The best diet for the menopause
I wrote this article for the Doctors Kitchen and Dr Louise Newson’s Menopause Charity about the best diet for the menopause, including foods that help and foods to avoid during the menopause. Included are some lifestyle tips, and more information about the menopause. At the end are some practical tips about foods for menopause to include in your diet. The menopause is a time that is challenging enough for most women, and this article isn’t about a long list of foods to avoid during the menopause, instead it’s about making some simple swaps to improve symptoms and your long term health.
The menopause is a time in a woman’s life when she stops ovulating, her periods stop and she is no longer able to become pregnant naturally. The timing of when a woman experiences the menopause varies, but usually occurs between the age of 45 to 55 years. While the average age is 51 years, around 1 in 100 women will experience the menopause before the age of 40 years, known as premature menopause or premature ovarian insufficiency.
What causes the menopause?
The menopause is caused by a natural decline in the production of female reproductive hormones, that happens with ageing.
Premature or early menopause can occur at any time, and in many cases there is no clear cause.
Symptoms of the menopause
As estrogen levels decline, most women will experience some menopausal symptoms, which can be severe, and have a significant impact on their day to day activities. Symptoms can start months or years before periods stop, and last until approximately 4 years after the last period.
Common symptoms include:
- Hot flushes
- Night sweats
- Joint and muscle pain
- Vaginal dryness and discomfort during sex
- Low mood or anxiety
- Reduced sex drive (libido)
- Difficulty sleeping
- Problems with memory and concentration
Health Issues after the Menopause
In addition to the day to day symptoms, after the menopause, because of lower estrogen levels, the risk of certain diseases is increased. The main issues are osteoporosis, cardiovascular disease (CVD) and an increased risk of dementia. There are foods that help and foods to avoid with the menopause, as well as other lifestyle changes that are aimed at reducing these risks. I’ve divided the treatment options into firstly those targeting the day to day symptoms, and then those that are aimed at longer term health.
Treatment options for menopausal symptoms
Every woman experiences the menopause slightly differently, and while some opt for no treatment, others prefer some form of treatment. If you are troubled by menopausal symptoms that are interfering with your everyday life, or that start before the age of 45 years, book to see your GP. There are treatments that your GP might offer you to help with the symptoms and these are described in more detail on the NHS website (https://www.nhs.uk/conditions/menopause/):
- Hormone Replacement Therapy (HRT)
- Non-Hormonal medical treatment
- For those women where replacement hormones are not appropriate, your GP may consider drugs such as gabapentin for hot flushes instead (1).
- Cognitive Behavioural Therapy (CBT)
- CBT is an effective treatment for helping low mood and anxiety related to the menopause.
Away from pharmacological treatments for the menopause there are lifestyle changes that can help. In this section I’ll talk about the benefits of exercise, foods that help and foods to avoid for the menopause.
There is no convincing evidence that exercise helps with hot flushes (2,3), but there is evidence that it helps reduce risk of cardiovascular disease (4) and improve bone health (5). Aim to combine moderate aerobic exercise, such as swimming, running, and also low resistance exercise (6) such as yoga, squats, resistance bands and Pilates for 30 minutes a day, five times a week.
Caffeine and Alcohol
Consider caffeine, alcohol and spicy food as foods to avoid during the menopause, as hot flushes may be helped by reducing consumption, but there is considerable variation between individuals (7,8). Additionally, limiting alcohol has other health benefits, such as a lower risk of heart disease, liver disease, osteoporosis, type 2 diabetes, and certain types of cancer such as breast cancer (8). Therefore, it is advisable to stay within the recommended alcohol limits of a total of 14 units per week (2 units per day).
There is weak evidence that acupuncture may help with hot flushes, although more research is needed (9).
Phytoestrogens are plant derived compounds, that have a similar structure to human estrogen, and similar but weaker activity. There is no strong evidence that phytoestrogens are foods to avoid in the menopause, instead they might help with hot flushes (see more about this below).
A number of herbal medicines are used by women to help with the symptoms of the menopause. There is some evidence that plant extracts such as St John’s wort, black cohosh (10), and genistein (11) are associated with decreased hot flushes.
There is mixed evidence that isoflavones (soya products and red clover) reduce hot flushes (11). While there is evidence that soy is probably safe in women with breast cancer, less is known about red clover (12,13) and so it is not advised for women with breast cancer. There is still also concern about interactions with medications for women with heart disease, epilepsy, and asthma. You should speak with your GP before starting any herbal medicine.
In contrast to conventional medicine, there is no legal obligation for herbal medicines to be licenced, and therefore, their contents may vary considerably. Always buy from a reputable setting, and check for a product licence or Traditional Herbal Registration (THR) number on the label.
The supplements mentioned above contain a more concentrated version of the phytoestrogen compounds found naturally in many foods. Given the mixed evidence about efficacy of the supplements, is therefore unlikely that consuming these food items, will have a significant benefit on symptoms.
Phytoestrogens occur naturally in some plant-based foods such as:
- Soybeans and soy based products
- Sesame seeds
- Tea (green and black)
Health after the Menopause
Estrogen and testosterone play important roles in our bodies. As the level of these hormones drops, this leads to an increased risk of coronary heart disease, osteoporosis (brittle bones), diabetes, depression, obesity and dementia. If you experience early or premature menopause, your risk is unfortunately higher (14). It is especially important to consider your long term health and make adjustment to your diet so you include more of the foods that help menopause long health term effects,
Estrogen plays an important role in bone health, and declining levels lead to softer bones (osteoporosis), which have a great chance of low energy fractures. A 50 year old woman only has a 2% risk of osteoporosis, compared with a 25% risk in an 80 year old lady, due to considerably lower levels of estrogen (15).
Diet can play an important role in bone health and are great foods that help with menopause long term effects:
- Protein: Include lean protein foods at every meal such as dairy, meat, poultry, seafood, beans and legumes.
- Calcium is an important mineral for bone health, and as an adult you need to take between 700-1000mg per day . This would roughly equate to two slices of wholemeal bread, one portion of spring greens, a portion of broccoli, 200mls of dairy milk or fortified plant based milk, half a tin of tinned fish and a yogurt. If you are unable to have enough in your diet, you might be prescribed a supplement. Good sources of calcium include dairy, calcium-fortified plant-based drinks, tinned fish (with bones), spinach, fortified bread, baked beans, tofu and dried figs.
- Vitamin D is produced by the action of sunlight on our skin during exposure outside. However current NHS guidance is for women to consider taking a supplement of 10mcg (400IU) during the autumn and winter months as it can be difficult to produce enough. Vitamin D is also found in low levels egg yolks, oily fish and some fortified foods, and so it is difficult to get all of the vitamin D needed from diet alone.
- Vitamin K is a micronutrient that has an important role in both bone strength. The term vitamin K, covers a number of different molecules, and these are found in green vegetables, fermented food, dairy, and meat. You need to eat a range of these items to ensure you get all the different elements that make up vitamin K. There is mixed evidence as to whether vitamin K supplementation improves bone strength and reduces fractures (16), but enough for a number of countries such as Japan, to now include vitamin K supplementation as treatment for osteoporosis. Vitamin K is a fat soluble vitamin which means that it is possible to have too much through supplementation, and we don’t know what these effects might be. Avoid taking vitamin K supplements if you are on blood thinning medication.
- Phosphorus is usually abundant in our diet, and found in foods such as poultry, meat, dairy, oily fish, potatoes, whole grains, pulses and beans.
- Magnesium again is usually abundant in our diet but good sources include whole grains, spinach, pumpkin seeds, almonds and beans.
- Resistance exercise is very important for bone strength, and the NHS advise that adults over the age of 35 years, undertake 30 minutes of this type of exercise at least twice per week. Examples include brisk walking, yoga, squats, weight training, resistance bands, Pilates, gardening and a brisk walk.
Cardiovascular Disease (CVD)
After the menopause, the risk of cardiovascular disease increases. This is partly related to the aging process, and also the effects of declining estrogen (14). Cardiovascular disease is a general term used for conditions affecting blood vessels and the heart by narrowing of the arteries (atherosclerosis) and an increased risk of blood clots. Additionally, weight gain associated with aging and also declining estrogen levels, leads to an increased risk of obesity, type 2 diabetes, higher blood pressure, and higher (LDL) cholesterol levels; these are all well recognised as factors for CVD (17,18). To mitigate these risks, best evidence suggests the following foods to help and foods to avoid with the menopause (6):
- Reduce fat content to less than 30% of your diet (approximately 60g per day)
- Include more extra virgin olive oil, rapeseed oil, avocado, seeds, nuts
- Eat at least 5 portions of fruit and vegetables a day.
- Replace refined carbohydrates (white bread, white rice) with whole grains (brown rice, brown bread, millet, bulgur wheat).
- Make Friday and Tuesday ‘fish’ night, where you and the family can enjoy a meal with oily fish. Or make yourself a big salad with mackerel. You can used tinned, smoked or some fresh from your fishmongers.
- Have at least 4 portions of unsalted nuts, seeds and legumes (like beans, lentils and chickpeas) each week.
- Remove convenience products that have high amounts of sugar and salt. And remove hidden sources of sugar (https://www.nhs.uk/live-well/eat-well/top-sources-of-added-sugar/).
- Chose wholegrain carbohydrates such as parsnips, butternut squash, swede, broad beans, amaranth, millet, and bulgur wheat,
- Women should consume no more than 14 units of alcohol per week (maximum of 2-3 units per day).
These are guiding principles for everyone not just foods for the menopause.
Maintaining a Healthy Weight
A healthy weight can help reduce your risk of diabetes and cardiovascular disease, however this can be harder with declining levels of estrogen. To understand the role estrogen plays, it helps to understand about metabolism and basal metabolic rate first.
Metabolism is the production of energy from food, whereas the basal metabolic rate (BMR) is the energy required for performing vital body functions at complete rest or asleep. Our brain, liver, heart and kidneys account for almost half of the BMR. An estimate of BMR can be calculated from weight, age and gender. Our BMR accounts for most of the energy we use, with thermogenesis only 10% and physical activity between 10-30%.
Your basal metabolic rate is determined by your genes, your body composition and your sex hormones. Exercise can increase your BMR and is important for so many factors of general health.
What is the Role of Estrogen in Energy Balance and Metabolism?
The main circulating form of estrogen in the body is 17β-estradiol (E2). E2 promotes energy homeostasis, improves body fat distribution, enhances insulin sensitivity, improves pancreatic β-cell function, and reduces inflammation. As estrogen levels naturally decline from perimenopause, there is an increased risk of developing metabolic dysfunction, leading to obesity, the metabolic syndrome, type 2 diabetes as well as cancers and other degenerative diseases of the skeletal, central nervous and cardiovascular systems (20). This role in energy metabolism is also supported by findings in evolutionary development (phylogeny) since ancestral estrogen receptors have been found in invertebrates before advent of sexual reproduction.
Estrogen also has a role in energy balance, acting in the hypothalamic area of the brain to both suppresses food intake and also stimulate physical activity, energy expenditure and regulate body fat distribution. The BMR varies across the menstrual cycle, and is lowest in the follicular phase (from the start of your period to ovulation), when ovarian hormones are lowest. Experiments on rodents have found that surgical removal of the ovaries leads to weight gain, which is reversed by estrogen supplements.
In summary, estrogen has an important role in energy balance, BMR and weight gain. As levels naturally decline at the perimenopause, increasing weight is linked with increased risk of cardiovascular disease and diabetes.
BMR is determined by our genes, our body composition and our sex hormones. Exercise can increase BMR and is important for so many factors of general health. While maintaining a steady weight used to be thought of in terms of simple energy balance, evidence of the important role of the gut microbiota, might explain why some people can appear to eat much more than the energy they expend, without gaining weight.
Microbiota and Their Role in Metabolism
The gut microbiota contains trillions of single celled microorganisms, that play an important role in our health. Multiple associations between the gut microbiota and chemicals along metabolic pathways have been found, with suggestion that the gut microorganisms have a role in shaping metabolism. Recent research has found that changing the composition of the microbiota, is associated with improvement of some of the parameters of the metabolic syndrome (a name given to a set of conditions seen together including increased blood pressure, high blood sugar, a large waistline, and abnormal cholesterol or triglyceride levels).
In studies of special germ-free mice, who have no organisms living on or inside them, they found that faecal transplant from obese humans, was associated with a greater weight gain than mice that received microbes from healthy weight humans. This suggests that maintenance of a steady healthy weight, is more than the simple balance of energy in, equalling energy out. Instead, it is also impacted by your gut microbiota. Most studies of people that were obese have found that their gut microbiota is characterised by a narrower range of organisms (lower diversity). Long term weight gain (over 10 years) in humans is correlated with low microbiota diversity (narrow range of species of microorganisms), and this association is worsened by low dietary fibre intake.
How single celled microorganisms have such a profound effect on our weight and general health is astonishing, but it is probably mediated by a number of different routes. Gut microbiota imbalance probably promotes weight gain and metabolic complications by a variety of mechanisms including immune dysregulation, altered energy regulation, altered gut hormone regulation, and pro-inflammatory mechanisms (such as lipopolysaccharide endotoxins crossing the gut barrier and entering the portal circulation).
The menopause is a time of immense change, with women experiencing a spectrum of severity of symptoms. Dietary changes might not be possible for you right away, but try to incorporate them where possible for long-term health benefits.
Aim to eat a variety of colours, whole grains, quality protein at every meal, unsaturated fats, whole plant-based foods, items rich in calcium and optimise your gut health.
Ultimately the best way to support a healthy weight, reduced long-term risk of cardiovascular disease and osteoporosis is by regular exercise and a healthy diet that follows these principles:
- Eat lots of different coloured fruit and vegetables.
- Choose wholegrains (bulgur wheat, millet, sweet potatoes, brown rice, brown bread).
- Eat a handful of nuts a day and add seeds to your food.
- Eat oily fish twice a week. If you do not eat fish, have daily nuts, and seeds which also contain omega 3.
- Chose lean or plant-based protein at every meal.
- Regularly enjoy beans, lentils and chickpeas.
- Enjoy healthy unsaturated fats such avocados, rapeseed, nuts and extra virgin olive oils.
- Aim for a handful of nuts and seeds a day.
- Avoid convenience products that have high amounts of sugar and salt, and sugary fizzy drinks.
- Avoid sweeteners.
- Support your microbiota to flourish by eating fermented foods, kefir, and 30g of fibre a day.
- Try to reduce alcohol, and try to keep less than 14 units of alcohol per week (maximum of 2 units per day).
- Enjoy lots of calcium rich foods (1200mg per day from the menopause onwards).
Ensure you eat a variety of colours, whole grains, soy, quality fats, whole plant based foods, and items rich in calcium think in terms of those foods for menopause. Consider foods to avoid during the menopause such as caffeine, spicy foods and alcohol if they worsen your hot flushes.
With regards supplements consider that regulation is different to that for medicines and beware of marketing claims. Those supplements containing phytoestrogens may help with hot flushes, so trial to see if they have an effect for you. Follow the NHS guidance for vitamin D supplementation during the autumn and winter months. If you suffer from menopausal symptoms that are interfering with your daily activities, discuss possible pharmacological options with your GP. Support groups both online and in person can help alleviate the psychological impact.
I know how confusing it can be knowing what 1200mg of calcium looks like practically. So I’ve designed a meal planner and nutrition checklist specifically for the menopause and beyond, to help you meet your needs. It’s free to download here.
Have you downloaded my FREE meal planner and nutrient checklist specifically designed for women going through the menopause? Get your copy here.
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