteria for strengthening when we learn new poses, but still lack the progressively nature of a strength program. 

Yoga asana CAN be resistance training if:

• You're progressively working toward more challenging variations (crow to side crow to flying crow)
• You're holding challenging poses for time and gradually increasing that time
• You're working dynamic sequences that build strength (jump-backs, jump-throughs, controlled lowering)
• You're progressing to advanced arm balances and inversions (handstands, forearm stands, etc.)
• You're focusing on building strength to achieve something like a single leg squat- adding pistol squats into practice.

The key word is progress. Just like with weights, your body needs increasing challenge over time. If you're doing the same flow you did five years ago, you're maintaining but not building. But if you're working toward more advanced poses, holding longer, moving more dynamically, then yes, this is resistance training.

Many women find that combining yoga practice with some traditional resistance work (even just 1-2 sessions per week with weights) gives them the best of both worlds. 

Join me for the Empowered Menopause Yoga Teacher Training to understand how best to support women with yoga and  to make informed choices during midlife and beyond.

2. Protein: More Than You Think

As estrogen declines, your muscles become less responsive to protein. It's called reduced anabolic sensitivity. This means you actually need more protein during menopause to maintain muscle, not less.

Target: For menopausal women, current evidence suggests 1.0-1.2 grams of protein per kilogram of body weight daily, with 25-30g per meal when possible. Some research on older adults generally recommends up to 1.2-1.6 g/kg/day for optimal outcomes.

Evidence shows:

• 20% increase in protein intake = 32% lower risk of frailty
• Better muscle strength, bone health, and satiety
• Improved mobility and decreased fracture risk

Key point: You're swapping foods, not adding extra. Replace some of the carbs or lower-protein foods with higher-protein options. E.g. lower fat greek yogurt replaces the fat with protein. Less calories but also more protein. (but personally I find I get hungier quicker if its low fat so it's all a balancing act!)

Protein powder can be a practical way to boost your daily intake by 25-30g in addition to whole foods. For vegans, pea and rice protein blends work well together to create a complete protein, though you may need slightly more total protein than animal-protein eaters to get adequate leucine, which is essential for muscle building.

3. Sleep and Stress: Not Optional

Poor sleep disrupts leptin and ghrelin (those hunger hormones we talked about), increases cravings, and affects how your body stores fat. Chronic stress elevates cortisol, which directly increases abdominal fat.

Here's where yoga absolutely shines:

Yoga can be profoundly supportive for encouraging the relaxation response that supports sleep. When you're sleepless at 3am, gentle movement and breathwork help manage cortisol levels far better than lying there worrying.

Practical approaches:

• Restorative yoga in the evening
• Yoga nidra for sleep preparation or at 3am!
• Breathwork practices (longer exhales activate parasympathetic nervous system)
• Regular meditation, even 5-10 minutes daily
• HRT can make a difference, speak to your medics and get a second opinion if you need to 
• I needed to go private to get a progesterone prescription because I had a hysterectomy and its seen only for its role in protecting the uterus. BUT it has a BIG role in mental health and sleep. (more below)
• And here's something crucial: shame and self-criticism worsen metabolic outcomes through cortisol elevation. Being kind to yourself isn't just nice. It's metabolically protective.

4. Hormone Replacement Therapy

HRT deserves consideration. The evidence shows it:

• Does NOT cause weight gain (despite myths)
• May help with weight management indirectly by improving sleep, energy, and mood
• Is associated with less visceral fat accumulation
• Improves insulin sensitivity and lowers diabetes risk

Women on appropriate HRT often find it easier to maintain healthy body composition. Worth discussing with your healthcare provider.

My personal HRT journey is included below in case you need more on this.

5. Supplements That Can Support Sleep and Metabolism

While food and lifestyle are the foundation, certain supplements can support sleep and metabolic health during menopause:

Magnesium is particularly helpful for sleep. Many women are deficient, and magnesium supports muscle relaxation, nervous system function, and sleep quality. Magnesium glycinate is well-absorbed and less likely to cause digestive upset. Typical dose: 200-400mg before bed.

Vitamin D is crucial for bone health (remember that fracture risk statistic) and may support metabolic health. Many women in the UK are deficient, especially in winter. Get your levels checked and supplement if needed (typically 1000-2000 IU daily, or more if deficient).

Omega-3 fatty acids (from algae for vegans, or fish oil) support inflammation reduction and metabolic health. They may also help with mood and brain fog that often accompany menopause.

Important: Supplements support but don't replace the fundamentals of resistance training, adequate protein, good sleep hygiene, and stress management. Always discuss supplements with your healthcare provider, especially if you're on medications or have health conditions. Quality matters - choose reputable brands that have been third-party tested.

Personal Experience 

I personally found magnesium seems to help my sleep quality, though for me the real game-changer was getting progesterone sorted (see above). I also take lion's mane as there is some evidence that it might help with brain fog. 

What Doesn't Work

Let's save you some time and frustration:

Extreme calorie restriction accelerates muscle loss and slows metabolism further. Your body holds onto fat when it thinks you're starving.

Cardio-only programs don't address muscle loss. Cardio is lovely and beneficial, but it can't replace resistance work during menopause.

Generic weight loss programs ignore the unique hormonal reality you're living in. Your body at 50+ doesn't respond like it did at 25.

The Integrated Approach

The most effective outcomes come from addressing everything simultaneously:

✓ Resistance training 2-3x per week with progressive overload
✓ Adequate protein (1.0-1.6g/kg body weight) distributed through the day
✓ Sleep optimization (7-9 hours)
✓ Stress management (yoga, breathwork, meditation)
✓ HRT consideration when appropriate
✓ Realistic timelines (meaningful changes take 12-16 weeks)

Realistic outcomes and self- kindness- 

Do what you can when you can. You have time. The body remains adaptable, we can always strengthen bones and grow muscle tissue. Manage the sleep and rest first, this is critical for your health and makes the weight management possible. Any movement is better than none. 

The Balance: Science AND Self-Compassion

Body composition changes during menopause are predictable, biochemical responses to hormonal shifts, not moral failings. The research gives us effective tools to support metabolic health. 

We can care about your health while rejecting the toxic message that we must be thin to be valuable.

We can do resistance training without believing we're "broken." You can eat adequate protein without diet culture mentality. Making informed choices can nurture our minds and bodies.

Join me for the Empowered Menopause Training to understand how best to support women with yoga and  to make informed choices during midlife and beyond.

Key References

Abildgaard, J., Ploug, T., Al-Saoudi, E., et al. (2021). Changes in abdominal subcutaneous adipose tissue phenotype following menopause is associated with increased visceral fat mass. Scientific Reports, 11, 14750. doi: 10.1038/s41598-021-94189-2

Beasley, J.M., LaCroix, A.Z., Neuhouser, M.L., et al. (2010). Protein intake and incident frailty in the Women's Health Initiative observational study. Journal of the American Geriatrics Society, 58(6), 1063-1071. doi: 10.1111/j.1532-5415.2010.02866.x

Davis, S.R., Castelo-Branco, C., Chedraui, P., et al. (2012). Understanding weight gain at menopause. Climacteric, 15(5), 419-429. doi: 10.3109/13697137.2012.707385

Greendale, G.A., Sternfeld, B., Huang, M., et al. (2019). Changes in body composition and weight during the menopause transition. JCI Insight, 4(5):e124865. doi: 10.1172/jci.insight.124865

Hughes, V.A., Frontera, W.R., Roubenoff, R., et al. (2002). Longitudinal changes in body composition in older men and women: role of body weight change and physical activity. American Journal of Clinical Nutrition, 76(2), 473-481.

Janssen, I., Powell, L.H., Kazlauskaite, R., & Dugan, S.A. (2010). Testosterone and visceral fat in midlife women: the Study of Women's Health Across the Nation (SWAN) fat patterning study. Obesity, 18(3), 604-610. doi: 10.1038/oby.2009.251

LeBlanc, E.S., Hillier, T.A., Pedula, K.L., et al. (2011). Hip fracture and increased short-term but not long-term mortality in healthy older women. Archives of Internal Medicine, 171(20), 1831-1837.

Lovejoy, J.C., Champagne, C.M., de Jonge, L., et al. (2008). Increased visceral fat and decreased energy expenditure during the menopausal transition. International Journal of Obesity, 32(6), 949-958. doi: 10.1038/ijo.2008.25

Nunes, P.R.P., Castro-E-Souza, P., de Oliveira, A.A., et al. (2024). Effect of resistance training volume on body adiposity, metabolic risk, and inflammation in postmenopausal and older females: Systematic review and meta-analysis of randomized controlled trials. Journal of Sport and Health Science, 13(2), 145-159. doi: 10.1016/j.jshs.2023.09.012

Phillips, S.M., Chevalier, S., & Leidy, H.J. (2016). Protein 'requirements' beyond the RDA: implications for optimizing health. Applied Physiology, Nutrition, and Metabolism, 41(5), 565-572. doi: 10.1139/apnm-2015-0550

Rondanelli, M., Gasparri, C., Peroni, G., et al. (2024). The importance of nutrition in menopause and perimenopause: a review. Nutrients, 16(1), 1-29. doi: 10.3390/nu16010001

My personal HRT journey in case its helpful 

Here's what I learned through trial and error: no-one refers you for HRT, refer yourself at the first sign of perimenopause if you are struggling with symptoms and want to know more. There is much research to show it can support heart health and bone health, as well as mental health.

Estrogen: I went up to the maximum dose, which really helped my anxiety. Don't be afraid to ask about adjusting your dose if symptoms persist.

Progesterone: I struggled with terrible insomnia that nothing seemed to help, even though I was on estrogen. I heard a podcast discussing progesterone and its role in sleep, so I asked my GP about it. But because I'd had a hysterectomy, the standard NHS guidance is that you don't need progesterone (since its main role is protecting the uterine lining from unopposed estrogen). However, progesterone does far more than that - it affects sleep, anxiety, mood, and overall wellbeing. I ended up going to a private GP to get a progesterone prescription, and it made all the difference to my sleep. The NHS has now agreed to prescribe it, but according to the prescription person I spoke to, they wouldn't have offered it otherwise.

Testosterone: This helped enormously with brain fog and anxiety. Here's the thing though: in the UK, testosterone for women is only prescribed if you report low libido. So say to your  doctor/ GP “I have low libido”! That's currently the only approved indication. I had to pay for it privately as it's not covered by the HRT prescription certificate. But for me, the cognitive benefits and anxiety reduction were worth it.

The reality of getting HRT in the UK (+ elsewhere I gather):

• You may need to advocate strongly for what you need

• Don't assume the first prescription is the right one - doses and combinations often need adjusting

• If you've had a hysterectomy, you may have to push for progesterone

• Testosterone requires you to mention low libido to get it prescribed

• Some components may require private prescriptions or payment

Where to get further advice:

• Balance app and website (balance-menopause.com) - evidence-based information and symptom tracking

• The Menopause Charity - free, evidence-based resources

• British Menopause Society (thebms.org.uk) - find accredited menopause specialists

• Your GP - though be prepared that not all GPs are well-trained in menopause management

• In Bristol - Rethink menopause. Sam Blackwell is an excellent private menopause specialist.

The key message: HRT can be life-changing, but you often have to be your own advocate. If something isn't working, don't accept "this is just menopause." Keep asking, keep pushing, and consider seeking specialist advice if your GP isn't helping.

I know in yoga we often think HRT is not "natural" but since we live so much longer now than "nature" intended by the same logic, its hard to say whats' natural or not in such a simple way! But obviously we can all do what we need to.