Method

Procedure

The ME-WEL project was approved by the Ethics Committee of ISPA-Instituto Universitário (ref. D/024/01/2020), following the guidelines of the Portuguese Psychologist Association (2011) and the American Psychological Association (2003). The initial participant recruitment phase, between May and December 2020, marked the inception of the ME-WEL project, which involved an online survey focused on menopause and weight management constructs. Upon completing the questionnaire, women who expressed interest in participating in the study´s second phase were invited to provide their contact details. A comprehensive overview of the entire recruitment process is presented in Figure 1. The final sample comprised 31 post-menopausal women who reported experiencing weight gain during the menopausal transition.The interviews, conducted during the pandemic, took place between December 2020 and February 2021. They were conducted by the first author and were carried out either via telephone (n = 28) or on Zoom (n = 6), based on the participant's preference. The average interviews duration was 23 minutes, with a range of 13 to 40 minutes (M = 23.02, SD = 7.57). No specific time constraints were imposed during the interviews. Before the interviews, the research objectives were clarified, and participants provided informed consent. Furthermore, participants were requested to grant permission to record the interviews. The interviews were audio-recorded and later transcribed to capture verbal and non-verbal elements (e.g., pauses, laughs). The initial transcription process took place from January to March 2021, followed by a comprehensive review conducted by the first author in April and May 2021. Each interview was assigned a unique alphanumeric code to ensure participant anonymity. The data coding process underwent a thorough review by two members of the research team. Initially, one of the authors conducted independent coding (ML). Subsequently, both authors (ML and FP) collaborated to ensure accurate categorization through clarifications and code refinements.

Figure 1 The recruitment process of interview participants. 

Results

Multiple correspondence analysis

Each subcategory was dichotomized into nominal variables (0 and 1) based on its absence or presence. Following this, a MCA was conducted, resulting in the development of a four-dimensional framework for “Weight gain factors during the menopausal transition”. Detailed statistical information, including factor loadings, variance, Cronbach's alpha (α), eigenvalue, and inertia values, is presented in Table 1.

Figure 2 displays the map featuring the final four-dimensional model of the underlying weight gain factors during the menopausal transition.

Figure 2 The final four-dimensional model of the underlying weight gain factors during the menopausal transition. 

Table 1 Four-dimensional model exploring the underlying factors contributing to weight gain during the menopausal transition, in women who have transitioned from a healthy pre-menopausal weight to post-menopausal overweight or obesity. 

Note. Dimension 1 = Emotional eating/ Cravings, Physical inactivity, and Pandemic effects; Dimension 2 = Health, Lack of self-care, and Stressful life events; Dimension 3 = Biological/Physiological factors, Binge eating, and Interpersonal influences; Dimension 4 = Changing habits and routines, and Work Environment; n* = participants who mentioned the sub-category, considering the total sample (n=31); N** = total number of times the sub-category was mentioned; %*** = percentage of participants who mentioned the sub-category; Y= Years (age); BMI= Body Mass Index (kg/m²); The bold values indicate the most significant factorial weights for each variable, obtained through Multiple Correspondence Analysis.

Discussion

Considering the prevalent issue of obesity in menopausal women and the resulting consequences, often linked to weight gain during the menopausal transition, this study aimed to explore the influential factors of weight gain in a sample of Portuguese post-menopausal women. Utilizing a mixed-methods approach, the study revealed a comprehensive four-dimensional model to understand these factors.

The first dimension - Emotional eating/Cravings, Physical inactivity, and Pandemic effects, highlights the significant roles of specific behavioural and environmental factors in contributing to weight gain during the menopausal transition. Specifically, food cravings, emotional eating, physical inactivity, and the influence of the pandemic were highlighted. In this phase of a woman's life, anxiety and depression, in addition to weight gain, are common concerns (^{Sociedade Portuguesa Ginecologia [SPG], 2018}), and various life situations (e.g., children leaving home, divorce) can impact emotional well-being (^{Bondarev et al., 2020}). A recent systematic review of the diverse interpretations of menopause found that approximately one-third of women believe that divorce rates may increase during menopause (^{Shamsalizadeh et al., 2023}). Emotional eating and/or cravings for specific types of food are common responses to emotional and physiological challenges (^{Burnatowska et al., 2023}). Additionally, the emotional distress associated with the pandemic has further disrupted eating patterns, leading to increased cravings and consumption of junk food (^{Coppi et al., 2021}). As a result, the later study found that more than half of women experienced weight gain.

Multiple studies have consistently shown a strong connection between physical inactivity and weight gain in women going through this life stage (^{Al-Safi & Polotsky, 2015}; ^{Bondarev et al., 2020}; ^{da Silva et al., 2018}; ^{Kapoort et al., 2017}; ^{Pimenta et al., 2014}). In particular, da Silva and colleagues (2018) have demonstrated that physical inactivity more than doubles the likelihood of weight gain in menopausal women and is linked to a prolonged period of obesity. Additionally, it is crucial to note that a sedentary lifestyle can have detrimental effects on the emotional well-being of these women, and physical activity plays a crucial role in enhancing life satisfaction and overall well-being (^{Bondarev et al., 2020}). This interaction of physical inactivity, emotional eating, and food cravings can result in a cycle that predicts weight gain or weight recovery. This combination can negatively impact mental health, potentially contributing to a vicious cycle (^{Kapoor et al., 2017}).

The second dimension - Health, Lack of self-care, and Stressful life events, unveils the contribution of various physical/biological factors (such as health problems and steady weight gain), behavioural factors (including a lack of self-care, increased frequency of eating, and reduced physical activity due to the pandemic), and environmental factors (like stressful life events) to weight gain during this phase. Some of these findings align with previous studies (^{Pimenta et al., 2014}). Menopause is a significant phase in a woman´s life, often accompanied by a range of symptoms (e.g., hot flashes) and health issues (e.g., muscle pain). However, many women tend to ignore these symptoms or delay seeking appropriate medical advice, often due to a lack of self-care, which can result in a decreased quality of life (^{Simbar et al., 2023}). This lack of self-care can be linked to insufficient health and menopause-related information, as well as certain life events (e.g., the "empty nest", the onset of chronic family or personal illnesses, the loss of family and friends), where women may prioritize the needs of others over their own (^{Atrian et al., 2018}; ^{Bondarev et al., 2020}). It is worth noting that another study identifies a shift towards self-care behaviours in post-menopausal women, with increased attention to nutrition, exercise, and weight control (^{Simbar et al., 2023}). However, approximately half of the women may not adopt these self-care practices (Simbar et al., 2023). Another noteworthy finding in this dimension pertains to an increase in the frequency of eating during the day, particularly snacks. A study conducted by ^{França et al. (2021}) revealed an association between an increased frequency of meals per day and the inclusion of a mid-afternoon snack, leading to a lower BMI. It is important to note that these meals were characterized by a dietary pattern rich in fruits and vegetables (^{França et al., 2021}). The present study highlights a higher meal frequency, though it lacks specific information regarding the nature of these meals. The relationship between meal frequency and its impact on obesity warrants further investigation, though the idea that a higher number of meals may be associated with health benefits, such as managing diabetes, appears to be a consistent finding among studies (^{França et al., 2021}; ^{St-Onge et al., 2017}). Moreover, during the pandemic, these behaviours (i.e., eating more frequently), as well as reduced physical activity, were notably prevalent (^{Coppi et al., 2021}).

The third dimension - Biological/Physiological factors, Binge eating, and Interpersonal influences, reveals that some biological factors (such as medication intake, menopause and its related symptoms, and metabolic factors and/or genetic predisposition), behavioural factors (unhealthy eating, binge eating, and greater pleasure in eating), and environmental factors (interpersonal environment) contribute to weight gain during this phase. Biological factors (e.g., increased insulin resistance, aging, medication intake) are well-documented contributors to weight gain, as supported by previous research, and can exert a significant impact on a woman´s ability to maintain a healthy weight during this phase (^{Kapoor et al., 2017}; ^{Monteleone et al., 2018}). Furthermore, the role of behavioural factors is also evident and interconnected. A recent study suggests that addictive processes may contribute to binge eating in women (^{Levallius et al., 2022}). These processes of addictive eating can be understood from two perspectives: the involvement of reward systems associated with appetitive motivation (biological processes) and the decision-making systems that control food intake choices (behavioural processes; ^{Burnatowska et al., 2023}; ^{Ho & Verdejo-Garcia, 2021}; ^{Levallius et al., 2022}). Moreover, this dimension underscores the impact of the interpersonal environment. Environments that encourage unhealthy eating can significantly influence food choices, as can binge eating (^{Ho & Verdejo-Garcia, 2021}). Additionally, the presence of emotional support from spouses can be crucial, particularly in reducing depressive and anxiety symptoms and aiding women in adapting to the menopausal process (^{Namazi et al., 2019}). As a result, women can have a better quality of life and, consequently, are more likely to adopt healthier behaviours. Previous research on menopausal women has explored traditional eating patterns, which include a mixture of healthy and processed foods, and has associated them with a higher BMI (^{França et al., 2021}). This emphasizes the need to consider dietary habits and their impact within the context of menopausal weight management.

The fourth dimension - Changing habits and routines, and Work Environment, highlights that certain behavioral factors (smoking cessation, increased appetite and higher food intake, and lack of daily routines) and environmental factors (professional life characteristics) contribute to weight gain during this phase. Smoking cessation is highlighted as a significant factor in an increase in appetite and weight (^{da Silva et al., 2018}). These authors suggest that when individuals quit smoking, it can lead to an increase in appetite, which, in turn, may result in higher calorie intake. Furthermore, additional research highlights that heightened appetite and increased calorie intake are prevalent during this phase and may also be related to physiological processes (^{Ali et al., 2020}). Compounded with all these menopausal challenges, women often face the perception that their professional commitments leave them with limited time for their personal lives, which is associated with higher stress levels and fatigue (^{Pinto et al., 2018}). The increased stress/fatigue and lack of daily routines (e.g., lack of time and organization to prepare meals, a loss of ability to maintain routines) can contribute to a greater likelihood of consuming more food (^{Ali et al., 2020}; ^{Pinto et al., 2018}).

The findings of this study are consistent with the conceptual model of Triadic Reciprocal Determinism (TRD), a component of Bandura's social cognitive theory. TRD highlights the dynamic interaction among personal, behavioural, and environmental factors that shape behaviour (^{Lo Schiavo et al., 2018}). Our four-dimensional model aligns with this framework, illustrating how these three factors interplay across most dimensions. It is worth noting that the factors may not hold the same level of significance within TRD and might change over time (^{Lo Schiavo et al., 2018}).

While this study provides a comprehensive exploration of menopausal weight gain through a mixed methods approach, several limitations warrant consideration. Firstly, despite being a qualitative study, the sample size is relatively small. Conducting online/telephone interviews may have influenced some results, as some women might not feel as comfortable discussing specific topics remotely. Moreover, the preference for telephone interviews over Zoom might have influenced some responses, as Zoom offers more direct contact and interaction due to its video component. Nevertheless, the flexibility in allowing participants to select their preferred interview method resulted in increased participation rates, preventing dropouts arising from potential discomfort or unfamiliarity with Zoom, despite the researcher's provided assistance. Thirdly, conducting the study during the pandemic introduced temporal factors (e.g., lockdowns, health concerns) that could have influenced participants' responses. The MCA analysis revealed alpha values below the 0.7 threshold. Nevertheless, this is somewhat acceptable in exploratory studies with limited sample sizes (^{Johnson and Wichern 2007}). This quantitative shortcoming may, to some extent, be offset by the richer context provided by the qualitative data. It is worth noting that although two team members conducted the coding process, interrater reliability was not formally assessed. Future research could use larger sample sizes, employ alternative theoretical frameworks (e.g., the common-sense model), and explore the role of romantic partners during menopause.

In conclusion, this study delves deep into menopausal transition-related weight gain, offering a four-factor model aligned with Bandura's Triadic Reciprocal Determinism. Tailored interventions for postmenopausal women and preventive measures for premenopausal women are needed.

Contribuição dos autores

Mafalda Leitão: Conceptualization, Methodology, Project´s administration, Data Analysis, Draft Original Writing.

Faustino R. Pérez-López: Writing - Revision and Editing.

Filipa Pimenta: Supervision, Validation, Writing - Revision and Editing.

João Marôco: Writing - Revision and Editing.

Funding

This research was funded by a research grant from the FCT - Portuguese Foundation for Science and Technology (grant SFRH/BD/144525/2019). William James Center for Research, ISPA - Instituto Universitário was funded by FCT (grant UID/04810/2020).