Menopause

Over the last 10 years of working with women of all ages, I've begun to think that middle aged and older women would greatly benefit from a little heads up about the changes that are coming their way. Many girls get this before puberty either through a health class, a book or their parents. I would argue that almost no middle aged women get the same benefit. Here I will give you the basics of a nutrition focused health education class for all middle aged women. Everything I am discussing here comes from scientific articles on the topic - they are listed below.

- Between 40 and 60, most women will gain weight, and the average weight gain is ~22lbs.

- Most women will notice the weight gain is focused in their abdomen

- Most women will lose muscle mass and staying active and ideally including some resistance exercise becomes even more important if you want to limit this loss.

- Due to hormonal changes, between ages 40 and 60, energy needs decrease, so you will need 250-300 less kcals per day than you did before.

Most women don't enjoy these statistically normal changes in their bodies and many come to me hoping that I can help them reverse these changes. While I am always happy to help people ensure that they are eating an overall healthful diet and staying active, many women are already doing those things when they come to my office and then the conversation has to shift.

- One of my favorite quotes from the papers talks about that shift "...it is also important to encourage acceptance and self-compassion towards the natural physical changes caused by menopause and aging (Braun et al. 2016), as they may not be avoidable." - Giroux et al

- Heavy calorie reduction is not the answer: if you eat less than 1200 kcals per day, you are more at risk of vitamin and mineral deficiencies. Very low calorie diets do not bring long-term change or sustainable weight loss. I have seen many clients undereat and others both undereat and overexercise and often instead of getting smaller, they just get tired.

- Many of my clients wonder how to know when and how much to eat. My answer is "when you are hungry." If most of the time you have filling, balanced meals with protein, carbs, fiber and fat then you should next eat when you are hungry. If you don't have filling balanced meals, I recommend working on that part and still eating when you are hungry. You wouldn't expect your car to drive you around all day without enough gas and it's unfair to regularly ask your body to keep functioning for you all day without enough food.

- There is no evidence-based diet for menopause, but the best information we have recommends things that will not surprise you like including a lot of fiber by eating plenty of fruits, vegetables, and whole grains and getting fats from vegetable sources like peanut butter and avocado.

- Around the time of menopause it's important to stay hydrated, but as you age your sense of thirst starts to decline, making this tricky to achieve. If most of the day your urine is very light to clear that's a good sign, if it's dark then you should be drinking more. All fluids count including coffee, tea, etc.

So in overview: It's not you, it's just normal menopause and aging. Remember that food is one of the only sources of joy we get multiple times a day every day, so if you strip all the joy out of food, it is likely to affect your emotional health and well being, and these matter too.

Questions and Answers

I am going to add in more detailed dietary recommendations here and I want you to know that after 10 years of working individually with people, I do not think making dietary changes is easy. At all. We all eat every single day and eating requires so many steps, shopping, preparing or cooking, eating, cleaning up. It's a huge part of our lives and this fact makes change extra hard. I think anyone trying to make dietary changes should have access to help from a registered dietitian if they want one.

If you don't want to meet with someone but you do want to get enough calcium or protein or fiber, you can use a tracking app. I recommend something like Nutritionix Track which uses USDA data. For example Myfitnesspal - anyone can add a food to the app, so make sure to look for the checkmark that shows the food info has been verified.

1. What dietary changes can help manage menopausal symptoms, such as hot flashes or weight gain?

- While there is still very little scientific data available on nutrition and hot flashes, there is one interesting recent trial which tested a 12 week low fat vegan diet with daily soybeans and saw a reduction in hot flashes in the group on this diet. The mechanism is not well understood and this is a very restrictive and intensive diet, so working with an RD would definitely be helpful if you wanted to try this.

- I talked about weight gain already, but I'm sure many of you are thinking (like my mom was when I discussed this talk), ok, I hear you, I will likely gain some weight, but can I lose it later? You won't love me for this answer, but the answer is "probably not." When it comes to weight loss through diet and exercise, about 95% of people will gain this weight back within 2 years. Some people return to their previous weight and some people gain more weight every time they lose weight. We call this weight loss and regain “weight cycling”, and this process of losing and regaining and losing and regaining has been studied. It is damaging psychologically and likely also on the rest of your body, though the physiological reactions to weight cycling are still a bit unclear in the science. So while some people think there is little harm in dieting or trying to lose weight, I feel differently about it, I know that it can be quite harmful.

- Because these body changes can feel really dramatic, they have studied disordered eating around the time of menopause and rates do go up. It seems reasonable to me that when normal body changes interact with our fatphobic culture it causes a lot of distress and panic and many people respond by restricting what they eat. There are high rates of eating disorders in adolescents and I wonder if one of the reasons is that both periods have this normal change in body size and shape in common.

2. Are there specific nutrients I should focus on to support muscle and bone health during menopause?

Muscle:

  • If you exercise regularly and are trying to get stronger or just maintain your muscle mass as you age, it is good to have a higher protein diet than the average person.

  • The average minimum protein recommendation is 0.8 g/kg of body weight and for adding muscle you want 1–1.2 g/kg body weight instead. This means at least ~70g/day for an 150 lb person and ~90g for a 200 lb person.

  • This isn't very hard for most omnivores, for instance you can meet the needs of a 150 lb woman with a standard chicken breast (37g), 2 slices of cheese (13g), a chobani single serve yogurt (13g) and a handful of cashews (5g) assuming these aren't the only foods you eat in the day and you get small amounts from other things like fruits, vegetables and grains.

  • I also want to make it clear that if you eat enough protein but not enough total calories, you won't be able to create more muscle, you can't make something from nothing.

Calcium

You may notice I mentioned multiple dairy products on the list above, which is partly because as women age, bone health becomes more of a concern, you are at higher risk for osteopenia and osteoporosis and including dietary sources of calcium becomes even more important.

- Guidelines recommend ~1200 mg daily of calcium, ideally from the diet, though supplements can be used if it's not possible to get enough. The typical recommendation is 3 dairy products per day, but figuring out how to work this into your life each day can be tricky especially if dairy doesn't work for you, this is something I've worked on with clients and it does take some time and energy to develop a settled pattern.

3. How can I maintain a balanced diet that supports my overall health during perimenopause and menopause?

Energy and Mood

I always recommend starting with regular, consistent meals and snacks every 3-5 hours. If you get tired most days at a certain time, it's worth trying to have a meal or snack a bit before that time and see if you feel less tired. If you get sugar cravings, you may just want something tasty and this is fine. I have also found that people who get frequent sugar cravings might not be eating enough and the craving is a signal they aren't eating enough food or sometimes a signal that they aren't eating enough carbohydrates. Cravings can be hunger signals. Often when I work with clients we are working together to figure out how to interpret the messages their bodies are sending. Sugar cravings are a common one we work on.

For a general overview of foods to include- the British Dietetic Association recommends that during menopause you include at least four to five servings of unsalted nuts, seeds, and beans per week and include whole grains like oats, whole wheat bread.

High Cholesterol

Around menopause often people develop high cholesterol and we do have dietary changes that for some people, can reduce cholesterol. These recommendations focus on including things like beans and whole grains and adding in healthy fats like salmon, tuna, nuts and nut butters, avocados, olive oil, seeds and having less fat from animals like lower fat dairy and leaner meats.

Fruits & Vegetables

I can't avoid the boring dietitian moment where I recommend you eat lots of fruits and vegetables. For most people the recommendation is two fruits per day and 3 cups of vegetables each day. A lot of people get nervous about fruit, there is lots of misinformation out there, but if you eat a cup size amount, there is no fruit that is too high in sugar.

Overview:

  • Focus on including healthful fats, whole grains and fiber

  • There are no evidence-based recommendations for these times of life that are dramatically different from typical healthy diet recommendations.

  • In my practice I always recommend people aim to find a diet that you can maintain for the rest of your life.

  • Find a healthful diet that is delicious, varied and fun so that you can keep it going for the long haul.

Reference List

[1] Al-Safi ZA, Polotsky AJ. Obesity and Menopause. Best Practice & Research Clinical Obstetrics & Gynaecology 2015;29:548–53. https://doi.org/10.1016/j.bpobgyn.2014.12.002.

[2] Fenton A. Weight, Shape, and Body Composition Changes at Menopause. Journal of Mid-Life Health 2021;12:187–92. https://doi.org/10.4103/jmh.jmh_123_21.

[3] Grisotto G, Farago JS, Taneri PE, Wehrli F, Roa-Díaz ZM, Minder B, et al. Dietary factors and onset of natural menopause: A systematic review and meta-analysis. Maturitas 2022;159:15–32. https://doi.org/10.1016/j.maturitas.2021.12.008.

[4] Erdélyi A, Pálfi E, Tűű L, Nas K, Szűcs Z, Török M, et al. The Importance of Nutrition in Menopause and Perimenopause—A Review. Nutrients 2023;16:27. https://doi.org/10.3390/nu16010027.

[5] Brennan H, Znayenko-Miller T, Sutton M, Holubkov R, Barnard ND, Kahleova H. Diet quality, body weight, and postmenopausal hot flashes: a secondary analysis of a randomized clinical trial. BMC Women’s Health 2024;24:620. https://doi.org/10.1186/s12905-024-03467-4.

[6] Barnard ND, Kahleova H, Holtz DN, Znayenko-Miller T, Sutton M, Holubkov R, et al. A dietary intervention for vasomotor symptoms of menopause: a randomized, controlled trial. Menopause 2023;30:80–7. https://doi.org/10.1097/GME.0000000000002080.

[7] Zarzour F, Didi A, Almohaya M, Kendler D. Cardiovascular Impact of Calcium and Vitamin D Supplements: A Narrative Review. Endocrinol Metab 2023;38:56–68. https://doi.org/10.3803/EnM.2022.1644.

[8] Vincent C, Bodnaruc AM, Prud’homme D, Guenette J, Giroux I. Disordered eating behaviours during the menopausal transition: a systematic review. Appl Physiol Nutr Metab 2024;49:1286–308. https://doi.org/10.1139/apnm-2023-0623.

Shira HirshbergComment