Managing Menopause by Christina Badaracco, MPH, RD
Menopause, which is a natural part of aging, brings with it an increased risk for various chronic diseases as well as a suite of unpleasant symptoms that most women will experience. Embracing these natural changes in the body and adapting dietary behaviors to manage the symptoms and reduce the disease risk can make this transition easier. As women commonly seek information about nutrients to consume (or not consume) to optimize their health during this time, it's important to share clear, evidence-based information about nutrition recommendations and other behaviors to adopt—and thus help prevent the spread of misinformation and promote safe and effective practices.
How do women's bodies and their nutrient needs change during menopause?
Perimenopause refers to the decade or so before the onset of menopause when menstrual periods start to become irregular (corresponding with declining estrogen production). It typically starts when women are in their 40s, and it is associated with many side effects related to nutrition (and the body's metabolism). Weight gain is often experienced; a reduced metabolic rate is often accompanied by symptoms such as fatigue and impaired sleep, which can reduce physical activity, elevate the hunger hormone ghrelin, decrease the satiety hormone leptin and lead to poor food choices. Hormonal changes can also increase visceral fat deposition (which releases pro-inflammatory molecules). Independent of a woman's initial weight, race or ethnicity, it's estimated that women gain an average of 1.5 pounds per year in their 40s and 50s. These factors all increase the risk of various chronic diseases, such as heart disease, diabetes and cancer.
It's been estimated that more than 50% of women over 50 have low bone density, driven largely by hormonal changes but also often by inadequate micronutrient intake and inactivity. Certain medications—such as proton pump inhibitors taken for acid reflux disease, selective serotonin reuptake inhibitors for depression and some diabetes and breast cancer medications—can also reduce bone density. All these medications are taken more commonly by older adults. In addition, older adults have a higher prevalence of diabetes than other age groups, presenting yet another risk factor for osteoporosis (its risk is also elevated in patients with diabetes, independent of their medication regimen).
Recent research suggesting important connections between the gut microbiota and estrogen levels indicates another pathway that affects the risk of developing these conditions. A recent paper by Ervin et al. referred to microbes in the gut that regulate hormone balance and estrogen metabolism during menopause as the "estrobolome." Further, when the gut microbiota ferment prebiotic soluble fiber, they produce short chain fatty acids that can help regulate the cells that control bone mass. We also know that they are intimately involved in the immune system and the inflammatory responses that drive the chronic diseases affecting older women.
Of note, the median age of reaching menarche (or the age of first menstruation) in the US is decreasing, which may lead to earlier menopause; this is of particular concern because we know that women who experience premature menopause may be at higher risk for diabetes and heart disease. Some of the many overlapping factors that may lead to this earlier timing include genetics and modifiable risk factors like a high percentage of body fat and exposure to endocrine-disrupting chemicals that affect hormone production and function.
Recommended behavior modifications to alleviate the symptoms of menopause
In addition to the increased disease risks of age and the physiological changes associated with menopause, women commonly experience many unpleasant symptoms. Dietary behaviors can help to alleviate some of those symptoms. [Note that for younger women, these behaviors can help to manage symptoms during premenstrual syndrome (PMS), too.]
For example, a recent randomized control trial (RCT) by Barnard et al. found that following a low-fat, plant-based diet that included soybeans (which are rich in phytonutrients including equol, which supports estrogen function) reduced the frequency of postmenopausal hot flashes by 84% (and their severity). Another RCT showed that a yoga-based intervention improved menopause-related quality of life. Other recommended behavior modifications are shown below.
How can nutrition reduce the risk of disease after menopause?
Following a balanced dietary pattern—such as the Mediterranean diet—consisting of whole foods rich in phytochemicals and fiber (and limiting processed foods like sodas and fried foods) can help prevent weight gain and stabilize blood sugar to prevent diabetes. Fiber will also promote satiety and limit overeating as well as help to lower LDL cholesterol. Following an active lifestyle by engaging in both aerobic activity and weight-bearing activity and getting plenty of high-quality sleep can promote good mental and physical health. Maintaining a healthy weight and stable blood glucose and insulin levels can also reduce the risk of cancer (especially breast cancer) during this period.
It's particularly important to maintain bone density during this stage of life to prevent bone fractures, falls and osteoporosis. Key nutrients that support bone health and examples of common food sources include:
Vitamin D: egg yolks, fatty fish, fortified milk
Calcium: most dairy products, bony fish, leafy greens
Magnesium: almonds, avocado, pumpkin seeds
Phosphorus: dairy products, poultry and organ meats, tofu and soybeans
Refer to this article from the Oregon State University's Linus Pauling Institute for more information about these and other micronutrient needs for older women.
Prevent the loss of muscle mass through adequate protein intake. Individual needs may increase after menopause, up to 1–1.2 grams per kilogram of body weight per day (which equates to about 70 grams for a 150-pound woman). Eating a variety of protein foods will help to ensure the consumption of all the necessary amino acids. Leucine is particularly important for generating new skeletal muscle cells and is found in greater amounts in animal foods (though it's also found in legumes, nuts and seeds). Protein intake should also be spread evenly throughout the day to maximize anabolism (synthesis of new molecules, including for muscle tissue).
Eating mindfully and intuitively can also help to prevent overeating and subsequent weight gain. Being aware of hunger signals and stopping when satiated can help to manage intake. Avoiding distractions like screens, chewing more slowly and preparing your own food can increase awareness of the ingredients and flavors in the food, leading to heightened enjoyment and satiety.
As cognitive performance can also start to decline in women in this age group (partly due to elevated insulin and other factors related to hormonal changes), eating foods that fuel the brain (such as seafood rich in omega-3 fatty acids and zinc) is also important during this time. Refer to this article about the MIND Diet for more information.
How should diet and lifestyle change after menopause?
Eating a nutrient-dense diet, minimizing exposure to endocrine-disrupting chemicals and leading an active lifestyle across the life course can help minimize the risk of disease following menopause and alleviate menopausal symptoms. More specifically:
Engage regularly in weight-bearing activity to maintain muscle mass and bone density.
Be careful about portion sizes and excess snacking to avoid gaining weight. Use smaller plates, keep snacks out of sight at home and avoid being distracted by screens while eating.
Make sure to eat foods rich in calcium, vitamin D and magnesium. If you're unsure of your serum vitamin D level, ask your doctor for a blood test. If necessary, consider a multivitamin supplement and/or a combination of vitamin D and magnesium (but check with your doctor or dietitian first if you take any medications to help prevent any negative interactions).
The growing evidence about the connection between a healthy gut microbiome and the risk of the diseases mentioned in this post should encourage menopausal women to reduce that risk by consuming fermented foods and foods rich in fiber and phytochemicals and engaging in behaviors that foster healthy bacteria (such as avoiding unnecessary antibiotics).
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Christina Badaracco, MPH, RD
Christina is a registered dietitian and author who aims to improve access to healthy and sustainable food and educate Americans about the connections between food and health. She loves to experiment with healthy recipes in the kitchen and share her creations to inspire others to cook.
Christina completed her dietetic internship at Massachusetts General Hospital and earned her Master of Public Health degree from the University of California, Berkeley. Previously, she graduated with a degree in Ecology and Evolutionary Biology from Princeton University, after conducting her thesis on sustainable agriculture and energy in Kenya. She has done clinical nutrition research at the National Institutes of Health, menu planning and nutrition education at the Oakland Unified School District and communications at the Environmental Protection Agency's Office of Water. She has also enjoyed contributing to children’s gardens, farmers markets and a number of organic farms.