I remember a time several years ago when I had a two-week-long gastrointestinal issue. I needed to be near a bathroom. Every meal just sat in my stomach longer than usual until it wanted to come out ASAP. I was a mess.

“You look great,” a mom I knew from my kid’s school said. I wanted to say: “Yeah, I’ve basically been in the bathroom all day, and that’s why I’ve lost weight — it’s not a good thing!”

Instead, I said: “Thanks.”

Nothing impedes life quite like digestion that moves too fast or too slow.

If it’s loose bowels, you’re frightened when a bathroom isn’t close. If it’s constipation, you feel you can’t go one more day with the bloating and discomfort.

Some experience a combination of both.

Doctors define irritable bowel syndrome as recurrent abdominal pain linked with a change in bowel function. It’s categorized into IBS with predominant diarrhea (IBS-D), IBS with mixed bowel habits (IBS-M), and IBS with mostly constipation (IBS-C).

The cause of IBS is multifactorial but linked to an altered gut-brain axis involving gut motility dysregulation — the topic of today’s post. IBS has always been more common in women, and at midlife that number trends upward.

For most midlife women, gut motility slows down, causing gas and bloating — but for some, it’s the opposite. Gut (or intestinal) motility is the coordinated movement of the digestive tract, essential for optimal digestion, nutrient absorption, and timely excretion of waste. When it’s off, our health and quality of life suffer.

Motility changes are extremely common at midlife, and it’s something we need to understand and talk about.

Let’s dig into the nervous system, smooth muscle, hormones, and the microbiome — and how they’re all related to how food moves through the digestive system. And most importantly, what we can do about it.

The enteric nervous system

Your gut has two connected nervous systems helping control digestion and movement: signals coming from the brain and nervous system outside the gut (extrinsic), and its own built-in network of nerves within the gut (intrinsic), called the enteric nervous system.

The enteric nervous system includes 200–500 million neurons that regulate digestive function, including motility, by controlling smooth muscle cells. Enteric neurons are categorized into two major subtypes: excitatory (Ach) neurons and inhibitory nitrergic (nNOS-producing) neurons.

Excitatory (Ach) neurons are like the gas in a car, and inhibitory nitrergic neurons are like the brake. You need a balance of both to keep things moving at the right pace, helping coordinate:

• Peristalsis (wave-like muscle contractions in the gut)

• Gastric emptying

• Esophageal relaxation

• Lower esophageal sphincter function

• Colonic motility

Just like everything else in the body, the enteric nervous system is affected by biological aging, which can include the loss of enteric neurons and degeneration of neural networks.

While complex and not completely understood, one proposed model for age-related loss of enteric neurons involves changes to the muscularis propria macrophages (MPMs) — specialized immune cells that communicate with the nerve cells controlling how food moves through the digestive system.

When these cells shift from anti-inflammatory to pro-inflammatory, it can lead to gut motility disorders like gastroparesis.

What can you do?

One of the best ways to keep the enteric nervous system functioning well is to increase vagal tone. Studies have shown that this activates the Cholinergic Anti-Inflammatory Pathway (CAIP), which keeps the MPMs anti-inflammatory.

One of the easiest (and free) ways to do that is a slow-paced breathing practice — and, just as importantly, coping with the stress in your life. More on the vagus nerve in our next post.

READ: Cultivate a Breathing Practice

Changes in neuromuscular function

The gut isn’t just nerves; it’s nerves plus muscle, forming the enteric neuromuscular system. This includes the excitatory and inhibitory neurons mentioned above, but also smooth muscle and interstitial cells like the interstitial cells of Cajal (the gut’s pacemaker cells).

These cells work together to keep your digestive system functioning properly, from moving food through the gut and absorbing nutrients to getting rid of waste. As these cells change or decline with age, digestion and gut movement can be affected.

One crucial player is the migrating motor complex (MMC), a four-phase stomach and gut motility pattern that works like an intestinal housekeeper — sweeping away undigested food, debris, and bacteria via smooth muscle contractions. The entire cycle occurs over 90-120 minutes during fasting (basically between meals and overnight), with phase 3 being the most active.

The MMC is controlled by gut hormones, the enteric nervous system, the vagus nerve, electrical pacemaker cells, and the smooth muscle of the GI tract.

When the MMC functions poorly, food remains longer than necessary, allowing bacteria to multiply. Although altered MMC may be a consequence of certain GI conditions, but it may also precede and increase the risk of small intestinal bacterial overgrowth (SIBO).

What can you do?

Increase the time between meals to 3–4 hours, and aim to fast at night for at least 12 hours. Most of the benefits of the MMC are mechanistic, but a 2022 study found that women with a regular meal pattern had a 44% reduced odds of IBS and symptom severity.

A pilot study this year explored how 8 weeks of time-restricted feeding (16:8) would affect IBS symptoms, and it showed a reduction across all IBS types — patients reported both physical and mental benefits. Sixty-two percent had a reduction in symptoms of over 50 points, and 12.4% met criteria for remission.

Might increased MMC activity be the cause of this? We need more research, but it’s promising for those who have IBS.

Subscribe now

Changing hormones and the gastrointestinal tract

As mentioned earlier, IBS is more common in women than in men. Women are also more likely to experience bloating, nausea, and constipation, along with more IBS-related psychosocial symptoms like depression and anxiety.

Experts believe sex hormones play a role, as symptoms vary with the menstrual cycle, and their are estrogen/progesterone receptors throughout the gastrointestinal tract. Symptoms often increase in the late luteal and early menstrual phase, when hormones drop. I, for one, could always tell when my period was coming based on this — if you know what I mean.

That said, the true effects of estrogen and progesterone on digestion aren’t entirely clear. Scientists are still trying to understand exactly why digestive symptoms may become more common during menopause. Hormonal changes — including rising LH and declining estrogen and progesterone — may affect the nerves, muscles, and lining of the digestive tract, as well as communication between the gut and other body systems.

An older study comparing non-IBS postmenopausal women to premenopausal women show they experience more pronounced changes in bowel function, higher laxative use, and more gas and reflux.

One 2021 study of 190 premenopausal women with IBS (average age 30), 52 postmenopausal women with IBS (average age 54), 190 men with IBS under 45, and 52 men over 45 found that postmenopausal women with IBS had more significant symptoms than premenopausal women and age-matched men.

Although constipation increased with age for both men and women with IBS, it was the predominant IBS subtype in postmenopausal women only.

It’s not only constipation that’s affected — reduced estrogen can also increase visceral sensitivity in some women, since it’s been shown to influence pain processing. The colon may contract normally, but the nerves become more sensitive, making those contractions feel urgent.

What to do?

Studies do not demonstrate that hormone therapy’ helps digestion. The key takeaway is that hormonal changes with menopause act as a trigger, and women need to be more aware and proactive about digestive symptoms, especially constipation.

The gut microbiome

The gut microbiome is essential for gut motility, and the relationship is bidirectional — motility can affect the composition of gut bacteria, and gut bacteria also help regulate motility.

Probiotics are live microorganisms that, when given in adequate amounts, benefit the host. While there are benefits to probiotics many of those benefits are strain-specific.

A 2014 meta-analysis of 14 randomized controlled trials (1,182 adults with functional constipation) found that probiotics, overall:

• Reduced whole-gut transit time by about 12.4 hours

• Increased bowel movements by about 1.3 per week

• Improved stool consistency

However, most of the benefit came from specific strains, particularly Bifidobacterium lactis HN019. This strain has also been shown to help with diarrhea.

The story of HN019 began with a bacterium isolated from yogurt. But researchers didn’t stop there — they tracked and studied this specific strain over time and discovered it appeared to have a distinctive effect on the gut, including the ability to influence intestinal transit and bowel regularity.

What to do?

For more on how to improve the gut microbiome through diet, go here. If you have motility issues, consider incorporating a probiotic with Bifidobacterium lactis HN019 (read labels). One of my readers wrote to me saying she used a product from NOW and it made a big difference.

Good old diet and exercise

What we already know about food and movement still holds true for midlife women, especially those with slow motility due to low fiber.

A review of fiber supplements for relieving constipation found that psyllium and pectin are most helpful, at >10g, but also produced more gas. Psyllium also helps lower cholesterol, making it a smart choice for midlife women. But if the problem stems from something already mentioned, more fiber could actually make things worse.

A greasy or high-fat meal can trigger the opposite response by stimulating the gastrocolic reflex—the natural increase in colon activity that occurs after eating. Fat is a particularly potent trigger of this response, and in people with a sensitive gut, such as those with IBS, the response may be exaggerated, leading to stronger contractions, cramping, and an urgent need to have a bowel movement.

Movement definitely helps keep things moving, including walking after meals.

“There are so many health benefits from walking after a meal. Some of them are not gastrointestinal, including improving your glucose control. But from my standpoint, walking after a meal can actually improve your gastric emptying,” said Jessica Philpott, MD, PhD, in this press release at Cleveland Clinic. “Studies have shown that walking immediately after a meal can rapidly shorten the amount of time food sits in the stomach, which can really improve symptoms of feeling excessively full, reflux, abdominal pain, and others.”

If you can’t find relief, find a dietitian who specializes in GI function — they can help you pinpoint dietary issues. A dietitian may initially recommend a low-FODMAP diet as you figure things out.

READ: This Type of Fiber Has the Strongest Effect on Cholesterol

Midlife Motility

Biological aging and changing hormones [Aging Pause] can alter gut motility in midlife women, affecting health and quality of life. Many women will have sluggish motility, while others may see an increase, or simply have a more sensitive gut.

The factors involved include changes to the enteric nervous system, smooth muscle function, sex hormones, and the gut microbiome.

Here is a review of some strategies that may help:

• Dealing with stress and turning up vagal tone with, for example, a slow breathing practice.

• Allowing time between meals (3–4 hours) and overnight (>12 hours), which can help increase MMC activity, your GI tract’s housekeeper.

• Increasing healthy bacteria in the gut — strains like Bifidobacterium lactis HN019 can help with transit time and motility.

• Looking at diet and exercise: getting enough fiber, pinpointing problem foods (greasy, high sugar, other triggers, etc.), walking after meals, and regular exercise will go a long way. See a dietitian if needed.

I’ve gotten some private messages from readers about digestive challenges. Have you noticed any changes to motility at midlife? What has or hasn’t worked for you?

Let’s talk in the comments.

Previous post in the series: The Digestion Superpower You Already Have (But Probably Aren’s Using)

Penn Holderness of The Holderness Family recently shared that he is micro-dosing a GLP-1 medication (tirzepatide) to help prevent Alzheimer’s. He has a strong family history and carries two copies of the APOE4 gene.

“If there is even the least amount of evidence that [a GLP-1] might help it, it’s a risk I’m willing to take,” he said on his podcast.

I’ve also seen the trend of cancer survivors taking GLP-1s to reduce their risk of recurrence — a trend based on observational studies showing lower disease recurrence and mortality among those who take them. Many claim previous joint pain disappears when they start taking them.

One thing is clear: GLP-1s are being touted for much more than weight loss. I’ve even heard some claim that eventually everyone will be on them.

The explanation for why they work this way is usually vague — something about anti-inflammatory effects. But that doesn’t do it for me. I need to understand the why behind it.

So I did some digging, and I think there’s an important piece all of this is revealing. In this post I want to talk about what I found, what the GLP-1 frenzy is teaching us, and more importantly, why it matters.

GLP-1: From vague to specific

Most of what we hear about GLP-1s is that they slow gastric emptying and work on the reward centers of the brain. We also hear that they have anti-inflammatory effects in people with established disease or who are at high risk of cardiovascular disease and diabetes.

Let’s take a step back and get into how these medications work, and why they’re found to boost health beyond weight loss.

Read more

Sharlene had reflux for about a decade. She tried everything but couldn’t kick it. On a whim, she slowed down her eating, chewed thoroughly, and let saliva do its thing. To her surprise, her symptoms pretty much went away.

“I feel so embarrassed; it was something so simple,” she said. “I just want others to know this may help.”

When most of us think about digestion, we typically think of our stomach and intestines. Yet the first step is actually chewing our food — and how we chew can make a big difference.

Chewing kicks off the digestion process, but it also primes the entire GI tract for what’s coming. It helps break food down, increases gastric emptying, improves satiety, and may even aid cognitive function.

We may have eaten quickly our entire lives and been okay, but Aging Pause has a way of saying, “Hey, wait — you can’t do this anymore.”

In this part 2 of this series (see the intro here), let’s dig into the science of chewing, why it’s really the first step to better digestion, and then get into tips for doing it well.

Subscribe now

Why chewing?

Gastrointestinal experts often say: “Your stomach doesn’t have teeth.”

That’s because swallowing chunks of food causes the stomach to experience more stress, which slows everything down.

Evolutionary biologists estimate that our ancient ancestors chewed for hours a day, versus the 35 minutes we spend today. With softer foods and hurried schedules, the act of chewing has been on the decline for decades.

Chewing breaks down food to ensure optimal nutrient absorption, stimulating both gastric and pancreatic juices. For instance, research has shown that chewing gum after surgery helps patients return to normal bowel function sooner than those who don’t chew gum.

Chewing stimulates saliva (along with taste), which is vital — it contains the enzymes lingual lipase and amylase, which begin breaking down fat and starch right in your mouth. Saliva also helps form a bolus, lubricating food so it can pass easily from the esophagus to the stomach.

Saliva also helps neutralize acids in the mouth and esophagus, kill unwanted bacteria via targeted enzymes, and provide minerals that repair and strengthen tooth enamel. It contains growth factors that protect the orophargyngeal mucosa.

From Chewing to Digestion

Researchers had 12 healthy adults eat the same meal under two conditions:

• Chew each bite 50 times

• Chew only 25 times (with larger pieces swallowed)

They measured gastric emptying using a breath test and found that more chewing significantly increased the rate at which the stomach clears food. Researchers also linked better food particle breakdown to even faster gastric emptying.

Of course, the evidence in this area isn’t perfect. A 2022 systematic review of chewing and digestion, covering 71 studies, found that 65% showed a positive effect of chewing on digestion — though most of those studies were of low quality.

In a survey of 89 people with and without digestive complaints, more of the GI complainers ate their meals rapidly (46%), much more than those without issues (17%).

A lack of adequate chewing may also disrupt the gut microbiome. Insufficient chewing can alter fermentation and the composition of the microbiota in the mouth and gut.

In short, mechanistic data and some direct evidence show that chewing food thoroughly supports digestion. Increasing the number of chews before swallowing can speed gastric emptying of solid foods and support overall gut health — likely because smaller, saliva-coated food particles are easier for the stomach and intestines to process.

What gets in the way?

Aging and menopause (Aging Pause) are linked with lower saliva levels, which may impact digestion. While it’s not entirely clear, aging can affect saliva production via related health conditions, hydration, and medications. Studies suggest estrogen and progesterone influence salivary flow, and postmenopausal women exhibit lower rates compared to menstruating women.

It is unknown whether hormone therapy helps, but some studies have shown positive results.

Lifestyle factors like smoking gradually reduce saliva production over time. Dehydration is another factor that can negatively affect saliva production. In healthy people, the daily average flow of saliva is between 1 and 1.5 liters.

A 1997 study had 24 young and older adults go 24 hours without food or fluid. Researchers measured salivary flow before dehydration and again after rehydration with IV fluids. Both unstimulated and stimulated saliva declined in both age groups, and rehydrating with IV fluids brought salivary flow back toward baseline.

In short, staying hydrated helps prevent lower saliva production, but drinking more water beyond that point doesn’t seem to overproduce it.

Last are people with GERD. Reflux itself is linked to reduced saliva and commonly prescribed medications like PPIs have been shown to decrease it further. A small, randomized crossover study showed that chewing sugar-free gum for 30 minutes after a meal reduced postprandial acid exposure in people with GERD.

The reason? Chewing gum stimulates saliva, which neutralizes acid and decreases esophageal exposure to it.

What to do?

With all the changes at midlife, giving your body an advantage with this first step of digestion — chewing — becomes even more important.

Here are the top tips:

🫦 Take time to chew. Counting bites is silly, and each food requires a different amount of chewing. Instead, chew until your food is soft and almost applesauce-like before you swallow. This is also tied to more food enjoyment (hello, mindful eating).

🫧 Give your jaw a job. At each meal, include at least one food you have to chew — an apple instead of applesauce, whole nuts instead of nut butter, raw vegetables instead of cooked, or intact grains instead of refined ones.

💦 Stay hydrated by drinking plenty of water and electrolytes, which — as I explain here — may be more challenging at midlife.

🧴 Limit or avoid chlorhexidine mouthwash which has been found to kill good bacteria in the mouth and make saliva more acidic. It also decreases nitrate reducing bacteria which I talk more about here.

If you have reflux, chewing sugar-free gum after meals can help increase saliva and clear acid from the esophagus. For people without reflux, there’s less evidence to support this.

Summary

Not everyone with GERD or other digestive issues will get results like Sharlene’s, but we all benefit from chewing thoroughly. And if you have constant dry mouth despite everything you do, see a doctor as it could be Xerostomia which may need treatment.

Chewing kicks off digestion, starts breaking down food, improves oral health, and primes our system for optimal digestion and nutrient absorption. It helps keep food from staying in the stomach too long, and it increases feelings of fullness and blood flow to the brain.

Next up, we’ll focus on gut motility because it’s the part of digestion that changes the most at midlife.

Let’s talk all things chewing in the comments.

Previous post in the series

August is here and summer is almost over. I always crave more structure around this time, feeling ready for fall and cooler weather.

This month, I landed on three studies that are worth sharing, ending with a few finds I think will interest you.

Let’s do this.

🦴 Weight during the transition and bone health

It’s no news that women tend to gain weight during the menopause transition. I discuss this more in detail here, and I myself am 10-15 pounds heavier now that I’m through menopause.

What we often don’t mention is a potential upside to maintaining or even gaining some weight. And that gets to our first study.

Researchers followed 223 Swedish women ages 50-60 as part of the ELBOW II clinical trial, all between 1-4 years post menopause. They looked at body weight, appendicular lean mass (ALM), and fat mass via DEXA, along with tibia bone microarchitecture and volumetric BMD — measures of bone strength.

They found that higher baseline body weight, fat mass, and BMI, as well as increases in ALM, were associated with more positive bone outcomes, particularly in cortical density, geometry, and total vBMD.

The first group/column (below) at baseline had BMI 22 and 28% body fat, group 2: 24.5 BMI and 36% body fat, last group: BMI 28 and body fat 45%,

When I was pleasantly surprised to learn I had gained bone through the transition without hormones, I looked into the weight factor. Women with a BMI ≥ 25 lose about 0.5% per year at the spine, compared with 1.5% per year for those with a BMI < 25. Higher body weight also predicted slower bone loss in large cohorts like SWAN.

It’s not just weight — it’s body composition. Both fat and lean mass have been found to predict better bone density, with lean mass alone mattering more in pre-menopausal women, and lean mass and fat mass protective after menopause. Yet other studies point to maintaining lean mass as the key factor in both populations.

Fat may help by increasing mechanical load, but also in conjunction with lean mass gains. Body fat is also a source of estrogen, which may benefit bone. Yet depending on where it’s stored and your exercise habits, unhealthy body fat can become a source of Infla-Stress. So you can see why the studies sometimes conflict.

Does this mean we should gain weight? Of course not. But I often wonder if the body does what it does by design. Just something to consider.

We can also choose hormone therapy — and lifting weights — to prevent bone loss, especially if we know our status before the transition.

READ: Two Exercises that May Prevent Bone Loss as Much as Hormone Therapy

🌸 UTIs and vaginal estrogen

Many of us have parents at risk for UTIs that end up in a hospital visit or worse. Using the Epic Cosmos database, researchers looked at women with two UTIs within 6 months and split them into two groups:

• Never received a prescription for vaginal estrogen

• Received vaginal estrogen within 2 months of the second UTI

Outcomes were tracked over 8 years and included sepsis, hospital admission, and all-cause mortality. Out of 1,891,956 females with a UTI, only 5.1% were prescribed vaginal estrogen.

Across all age groups, women prescribed vaginal estrogen had significantly lower odds of sepsis, hospitalization, and death following recurrent urinary tract infections than women who did not receive it. Just imagine if most of those women had gotten vaginal estrogen.

And if these women had started earlier, they may not have gotten the UTIs in the first place. A meta-analysis of 8 randomized controlled trials (4,702 women) found that women using vaginal estrogen had a 58% lower risk of recurrent UTIs compared with placebo.

Systemic menopausal hormone therapy, on the other hand, has not been shown to improve recurrent UTI risk.

There’s no age limit on vaginal estrogen, so advocate for your loved ones who are at risk of these serious UTIs.

Subscribe now

💪 Does low protein increase lifespan?

You may have heard about a new study claiming that a lower-protein diet may promote longevity.

This is based on a new systematic review of more than 350 papers on protein restriction and aging, led by Dudley Lamming at the University of Wisconsin-Madison. The researchers argue that consuming less protein could carry greater health benefits and, in some cases, extend lifespan — due to improved metabolism, altered nutrient-sensing pathways, reduced cellular damage, and better-preserved cell function.

A key player is fibroblast growth factor 21 (FGF21), a hormone that rises when protein intake is low and can increase energy expenditure, improve blood sugar control, and reduce inflammation. In mouse studies, higher FGF21 levels were linked to longer lifespan, with a more pronounced effect in males than females, and the review notes that lowering protein intake raises FGF21 in humans too.

I did what I always do when I want to understand something: I searched FGF21 and nitric oxide. Sure enough, it increases nitric oxide (NO) while also decreasing inflammation — yep, the One Health Principle again. It does this by activating signaling pathways that increase eNOS, the enzyme that makes NO in blood vessels, and decreases inflammation.

It’s a type of I’m-not-getting-enough-food response in the body.

When the liver senses a shortage of amino acids — especially methionine and branched-chain amino acids — it triggers a spike in FGF21. But when protein intake is high, it signals the liver that there’s enough for growth, so FGF21 stays low. It also rises with fasting and other stressors.

Lamming’s take isn’t that protein is bad — it’s that while protein clearly benefits muscle and exercise recovery, most people are sedentary and likely eating more than they need. He points out that athletes eat their share of protein without the same metabolic downsides, suggesting activity level — not just age — should shape individual recommendations.

It’s important to note that this is more of a mechanistic argument than a randomized trial proving restriction extends human lifespan. Most of the longevity data comes from flies and rodents, and the human evidence cited is largely about metabolic markers (weight, fat mass, fasting glucose) rather than lifespan itself.

FGF21 is just one piece of a much larger puzzle — your body has multiple major pathways that achieve these same protective benefits. Low protein may raise it, but there are downsides too, such as the potential for increased bone turnover, reduced bone mass, and loss of lean mass — a key issue for midlife women and active people.

I’ve written before about the idea that protein isn’t the be-all end-all — it’s one of many factors in the diet.

✨Cool Things

🎓 When Dagmara Beine was asked why someone should trust her health advice, she answered back with You Shouldn’t Trust Me. As I read through this piece, I said yes — what felt like a thousand times. It’s such an important read.

✉️ Latest Substack find? Letters to Midlife Women by Claire Moore: These are short reads — letters about some important aspect of life, with humor and meaning, that often hit home.

📖 New on my bookshelf: On my summer vacation I read Cleaning Up Your Mental Mess by Dr. Caroline Leaf and signed up for her app. If you find certain toxic thinking patterns are getting in your own way, this in-depth form of cognitive behavioral therapy is a must.

That’s it for now. Enjoy the weekend, and let’s meet up in the comments.

You go to speak and you can’t think of the word. Mid-sentence, you forget what you were trying to say. Staying focused feels harder than it used to.

Brain fog is unsettling, to say the least. And in my opinion, it’s the one place midlife women have been left to fend for themselves.

So what exactly is brain fog?

Here’s the definition used by Maki and Jaff in their 2022 paper in Climacteric:

The constellation of cognitive symptoms experienced by women around menopause, most frequently manifesting as memory and attention difficulties — trouble encoding and recalling words, names, stories, or numbers; difficulty maintaining a train of thought; distractibility; forgetting intentions (like the reason for walking into a room); and difficulty switching between tasks.

It’s typically described as harmless and transient, even though a small percentage of women are vulnerable to more lasting changes. Most of the advice out there focuses on preventing dementia — exercise, diet, social engagement, and learning.

I know the advice by heart, and I’m sure you do too.

But here’s the thing: even if none of us ever develop dementia, don’t we all want our brains to work well, starting now? And how do we know which of us are the ones whose brains won’t fully adapt?

I see something new on the horizon that might help.

In this deep dive for paid subscribers, we’ve looked into brain energy metabolism — which seems to sit at the core of brain fog symptoms — why MHT may not be the full answer, and why homocysteine is being considered a marker of disease severity.

Now it’s time to talk about nutrition-related solutions. A new review study, and another one on the horizon, might point us in the right direction. The answer, unsurprisingly, isn’t just one thing. But a combination just might hold more promise than we’ve realized.

The brain metabolism gap (quick review)

In papers on menopause, brain researchers now describe it as a neurological transition state — one where most women experience no long-term effects, but a subset may face real risk of neurological decline.

As we’ve learned, estrogen is a master regulator of the brain’s metabolic system, helping it use glucose, its preferred fuel. Perimenopause brings on a hypometabolic state as the brain gradually loses its estrogen-driven connection to that bioenergetic system.

The brain compensates by increasing fatty acid metabolism to generate ketone bodies as an alternative fuel. One theory for how this can go wrong if its chronic is myelin lipid catabolism — the idea that the brain, running short on energy, starts breaking down its own lipid-rich white matter (myelin) for fuel.

Social media puts it more bluntly: the brain eats itself. Here’s the more technical version, but we need to remember this is still a theory:

The aging brain may compensate for its energy deficit by maladaptively catabolizing lipid-rich myelin to produce fatty acids that can be converted to ketones, inadvertently causing white matter degeneration.
— Kapogiannis & Avgerinos, Int Rev Neurobiol. 2020; 154: 79–110

We know from that the menopausal brain can adapt — but could we do something to help bridge that gap sooner? And could this alternative fuel source, ketones, help with brain fog symptoms specifically? Let’s take a look.

Read more

We all come to midlife with our own eating history. Some have yo-yo dieted, others have been steadily health-conscious, and others fall somewhere in between. Now, at midlife, we understand on a deep level the importance of our health — and eating is a big part of that.

But knowing this doesn’t always make it easy.

Recently, I’ve seen posts about women having a hard time getting in the protein and fiber they think they should. “It just feels like so much food.” Sometimes they just want a tomato sandwich (low protein) or don’t want to have to think about it at all.

And I realized there’s a foundational piece missing — something I take for granted as a dietitian and a lifelong health enthusiast. It’s not just that I have certain eating rituals; they’re deeply integrated into my self-concept.

Last time, I talked about hunger changes at midlife and how they can be more unpredictable than ever before. Now let’s talk about the foundational piece that’s often missing, and the four non-negotiable eating habits tied to it.

Why identity is the key at midlife

Researchers asked people one of two questions, then watched their behavior:

• “How important is it to you to vote?” versus

• “How important is it to you to be a voter?”

By framing the question around identity (”be a voter”), turnout was much higher. Why? Because it connected the behavior to how people saw themselves.

This shows that people are more likely to repeat behaviors that reinforce their identity. It goes beyond simple motivation — it’s more like DNA. It’s not something you change from one day to the next; it’s part of the fiber of who you are.

I realize how central this has been to my own health journey. When I reached midlife and knew I needed to make changes, I already had that foundational self-concept: I’m someone who takes care of their health.

Research suggests that identity-based habits are more stable under stress and life transitions. That’s why one person can stop exercising after an illness, say, while another can’t wait to get back to it — the latter never stopped seeing themselves that way.

I find this vital at midlife because we want sustainable healthy habits. Extremes, temporary diets, and under-fueling no longer match the wise women we are.

So here are the four non-negotiables, plus the identity statements that help them stick.

1. Rhythm over chaos - “I’m someone who fuels my body consistently”

Skipping a meal never enters my mind (unless I’m flying), because I have a regular rhythm of meals that’s personally important to me.

For me, that’s breakfast after working out, around 6:30–7. Lunch around 11:30. An early afternoon snack (unless I’m not hungry) and an dinner around 5:30. Weekends look different — breakfast and dinner are later — but even my weekends have rhythm.

Weekends are also when I think through the week ahead and do a rough plan: dinners that turn into lunch leftovers. Breakfast is the one meal that stays fairly similar, even on weekends — hearty oatmeal with nuts, blueberries, and bran buds, plus an added protein source.

The identity tie: We know the advice by now — don’t skip meals, avoid overeating later, and so on. The deeper framing: this is about becoming someone who keeps their body out of crisis mode.

Where to start:

• Start with one consistent meal, not all three

• Build rhythm before perfection

2. Eat with awareness - “I pay attention, but not obsessively”

With the appetite changes that happen at midlife, listening to our bodies has never been more important. This is where mindful and intuitive eating fit in — but let’s make it realistic.

Even “listening to your body” can turn into a rulebook. Perfect mindfulness doesn’t exist. Here’s what I actually do.

I notice hunger before I’m starving and fullness before I’m stuffed, but I accept that I’ll eat distractedly or emotionally sometimes. I find a hearty breakfast and lunch fuel my day best, so I’m less hungry by dinner and keep it simple.

The identity tie: Instead of chasing some utopia of mindful eating and never eating emotionally, simply eat with awareness. The deeper framing: this is about becoming someone who’s aware of their eating and internal signals, and is working toward better alignment.

Where to start:

• Again, start with one meal, not all three

• Notice the disconnects (looking at your device during meals, eating in the absence of hunger) and set small goals around them.

  Thanks for reading Midlife Strong! This post is public so feel free to share it.

  Share

3. Avoid extremes - “I eat in a way I can sustain on hard days, not just ideal ones”

Midlife women are often told not to diet, or to stop cutting out foods they love, and to take small steps toward healthier eating. But what does that actually mean?

It comes down to sustainability. When we start something new, we’re gung-ho and full of willpower. But as life starts life-ing (we all know what that means), extreme behavior gets harder to sustain.

The changes of menopause are no joke, and more extreme approaches have crossed my mind. But deep down, I know extremes break trust with my body — one of the most important relationships I have. Considering what my body actually needs has been the key to avoiding extremes.

The identity tie: Extremes may get results faster, but they’re hard to sustain. The deeper framing: this is about becoming someone who works toward their nutrition goals while respecting and honoring their body, because that relationship is the cornerstone of solid health.

Leanne Ely puts it perfectly in her post about what she’d tell her 50 year old self:

The idea that we are either “dieting” or just “letting ourselves go” has to stop. It’s that mentality that puts us on the carousel of crazy–with weight fluctuating all over kingdom come; I speak from experience–I’ve been 237 and I’ve been 137. And it’s all due to an all or nothing approach to food and fitness.

Where to start:

• Again, start with one goal and one meal. If you want to work on protein, try a few different ideas at breakfast first. (See my strategy below.)

• Once that goal is met, move on to other goals and meals. Refine until it works for you.

• Stay flexible. It’s about building a way of eating you can return to, again and again, until it becomes how you naturally live

  READ: Meet Your Protein Needs with These 3 Simple Strategies

4. Satisfaction matters - “I eat in a balanced way that is satisfying and nourishing”

My kids are older now, and I’m constantly telling them that food needs to be satisfying if it’s going to be a choice they keep making, especially as they get pulled into nutrition trends. They stare at my midlife salad and ask, “You really enjoy that?”

“Absolutely,” I reply.

But I also enjoy the Tate’s cookie or dark chocolate I have after lunch. That wasn’t always the case.

In my early twenties, I’d eat healthy all week and binge all weekend. I didn’t know how to combine the nutritious foods I loved with the not-so-nutritious foods I also loved. In my mid-twenties, something shifted, and giving myself permission to include indulgent foods anytime became key.

It comes down to this: I enjoy food most when I combine satisfaction and nutrition — knowing I’m nourishing myself, but also enjoying myself.

The identity tie: We often put nutrition before satisfaction, but that backfires eventually. The deeper framing: this is about becoming someone who makes satisfaction a non-negotiable part of nutritious eating, because food and eating are among life’s greatest pleasures.

Where to start:

• Some of us need to work on allowing non-nutritious foods more freely; others need to build a bigger repertoire of nutritious foods they actually love.

• If you’re in the first group, books like Intuitive Eating can help — along with identifying the non-nutritious foods you enjoy most and finding a sensible way to include them.

• If you’re in the second group, remember there are a gazillion ways to make food. Invest some time looking up recipes or easy meal ideas to expand what you love.

Long-term healthy eating isn’t about choosing between nutrition and enjoyment — it’s about learning to prioritize both.

From overwhelm to problem-solving

Last time, we touched on appetite changes at midlife — how they often intensify during perimenopause as the hunger hormone ghrelin rises.

This gets at one of the most important identity shifts: moving from “this is overwhelming, this is too hard” to becoming a problem solver. When issues arise, there’s always an answer. Let’s use three common drivers — increased hunger, cravings, and nighttime eating — as an example.

Here are some questions to ask:

Am I feeding myself adequately during the day? Did I skimp on breakfast or lunch, making me hungrier later? If so, work on rhythm and structure.

Are my meals balanced? Am I getting filling fiber and protein in a satisfying way? If not, schedule time on the weekend to look up recipes and meal ideas.

Add some awareness. Is this a stressful moment? Am I hungry, wired, or just finally alone? Be honest, keep up the awareness, and the answer will eventually come.

Am I just looking for an excuse to include foods I love? This one’s often hidden, so it’s especially important. Making eating more satisfying is frequently the missing key.

Also consider non-food factors like stress, sleep, and exercise patterns. While that’s beyond the scope of this post, they’re vital to keep in mind.

I am midlife strong

Having a strong identity around eating to nourish our midlife bodies is a missing key for many women. It doesn’t happen overnight, but it’s a non-negotiable part of sustained eating — something we don’t talk about enough.

Keeping a regular rhythm of meals, eating with awareness, making it sustainable, and moving satisfaction up the priority list are all simply extensions of that identity.

Like almost everything else, Aging Pause shines a bright light on what we need to work on, and eating is no different. If you find yourself lamenting about all the food rules being thrown at you, ask yourself: are you becoming the version of yourself who takes that information and truly makes it your own?

What do you think? Does this ring true to you?

The first time I tried a nitric oxide supplement was over five years ago. The effect was pronounced. I had more energy all day and found myself nodding off while watching TV that night, leading to a blissful night of sleep. I knew there was something different about these products, or at least what they were providing. They were giving my body something it needed.

Now, all these years later, I’m seeing more products pop up, even ones targeted at midlife women. I also know a lot more about nitric oxide than I did when I first started experimenting with products that boost NO.

I want to help you understand what these products offer, the different types, and what research shows they can — and can’t — do.

But first, why nitric oxide? (skip ahead if you don’t need the review)

A quick review

Nitric oxide is one of the body’s master signaling molecules. It tells blood vessels when to relax and widen, improving blood flow and delivering oxygen and nutrients where they’re needed. Beyond circulation and blood vessel health, nitric oxide also helps regulate brain function, muscle performance, metabolism, insulin sensitivity, and immune defense.

There are two pathways that deliver nitric oxide. The first is via nitric oxide synthases (NOS), a family of enzymes that produce nitric oxide from the amino acid L-arginine (endogenous). The most relevant for this discussion (cardiovascular health) is endothelial nitric oxide synthase (eNOS), which is found in the cells lining blood vessels and helps regulate blood flow, vascular tone, and endothelial function.

The second pathway (exogenous) is the nitrate-nitrite-nitric oxide pathway. When we eat foods rich in nitrate, bacteria in saliva reduce it to nitrite, which is then converted to nitric oxide in the stomach before circulating through the body to be used or stored.

Due to both biological aging and menopause (Aging Pause), nitric oxide production via the first pathway declines. This is driven by rising Infla-Stress (inflammation and oxidative stress) and falling estrogen, which normally stimulates eNOS. Experts often say nitric oxide decreases by 50% from the 20s to the 40s, though this likely varies from person to person.

This makes the second pathway increasingly important — and that’s where most supplements come in.

In midlife women, supplemental nitrate has been shown to improve vascular (endothelial) function, muscle strength and power, exercise tolerance, aerobic capacity, and blood pressure.

Let’s take a closer look at the different products.

Beetroot powders vs. juice vs. chews

The majority of research focuses on dietary nitrate, also called inorganic nitrate. For the benefits already discussed, researchers usually aim for approximately:

• 5–8 mmol nitrate/day

• Roughly 300–500+ mg nitrate/day

These products — considered nitric oxide precursors (nitrate/nitrite), not nitric oxide itself — come as liquid beetroot juice, powders, or chews.

Recently, ConsumerLab’s tested a variety of these products and found nitrate content ranging from as much as 495.7 mg to as little as 4.3 mg — more than a 100-fold difference.

• Beetroot juices have the highest amounts — about 200–300 mg nitrate per 8 oz, or up to 500 mg per shot in concentrated versions (Beet-it Sport used in many studies)

• Beetroot powders varied widely, from 4.1 mg to 173.5 mg, often falling short of the amounts used in studies

• Chews had the least, with some containing only single-digit milligram amounts

Beetroot powder and chews are not reliable sources of nitrate. These labels often claim something like “5 grams of beet powder,” but that doesn’t tell you how much nitrate you’re actually getting. That’s one reason most studies rely on standardized beet juice concentrates rather than generic powders.

Pills and lozenges

There are also pills and lozenges claiming to increase nitric oxide. One I noticed targeted at midlife women is Berkeley Life Nitric Oxide. They even have a menopause support product.

Their main product, taken as a two-pill serving, contains vitamin C, B12, magnesium, and 500 mg of a proprietary blend that includes potassium nitrate, beetroot extract (25% betaine nitrate), and beetroot powder.

The company states this blend delivers at least 314 mg of nitrate, with a target range up to 400 mg. They have some published studies showing it improves blood pressure, flow-mediated dilation (a measure of endothelial health), and sexual function.

When highlighting benefits, they also draw on beetroot juice studies because of similar total nitrate content — though a pill may behave differently than a drink or lozenge that coats the tongue, since the latter enhances nitrate-reducing bacteria in the mouth.

Their menopause product contains fewer nitrates than the above product, plus pollen extract and turmeric root powder, purported to help with menopause symptoms. I’m not a fan of all-in-one supplements and won’t go into these other ingredients since this post is focused on nitric oxide.

They also sell test strips that show nitrite levels on the tongue to indicate whether it’s working. Keep in mind this measures nitrite — a precursor — not nitric oxide itself.

Lozenges include products like N101 and Neo-40. N101, Nitric Oxide Releasing Lozenge, contains sodium nitrite, which bypasses the nitrate-to-nitrite conversion step and acts more quickly. The product doesn’t disclose how much nitrite it contains.

There’s less overall research on nitrite compared to nitrate, but the animal and human studies done to date are promising. They are created by leading nitric oxide expert, Nathan Bryan, of which his website states there are six clinical trials.

Neo-40, from humann, is a mix of beetroot powder, Hawthorn berry extract, L-citrulline, and sodium nitrite, making it difficult to tell how much of each ingredient is in a serving.

READ: Are the Pause Supplements Worth It? A Midlife Dietitians’s Review

eNOS boosters

Because L-arginine is used to make nitric oxide in the endothelium, it’s been a supplement of interest for years. Early results were promising, but most studies are inconsistent.

The amino acid L-citrulline increases arginine levels more effectively than L-arginine itself. Several studies show some benefits in midlife women.

A 2026 review looked at twelve RCTs involving 360 postmenopausal women, ages 50–75, over 4 to 8 weeks. Most showed a reduction in blood pressure; two of four studies showed improved flow-mediated dilation; and muscle function improved when resistance training was included. There were no changes in weight, glucose, insulin, or lipids. Overall, studies use 3–10 g of L-citrulline, taken about an hour before exercise.

Share

Are there side effects? And are they safe?

Side effects of nitric oxide supplements can include headaches, dizziness or lightheadedness, and GI discomfort, and they tend to go away with continued use. Some who take lozenges complain of tongue discomfort. Beetroot juice can cause a harmless pink color in urine and stool, called beeturia.

People who should be cautious include those on blood pressure medications, those already taking organic nitrates for a heart condition, anyone with low blood pressure, pregnant or nursing women, and anyone with a heart condition on certain other medications (including another NO enhancer, PDE5 inhibitors in men). When in doubt, check with your healthcare provider.

Unlike processed meats, vegetables naturally rich in nitrate have not been associated with an increased cancer risk. In fact, a recent meta-analysis showed a reduced risk of gastric cancer with dietary nitrate. Researchers believe this is because vegetables also provide vitamin C, polyphenols, and other antioxidants that help prevent the formation of potentially harmful N-nitroso compounds (NOCs). However, we still need more research on the long-term safety of nitric oxide supplements, even though most contain added vitamin C.

“We get nitrate from three major dietary sources: meat, water, and vegetables,” said Dr. Catherine Bondonno on Science Daily, who led a review of nitrate benefits and risks in 2023.

“Nitrate’s reputation as a health threat stems from 1970, when two studies showed it can form N-nitrosamines, which are highly carcinogenic in laboratory animals. However, no human studies have confirmed its potential dangers, and our clinical and observational studies support nitrate’s role in preventing cardiovascular disease when it’s sourced from vegetables.”

The conclusion of the review is that nitrates from vegetables are unlikely to be problematic, but we need more research if we’re to change recommendations. Longer, larger, and better studies, please.

Putting it all together

The chart summarizes the different types of supplements, research, and what to look for. Always check ingredients and look for amounts of nitrate. Feel free to contact the company, as it’s best practice to list — and ensure — the total amount of nitrate/nitrite, or other ingredients they are claiming increase NO.

Look for the official logos of NSF, Informed-Choice / Informed-Sport, USP, or ConsumerLab to ensure there is third party testing. If the label only says "Third-party tested" without a organization's seal, the claim may be unverified or refers to a private, non-standardized lab.

When I first discovered this world of nitric oxide supplements, I was obsessed. I’d panic if I forgot it on an overnight stay, especially because I noticed it helped with sleep. But a nagging part of me wondered about the long-term effects of taking them every day. After a while, I just didn’t feel as well, and backed off.

As I learned more about nitric oxide, I realized these supplements are tools that still need refining — and for me, they’re better used intermittently. I also began learning how to stave off the NO decline that comes with the Aging Pause, through strategies I talk about here — breathing, preventing micronutrient deficiencies, diet and exercise, and sauna, to name a few.

Even though nitrate content in vegetables varies so they are less reliable pre-exercise, nitrate-rich veggies (paired with avoiding mouthwash) are the foundational piece. Other plant compounds, like polyphenols, also promote NOS activity and reduce Infla-Stress, helping balance the One Health Principle. I think the oral microbiome is a missing piece — some people respond better than others, likely due to having more nitrate-reducing bacteria.

Not only that, nitrate reducing bacteria has been linked to insulin sensitivity, improved blood pressure and cognitive function. Does toothpaste matter? How do we get the best mix of bacteria in oral microbiome? We need more research!

For now, here’s what I do. I generally include 1–2 nitrate-rich foods per day, and array of other polyphenol rich plant foods. Before tennis matches and personal training sessions, I take a Beet-It shot two hours beforehand. A couple of times a week, I take 3 g of L-citrulline (1 tsp) before other exercise. I’ve completely stopped using the powders, and probably won’t buy more chews once they’re gone.

Have you tried any nitric oxide supplements? What confuses you? Let’s talk in the comments.

I’ve been noticing a sentiment lately in the midlife and healthy aging space. And a recent comment I received on Notes in response to a question I asked about what’s most confusing reminded me of this yet again:

It makes the combo of nutrition, lifestyle, and workouts a full-time job. Is everyone expected to work part-time in this period?

It’s basically overwhelm from the sheer amount — and often conflicting nature — of information coming at women: different takes on hormone therapy, protein targets, and the best exercise.

It’s all too easy to throw your hands up, give up, and just live a peaceful life without all this health noise.

But I think there’s a solution to this very understandable reaction — and another way of looking at it.

Understand why

I’ve said it before and I’ll say it again: we really have no solid foundation for nutrition and lifestyle advice for the midlife stage. It’s a glaring problem that isn’t acknowledged enough.

Because of this, everyone is developing their own guidelines based on the limited evidence. Some make bold claims even though the evidence isn’t there, and others hold back more.

It’s like trying to predict hurricanes before satellites existed. People made their best guesses based on what they could see locally. Some predictions were right, many weren’t, and everyone had a different explanation. As better technology arrived, the picture became much clearer.

That’s similar to midlife and menopause science. We’re finally getting better “satellites” — more women in studies, better imaging, biomarker research, and recognition that women’s biology changes at midlife and after menopause.

Keeping this in mind can help us feel better about not having all the answers, even when someone acts like they do.

Subscribe now

Choose who you follow carefully

I used to follow a wide variety of midlife and menopause health experts in the name of “research.” The problem was, I spent so much time fact-checking, leaving comments that went unanswered (usually asking: what research do you have to support this?), and getting pulled into negative energy.

It was when I got blocked from an account for pointing out the research on body fat percentage (as I describe here) that I decided something had to change.

I cleaned up my feed, unfollowing accounts that didn’t align with my values, and it made a huge difference. I was finally seeing people and experts I had much more in common with.

I’ve been thinking a lot about how the energy behind health information matters as much as the information itself.

Let’s face it. Fear results in more clicks because it creates a sense of urgency, and many influencers know this and use it. This is worth paying attention to, especially in midlife.

So, I’ve started asking a simple question when I consume health content: Is the intent to inform me, or to create fear so I’ll do something?

If it’s the latter, I’m out. And if there are strong health claims with no study or substantiation behind them, I’m definitely out.

You don’t have to do everything

I’ve seen many comments from women who were feeling fine but decided to try hormone therapy because they kept hearing that they couldn’t be healthy without it. In the end, many report not feeling better — and sometimes feeling worse.

A potential reason for this may be that it takes time to get MHT right, and if you’re already feeling good, you may not be willing to stay the course.

It comes back to the idea that if something isn’t broken, we don’t have to fix it. If you enjoy a certain exercise like swimming but hear that HIIT and/or sprinting is what you should be doing, you don’t have to switch unless, of course, you want to try it.

Not only that, but the benefits also mainly come from vigorous activity, so having some sessions where you swim faster in intervals can get you there too. The same is true for walking — you can add in some hills on certain days to up the intensity.

After trial and error, I’ve decided that tennis is my HIIT because it’s intermittent sprinting followed by more moderate exercise — something I already love.

This gets at an important factor rarely mentioned in the endless advice aimed at women.

READ: So…What’s The Best Exercise for Midlife Muscle?

Create your own MHR

My first book idea, over 20 years ago, was entitled The Lifestyle Connection: How to Connect Nutrition, Exercise and Healthy Habits to the Way You Live. It was based on the radical-at-the-time idea of making nutrition and exercise fit your life, instead of the other way around. This came from my early experiences as a dietitian watching people try to do all the right things, only to stop when life got in the way.

I have created my own midlife health routine (MHR). It’s different in the summer than the rest of the year – and it’s flexible.

Through the years of studying midlife, I’ve added more strength work — especially compound lifts — made a jump in tennis (2-3 times a week) after years of weekly lessons, settled on supplements I alter based on annual testing, made tweaks to my diet, and added a breathing routine.

I didn’t add these all at once, and there are things that I have dropped. But the idea is that we must start somewhere and gradually add on, or remove what isn’t working. We can simply maintain when life gets crazy – or do the minimum – and that’s okay. Over years we find that this adds up to a lifestyle that supports our health in a way that is sustainable for us.

Of course, there are times we need to do more if we experience a health issue or aren’t feeling well, but it pays to make the process as enjoyable and as individualized as possible, while staying open.

Consider setting aside time once a week or once a month to review your routine, read some articles (mine, of course — ha, ha), and make a plan.

Mindset matters

Stanford researchers Alia Crum and Christopher Lyddy Phillips have investigated the psychology of mindset in a variety of studies. For instance, they found that those who believe stress enhances their life tend to be happier and healthier than those who view stress negatively.

This shows us the power of our mindset and how it can not only dictate perception but ultimately predict what our experience will be. This is why placebos work in studies — what we believe can even affect our physiological response.

There are many ways to think about midlife health, but the question is, which one will help us be most successful?

Consider these three:

Mindset 1: “There are so many conflicting opinions that I don’t know what to believe, so I’ll just give up for now and keep searching for the ‘right’ answer.”

Mindset 2: “I need to get everything right from the start and it all takes too much time. If I can’t do it perfectly, I’ll wait until I can.”

Mindset 3: “My health is a long-term investment, not a race. I’ll choose a few trusted sources, give new habits time to work before starting the next one, fit them into my life in a sustainable way, and pay attention to how my body responds.”

The first may be true, but it’s not a reason to give up or declare there is one right answer (because there isn’t). The second comes from feeling like we need to do things a certain way to get results. But even if an expert tells you the “rules,” science doesn’t always support it (e.g., saying women need to do 11 push-ups or need to be able to carry half their body weight in a farmer’s walk, or chase an ideal estrogen lab value).

The last one is considered more of a growth mindset and is about us taking the reins, fitting new habits into our life, and staying open to trying things. Over time this adds up and eventually time will open, meaning you can make bigger jumps from the foundation you’re now building.

A friend of mine really wanted to do barbell work at a gym, but for now, she’s opting for dumbbells at home because it fits her life better. She felt relieved when I told her that was a great option.

Filter the health noise

I know it can feel like a lot and like someone’s always moving the goal post. But don’t let all the health noise rob you of an opportunity to invest in your health at midlife.

Understand the research just isn’t where it needs to be (yet), follow a credible few to avoid overwhelm, create your own MHR, add on when you can or maintain at busy times, and work on adapting a mindset that will set you up for success.

And that’s what got me here — working to understand the why behind midlife health, share it with women, so they (you) can make decisions based on the full picture, not just snippets.

So, let’s get into it. What is the hardest part of midlife health information? What confuses you and how are you dealing with it?

Leave a comment

This is Behind the Scenes, a twice-monthly post for paid subscribers

Back in 2007, researchers from Oregon State University compared bone density across three groups of menopausal women: those on menopausal replacement therapy (MHT), those who strength trained alone, and those who did a combination of both.

Women who strength trained twice a week — doing squats and deadlifts — did not lose bone during the rapid bone loss phase of the menopause transition, and their results were similar to the MHT group.

I wrote more about the study here.

I’ve always been struck by the simplicity of this study (two exercises, 30 minutes twice a week), and if replicated, how amazing it could be to help women avoid the average 10% bone loss that occurs as they sail through menopause.

For the life of me, I can’t figure out why there’s been no follow-up study in these almost 20 years.

While on Instagram, I heard about a brand-new study showing even better results. This time researchers included heavy lifting. Yet the message in the post wasn’t even about the results — it was that the study still doesn’t tell us women need to lift heavy, because there was no moderate-load arm.

What?

There’s a lot of pushback on the lift-heavy message, and I get it — it isn’t the only approach for bone health and building muscle, and it’s overly simplistic.

But I feel we’re losing a vital message in the heat of this debate. After digging further, I found a new trial that just might help settle the controversy.

So let’s dig into these studies to see what answers they bring — and the important discovery completely missed in the lift-heavy-or-not conversation.

Read more

Jane was perimenopausal and frequently felt bloated, gassy, and constipated. In the past, upping the fiber and water did the trick—but now it only made things worse.

How could that be?

Jane is certainly not alone. According to an abstract presented at the 2025 Menopause Society meeting, out of nearly 600 women ages 44 to 73, most everyone (94%) complained of digestive symptoms including bloating (77%), constipation (54%), stomach pain (50%) and acid reflux (49%). And most (82%) noticed a worsening during the menopause transition.

I realized that after my series on the microbiome, I didn’t fully cover digestive issues at midlife. This is the topic of this series as I work through the research, connecting it to what I’ve already covered.

And, not surprisingly, it’s all connected.

In this introductory post, I’m touching on why digestion matters at midlife, the basic elements of digestion, midlife drivers, and a preview of what the series will cover.

Why digestion matters?

In my 40s, every so often, my stomach would hurt. I’d let my husband know because I had to sit on the couch and let it pass. Usually, 5–10 minutes of taking a time out did the trick.

Like a lot of women, I assumed it was hormonal—around my cycle—likely having to do with being in the beginning stages of perimenopause.

When women experience GI issues, it’s all too easy to brush them off as hormonal, aging, or stress. Yet getting help isn’t always teh answer.

In that same study, even though 50% of the women sought help, more than half felt the care was poor, with most turning to their own strategies like changing their diet, managing stress, and taking supplements.

Yet many of us—including me at the time — have little understanding of what’s actually causing digestive issues at midlife. And if we go to the doctor, we may not know the right questions to ask or tests to consider.

I will not pretend there’s a simple solution because digestion can be complex. But learning what’s going on behind the scenes—especially at this time of life — can make a big difference. And it matters because it’s not just an uncomfortable issue, it’s a health issue.

Let’s start with the basics.

The Digestive System

The digestive system is made up of the gastrointestinal (GI) tract and the organs that support it: the liver, pancreas, and gallbladder. The GI tract includes the mouth, esophagus, stomach, small and large intestines, and the anus.

Digestion starts when we chew food, and digestive enzymes in saliva break down starch. After swallowing, food and liquid are transported via smooth muscles in the esophagus in a process called peristalsis, where food is then emptied into the stomach.

The lower esophageal sphincter and the crural diaphragm combine to form the anti-reflux barrier, keeping food in the stomach and preventing acid from coming back into the esophagus. The stomach’s acidic environment and digestive juices kill pathogens, prepare nutrients for absorption, and break down protein.

The stomach turns food and drink into a semi-liquid mixture called chyme, which then enters the small intestine. Muscles in the small intestine move the chyme through and mix it with digestive juices from the pancreas and liver, and the small intestine absorbs most nutrients into the bloodstream.

As peristalsis continues, what’s left over moves into the large intestine, and this organ reabsorbs water and some nutrients until it forms stool.

Hormones direct this entire process. In fact, the GI tract is the largest endocrine organ with its own enteric endocrine system.

For instance, once acid-rich food leaves the stomach, the small intestine releases secretin, which stimulates the pancreas to release bicarbonate-rich fluids to protect the intestine.

The watch-outs: motility, anti-reflux barrier, and the intestinal barrier

Similar to the muscles we discussed in the Midlife Muscle Series, the nervous system coordinates the muscular contractions that drive gastrointestinal motility. This control comes from both the extrinsic autonomic nervous system (ANS), which connects the gut to the brain and spinal cord, and the intrinsic enteric nervous system (ENS), a network of neurons embedded within the gut wall that can coordinate many digestive functions on its own.

The main nerve connecting the GI tract to the brain is the vagus nerve, which is why stimulating it and increasing parasympathetic tone is called “rest and digest.”

One of the most overlooked causes of digestive disturbances during Aging Pause is changes in motility (dysmotility)—a slowing or less coordinated movement of food through the digestive tract.

This is why just adding fiber didn’t help Jane: the food was sitting there, causing more fermentation and hence the gas and bloating. This also increases her future risk of other GI issues like small intestine bacterial overgrowth, diverticulosis (small sacs formed in the large intestine), and reflux.

Second is the anti-reflux barrier. With biological aging, this barrier may become less effective, allowing stomach acid and partially digested food to flow back into the esophagus and throat. At the same time, slower motility can delay stomach emptying and increase the likelihood of reflux.

Last is the intestinal barrier: the defense system comprising the gut microbiome, mucus, the epithelial layer, immune defenses, and the more recently discovered vascular barrier beneath it all.

Together, these layers regulate what enters the body, allowing nutrients through while keeping harmful substances out. When this barrier breaks down, it causes intestinal permeability, or better known by its non-medical name, leaky gut.

In a small study of 65 women from the Study of Women’s Health Across the Nation (SWAN) cohort, leaky gut increased by 22% as women transitioned through menopause. This was linked with inflammation and lower hip and spine bone density.

Subscribe now

Midlife drivers

I’ve written about the gradual uptick of sympathetic nerve activity with Aging Pause. This can inhibit digestion by slowing motility, reducing secretions, and decreasing intestinal blood flow. In one study, autonomic dysfunction predicted delayed gastric emptying nearly 14-fold!

Chronic stress - and history of adverse childhood experiences — is linked to higher risk of IBS and related digestive issues.

Biological aging itself is linked to the loss of enteric neurons, degeneration of neural networks, and changes in neurotransmitter signaling—contributing to:

• Constipation

• Dysphagia (difficulty swallowing)

• Reflux

• Slower transit times

Of course, there are also hormonal changes: Estrogen and progesterone both play a role in digestive health — estrogen helps regulate gut motility, protect the gut lining, and maintain a healthy microbiome, while progesterone slows things down by relaxing smooth muscle in the GI tract. And simultaneous changes in cortisol and thyroid function alter digestion too.

This is why many women notice changes like bloating, reflux, constipation, or IBS-like symptoms during the transition.

The anti-reflux barrier depends on a team of structures working together. During Aging Pause, muscle strength, motility, and tissue function can decline, making it easier for stomach contents to flow back into the esophagus

Last and certainly not least: when inflammation and oxidative stress increase (Infla-Stress) and nitric oxide declines – The One Health Principle – the gut feels it too. Chronic low-grade inflammation and reduced nitric oxide can lead to immune remodeling, barrier dysfunction, dysmotility, and increased inflammatory signaling.

What can we do to improve digestion?

At midlife, digestion is at risk because of both hormonal and metabolic changes—in particular, decreased motility, a more fragile anti-reflux barrier, and a compromised intestinal barrier.

I wish I would’ve known this when I had my mysterious stomach pain, likely tied to heightened anxiety, lower vagal tone, and higher stress I felt during that time.

This is why midlife is such an important time to be more intentional about digestive health — not because problems are inevitable, but because both biological aging and the hormonal buffer we once had diminish, increasing the importance of lifestyle factors. I’ll cover those throughout this series.

We’ll focus on timing and rate of eating, what the latest research says about both diet and non-diet strategies, what tests we can ask for, medications, and a lot more.

Let’s talk digestion in the comments! I’d love to learn about your experiences and any questions you have.

Next post in the series

Summer is here! And I’m a little late on this roundup — but that’s summer for you. It’s all about flexibility right now.

With my daughter home from college and four drivers sharing three cars, we’re all improvising. As I write this, my son just dropped me off at a coffee shop so he could use my car, and I could finish this roundup.

Anyway — like usual, there’s a lot going on in midlife health this month.

We’ve got big news on funding for women’s health research, two brain studies worth knowing about, small but mighty research bites, and several gems I think are worth your time.

Let’s do this.

💰Money for Midlife Health

Melinda French Gates recently announced $215 million in new funding through Pivotal, her philanthropic organization, bringing her total investment in women’s health to $600 million over the past two years. The funding focuses on reproductive health, maternal care, and — notably for us — midlife women’s health, including research on menopause.

Her reasoning cuts right to what we talk about here. She’s been vocal that medical research has historically focused on men, leaving women’s health — especially in midlife — chronically understudied. As she put it:

My hope for the future? That every woman—no matter who she is or where she lives—can step into her full power because she’s able to get the care she needs.

We shouldn’t have to wait decades for research to catch up. In the meantime, connecting the dots with what we do know — and helping women understand their changing bodies — is exactly what I’ll keep doing here.

Though I’ll just say: we still need a dedicated society and journal for midlife women’s health, one that addresses this stage as a whole rather than examining everything through the menopause lens.

For more: see an interview with Melinda Gates over at The Vajenda.

🧠 Brain Gains — And an Omega-3 Surprise

Good News First: Brain Improvement Is Possible at Any Age

A three-year longitudinal study of nearly 4,000 adults (ages 19–94) found that people of any age can measurably improve their brain performance — and there’s no ceiling on how much.

What makes this study stand out is the measurement tool. Instead of the usual deficit-focused metrics, researchers used the BrainHealth Index (BHI), a multidimensional tool that measures three pillars of whole-brain health including clarity (thinking skills), connectedness (social purpose) and emotional balance(resilience).

The key findings:

• No ceiling for improvement — even top performers continued to improve over 1,000 days

• Those with the lowest baseline scores saw the greatest gains

• Consistency mattered more than intensity — just 5–15 minutes of daily micro-training was enough

• Age made no difference — gains in younger adults were equal to those in their 70s and 80s

The training used was the SMART program (Strategic Memory Advanced Reasoning Tactics), developed over 30 years at the Center for BrainHealth at UT Dallas. It’s focused on higher-order strategy and reasoning.

Learn more about it here and even enter a clinical trial.

Now the Surprise: An Omega-3 Study With an Unexpected Result

A study using data from the Alzheimer’s Disease Neuroimaging Initiative (ADNI) compared omega-3 supplement users (fish oil, flax, or krill oil) to non-users. Researchers found no difference between the groups in amyloid-beta deposition, tau aggregation, or gray matter atrophy. But the omega-3 group actually showed a significantly greater decline in cognitive function, partly linked to decreases in glucose metabolism.

Here’s my biggest critique of the study: the researchers never measured omega-3 index, the gold standard for determining omega-3 status. Supplement use was based entirely on self-report.

Why does that matter?

• Two people taking the same fish oil dose can have very different Omega-3 Index values

• Adherence is unknown

• The study can’t distinguish between people with low versus high tissue omega-3 levels

• It can’t tell whether any association reflects omega-3 biology or characteristics of people who choose to supplement

Interestingly, an earlier ADNI analysis found the opposite: long-term omega-3 supplement use was linked to lower Alzheimer’s risk — and that study did examine blood biomarkers, finding higher plasma EPA and erythrocyte membrane DHA associated with lower risk of cognitive decline.

Share Midlife Strong

🔬 Research Bites

Coffee cuts dementia risk! A study in JAMA Network found that 2–3 cups of caffeinated coffee or 1–2 cups of tea per day had the strongest effect on reducing dementia risk. The mechanism involves caffeine’s ability to modulate synaptic transmission and reduce amyloid-beta accumulation. Good news for coffee lovers like me!

Speed training’s 20-year payoff. A study in Alzheimer’s & Dementia found that long-term cognitive speed training reduced the risk of Alzheimer’s disease and related dementias — but only when participants completed one or more booster training sessions. The initial training alone wasn’t enough; the boosters were key.

Creatine and kidney health. A systematic review and meta-analysis of randomized controlled trials published in the Journal of Renal Nutrition found that creatine supplementation increases serum creatinine but was not associated with changes in urea concentration or eGFR. Overall good news, though studies beyond one year are still needed. When in doubt, check with your healthcare provider.

Best evidence for sleep during the menopause transition. A recent meta-analysis points to nonpharmacological interventions as having the strongest evidence for improving sleep during the menopause transition — specifically cognitive behavioral therapy and anything that reduces sympathetic hyperarousal, such as breathing techniques, acupuncture, and massage. Pharmacological options still need more long-term study.

For a more in depth look at research, upgrade to paid with posts like: 5 Under the Radar Midlife Studies I Can’t Stop Thinking About and Three New Studies and the Surprising Thread That Connects Them

Upgrade

✨ Cool Things

This viral Substack article is making the rounds for good reason: If I Were 50 Again, Here’s Exactly What I’d Do. Worth a read.

Ann Marie McQueen has finally released her Hot Truth About Hormone Therapy. I haven’t read it yet, but I trust her to deliver a balanced and credible look at hormone options for women. There are many ways to prescribe hormone therapy, and this resource could save you years of confusion. Don’t miss it.

A solid, evidence-based review of red light therapy caught my eye: Does Red Light Therapy Work? Here’s What the Science Says.

Jenn at the Midlife Feast dishes on the drawbacks of the current protein obsession in Protein is The Gateway Drug to Diet Culture in Midlife.

Latest Substack find? Reinvent Yourself by Blue, an 82-year-old women who has reinvented herself 14 times (and counting).

New on my bookshelf: Maryann Selfe’s The Billion Dollar Blindspot: Why Women’s Health is the Investment Opportunity of Our Time. I haven’t finished it yet, but so far she makes a strong case for a missed medical and investment opportunity in women’s health.

That’s it for June! See you next month, and let me know how you’re doing in the comments — Maryann

“Brain scans don’t lie. Women who take hormone therapy have brains that light up on scans. Women without estrogen show shrinkage and atrophy.”

That social media post from a popular menopause doctor stopped me in my tracks. The problem? That’s not what the research actually shows.

Yes, estrogen affects the brain. We see effects on brain metabolism, connectivity, and sometimes brain structure. In some studies, there are positive effects, and others, not-so-positive ones .

But brain scans are not a simple before-and-after scorecard for brain health. What’s often left out is that brain health depends on much more than estrogen.

Nothing has perplexed me more than the disappointing and often conflicting studies on menopausal hormone therapy and the brain. But I think I’m understanding why estrogen therapy often falls flat in randomized controlled studies despite what those social media posts imply.

As we continue this deep dive into brain health energetics, let’s take a look at the controversial role of estrogen on brain health.

Estrogen and brain energetics

Estrogen helps support nearly every step of the ATP-producing process. First, estrogen binds to estrogen receptors (ERα and ERβ) in endothelial cells of the blood-brain barrier and neurons, signaling for increased expression and activity of glucose transporters.

Next, it stimulates glycolysis, allowing neurons to convert glucose into pyruvate more efficiently. It increases mitochondrial oxidative phosphorylation, promotes mitochondrial biogenesis, and decreases oxidative stress. And last, estrogen helps increase blood flow by upregulated eNOS to produce nitric oxide.

Early reports in brain imaging analyses conducted on post-menopausal women showed declines in glucose metabolism and gray matter volume, with hormone therapy attenuating this.

Done deal, right?

Well, that’s what we thought until the infamous Women’s Health Initiative changed everything.

Disappointing research outcomes

The Women’s Health Initiative study, in particular the subset Women’s Health Initiative Memory Study (WHIMS) study, found women in the estrogen plus progestin arm had 1.5-2 times the risk of dementia.

But as most of us have learned by now, those were with synthetic forms and in older women, which was women 65+.

Because of controversy of WHIMS, the ELITE trial (Early vs Late Intervention Trial with Estradiol) tested the “timing hypothesis” comparing women on hormone therapy in early post menopause (<6 years) vs late (>10 years), looking at cognition and vascular brain markers.

Researchers gave the women oral 17B-estradiol 1 mg/day and 10 days of vaginal micronized progesterone. This is key because they were not synthetic forms of estrogen (CEE) or progestins.

After 5 years, the researchers found no meaningful improvement in cognition in the early group, as determined by neuropsychological testing of memory, executive function, verbal fluency, and global cognition composites.

Next was the KEEPS trial (Kronos Early Estrogen Prevention Study) enrolling recently postmenopausal women (~6 months–3 years since menopause, ages ~42–58) to test whether early menopausal hormone therapy affects cardiovascular risk markers and other aging outcomes.

Participants were randomized to oral conjugated equine estrogen (CEE) + cyclic progesterone, transdermal estradiol (patch) + cyclic progesterone, or placebo.

The cognitive arm of the study assessed verbal memory, executive function, working memory, and global cognition composites. The study followed women for about 4 years of treatment. Across all groups, there were no significant differences in cognition. A longer-term follow up showed no difference as well.

And a recent pooled analysis combining RCTs and observational data in Lancet Healthy Longevity 2025 with 1 million women found no significant association between menopause hormone therapy and dementia risk overall.

So, what gives? I want to discuss three potential reasons estrogen hasn’t produced the brain health effects we thought it would, the first being the most important.

Read more

I’ve been following Dr. Sabrina Brar on Instagram — she’s the Chief Future Officer at PowerBreathe. When I saw her post about the benefits of inspiratory muscle strength training (IMST) and how she fits it into her own life, I knew I had to have her on.

I’d recently switched to using the PowerBreathe device and wanted her to not only talk about the benefits, but show us all how to use it correctly. In this live, we get into all of it — and best of all, I picked up plenty of tips on how to improve my own diaphragm exercise form.

Here are the highlights:

• Dr. Brar’s background as an ENT surgeon with the NHS and why she made the move to PowerBreathe.

• What IMST (or IMT, as it’s known in the UK) actually is — and where I got the “Dumbbells for Your Diaphragm” tagline.

• The first studies in the 1980s and how IMST gained traction, with early benefits seen in rowers.

• What the research says about IMST’s benefits — from heart health to pelvic health to digestion (the diaphragm plays a role in the lower esophageal sphincter).

• Dr. Brar answers listener questions, including: Is it safe if you already have low blood pressure? Is there a risk of ingesting microplastics from the device? Can it help with high blood pressure?

• The protocols and intensity levels that are most effective, based on the latest research.

• A step-by-step demonstration of how to use the PowerBreathe device, the different types available, and what I’ve been doing wrong.

• Links: Powerbreathe website, Powerbreathe on Amazon, Dr. Sabrina Brar on Instagram, my interview with Daniel Craighead, and the review on blood pressure

  “Your lungs aren’t muscles, they are spongy air sacs, fueled by predominately the diaphragm…If you go to the gym, if you did a squat or you were doing bicep curls, imagine doing that but for your diaphragm.”

  - Dr. Sabrina Brar

Get more from Maryann Jacobsen in the Substack app

Available for iOS and Android

Get the app

“Let’s go around the room and have everyone say a little something about themselves.”

For as long as I can remember, I dreaded hearing those words in a group setting. My heart rate would creep up until I got the dreaded task over with — unable to recall exactly what I’d said.

Public speaking had been my nightmare, one I managed to mostly avoid until my dietetic internship, when we had to present case studies. My hands would shake, my voice would change, and I have no doubt the audience felt uncomfortable watching me suffer. One comment from my preceptor, in large bold letters, was: RELAX! I dreaded those presentations for weeks beforehand. It was horrid.

As I progressed in my career and in life, my speaking did improve — but it became something I got through and tolerated, not thrived in. And on a more subconscious level, I still seemed to avoid it.

Then one night, over two years ago, I was talking to my husband about my professional goals, and he suggested I join Toastmasters. And like anyone afraid of public speaking, I knew exactly what that meant: a complete focus on the very thing that scares most of us.

Fear of public speaking — technically called glossophobia — is one of the most common fears, ranking ahead of heights, spiders, and even death in some surveys. According to Teleprompter.com, 75% of people worldwide fear public speaking, and only 10% do anything about it.

Even though I had heard of Toastmasters, I knew very little about what it actually involved. So, I decided to try a meeting, which happened to be five minutes from my house.

Structured meetings

When I arrived, everyone was welcoming. If you want positivity and to feel genuinely safe, go to a Toastmasters meeting.

I was immediately impressed by Jim — not only did he give an amazing speech, but he has been part of Toastmasters for 30 years, is in his 80s, and is a TEDx coach. I thought, I want to be him when I grow up.

The meetings are routine and structured. Members take on roles like Toastmaster of the Day (who runs the meeting), Ah Counter (who tracks filler words), and Timer (who keeps everything on track).

There are both impromptu and prepared speeches. The impromptu speeches — called Table Topics — are one to two minutes long. A Table Topics Master comes prepared with questions based on the meeting’s theme. If the theme is travel, for example, a question might be: “Where is somewhere you’ve always wanted to visit and haven’t yet — and why?” You then have one to two minutes to answer on the spot.

Distinguished Toastmaster Francine Juhlin describes the benefits of Table Topics in this article:

The opportunity to participate in Table Topics has been one of my favorite aspects of Toastmasters. It allows me to practice thinking quickly and speaking clearly. This has been especially helpful during author interviews when promoting my books, and as a podcast host actively listening to my guests to ask the perfect question to make them sparkle.

Then there are two to three prepared speeches that members sign up for, usually five to seven minutes long. Each member works through an education series called Pathways, which guides speeches and projects.

Last — and perhaps most important — are the evaluations, where members give two-to-three-minute feedback on the prepared speeches so everyone can learn. Evaluators look for things like vocal variety, clarity, intro/closing, speech structure, storytelling, and movement and gestures.

At the end of each meeting, the Ballot Counter announces the winners for best Table Topics, best Speaker, and best Evaluator. The winners take a photo and the meeting adjourns.

Between the roles and speaking assignments, there are plenty of opportunities to speak. And if you somehow get through a meeting without saying much, they make sure you say something at the end.

After my first meeting, I knew instantly I wanted to join.

Subscribe now

All my firsts

I started by taking on smaller roles like Ah Counter and Timer. I was nervous even about those — you have to describe the role at each meeting and comment on the theme, and that alone felt like a lot at first.

I also chose my Pathway: Presentation Mastery, which most newcomers select. The first speech is an icebreaker — essentially an introduction to the group. I did mine on the three reasons I had always feared public speaking.

First: not wanting attention on me. Second: fear of being judged. And third: the bad experiences — like those case study presentations during my internship. Somewhere along the line, I had decided there were people who could speak and people who couldn’t, and I was firmly in the latter camp.

Everyone could relate, and it was a great start. I eventually took on every role — including Toastmaster of the Day and evaluator, which scared me the most.

And with each role and each speech, something started to happen. I became increasingly comfortable getting in front of people and speaking.

Where I am now

In February, Toastmasters in San Diego held an expo where all the clubs come together. Part of the event involved giving a 30-second pitch about your club, and I had volunteered to help.

One of our lead speakers was going to deliver it, but she had to leave early — and they asked me to be the backup. I ended up doing it.

This time, instead of my safe Toastmasters crowd, I had a bigger audience. I was nervous, but when I watched the video afterward, I thought: well, that didn’t suck.

It was a moment I realized how far I’d come — and how much farther I wanted to go.

It’s easy to fall into a rut of only filling roles and skipping speeches. Late last year, my mentee and I committed to giving one speech a month in 2026. So far, I’ve kept that goal.

In the past, my nerves would take over and make me speak too fast and lean on filler words like “you know.” It took a couple of years, but now that those nerves have settled, I can work on all those details: slowing down, pausing instead of filling silence, and — as Jim frequently puts it — filling my speeches with “stories and emotion.”

The real lesson

If you share this fear or feel that speaking is holding you back, I do recommend trying Toastmasters. But that’s not really what this post is about.

The reality is that as we age, the pull toward comfort grows stronger. The moment we encounter something that touches a deep-seated fear or unfamiliar territory, the reflex to avoid it can be so automatic we don’t even notice it happening.

I don’t want a comfortable, easy life. I want to be challenged. I want to keep learning — not just about the world, but about myself.

I will never be the best speaker. But I’ve learned it’s a skill I can improve and refine. And there is something incredibly liberating about conquering a lifelong fear and discovering what’s on the other side of it.

Time is a funny thing. It’s easy to complain about how fast it goes — especially as another birthday approaches — but we can use that to our advantage. Think about where you could be in a year, or two, or three, if you started something new today.

It’ll fly by…

For me, it’s no longer about reaching a goal or destination. It’s about who I become in the process. I’m proud to say I’m no longer the person who shakes and dreads speaking, making the audience uncomfortable alongside me. Now, when there’s an opportunity to speak, I’m the first to volunteer.

It sounds cliché, but it feels like I’m growing into the person I’ve always wanted to be. Not a perfect person who does everything right — but a courageous one who has finally stopped letting fear run the show.

Have you taken on something that scared you at midlife? I’d love to hear about it in the comments.

Every week I collect research — from google and pubmed keyword alerts, social media screenshots, and my own searches. Most of it stays in my files or is shared in my monthly round up. But lately I have been thinking: why not share more of them with paid subscribers in a Research Watch post? Like in real time?

Because so much of what I find is emerging science — not established or mainstream yet — so keeping up with it matters. Especially in this case when three seemingly unrelated studies I found in the same week turn out to be surprisingly connected.

This week those three studies are:

Study 1: HRT vs. no HRT on nitric oxide-mediated skin blood flow

Study 2: Low eNOS (the enzyme that makes NO) as a predictor of AFib recurrence

Study 3: A review on women and coronary microvascular dysfunction

Each one tells part of a story. But together, they tell a much more intriguing one.

Read more

It’s amazing that just 10 years ago, my nutrition and lifestyle habits differed greatly from today. That’s about the time I started looking into this space—not deeply, but I knew my body was changing.

I thought I’d let you know about some current habits I’ve added that I’m really digging. These are making a real difference. Some are more like an added layer to what I was already doing, while others are brand new.

Sure, I wish I had started these sooner, but that’s okay because I’m doing them now.

1. Hydration and electrolytes

I always poo-pooed electrolytes because they were supposedly for super intense activity only. But upon getting slight headaches and lightheadedness standing, I realized my hydration needs have changed.

I write more about that here, but this is yet another area that needs attention. As we age, hydration becomes trickier. But since playing closer attention to my low blood pressure, headaches, and dizziness when standing are gone.

Part of my realization was how low in sodium my breakfast typically is. That’s important because sodium helps cells absorb water. Plus, I typically work out before breakfast, increasing my needs even more.

I’ve been using Liquid I.V. but have recently found VINIA as it touts increases in nitric oxide and blood flow. Stay tuned.

VINIA is a red grape polyphenol supplement with electrolytes marketed to support blood flow and hydration by increasing nitric oxide and reducing oxidative stress. Right up my alley.

Although its proposed mechanisms are biologically plausible (polyphenols upregulate eNOS, the enzyme that makes NO), most VINIA-specific studies are small and company-sponsored.

Even though the science isn’t all buttoned up, I’m trying it. Have you heard of it?

2. Buying clothes that fit me well

I realized that a lot of my clothes no longer fit my body comfortably—and maybe never did. After spending hours going through them, I ended up donating four bags to Goodwill.

I have a low tolerance for pulling down shirts that creep up or feeling uncomfortable in any way because of clothing. And truth be told, my breasts have, ahem, gotten a bit larger with menopause.

I absolutely love the built-in bra tanks available these days. They fit so nicely and provide plenty of support. Two brands I like are Honey Love and Evelyn & Bobbie. The wireless bras at Evelyn & Bobbie are also my new go-to bra. No more Victoria Secret for me!

As for workout clothes, I’ve really liked the Fanka tops. Just so supportive and comfortable.

I plan to get more of the built-in bra tanks and wear these all summer. Life is too short to wear clothes that don’t feel good on your body.

3. Playing a sport

I took tennis lessons once a week for seven years before finally joining a league. Seven years! There was always an excuse: my kids need me, I rest on Sundays, I’m too busy.

I finally joined a non-competitive Sunday league and I’m loving playing games with other women. It’s inspiring because there’s such a huge age range. It also opened the door to other opportunities, and now I’ve added a high-intensity tennis clinic during the week.

I played sports growing up, so this scratches an itch for me. I love running after balls (ha ha), being competitive, and working to improve a skill. It’s also social.

Someone else may prefer dance or art, but the point is finding something that makes your heart sing.

4. Focusing on recipes for me

When I worked in a hospital educating post-heart attack patients, I observed a pattern: many women cooked for their families for years, but once their kids grew up, they started outsourcing meals to restaurants.

I get it. Cooking for a family can feel endless and thankless. For the last two decades, most of my recipe searching revolved around feeding everyone else.

But now that my daughter is in college and my son is in high school, the focus is turning to me, me, me! (and my husband). It also helps that my daughter now comes home wanting to meal prep.

Another shift has been eating earlier. I aim for 5 p.m. when I can because I simply feel better that way.

I’ve also been experimenting with more bowl recipes. Here’s one that I’ve added to the rotation: a Chipotle Chicken Copycat Recipe, which I marinade over night.

5. Making a meal every Saturday morning

A while back, I used to make food for my mom on Saturday mornings—usually something in the Instant Pot like chili or chicken tortilla soup. Eventually she tired of it, so I stopped.

Then, a few months ago, I made a meal for a friend during that same Saturday morning window: after my run.

I realized this is the time cooking feels least like work because I’m already in the kitchen cleaning up and planning meals for the week.

So for the past month, I’ve been making an Instant Pot meal every Saturday after my run. The best part is that it gives us food for the weekend, which is usually the time I least want to stop and cook. It’s much easier—and honestly satisfying—to heat up some chili.

And bean-based soups/stews like this are some of my favorite foods anyway (remember, it’s about me now).

The key is to make sure I have the ingredients ready Friday night.

Subscribe now

6. Switching to PowerBreathe

I’ve posted about inspiratory muscle strength training before, but for those new here, it’s basically strength training for your breathing muscles—and the emerging health benefits are fascinating.

I recently wrote about oxygen as a nutrient. Inspiratory Muscle Strength Training (IMST) helps your body use oxygen more efficiently by strengthening the diaphragm and breathing muscles. When those muscles work more efficiently, they require less oxygen themselves, leaving more available for the rest of your body.

Such an underrated practice.

For a long time, I used a cheap device from Amazon, but recently upgraded to the PowerBreathe Plus because it’s the brand used in many of the studies. I use it for about five minutes at high intensity while cooking dinner.

I enjoy being able to track and gradually increase the resistance. I’m planning on having on Dr. Sabrina Brar from Powerbreathe on a live interview to show how to use it, so look for that being scheduled.

7. Personal training

For a long time, I never even considered personal training. After all, I told myself, I’m a class person. And honestly, the expense felt like a huge barrier.

I talk more about it in my behind-the-scenes posts for paid subscribers, but I finally tried it to improve my compound lifts: squats, deadlifts, and bench press.

I’m so glad I did. It has fine-tuned my form, and I get to move at my pace instead of keeping up with a class. I’ve gained more confidence and made more progress than I did on my own.

Personal training isn’t for everyone, but if you’ve been considering it, it may be worth trying—even short-term. The individualized attention can be incredibly helpful.

Just make sure the trainer has the expertise you’re looking for. My trainer is a competitive power lifter herself, which has been key.

READ: Can These Two Exercises Prevent Menopause Bone Loss as Effectively as Hormone Therapy?

So those are a few new-ish midlife habits I’ve really been enjoying lately. Any resonate with you? What have you added—or changed—in this season of life?

Are you a mouth-breather?

How are your allergies? Are you stuffy?

Do you feel short of breath?

How are you sleeping?

Let’s check your iron and B12…and if you’re over 50, a screening for sleep disordered breathing.

Imagine treating oxygen like a nutrient. Those questions above? That’s what your doctor would ask.

A few years ago, I ran across a paper by UK researcher Paul Trayhurn, arguing that oxygen should be considered a nutrient. And knowing what I now know, I couldn’t agree more.

Oxygen deficiencies are endemic and increase with age. And sadly, our medical system is doing next to nothing about it.

Why Oxygen?

Trayhurn builds the case that oxygen is an essential nutrient. After all, you can live for days without water, weeks without food — but only minutes without oxygen.

As he points out, the definition for a nutrient according to the Oxford Dictionary of English, 2nd edition (2005) is — “a substance that provides nourishment for the maintenance of life and for growth.

The major difference that separates oxygen from other nutrients is the way it’s obtained. It’s delivered via the nose and lungs instead of the mouth and digestive tract.

When someone breathes in O2 through the nose, it passes into the alveoli, which as highly vascularized sacs in the lungs, allowing for it to cross over to the bloodstream. Once in circulation, hemoglobin in the erythrocytes (red blood cells) binds to O2 and immediately transports it to tissue.

Oxygen is needed for the last step of the electron transport chain to generate ATP. This is especially vital for oxygen-hungry organs like the heart and the brain.

Despite weighing only about 2% of your total body weight, the brain consumes a massive 20% of the body’s resting oxygen supply. The heart consumes about 7% of the body’s oxygen but is the pump that makes the entire system work.

Oxygen meets every criterion for a nutrient. And here’s what most people don’t realize: threats to your oxygen status are all around you.

Oxygen disruption leads to deficiency

We all breathe the same oxygen — yet some of us will experience oxygen disruption, which differs from typical nutrient deficiency states.

To understand this, imagine the respiratory system as a train network. Your airways (nose and throat) are the tracks, your lungs are the train station, your red blood cells are the train cars, and hemoglobin are the cargo spaces inside the cars. But the analogy has a missing piece — the door that lets oxygen into your cells via nitric oxide. More on that shortly.

If any part of this system breaks down, your organs and tissues experience adverse effects from less-than-optimal oxygen (hypoxia).

First are problems getting oxygen into the lungs, those train tracks. If there are airway blockages, like sleep-disordered breathing, it causes oxygen levels to plummet during sleep. If there’s chronic rhinitis (stuffy nose), it may force you to mouth breathe, which is shallow and inefficient, lowering the total amount of oxygen your lungs can absorb.

Breathing too fast, too shallow, or constantly from the upper chest (instead of from the diaphragm) alters your blood chemistry, making it harder for your blood to release oxygen to your tissues (the Bohr effect).

Second are problems carrying the oxygen, the cargo spaces in the train cars. Healthy red blood cells require vitamin B12 for their development. Without it, your body creates oversized, fragile, and broken “train cars” that can’t travel through your tiny blood vessels.

Iron is the magnet that holds oxygen inside your blood cells. Without enough iron, your blood cannot grab onto oxygen to carry it around.

Low oxygen triggers a biological panic button in your cells (called hypoxia-inducible factor or HIF), to help it adapt. Continuous activation of HIF causes free radicals to build up and damage blood vessels, causing inflammation. Or what I call Infla-Stress, which disrupts the One Health Principle.

As a result, the brain isn’t getting the oxygen it needs; the heart works harder so blood pressure rises, the sympathetic nervous system turns on, and it creates a shift in metabolism as the body adapts to a less-than-optimal oxygen state.

Which lever is it?

My son is a high school runner and last summer he attended high-altitude training in the mountains. He just had his first full year of running both cross country and track, and I wanted to check his iron via ferritin, the gold standard.

Before checking his iron I read that in order to adapt positively to altitude training, he needed a ferritin of at least 50ng/ml. That’s because anything less than that would not allow him to make new red blood cells, an important part of the adaptation process.

His was 45.

We got his levels up before that trip, and he had an amazing cross-country season. At the awards banquet, the coach said there was only one other time in his long career he’s seen a jump like my son had had, from one season to the next.

I don’t think it was only the iron, but the point is, we need all parts of the system, like the train network, to be in working order for optimal oxygen utilization.

Why more oxygen isn’t the answer

Usually when there’s a nutrient shortfall, we give more via diet or a supplement. Although giving oxygen can help in certain situations, it’s not the way out of this. Back to the missing piece in the train analogy. You have the track, the cars and cargo, but you also need to open the door to allow oxygen into the cells.

So, what opens that door?

In 2002, Dr. John Stamler, professor of medicine at the Case Western Reserve University School of Medicine and President Harrington Discovery Institute, proposed that we have a three-gas system that involves not just oxygen and carbon dioxide but also nitric oxide (NO), a vasodilator I detail here.

Stamler and his team discovered that NO bioactivity is preserved in red blood cells in a form called S-nitrosohemoglobin (SNO). The release of SNO triggers oxygen release into cells. To form SNO, you need nitric oxide. This makes sense because for oxygen to transport, small blood vessels need to dilate.

Let’s go back to what happens at high altitudes, where there’s less oxygen in the air. To adapt, the body needs to deliver oxygen more efficiently to tissues. Besides increasing red blood cells, it also increases nitric oxide (NO).

Tibetans are famous for positive adaptations to high altitudes. Research shows they have 10 times the nitric oxide and twice the blood flow and oxygen delivery compared to a low-altitude US population.

Yet not everyone adapts in this way. Some people struggle to increase circulation, widen blood vessels, and oxygenate tissues, leading to fatigue, headaches, poor exercise tolerance, sleep problems, altitude sickness, and in rare cases, fluid buildup in the brain or lungs.

This may also be why health effects of living at high altitudes are a mixed bag in terms of health outcomes—some show benefit, some show increased risk.

Sleep and oxygen

There’s another important piece to the puzzle.

In 2018, researchers from the University of Alberta administered high levels of oxygen to rats and examined the resulting activity in their brains.

“We found that when we administer oxygen, our subjects’ brains switch out of active sleep and remain in a deactivated, slow-wave state the entire time,” said Brandon Hauer, a PhD student [Science Daily]. “Interestingly, when we removed the oxygen, the brain started cycling back through active, or rapid-eye-movement, sleep again.”

We know from sleep apnea research, those with more oxygen desaturation are more aroused during sleep. It makes sense that if oxygen isn’t reaching tissues optimally, the body will stay on high alert. In one study, as oxygen saturation decreased, so did time spent in deep sleep, and this was independent of AHI levels.

This is also what’s behind what’s called “altitude insomnia,” the disrupted sleep that occurs during adaptation to lower oxygen levels.

This naturally led me to investigate research on inorganic nitrates like beetroot juice—the dietary path to NO — and sleep. There a few positive studies including a small pilot study with 7 healthy early midlife adults. Compared to placebo, those who consumed beetroot juice before had higher total sleep time (434 vs. 412 minutes), sleep efficiency (89.3 vs 85%) and deep slow wave sleep (75 vs. 66 minutes) and spent less time awake after sleep onset (47 vs. 62 minutes).

Our nasal sinuses also contain nitric oxide, and breathing through our nose benefits, which is no coincidence. Nitric oxide also helps dilate our airway.

Researchers had 7 males and 5 females wear a mask that had them switch from mouth breathing to nasal breathing every 2 hours. When mouth breathing, the subjects showed much worse sleep outcomes in terms of airway resistance (narrow airway) and apneas (stopping breathing), as shown in the diagrams.

We still need more research, but optimizing oxygen delivery is important for sleep. Nitric oxide (and nasal breathing) is key to helping regulate sleep, breathing, blood flow, and oxygen delivery during the night.

READ: The Quiet Sleep Thief You’ve Probably Never Considered

Oxygen as a nutrient could change the game

Quick recap: Efficient oxygen delivery depends on three things: breathing mechanics (day and night), adequate iron and B12, and nitric oxide (blood flow).

Oxygen fuels ATP production — the engine of life at the cellular level. When delivery is compromised, Infla-Stress rises, the brain and heart suffer, and sleep deteriorates.

Unfortunately, most doctors only consider oxygen disruptions in disease states like COPD, heart failure, severe anemias, and sleep apnea (when tested). Yet for many, oxygen delivery to tissues is not optimal.

One thing worth knowing: the oxygen saturation reading on your finger only tells you whether your cells are saturated — not how efficiently oxygen is being delivered, as Stamler pointed out more than 20 years ago.

The bottomline: Oxygen isn’t just air. It’s a nutrient — and it’s time medicine treated it like one.

Trayhurn puts it well:

It is concluded that O2 is an important nutrient, and indeed an essential one, that is required in large quantities and which should be considered in conjunction with what are conventionally regarded as nutrients. As such, O2 should be firmly viewed as being part of the landscape of nutritional science.

I experienced this blind spot in medicine 10 years ago when I was suffering from fatigue, anxiety, shortness of breath, heart palpitations, and sleep disruptions because of an undiagnosed iron deficiency (oxygen saturation 99%, thank you very much). Their solution? A beta-blocker to bring my heartrate down.

Fast forward to today, and I’m sure to get a full iron panel, track my B12 levels, focus on proper breathing and training my breathing muscles, and work to keep Infla-Stress down and nitric oxide up.

So, do you agree? Should oxygen be considered a nutrient?

There’s no doubt the midlife strength training conversation has gone mainstream.

I’ve been on my own journey and recently realized, for the first time in a long time, that I’m pretty content with where I am. Over the last seven years, I’ve tried several classes, apps, doing my own thing, and now personal training.

I got excited about each new opportunity, but as time went on, I got a sense of whether it was actually working for me. Each time, I went with my gut, and I’m glad I did.

As I’ve written about before, this journey has been personal. We are all so different, and it makes sense that we’re not all going to find success doing the same thing.

I wanted to give paid subscribers a little behind-the-scenes look into my workouts — along with a free resource to help ensure you’re working your whole-body week after week.

Let’s start at the beginning.

Read more

In my twenties, I became an intuitive eater by accident. Ironically, it happened during my 10-month internship to become a dietitian.

It was the mix of having regular planned meals (at the hospital), being surrounded by indulgent foods (I was in New Orleans), and that for the first time in a while I felt really happy.

Something just clicked, and I no longer had trouble moderating indulgent foods like sweets and I liked how regular, filling meals – different from my typical mindless eating– made me feel. My weight stabilized like never before.

I couldn’t believe that by listening to my body – those hunger and fullness signals– could transform not only my relationship with food but make nutritious eating even more appealing. And the food noise?

Gone.

This served me for many years until perimenopause, when I started to wonder: Am I still getting strong fullness signals? Did I just wolf-down dinner? How did I make it to 12:30 without being starving for lunch? To be honest, these signals I had trusted for over 25 years felt a bit more muted and unpredictable.

And like everything else, hunger and fullness (and hunger-related hormones) change at midlife. Let’s start with a basic understanding, including how the body regulates hunger and satiety.

Hunger & hormones 101

A network of hormones guides appetite, providing important information to the arcuate nucleus (ARC) in the hypothalamus. The hypothalamus acts like a “master switchboard,” integrating a variety of hunger and satiety signals/inputs.

The hypothalamus receives signals from ghrelin, the primary hunger hormone, secreted from the stomach. Then there’s leptin, the key satiety hormone made by fat tissue. After eating, your body produces insulin, which signals fullness, lessening the desire to eat.

Last are hormones produced by the gut, including PYY (peptide YY), CCK, and the GLP-1, which slow down digestion, suppress appetite, and signal meal termination.

Estrogen doesn’t directly affect hunger, but it modulates and helps strengthen the communication of hunger and satiety signals to the hypothalamus.

I liken it to how I come up with meals for my family. I’m like the hypothalamus, considering everyone’s likes and dislikes – including me – that’s four inputs. Now that my kids are older the inputs aren’t as strong but with a little effort, I am able to decide on a meal plus sides that will satisfy everyone.

Here’s a quick summary:

• Ghrelin → turns hunger up

• Leptin & insulin → turn hunger down

• Gut hormones → turns up fullness and slows down digestion

• Estrogen → fine-tunes how sensitive the system is

Let’s dig a little deeper into how these inputs change at different periods in our life.

Hunger hormones throughout the lifecycle

A 2025 narrative review by Holliday et al., makes the case for specific hunger hormone patterns depending on life stage. This makes intuitive sense to me since I spent 10-plus years studying nutrition and growth and development.

For instance, during childhood and adolescence, growth is the priority, so hormone levels must reflect that. During specific transitions – pregnancy, menopause, and fluctuations in body composition/weight and physical activity – hunger and fullness signals are impacted yet again, but in ways that researchers do not completely understand.

And overall, women show greater ghrelin levels than men.

Emerging evidence reveals perimenopause is a time of heightened appetite (and ghrelin) for women (more on that next). In older age, appetite and food intake decrease as levels of insulin, CCK, PYY, and leptin increase.

Although not entirely clear, the switchboard of hunger hormones reflects where you are in the lifecycle. And midlife – and menopause – is no different.

From cycling to non-cycling

The menopause transition reflects a less stable appetite control system, not “more or less hunger.”

During a menstrual cycle, hunger hormones and food intake fluctuate. Studies show women eat less during the follicular phase when estrogen is high, and more during the luteal phase when progesterone increases.

Estrogen (estradiol) regulates appetite by acting on the brain and enhancing gut satiety signals — it can directly reduce food intake. Gut hormones that signal fullness (like CCK and GLP-1) work more effectively when estrogen is present.

When estrogen drops at menopause, appetite may increase, contributing to both weight gain and insulin resistance. It’s also suggested that estrogen’s appetite-suppressing effects may weaken with age, though we need more research.

As just mentioned, perimenopause may be a sensitive time for an increase in hunger. In one study with 40 women, there were significantly higher ghrelin levels in perimenopause compared to pre- and post-menopausal women.

This does not mean that menopause – or perimenopause for that matter – will make you uncontrollably hungry. In fact, in the Monet study, even though postmenopausal women had higher hunger ratings, they consumed 256 fewer calories per day than premenopausal women, but they had lower energy expenditure.

Instead of a simple increase or decrease in appetite, women may experience:

• Less hunger earlier in the day

• Stronger hunger later

• More variability day-to-day

  What about hormone therapy? Research looking directly at menopausal hormone therapy (MHT) and appetite hormones shows some evidence of beneficial effects, but findings are mixed and not entirely consistent across studies. Studies show MHT does not prevent weight gain but may benefit body composition, reducing visceral fat and helping to preserve lean mass.

What about insulin resistance?

We often hear that insulin resistance drives appetite and weight gain, especially in the midsection. This is oversimplified and doesn’t match the data to date.

In controlled overfeeding studies, people gain weight when they eat more calories than they burn—consistently and predictably—while insulin levels rise alongside that weight gain rather than driving it. In other words, insulin changes tend to follow weight gain, not lead it.

Some studies show that higher insulin is linked with less body fat and weight gain — as we’ve learned, it’s one of the satiety hormones.

That being said, a large meta-analysis in JAMA Network Open found that higher insulin levels can predict some future weight gain—but the effect is modest, and body weight also predicts rising insulin.

It appears to be more like a feedback loop: weight gain with poor lifestyle habits and insulin resistance reinforce each other. Insulin may make weight regulation more challenging for some people, but it’s not the primary driver. And you don’t need to gain weight to have insulin resistance.

What about ‘cortisol belly’?

It’s true that chronic HPA activation is associated with greater abdominal fat — though human studies show mixed results and don’t support a simple cause-and-effect relationship.

What most likely happens is that negative mood in response to stress leads to greater food consumption. More importantly, research points to people with high cortisol reactivity, meaning some people are simply more sensitive to cortisol.

In one study, researchers categorized 40 participants as high cortisol reactors (HCR) or low cortisol reactors (LCR), assigned them a stressful task, and then observed them eating a standardized meal afterward.

The key finding: HCR participants with BMIs over 30 ate significantly more than LCR participants after the stress task. Of course, this was a small study and done in a lab, but other studies have shown that certain populations are more sensitive to cortisol.

Stress-induced eating is a real phenomenon related to cortisol reactivity. For midlife women already experiencing hormonal appetite disruption, chronic stress adds another layer.

Environment and individual differences

The reality is that appetite is complex with many moving targets. Besides hunger and satiety hormones, there are environmental and individual factors behind the scenes that drive appetite, hormone levels, perceptions, and behavior. This is likely why the research is more consistent in animals than humans.

For midlife women changes in sleep and mood will certainly influence appetite. For instance, a single night of poor sleep has been found to increase ghrelin levels.

There is also something called hedonic hunger, eating for reward or emotional comfort in the absence of hunger. Yo-Yo and restrictive dieting, upbringing around food, life satisfaction, food-related beliefs, and genetics all come into play.

Lifestyle also plays a role including work-life balance, exercise, quality of the diet, and how accessible these things are. But cortisol and insulin resistance….not so much.

The question is…why does knowing all this matter for how we eat tomorrow?

Well, 25-plus years ago I made a breakthrough that helped me regulate food during my younger adult years. This means getting the right amount of food for me, enhancing my relationship with food, and nourishing myself with the quality nutrients I needed to thrive.

But as I’ve shown you, things change – and I’ve had to adapt to where I am now. To the midlife stage.

Can you trust your hunger in midlife?

Of course you can trust your hunger. But first comes understanding. Understanding that changing hormones can affect the intensity of those signals. And all that comes with it – aging, stress, sleep, body composition and well-being – affect appetite too.

I plan to address more of these layers and actions women can take (including what I’ve done) in follow up posts. In the meantime, have you noticed changes in appetite and/or hunger and fullness cues at midlife?

What — if any — strategies have made a difference?

Let’s discuss in the comments.

Leave a comment

I leave Thursday to move my daughter out of her dorm. Can you believe it? Her first year of college is almost over.

Wasn’t I just writing about her senior year?

The months really do fly by—and here we are again with more midlife health news. This week: a rethink on how to define perimenopause, a new paper on iodine and breast cancer, two studies that help clarify what’s really going on with midlife metabolism, and much more.

Let’s dig in.

Time to change the definition of menopause?

I follow researcher Susan Davis on Instagram because she brings a refreshing, research-based perspective. In a recent Instagram post, she pointed out that perimenopause has traditionally been defined by changes in the menstrual cycle—typically about a week of variation.

But we’re seeing that some women experience symptoms before any cycle changes.

She referenced the Australian Women’s Midlife Years (AMY) study, which was new to me. The study included over 8,000 women, categorized using STRAW+10 staging. What stood out is that while hot flashes and night sweats were more common in later perimenopause, 8.8% of women with no cycle changes were already experiencing hot flashes.

Other symptoms—like low mood and memory issues—didn’t vary as much by stage. Vaginal dryness, however, increased more clearly as women moved from premenopause into perimenopause.

We’ve seen something similar in the Women Living Better survey, where symptoms in the late reproductive stage looked a lot like those later in the transition—except for hot flashes.

While talking with Ann Marie during our last live, she mentioned a social media post from Lara Briden about different estrogen patterns during the menopause transition. That led me to a 2020 study using data from Study of Women’s Health Across the Nation and the Melbourne Women’s Midlife Health Project.

It showed four distinct patterns of estrogen change.

We often hear that estrogen declines about two years before the final menstrual period—and that’s true on average. But the pattern isn’t the same for everyone. In nearly half of women (44.5%), estradiol actually rises about 5.5 years before the final period, followed by a sharper drop closer to it. Others show a slow decline—or very little change at all.

When you put this together with the AMY study, it helps explain why symptoms can be so different in women. Some women may be experiencing lower estrogen earlier, while others are still seeing higher levels.

Looking back, I suspect I was in the “higher estrogen” group—due to my heavy bleeding and iron deficiency.

This is where individualization really matters. But just as important—and something the AMY researchers emphasized—is ruling out other issues first, especially iron deficiency. Symptoms like fatigue, low energy, palpitations, and sleep issues can overlap.

READ: Why Iron Deserves Attention at Midlife

Micronutrient + lifestyle highlights

A new paper published in Frontiers in Oncology (April 2026) proposes a mechanism for how iodine deficiency could contribute to breast cancer. The authors suggest it may disrupt reproductive hormones and alter signaling pathways involved in tumor growth and spread.

I wrote about this connection last year—but this paper adds an important piece: the how.

The takeaway? Until we get more research, midlife women—and the girls and young women in their lives—should aim to meet the iodine RDA of 150mcg (250mcg during pregnancy - check those pre-natals!). Read last year’s post to find out how.

Another study, published in Neurology, followed adults for over 16 years. Higher vitamin D levels (>30ng/ml) in midlife were associated with lower accumulation of tau protein, a marker linked to Alzheimer’s disease. This vitamin D and Alzheimers link is getting stronger by the day.

There’s also an interesting study published in Arteriosclerosis, Thrombosis and Vascular Biology on timing of eating (shared in a recent roundup from Hot Flash Inc). Participants who stopped eating three hours before bed and dimmed lights in the evening extended their overnight fast by about two hours—and saw improvements in blood pressure (including during sleep), heart rate, and blood sugar.

We’ve been working on moving dinner earlier in our house since we go to bed—and wake up—early during the week.

5pm dinner, anyone?

As one of the study authors, Daniela Grimaldi, put it:

“Timing our fasting window to work with the body's natural wake-sleep rhythms can improve the coordination between the heart, metabolism and sleep, all of which work together to protect cardiovascular health.”

Midlife metabolism (again)

It wouldn’t be a roundup without something on metabolism.

A small 2026 study found that menopausal stage itself does not meaningfully change energy expenditure, including after eating, when body composition and activity levels are similar.

There was a slightly higher thermic effect of food (TEF) in perimenopausal women compared to premenopausal women—but no consistent differences overall. What mattered most? Fat-free mass (muscle) and movement.

The study also found that higher FSH—expected during the transition—was associated with reduced fat oxidation after meals, suggesting hormones may influence how fuel is used, rather than how much energy is burned.

A similar (recent) study reached the same conclusion from a different angle: when women are matched for body composition and activity, menopausal status doesn’t significantly change metabolism at rest or during activity.

Taken together, this challenges the idea that menopause is the primary driver of metabolic slowdown.

A more accurate picture:
Changes in muscle, movement, and metabolic health play a much larger role—while hormonal shifts alter how energy is used. Metabolism doesn’t slow, it just changes.

In the real world

🎤 Interview: Don’t miss my conversation with Anita at Midlife Unfiltered — we talk about Nutrient Bioavailability — and how to tell if you’re meeting your micronutrient needs.

🛒 Product: In my cholesterol series I mentioned Standing Tall roasted soybeans. I’ve had the chance to try more flavors and I love these! They have Sea Salt, Salt and pepper and Chili Lime. They’re a convenient way to get plant-based protein and soy. You can find them at their website, large online retailers like Amazon and Walmart (not sponsored, just a fan)

📰 Read: If you’ve been affected by the estrogen patch shortage, this article has some helpful guidance on what to do.

🍗 Recipe: I make a lot of chicken and can never have too many ways to prepare it. This is hands down my favorite marinade — works great with boneless, skinless thighs.

📲 Follow along: I’m posting more on Instagram and Facebook — my goal is one reel a week plus slides based on my Substack posts. Come find me there!

That’s it for May. Any thoughts or reactions? Let’s talk in the comments.