Diabetes and obesity management in menopause
Itunu Johnson-Sogbetun, GP with experience in women’s health, sexual and reproductive health and menopause care. GP tutor and examiner, Queen Mary University of London
● Menopause affects the whole body: energy, mood, sleep, weight, bones, heart and brain function. Experiences vary.
● Menopause is stigmatised and taboo in many Black, Asian and minority ethnic communities – women are expected to endure silently.
- Beliefs and attitudes impact health-seeking behaviour.
● Decreases in oestrogen, testosterone, progesterone and insulin sensitivity, and increases in cortisol, occur.
● Cardiovascular protection is reduced with declining oestrogen:
- Promotes visceral fat accumulation.
- Vascular dysfunction raises blood pressure.
- Adverse lipid profile develops, increasing risk of atherosclerotic cardiovascular disease (ASCVD).
● Menopause is a critical window for risk stratification and prevention:
- Screen early, intervene proactively for all of these risk factors, not just symptoms.
- Multidisciplinary approach improves long-term outcomes.
● Menopause impact varies by diabetes type:
- Type 1: increased basal insulin needs and complicates insulin dosage.
- Type 2: insulin resistance worsens, risking disease progression.
- Prediabetes: menopause may increase risk of transition to type 2 diabetes.
● Risk of type 2 diabetes increases by 24% with early menopause (Yazdkhasti et al, 2024).
● Hormone replacement therapy (HRT) in women aged <60 years or within 10 years of menopause may:
- Improve endothelial function.
- Improve lipid profile.
- Reduce ASCVD progression.
- Improve insulin sensitivity.
● Non-hormonal options for symptoms:
- SSRIs, SNRIs, gabapentin and clonidine for hot flushes and mood disturbance.
- NK3 receptor antagonist fezolinetant for vasomotor symptoms (MHRA warning: risk of liver injury). NK1/NK3 anatagonist elinzanetant for vasomotor symptoms and sleep disturbance.
- Lifestyle changes and cognitive behavioural therapy may also be helpful.
● Ethnicity:
- Aim for an individualised, culturally competent approach to assessment, risk stratification and management.
- Use ethnicity-adjusted BMI and waist circumference thresholds.
- Incorporate traditional foods in culturally tailored dietary advice.
● Address hormone hesitancy:
- HRT is safe for many women when carefully prescribed and monitored; help women make confident, empowered decisions.
● Practice culturally responsive care:
- Clinical curiosity: Take interest in people’s lives, not just their symptoms.
- Open communication: foster a safe, judgement-free space.
- Education and awareness: provide clear, culturally sensitive information.
- Trauma-informed care: respect cultural factors and understand minority trauma in healthcare settings.
- Symptom recognition: actively listen and acknowledge symptoms.
- Shared decision-making: treat women as equal partners in care decisions.
● Clinical pathway:
- Consider HRT first.
- Review diabetes medication.
- Consider weight loss medication.
- Assess and monitor key cardiometabolic and renal markers.
Further reading
- Yazdkhasti M et al (2024) The association between age of menopause and type 2 diabetes: A systematic review and meta-analysis
- Forde R et al (2024) Type 1 diabetes and menopause, what women would like to know: A public and patient involvement exercise
- Partridge C (2023) At a glance factsheet: Diabetes and menopause
Diabetes and obesity management in complexity: Mental health
Disordered eating, substance misuse and GLP-1 RA therapy
Zoe Kolokotroni, Senior Lecturer in Behavioural Pharmacology, Leeds Beckett University Obesity Institute
● Eating behaviour assessment should be central to metabolic care:
- Obesity, type 2 diabetes, eating disorders and mental health share biological and psychological pathways, and frequently coexist.
- People with type 2 diabetes:
- Around 25% have disordered eating (not an eating disorder – subthreshold patterns that harm glycaemic control and wellbeing).
- 7–20% have binge-eating patterns. Night-eating syndrome also common.
- Increased alcohol and nicotine use compared with the general population.
- People with obesity:
- 20–30% have disordered eating (binge, restrictive, emotional and night eating).
- Around 14% have binge eating disorder (BED).
- Increased alcohol and nicotine, especially in those with BED.
- Screening for eating disorders, disordered eating and substance use should be routine, not exceptional.
- People want non-judgemental, practical and psychologically informed support.
● Assess eating behaviour routinely when considering GLP-1 RA therapy:
- Assess binge eating, restrictive eating, compensatory behaviours, eating disorder history and, where relevant, substance use.
● Think beyond weight and HbA1c:
- Explore the “why” behind eating behaviours; monitor psychological wellbeing alongside metabolic outcomes.
● Work across services:
- Integrated diabetes, obesity, dietetic and psychological care are essential for people with complex eating behaviours.
● Prescribe GLP-1 RAs carefully – evidence of benefit and potential harm:
- May help with satiety regulation, modulation of reward pathways, improve impulsivity and inhibitory control.
- However, potential to harm:
- May reactivate or entrench restrictive pathology in those with history of anorexia or avoidant/restrictive food intake disorder (ARFID).
- Profound appetite suppression.
- Rapid weight loss can be misused.
- Gastrointestinal effects may mask, mimic or enable purging, with rebound when stopped.
- May benefit binge-type pathology but require caution in restrictive eating disorders.
- Emerging evidence in BED:
- Reduction in binge eating severity, Binge Eating Scale scores, binge frequency, cravings and emotional eating.
- Reduction in binge eating severity, Binge Eating Scale scores, binge frequency, cravings and emotional eating.
- GLP-1 RAs are one component of care, not a treatment for eating disorders.
- Signals of risk and misuse:
- Population data largely reassuring, but screen for individual risk.
- Absence of evidence is not the same as safety.
- FAERS US pharmacovigilance confirmed intentional overuse and use without prescription.
- EMA review of suicidal ideation and self harm – no causal link established.
- Promotion for aesthetic weight loss in adolescents raises exposure in vulnerable groups.
Key conclusions
● Metabolic health and eating behaviours cannot be considered in isolation.
● Effective metabolic care is not just about prescribing the right medication; it is about understanding the person behind the condition and the drivers of eating behaviour.
Further reading
- Whatnall M et al (2026) The relationship between weight, eating behaviours and mental health over time in the YOUTH longitudinal cohort study
Depression, stress and trauma
Professor Jason Halford, School of Psychology, University of Leeds
● Eating behaviours associated with obesity include:
- Emotional eating.
- External eating (driven by environmental cues).
- Mindless eating – while distracted, ignoring appetite cues.
- Reward-driven eating – high-fat, high-sugar, energy-dense, ultra-processed foods; large portions.
- Eating patterns – eating away from home, skipping breakfast, fast food, sweetened drinks.
● Mental health issues associated with obesity:
- Anxiety, depression.
- Eating disorders.
- Neurodivergence.
- Psychotic disorders – bipolar disorder, schizophrenia.
- Substance use disorders.
- Personality disorders.
- Psychological factors.
- Biological factors.
- Side-effects of medications (antidepressants, antipsychotics).
● If onset of obesity <20 years:
- Associated with higher current BMI, more weight loss attempts, greater feelings of helplessness.
- Impact more severe and harder to manage.
- Healthcare professionals should consider depression screening in adolescents living with obesity.
- High proportion have poor mental wellbeing and low self-esteem (especially in females, older adolescents, and those with obesity class II and III).
● Bariatric surgery candidates:
- 37–72% have a psychiatric disorder.
- Up to 33% have a substance misuse disorder.
- Up to half may have an eating disorder.
Stress, mood and weight
● Repeated stressful life events are associated with emotional eating and preference for energy-dense foods rich in sugar and fat (Torres and Nowson, 2007).
- Mechanisms include elevated cortisol, hormonal and metabolic changes, and inflammation.
● Perceived stress (global and job-specific) correlates with waist circumference and visceral obesity.
● Psychological approaches include:
- Cognitive behavioural therapy.
- Behavioural therapy.
- Motivational interviewing.
- Acceptance and commitment therapy.
- Mindfulness-based cognitive therapy.
- Compassion-focused therapy.
- Trauma-based therapy.
● Compassion-focused therapy for obesity:
- Aims to reduce shame, self-criticism and emotional distress.
- Helps develop self-compassion, understanding that weight-related struggles are not due to personal failure.
- Includes soothing-rhythm breathing, compassionate imagery and reframing negative self-talk.
- Supports emotional regulation, reduces binge or comfort eating, improves motivation for health behaviours.
- Kinder self-relationship may enhance engagement with therapy and sustainable lifestyle change.
Practising trauma-informed care
● Consider:
- Current events.
- Past trauma, including post-traumatic stress disorder (PTSD).
- Childhood maltreatment, including neglect; bullying; physical, emotional, verbal and sexual abuse (severity more important than type of trauma).
● Drawing a life events weight graph (see Kushner, 2020) can be helpful in understanding when and why weight gain occurred.
● Obesity and trauma (Mason et al, 2016):
- Multiple adverse childhood experiences (ACEs) associated with a 46% increased likelihood of adult obesity. Two in three adults have had at least one ACE.
- 69% of bariatric surgery patients have a history of child abuse or neglect.
- 39% of people with PTSD are obese.
- Possible mechanisms include maladaptive coping, defence mechanisms, changes in emotional regulation.
● Healthcare settings may reinforce trauma due to weight stigma and discrimination, resulting in reduced clinician trust, healthcare avoidance and less engagement with treatment.
● Effective obesity care requires addressing underlying trauma, not just weight.
- Aim to improve engagement, reduce re-traumatisation and support sustainable health rather than focusing solely on weight loss.
● Trauma-informed care for obesity:
- Recognises that past trauma can shape eating behaviours, metabolism and engagement with healthcare professionals.
- Creates safe, respectful, non-judgemental environments, avoids weight stigma and builds trust.
- Focuses on understanding the “why” behind behaviours; aims to improve engagement and reduce harm.
- Includes collaboration, empowerment and choice. May include trauma screening, supporting emotional regulation and tailoring treatment to individual needs.
Resources
- West Yorkshire Health and Care Partnership. More than weight: Exploring the human, social and economic cost of obesity
- Gilbert P (2010) Compassion Focussed Therapy. Routledge, London
Guest Editor Hannah Beba asks which outcomes – beyond mere numbers – are most important to the individual, the clinician and the NHS.
7 Jul 2026