Nutraceutical

We recognize, and may occasionally use, the term nutraceutical, which comes from two words: “nutrient” (food component) and “pharmaceutical” (medical drug), to reflect the use of  foods, parts of foods, and botanicals that claim to provide medical or health benefits, including the treatment of menopausal transition symptoms. Similarly, we use the term functional foods to describe foods that may offer health benefits in addition to their basic nutritional value. Fruits and veggies, which are nutrient-rich, are functional foods as are foods that have been fortified with vitamins, minerals, probiotics, and/or fiber.

Menopause and Nutrition

Nutritional choices cannot ‘un-age’ you – but healthy choices can compensate for the impacts of your natural menopausal transition by helping to influence individual symptoms that are affecting you. 

Additionally, healthy nutrition can prevent, delay and treat the onset of many symptoms, improving the aging experience. For example, as our bodies enter the menopausal transition, hormone production fluctuates a lot (Menopause101) and we can experience many changes to our bodies including (but not limited to) weight gain; type 2 diabetes; bone loss; cognitive decline, and cardiovascular disease. Below we give a short summary of research on nutrition as it impacts menopausal transition changes. 

A 2019 study by Dunneram et al. looked at how diet can influence the age at which a woman reaches menopause (defined as one full year without a period). The key findings included the fact that a high daily individual intake of oily fish, fresh legumes, vitamin B6, and zinc was associated with a delayed onset of menopause, whereas a high daily intake of refined pasta or rice was associated with an earlier onset of menopause. Women who self-report as vegetarians were found to have an earlier menopause onset age relative to non-vegetarians. The advantages of a later age at menopause is found in the extra time that women benefit from high levels of estrogen, lowering their risk of osteoporosis and heart disease. This same study also noted, however, that an earlier age at the onset of menopause is associated with lower risk of breast, endometrial, and ovarian cancers. [27]

What are the  Recommendations for Nutrition during Menopause?

Any nutrition plan that focuses on fish, whole grains, fruits, vegetables, olive oil and lean meats while limiting salt intake, sweets, processed foods, refined carbohydrates, and sugar loaded drinks is optimal during the menopausal transition. Low-fat and plant-based diets (vegan and vegetarian) are associated with heart health benefits and beneficial effects on body composition. However, they may require supplementation with vitamin B12, micronutrients like iron and omega-3 fatty acids. [1]

There are multiple ‘diet’ plans that meet these requirements easily available. You can ask your healthcare provider for recommendations, do your own research, or consult a certified Nutritionist to create your individualized plan based on your preferences and food intolerances to make this a more sustainable approach. . Three well-known food plans, or ‘diets’ also fit the requirements – The DASH diet (dietary approach to stop hypertension), the Mediterranean diet (MD), and the MIND diet (Mediterranean-DASH intervention for Neurodegenerative Delay), but they are not the only choices. These three diets, or others that decrease processed food intake and increase vegetable, fruit, whole grain and lean proteins, should help the primary prevention of bone, metabolic, and cardiovascular diseases in the postmenopausal period. [1a]

Phytoestrogens are natural substances that include isoflavones, lignans, coumestans, stilbenes, and flavonoids. Plant-based diets, especially those that include soy products, are rich in phytoestrogens. Studies support the idea that phytoestrogens can improve many symptoms seen during the menopause transition, including reducing hot flashes.[2] However, as with any nutritional supplement, talk to your health care provider before using them, particularly to ensure there are no interactions with other medications or supplements you are taking.

The science

Nutrition and Cardiovascular Disease

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Nutrition and Cardiovascular Disease

Cardiovascular disease is actually a group of disorders that affect the heart and blood vessels. The most commonly known CVD is coronary heart disease that affects the vessels supplying blood to the heart. This is a leading cause of heart attacks. Other types of CVD include (but are not limited to) cerebrovascular disease (affecting the vessels supplying blood to the brain) and peripheral arterial disease (affecting the vessels supplying blood to the arms and legs).

Longitudinal studies of women navigating menopause have contributed significantly to our understanding of the relationship between the menopausal transition and the risk of cardio-vascular disease (CVD).

Perimenopausal sex hormone changes, increased adipose (fat) relative to other tissues, increased chronic stress, and physical inactivity all increase a woman’s risk of developing CVD. Therefore healthy eating habits can reduce the risk for CVD. [3]

Postmenopausal women not only have higher total low density lipoprotein cholesterol (LDLc) plasma levels, but also the LDL particle itself becomes more dense.[4] This smaller, denser form of LDL is linked to development of heart disease. The high density lipoprotein cholesterol plasma level decreases with the onset of menopause, and the HDL particle itself changes. [5]

Menopause is associated with a progressive increase in total cholesterol, with, in particular, an increase in low-density lipoprotein (LDL), lipoprotein-α and triglycerides and a decrease in high-density lipoprotein (HDL).[6, 7, 8] Therefore, menopausal women are exposed to a more atherogenic lipid profile (one with a greater tendency to promote the formation of fatty plaques in the arteries) than pre-menopausal women. Total cholesterol levels peak in women at 55–65 years of age – about 10 years later than they peak in men.

The increase in risk factors of diabetes, raised cholesterol, the shift in fat distribution and storage leads to a four-fold increased risk in CVD in women in the 10 years after the menopause. The belief that this increase is menopause- or estrogen-deficiency-related rather than purely age-related is confirmed by the findings that for post-menopausal women at any age there is an increased risk of CVD.[9]

One study hypothesized that the ‘myoprotective’ effect of the Mediterranean diet could be linked to higher intake of plant-based foods and the potential benefits of the Mediterranean diet on body composition (especially managing body mass index) in postmenopausal women. The presence of antioxidants like beta-carotene and vitamins C and E might protect people from effects of oxidative stress. Magnesium improves energy metabolism, transmembrane transport, and skeletal muscle function. [10] The Mediterranean diet especially consists of foods that have anti-inflammatory and antioxidant properties. It is associated with a small but significant decrease in blood pressure, reduction of fat mass, and improvement in cholesterol levels and represents an ideal nutritional pattern in menopause.[11]

Definition: Oxidative Stress

Oxidative stress occurs when there is an imbalance between free radicals (oxygen-containing molecules with an uneven number of electrons that allows them to react chemically with other molecules easily) and antioxidants in your body. Antioxidants are molecules that can give away an electron to a free radical while still staying chemically stable themselves. When the free radical receives the extra electron, it becomes stable and less reactive.

Free radicals can cause oxidation – or large chain chemical reactions in your body – because they react so easily with other molecules.

Nutrition and Type 2 diabetes

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Nutrition and Type 2 diabetes

Type 2 diabetes occurs when the body is unable to properly regulate and use sugar (glucose) as a fuel. This is a long-term condition that results in too much sugar circulating in the bloodstream affecting insulin production that will eventually lead to disorders of the circulatory, nervous and immune systems.

Changes in insulin secretion and insulin sensitivity after the menopause transition, due in part to hormone changes, can contribute to an increase in diabetes in women. The risk of death from CVD associated with diabetes is higher in women than in men: in the 20-year Framingham study, women with diabetes were 3.3 times more likely to die from CVD than women without diabetes, whereas the risk for diabetic men was only 1.7 times that of non-diabetic men. [12]

Nutrition and Obesity / Weight change

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Nutrition and Obesity / Weight change

Energy from food is stored in the form of adipose tissue (fat) beneath the skin (called subcutaneous fat) and around the organs (called visceral fat or central adiposity). Women in the perimenopausal transition typically gain weight and experience changes in the composition of their body fat [13]. The increase in body mass index (BMI – one commonly used measure of adiposity), is seen in multiple studies regardless of menopausal status, so menopausal changes are not the only cause. However, the increased storage of central adipose tissue is clearly linked to menopausal stage. As women enter the menopausal transition, their follicle-stimulating hormone levels (FSH) levels start to rise and towards the end of the menopausal transition there is a sharp increase in FSH levels. This occurs at the same time as a rapid increase in the onset of central adiposity, leading to the conclusion that FSH is a fat-stimulating hormone.[13]

Postmenopausal women lose ‘metabolic flexibility’, which is the ability to respond or adapt to changes in metabolic or energy demand according to their activity levels. Metabolic flexibility diminishes due to estrogen reduction and more fat accumulating in central depots. [14]

All this together means that careful healthy nutrition is especially important during the menopausal transition.

Phytoestrogens (plant-based estrogens)

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Phytoestrogens (plant-based estrogens)

Phytoestrogens are compounds that naturally occur in plants and that many women use as an alternative to Hormone Therapy. Phytoestrogens are not estrogens, nor can they be converted into estrogen, but they can mimic or interfere with estrogen. There are five classes of phytoestrogens: isoflavones (soy and soy-based products, legumes), coumestans (beans, clover sprouts), prenylflavanoids (beer, hops), lignans (flaxseed, whole grains, legumes) and stilbens (red grapes, red wine). Their chemical structure is similar to estradiol, the strongest of the three types of estrogen. [15] Hops (Humulus lupulus) is a source of the phytoestrogen 8-prenylnaringenin (8-PN), which is thought to be a more potent phytoestrogen than soy isoflavone. [15a]

Isoflavones are the most important compound of phytoestrogens and are produced almost exclusively by the members of the Fabaceae family – commonly known as the legume or bean family. Soybeans, a member of the Fabaceae family, are a well known source of phytoestrogens and the most studied in terms of impacts on menopausal transition symptoms. Isoflavones also stimulate the production of sex hormone binding globulin (SHBG), which is a protein that carries estrogen throughout the body. [16]
Some phytoestrogens have to interact in the intestines with bacteria to be absorbed. The absorption of isoflavones requires the presence of the intestinal bacteria that enable the hydrolysis (breakdown) of genistein and daidzein into their active components. Due to this, there are suggestions to combine soy isoflavones with lactic acid bacteria to ensure that the soy isoflavones are available for use in the body. [17].

In a systematic review and meta-analysis of phytoestrogen use for vasomotor symptoms among peri- and postmenopausal women, researchers identified 43 randomized control trials (RCT), including one unpublished trial, that tested the effectiveness of dietary soy, soy extracts, red clover extracts, genistein extracts, natural S-Equol, flaxseed, Rheum rhaponticum extract, and hop extract, for at least 12 weeks. Note that the majority of these studies were not able to be combined into a meta-analysis because the methods were too variable and therefore not able to be meaningfully combined.

The authors of this review concluded that the evidence did not support the use of phytoestrogens to reduce the frequency or severity of vasomotor symptoms at the time. More RCTs that use standardized methods, including standardized isoflavone content in soy products under study, are needed to draw definitive conclusions regarding the use of phytoestrogens for menopausal symptoms.[17, 18]

Products that contain phytoestrogens may only have minimal benefits for hot flashes however they may produce other positive health effects, such as reduction of bone loss [19]. Isoflavones exert a limited beneficial effect on cognition however, this effect may be modified by age, gender, ethnicity, menopausal status, and length of treatment [20]. The effects on bone metabolism show a significant decrease in bone resorption process, especially if associated with HRT [21]. When used topically phytoestrogens had a positive effect on vaginal health and painful sex (dyspareunia). [22]

In studies, stomach and bowel problems were more common in women who took phytoestrogens than in those who did not. However, taking isoflavones for up to 12 months of continuous use was found to be safe. [18]

Vitamin E

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Vitamin E

Vitamin E is a fat-soluble vitamin thought to act as an antioxidant in the body. Few studies have been performed specifically to investigate the effects of Vitamin E on menopausal transition symptoms. One study that investigated the use of vitamin E for menopause symptom reduction had 120 women receiving 800 IU of vitamin E followed (4 weeks) by placebo (4 weeks) or vice versa. Participants reported a decrease of 1 hot flash per day with vitamin E, which the authors found not clinically meaningful (there was no difference that could be identified by physicians in a clinical setting) [23].

In a similar randomized study, 50 women taking 400 IU of vitamin E followed by placebo or vice versa for 4 weeks each, participants showed a reduction of about 2 hot flashes per day and reduced hot flash severity with vitamin E.[24] Based on these limited research results, there is insufficient empirical evidence to make conclusions about the effectiveness of vitamin E supplementation for menopausal symptoms.[18]

The National Center for Complementary and Integrative Health, a division of the National Institutes of Health, states that Vitamin E, taken as high doses found in supplements, may increase the risk of bleeding (including strokes due to bleeding in the brain) and interact with anticoagulant (blood-thinning) medications such as warfarin (Coumadin).[28]

Omega-3 fatty acids supplements

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Omega-3 fatty acids supplements

Omega-3 supplements contain polyunsaturated fatty acids (long-chain fatty acids), including eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA), and α-linolenic acid. Two studies looked at the use of omega-3 fatty acids for treatment of menopausal transition symptoms. In one, an 8-week trial of 91 women randomized to placebo or omega-3 supplement (total daily dose: EPA 1,100 mg + DHA 150 mg), vasomotor symptom frequency and intensity were significantly improved with omega-3 compared with placebo. In a second 12-week study, women were randomized to either an omega-3 supplement (n = 177) or placebo (n = 178) and at the same time also randomized into an activity (yoga, aerobic exercise, or their usual physical activity). There were no significant differences found for either vasomotor symptom frequency or severity (bother). [25]

MYTH

One paper did find that vegetarians have an earlier menopausal transition onset and that higher meat consumption was associated with delayed onset of menopause in a group of women between 45 and 49 years of age [27]. However, another paper found that there might be a delay in onset of menopause transition by eating lots of vegetables. [26] 

MYTH

While adequate water intake is critical for overall health, 8 glasses is not a hard and fast requirement. Women usually get water from multiple different sources, including hydrated foods like fruits and vegetables.

MYTH

Healthy weights can be obtained and maintained! While the metabolism does slow down during the menopausal transition, metabolism is still happening. Adequate exercise and maintaining healthy eating habits empowers women to control their weight.  

Nutritional Recommendations

How many calories, which are units of energy, are needed per day depends on a person’s level of physical activity, age and height. Middle-aged and older women need fewer calories than younger women. Active women need more energy than sedentary women. Nutrition scientists recommend 1600 calories per day for weight maintenance.

Cholesterol

less than 300 mg/day

Fiber

25-30 g/day

Protein

10-35% of daily calories

Carbohydrates

45-60% of daily calories

Sodium

less than 2400 mg/day

Compiled References

  1. Weikert, C 2020: Vitamin and Mineral Status in a Vegan Diet. Dtsch Arztebl Int. 117(35-36):575-582.
  2. Franco OH, Chowdhury R, Troup J, et al. Use of Plant-Based Therapies and Menopausal Symptoms: A Systematic Review and Meta-analysis. JAMA. 2016;315(23):2554–2563. doi:10.1001/jama.2016.8012
  3. Al-Anazi AF, Qureshi VF, Javaid K, Qureshi S. Preventive effects of phytoestrogens against postmenopausal osteoporosis as compared to the available therapeutic choices: An overview. J Nat Sci Biol Med. 2011;2(2):154-163. doi:10.4103/0976-9668.92322
  4. El Khoudary, S.,, B., Beckie, T.M., Hodis, H.N., Johnson, A.E., Langer,R.D. Marian C Limacher,M.C., Manson, J. E., Aggarwal Stefanick, M.L., Allison, M.A. (2020), CirculationVolume 142, Issue 25: Menopause Transition and Cardiovascular Disease Risk: Implications for Timing of Early Prevention: A Scientific Statement From the American Heart Association
  5. Campos H, McNamara JR, Wilson PWF, Ordovas JM, Schaefer EJ. (1988) Differences in low density lipoprotein sub fractions and apolipopro- teins in premenopausal and postmenopausal women. J Clin Endocrinol Metab 1988;67:30-35.
  6. Bittner V. (2002) Lipoprotein abnormalities related to women’s health. Am J Cardiol. 2002; 90: 77i–84i.
  7. Schnatz PF, Schnatz JD, Dyslipidemia in menopause: mechanisms and management, Obstet Gynecol Surv, 2006;61(9):608–13.
  8. Williams CM, Lipid metabolism in women, Proc Nutr Soc, 2004;63(1):153–60
  9. Rosano GMC, et al., Menopause and cardiovascular disease: the evidence, Climacteric, 2007;10(1):19–24
  10. Kannel WB, Levy D, Menopause, hormones and cardiovascular vulnerability in women, Arch Intern Med, 2004;164:479–81
  11. Kannel WB, Levy D, Menopause, hormones and cardiovascular vulnerability in women, Arch Intern Med, 2004;164:479–81
  12. Granic, A.; Sayer, A.A.; Robinson, S.M. (2019) Dietary Patterns, Skeletal Muscle Health, and Sarcopenia in Older Adults. Nutrients 2019, 11, 745.)
  13. Granic, A.; Sayer, A.A.; Robinson, S.M. (2019) Dietary Patterns, Skeletal Muscle Health, and Sarcopenia in Older Adults. Nutrients 2019, 11, 745. )
  14. Cano, A.; Marshall, S.; Zolfaroli, I.; Bitzer, J.; Ceausu, I.; Chedraui, P.; Durmusoglu, F.; Erkkola, R.; Goulis, D.G.; Hirschberg, A.L.; et al. (2020) The Mediterranean diet and menopausal health: An EMAS position statement. Maturitas 2020, 139, 90–97.)
  15. Kannel WB, McGhee DL, Diabetes and cardiovascular disease. The Framingham study, J Am Med Assoc, 1979;241:2035–8
  16. Farvid, M: Post-diagnostic dietary glycemic index, glycemic load, dietary insulin index, and insulin load and breast cancer survival (2021). Cancer Epidemiology, Biomarkers & Prevention.
  17. Eaton, S.A.; Sethi, J.K. Immunometabolic Links between Estrogen, Adipose Tissue and Female Reproductive Metabolism. (2019) Biology 2019, 8, 8.
  18. Nagata, C 2000: Association of diet with the onset of menopause in Japanese women. Am J Epidemiol. 152(9):863-7.
  19. Dunneram, Y 2019: Proc Nutr Soc 78(3):438-448.