With the increasing numbers of women entering the baby boomer generation, and the average age of menopause in the United States hovering around 51, now more than ever is an opportunity for health care providers to instruct female patients how to eat through menopause. The National Institutes of Health recognize women entering menopause are at an increased risk for chronic disease, and an increased reliance on medicines and the medical field (Bleil, 2011). The purpose of this paper is to examine some of the more common symptoms of menopause for which women turn to medication and devise a healthy dietary alternative geared towards improving symptoms with less reliance on risk-laden medications (Manson et al., 2003). The more common symptoms of menopause will be evaluated along with a discussion of research supporting nutrition as a possible corrective measure in easing the signs and symptoms of menopause. Symptoms evaluated in this paper are hot flashes, night sweats, irritability (mood swings), vaginal and breast changes, weight gain, insomnia, and thinning of the skin.
Signs and Symptoms of Menopause - The Nutritional Challenge
Hot Flashes and Night Sweats.
The true definition of a hot flash, hot flush, or vasomotor syndrome is inconsistent and yet seems to be the most understood between women experiencing this symptom (Pinkerton & Zion, 2006). It is the most common symptom experienced in menopause and is the main reason women seek medical attention. Interestingly enough, the only FDA approved method of treating hot flashes is hormone replacement therapy. Despite the fact that foods and nutrition are easily obtained and consumed on a daily basis, the FDA looks as hot flashes as a disease process and not a continuum of normal ageing. While we understand a hot flash occurs from a vasodilatory response it is still uncertain what causes this to occur in the body. Many in the medical profession consider the night sweat a byproduct of the vasomotor hot flash. In most instances a hot flash while sleeping can cause increases in body temperature stimulating a sweat response to cool the body. So how can one eat their way through hot flashes?
Dietary methods. A diet rich in soybeans is attracting the most attention today in the research and lay media. There are many studies showing a diet rich in soy and isoflavones can decrease the occurrence of hot flashes. In one study, a group consuming 60 grams of soy protein powder daily reported a 45 percent decrease in the number of daily hot flashes after three months consumption (Baber, Templeman, Morton, & Kelly, 1999). The isoflavones genistein, daidzein, and glycetin are broken down during the digestive process and are in effect a weak estrogen. Because of this estrogen-binding potential there are debates as to whether or not these phytoestrogens increase cancer risks in postmenopausal women. One must use discretion when comparing isoflavones because some studies will use soy derived compounds while others will use red clover (which has not been shown to decrease hot flash frequency) (Tice et al., 2003). Ultimately, a recent meta-analysis has shown that soy isoflavones decrease the frequency of hot flashes especially in women with more frequent episodes (Howes, Howes, & Knight, 2006). So, if a majority of the data shows a decrease in the number of hot flushes in women eating soy protein, what is the downside; rying to find those foods high in isoflavone content or soy products enjoyable to one's tastes. Examples of soy protein are those products with soy beans, miso, soy flour, soy milk, tofu, tempeh, or texturized vegetable proteins. Susan Dopart (2009) goes further into soy by giving examples of soy's potential harmful effect on the thyroid and how many soy products use genetically modified plants to make the powders and substances. She also states, "in Asian cultures, soy is used as a condiment rather than a food...Asian cultures use about 2 teaspoons per day fermented soy versus the unfermented soy foods Americans consume (1-2 cups per day)" (p.55). The take home message is soy can be added as a healthy part of the menopausal diet, and the patient/client should choose fermented soy in moderation. Good examples of fermented soy products are miso, natto, fermented tofu, and fermented soy milk. Adding these foods to your diet is healthy and may potentially help with hot flashes, but they unfortunately are not a magic bullet.
Secondarily, one should consider cutting products that increase incidence of hot flashes. Mold, Roberts, & Aboshady (2004) recommended cutting caffeine from the diet when they found increased rates of night sweats in women consuming caffeinated beverages. Ideally reduction in caffeine and alcohol, along with one serving of fermented soy daily and increased vitamin C and E have shown decreased vasomotor symptoms. If one still continues to have hot flashes which are affecting their lifestyle then black cohosh has been shown to decrease hot flashes in many studies, but data is confusing, and this is an herbal supplement not a dietary change.
Insomnia - Eating Through Sleepless Nights?
Menopausal insomnia may be related to night sweats waking women in the middle of the night, but dietary changes may also need to happen as part of a good sleep hygiene program. Other than the recommendations from grandmothers regarding chamomile tea it may be more about what you avoid rather than what you consume to help you sleep during menopause.
Dietary recommendations. While large amounts of caffeine have not been shown to be a risk for healthy nonpregnant individuals, it can keep you awake. In addition to decreasing caffeine consumption it has been shown that alcohol impairs REM cycles during sleep (Landolt, Roth, Dijk, & Borbely, 1996). Is there anything you can alter in your diet to help with sleep? There have been studies showing a high glycemic index meal four hours before bedtime can decrease one's onset to sleep (Afaghi, O'Connor, & Chow, 2007), however, this may be difficult for patients desirous for weight loss. A diet deficient in vitamin B12 may also promote insomnia and it may be important to recommend menopausal women increase consumption of foods rich in cyanocobalamin like meat, poultry, fish, eggs, milk and other dairy (Dopart, 2009, p. 90). Many ageing patients take acid inhibitors like Zantac, Pepcid, and Prilosec, and because these medications decrease the production of stomach acids, menopausal women may be deficient in vitamin B12 due to malabsorption. A final note on dietary recommendations in menopause would not be complete without reference to progesterone deficiency. Like estrogen, progesterone is deficient in the menopause and progesterone is known to have an anxiolytic effect on the brain (Bitran, Shiekh, & Mcleod, 2006). One common myth in our culture is one can have progestational effects by consuming wild yam. Wild yams do have a compound called diosgenin (a precursor to progesterone), but in order to convert diosgenin into progesterone it must undergo a chemical restructuring in the lab. The human body does not have the ability to make progesterone from wild yam (Dollbaum, 1995)(Araghiniknam, Chung, & Nelson-White, 1996). There is no quick solution to insomnia and diet, but the above suggestions can help one increase l-tryptophan production which is a precursor in the body to melatonin. If one can increase melatonin prior to bedtime by eating a meal of a slightly carbohydrate nature and increasing foods rich in vitamin B12 (meats, cheeses, and eggs) it may help with sleep induction.
Moods and Foods in Menopause
Unfortunately, in our society, we blame women's mood swings on hormones. It is not she is simply having a bad day or is responding to some external stressor; it must be menopause and lack of hormones. What is usually absent in the conversation with physicians and menopausal patients is how foods can effect mood. It is also not in the usual discussion how certain dietary restrictions can alter mood. Hibbeln & Salem (1995) have shown that diets low in omega-3 fatty acids may contribute to depressive symptoms, and in this era of low fat diets, women trying to lose weight may be making menopausal mood symptoms worse.
It is this author's opinion that weight gain during the menopause is an evolutionary error. When we were an agrarian society or hunter-gatherers, our bodies were programmed to store energy as fat because the next famine could be our last. We currently have a dense over-supply of calories, but our bodies have not had enough time to make the evolutionary adjustment to the industrial revolution. If you look at pictures of a female patient through her twenties and thirties and then in her fifties and eighties, you may notice the fifty year old portrait has a woman with more abdominal and pelvic fat; then in her eighties she becomes thin again. Why would this be? Because our bodies are preparing for famine, and it is natural for the female body to store fat during menopause, and fat creates estrogen (Simpson et al., 1994). By storing fat and aromatizing estrogen the body is able to make estrogen to perform vital functions like preserving bone mass. As women age and near the end of life there is no need for the additional adipose (fat) and the body naturally thins. In a society where beauty equals thin, women restricting essential fatty acids in their diet may be increasing the risk of depressive symptoms.
The amino acid tryptophan is readily available and may play a role in depression (Leyse-Wallace, 2008, p. 68). While the data on tryptophan and serotonin production is limited it may be helpful to recommend a diet inclusive of soy proteins, spinach, and seaweed which are high in tryptophan. One must also consider that many women in menopause with depression may already be taking prescription anti-depressant medications which may affect appetite. While all anti-depressants can cause weight gain, imipramine and amytriptylline produce larger increases in weight (Leyse-Wallace, 2008, p. 174). It is therefore important to discuss mood, medications, weight gain and diet with patients as they are all inter-related. Another reason why women may see weight gain in menopause is self-treatment with carbohydrate rich foods. It has been shown that women with depression report and elevated mood after consuming a carbohydrate rich drink (Wurtman & Wurtman, 1996).
A common food for elevating mood is chocolate for its release of serotonin, methylxanthines, and euphoric effect (Macdiarmid & Hetherington, 1995). Dark chocolate can be a healthier option, but most mood modulators can also bring on extra pounds and have to be counseled as such.
To summarize moods and foods, we know women with lower levels of omega-3 fatty acids not only have higher rates of depression, but low levels can determine depression severity (Edwards, Peet, Shay, & Horrobin, 1998). Omega-3 sources are cold water fish, but if you cannot tolerate fish then foods and oils from flaxseed, walnuts, soybeans, and green-leafy vegetables are excellent sources. Vitamins and minerals also play a part in mood change and depression. Vitamin B6 has been shown to improve mood symptoms in premenstrual syndrome and can be found in beef, pork, fish, cereals, avocados, bananas, and grains. It is important with depressed clients to recommend eating smaller balanced meals five to six times per day. As stated earlier proteins from meats are rich in vitamins and grains, fruits, and vegetables can help balance the carbohydrates, fats, and proteins. Cessation of caffeine and alcohol and increasing omega three fatty acids (one gram per day of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) can cause a protective effect from mood disorders (Freeman et al, 2006). Ultimately, if someone is trying to manage moods with food and their symptoms are worsening then medications and clinical therapy may be necessary.
Not Right Now Honey, I Need to Eat - Sex and Menopause
Decreased sexual desire is a byproduct of vaginal dryness, because vaginal dryness contributes to dyspareunia (painful intercourse). Does this mean there is a solution for vaginal dryness through diet? Possibly, because estrogen is the hormone keeping vaginal tissues thickened and lubricated, therfore foods like soy and isoflavones may be helpful for reasons listed early in this paper. Currently isoflavones in the diet are thought to aid in vaginal dryness but which foods and amounts are still under debate (Reed et al., 2008). It may not seem obvious, but if one is talking about lubrication then it makes sense to refer the patient to water and potential dehydration effects. If one is already adding soy isoflavones to the diet for vasomotor symptoms then vaginal symptoms may improve as well.
Weight Gain - Blunders and Wonders
Weight gain is an issue for this country; not just those in menopause. The fad diets, the restrictions, pills, and flushes are all made to detract us from the issue at hand. We gain weight when calories going in exceed the number of calories going out. When counseling a menopausal patient on healthy weight there needs to be an emphasis on exercising regularly, eating regular scheduled meals and not skipping, being aware of what and why you are eating, self-image and if weight loss is necessary, and giving yourself the time to create wonderful healthy meals.
One reason for eating more frequently throughout the day is maintenance of stable blood glucose levels. Therefore, foods with a high glycemic index have been show to stimulate appetite because of the resulting drop in blood sugar hours after consumption (Ludwig et al, 1999). As stated earlier, some weight gain in menopause may be the body's way of creating its own estrogen.
If you are already overweight then there may be a need to lose weight, but if you were at a healthy body mass index and gained five to ten pounds during menopause it may be normal to allow your body to try and respond naturally to menopause. It may seem simplistic, but if you need to lose weight during menopause then make sure you balance your meals with a lean protein, low glycemic index and starch, limit sugars and sweeteners, eat healthy fats like polyunsaturated olive oils and cold water fish or flax seeds, limit alcohol , increase exercise and realize you will make mistakes. Be forgiving and make the weight loss more a life change than a two or three month plan.
Women are living longer.
In 1850, the average life expectancy for a white female was 40.5 years and non-white females a dismal 35 years. By 2004 life expectancies for these same groups were 81 and 76.5 years respectively. In little more than 150 years our species has doubled its life-expectancy. Adaptation or that evolutionary process bringing about changes in a species so it may better tolerate its environment can take generations. With women living longer and the average age of menopause in this country at 51 years we will be seeing hundreds of thousands of women entering menopause over the next few years. Pharmaceutical companies are eager to profit from the quick fix of hormone replacement and for some women this may be necessary, but it may be healthier to eat one's way through menopause. In this paper we discussed the importance of isoflavones for vasomotor symptoms and vaginal dryness. Plant based isoflavones are currently prescriptions in countries like China and Germany, and yet in this country many women will opt for conjugated estrogens that have been shown to increase the risks of breast cancer and deep venous thrombosis.
With increased consumption of isoflavones from vegetables, omega-3 fatty acids from cold water fish and grains or seeds many women may feel improvement of the menopausal symptoms. It is not suggested these nutritional therapies are a panacea for menopause but most women will find enough relief from symptoms and thus may not decide to take potentially harmful medications for hot flashes, sleep, or weight loss.
I would like to close with a patient encounter emphasizing the need for nutritional medicine in menopause. I met RF, a 55 year old woman from Russia who was a physician in her country, but she married a man from the United States and had lived in this country for over twenty years. She was presenting to my office for recommendations on dealing with menopause. She was irritable, having difficulty sleeping, experiencing vasomotor symptoms and decreased libido. She was thin, so weight loss was not an issue for her but she was very concerned about the thinning of her skin and how dry it had become. She had a family history of breast cancer and thus I was reluctant to prescribe hormone replacement therapy.
In sitting with the patient I discovered she had a poor diet and was overweight with a body mass index of 40. We discussed obesity and the issues of cancer and diabetes. I then prescribed the following changes in her diet:
• Decrease caloric load to 2000 to 2500 calories per day divided amongst five balanced meals. Caloric restriction is associated with increased longevity and health (Mehta & Roth, 2009).
• We decided to add small amounts of sockeye salmon (3 to 6 ounces) once a week and a supplement of Nordic Naturals Pro EPA which adds 850 mg EPA and 200mg of DHA daily.
• Although, not discussed in this paper, a high fiber diet is important in decreasing estrone which is an estrogen associated with higher breast cancer rates. A daily consumption of 30 grams of wheat bran has been shown to decrease levels of circulating estrone and potentially decrease cancer rates (Rose, Goldman, Connolly, & Strong, 1991).
• Recommendations were made for the patient to consume 1-2 servings of fermented soy products, miso, or tempeh per day. Because she might not be able to get this much soy I recommend VegLife fermented soy milk powder to be mixed with berries in the morning and evening as a treat for her and to increase isoflavones and protein in her diet.
• In patients with weight loss I will usually recommend a standard over the counter multivitamin from a reputable brand.
• Five servings of fresh fruits and vegetables of different colors are recommended to begin. We will usually increase this number to ten servings when they have become accustomed to the additional vegetables.
• Finally, I recommended 400mg of magnesium at bedtime in chelated or oxidized form along with a chamomile tea or a hops-valerian tea to aid in sleeping if she has issues with sleep.
The goals with changing a patient's diet to aid in menopause or other medical conditions is to slowly give them a framework to adapt changes. Slow progress may be easier and it may have taken them twenty or thirty years to indoctrinate their current system so a few months to years can help them retrain their habits into healthy choices.