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 Fat

Not all 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. So understanding body composition is much more important than the numbers on the scale or BMI. 

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, this is the process by which your body breaks down stored fat and burns it for energy. It's literally "fat burning.". Your sleeping energy expenditure (the calories you burn just lying in bed) decreases 1.5 times more after menopause.

Muscle mass declines. Muscle mass declines dramatically during perimenopause, lean body mass decreases by approximately 0.5 or 1% per year. However, the real acceleration happens by late perimenopause, women can lose up to 10% of their muscle mass in their arms and legs. The prevalence of sarcopenia (muscle loss) jumps from just 3% in early perimenopause to 30% in late perimenopause. Since muscle is metabolically active tissue, this loss significantly affects overall metabolic rate and health.

Inflammation

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
• Muscles at work are effective at removing glucose from the blood stream and as our muscles grow our metabolism increases so we more easily burn off calories.
• This means muscles improve metabolic markers including glucose control and inflammation and thereby reduce the risk of type 2 diabetes 
• Supports healthy body composition changes over time
• Improves bone density (crucial for fracture prevention)

2. Protein: More Than You Think

Protein is the building block of muscle. 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. 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; the role of progesterone is key here as it helps with anxiety and sleep. Although it is not prescribed after a hysterectomy, it can be safely taken and recommended once the mental health piece of the puzzle is understood.
• Yoga can also be adapted to really support mental health and reduce anxiety. I cover this in depth in the Yoga for Anxiety & Trauma course and give the "how-to" approach in the Empowered Menopause training. 

4. Hormone Replacement Therapy

HRT deserves consideration. The evidence shows it:

• May help with weight management directly by shifting the hormone balance 
• May also support indirectly by improving sleep, energy, and mood, especially Progesterone 
• Is associated with less visceral fat accumulation
• Improves insulin sensitivity and lowers diabetes risk
• Testosterone can support muscle growth but is only given "off" prescription in the UK when you tell your GP you have lost your libido (I believe this is similar in US)

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

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. Quality matters - choose reputable brands that have been third-party tested. There are MANY supplements now recommended for menopause but these 3 have some really good research behind them. 

6. The Role of Fiber

Often forgotten, but alongside protein intake fibre slows glucose absorption, preventing blood sugar spikes that trigger hunger and fat storage. It keeps you full longer by forming a gel-like substance in your digestive system that physically slows digestion. During menopause, when hormonal changes increase appetite and cravings, this sustained fullness is invaluable.

Aim for 40 grams of fiber daily, most women get only about half this amount.

A Brief Word on GLP-1 Medications

GLP-1 medications like Ozempic and Wegovy are proven effective for weight loss. However, they can reduce bone density alongside muscle mass, which is particularly concerning for menopausal women already at increased risk of osteoporosis.

If you're considering GLP-1s, work with a qualified medical provider who will monitor your bone density, ensure adequate protein intake, and supervise your strength training. These medications have their place, but they're not a shortcut that bypasses the fundamentals of building muscle, eating well, and moving your body.

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 (7-8 hours)
✓ Stress management (yoga, breathwork, meditation)
✓ HRT consideration when appropriate
✓ Realistic timelines (meaningful changes take 12-16 weeks)

Conclusions: Science AND Self-Compassion

Start with rest and getting the medical support you need, and practice acceptance. 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.

What About Yoga?

You might expect me to claim that yoga is the answer to everything! While any movement is better than none, so if you love asana- keep going! But traditional asana practice alone is unlikely to be enough to create the body composition changes you need during and after menopause.

Most yoga styles don't provide the progressive overload necessary to build significant muscle mass. Progressive overload means consistently challenging your muscles with increasing resistance, which is what stimulates muscle growth and metabolic change. Even vigorous vinyasa or power yoga, while demanding, typically uses bodyweight in repetitive patterns rather than the heavy, progressive resistance your muscles need to grow stronger and more metabolically active.

But yoga absolutely has a place to support an Empowered Menopause

Even with all the other changes to our daily, even if we do want to take HRT, yoga practice offers a deep foundation for health and path for acceptance that will support everything else we do.

Here's what a regular yoga practice genuinely contributes:

Mental Health and Stress Management: Chronic stress elevates cortisol, which directly promotes abdominal fat storage. Yoga's combination of movement, breath work, and mindfulness effectively reduces stress and regulates your nervous system. This matters for your belly fat because a calmer nervous system means better hormone regulation.

Sleep Quality: Poor sleep disrupts hunger hormones (ghrelin and leptin) and increases cortisol, both of which promote weight gain around your middle. Yoga, particularly restorative and yin practices, significantly improves sleep quality. Better sleep means better hormone balance and better body composition outcomes.

Cardiovascular Support: While not a substitute for dedicated strength training, yoga does support heart health through gentle cardiovascular conditioning, blood pressure regulation, and improved circulation. Given that heart disease risk increases sharply after menopause, this cardiovascular benefit matters.

Flexibility and Joint Health: As you add heavy strength training (which you need for muscle building), yoga helps maintain mobility, prevents injury, and aids recovery. Think of it as essential maintenance that allows you to train consistently.

Body Awareness and Sustainable Practice: Yoga teaches you to listen to your body, recognize what it needs, and build a sustainable relationship with movement. This body literacy is invaluable as you navigate the changes of menopause. 

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

Where to find more support

• Unpaused podcast  
• 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
• The Menopause Society (US) menopause.org

• Your doctor- some are better than others, shop around! Not all GPs or healthcare providers are well-trained in menopause management
• Private doctors- you might find a private specialist who is able to prescribe outside the established "rules". In Bristol - Rethink menopause. Sam Blackwell is an excellent private menopause specialist.

How to Measure for Visceral fat versus Subcutaneous 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.