Abstract
Eating well and keeping active remains the cornerstone of a healthy menopause, regardless menopausal hormone therapy (MHT) status. During a consultation, it can be all too easy to gloss over lifestyle aspects of menopause care assuming the patient knows what a healthy diet and lifestyle is. There remains both lay and health professional confusion about the evidence-based approach to nutrition. Poor science and celebrity ‘anecdote’ flood consumer and social media with misinformation about what a healthy diet and lifestyle should look like.
Eating well and keeping active remain the cornerstone of a healthy menopause, regardless of menopausal hormone therapy (MHT) status. During a consultation, it can be all too easy to gloss over lifestyle aspects of menopause care assuming the patient knows what a healthy diet and lifestyle is. There remains both lay and health professional confusion about the evidence-based approach to nutrition. Poor science and celebrity ‘anecdote’ flood consumer and social media with misinformation about what a healthy diet and lifestyle should look like.
For the purpose of this chapter the focus is on the practical elements of diet and lifestyle which are relevant to the majority of women. My focus will also be on the methods you can use to encourage and motivate a woman to make changes and put these into practice.
In my experience, the menopause is a window of opportunity in a woman’s life. Now, she may have the motivation, time and mindset to make positive changes to her diet and activity levels. As health professionals, our role is to help her understand exactly what she’d benefit from changing and to help her make an effective, personalized plan of action.
Throughout the chapter, I have referenced several Food Fact Sheets produced by the British Dietetic Association [1].
Weight Management and Menopause: The Big Issue
The women who come to my clinic complain more about weight gain than any other aspect of their menopause – they tell me its ‘unexplainable, persistent and all sits around the abdomen and upper body’. Usually they feel miserable and out of control. Their self-esteem, confidence and general outlook on life can all be significantly affected by their excess weight. Often, they’re convinced their weight gain has occurred since commencing hormone therapy.
Rarely does a woman tell me she’s worried about her bone health or her increased risk of cardiovascular disease. Fortunately, the dietary strategies to help manage her weight concerns will also improve her bone density and help manage her CVD risk.
The 2018 All Party Parliamentary Group on Obesity found that only 26 per cent of people with obesity reported being treated with dignity and respect by health care professionals.
In my experience, the greatest skill required to give good menopause dietary advice is listening and understanding. If you understand what is motivating the woman, and can support her in the way that’s right for her, the technicalities of a good diet and lifestyle are easy.
Tip: It is important to ask for permission to discuss the woman’s weight. This can often be achieved by simply asking what issues surrounding her menopause bother her the most. If weight gain is mentioned, simply ask ‘are you happy if we talk about your weight?’
Menopause Diet and Lifestyle: Facts and Trends
Weight gain at the menopause affects around 50 per cent of women. It is due to a fall in metabolic rate by around 10 per cent, and equates to an average weight gain of 1.5 kg/year and as hormone levels change the additional weight tends to be deposited centrally leading to increased risk of metabolic disorders such as diabetes and cardiovascular disease [2].
HRT does not cause weight gain: The evidence is just not there to support this theory.
Bone health: Bone loss is escalated during the menopause and continues for up to 10 years after [3]. The daily recommended amount of calcium intake for women of menopause age is 700 mg, but the National Osteoporosis Society suggest that those with or at risk of osteoporosis should have 1000–1200 mg/day. Weight-bearing exercise, possible Vitamin D supplementation and weight training may all help too.
The risk of breast cancer can be reduced by some simple dietary measures such as avoiding excess weight gain, eating more brassica vegetables [4], upping fibre intake, especially soluble fibre, and replacing some meat with oily fish. Keeping to dietary fat recommendations and obtaining enough Vitamin D are all relevant.
Less active: Regular aerobic exercise can reduce the severity and frequency of vasomotor symptoms, and if exercise is combined with diet for weight loss there may be a 30 per cent reduction in symptom severity for every 5 kg lost [5, 6]. Both aerobic and resistance exercise are an essential part of managing menopause weight gain.
Lipids and blood pressure: Total cholesterol tends to rise but levels of HDL cholesterol tend to fall after menopause. This is exacerbated if accompanied by weight gain, especially centrally deposited fat and a sedentary lifestyle. Blood pressure may increase too so with the fall in cardioprotective estrogen women’s risk of heart disease equals that of men.
Strategies to lower LDL cholesterol and raise HDL cholesterol include keeping a healthy weight, reducing saturated fat intake (replacing with polyunsaturated and monounsaturated fats), keeping physically active, eating more soluble fibre and adopting a more Mediterranean diet [7]. Eating more soya-based foods may also help [8].
Caffeine and alcohol drinks can exacerbate hot flushes and are often but not always high in empty calories – stick to DoH guidelines.
Menopause: Weight Gain, Body Composition and Fat Deposition
Weight gain is a common complaint among about half of women during the menopause. The transition to menopause is associated with changes in body composition and body shape, and increasing weight and BMI.
Evidence from the SWAN study and The Healthy Women’s Study suggest that on average, women gain around 1.5 kg weight per year during their forties, fifties and sixties. Much of this weight gathers around the upper body and abdomen. As estrogen levels decrease, visceral fat deposition increases from 5 to 8 per cent total body fat premenopause, to 10–15 per cent total body fat postmenopause. To add to the problem, lean muscle mass and metabolic rate reduces. Most of the evidence supports changes in BMI and weight gain with ageing and changes in body composition with reproductive hormone changes [9].
Treatment and Advice: Where to Start
If you are fortunate to work amongst a multidisciplinary team including dietitians, exercise specialists and psychologists they can provide this advice and support for women. However, if it falls to you to support your patient, this section will help you focus more on the lifestyle modifications needed.
Eat Less and Move More
High-quality studies evaluating the effectiveness of interventions targeting body weight and composition changes in women during the menopause are needed. Evidence from one high-quality study indicates that women who followed a year-long plan of calorie restriction and increased exercise improved their body weight and reduced central adiposity. Reductions in waist circumference and body fat were also maintained for over 4 years [10, 11].
Dietary Change
The fundamental elements of any effective weight loss plan require a daily calorie deficit of around 500 Kcals or 3500 calories per week and a regular increase of both aerobic and resistance exercise [12]. How the calorie deficit is achieved is best assessed by determining where the majority of excess calories are coming from in the woman’s diet.
Potential high-calorie contributors include
Snacks and grazing
Alcohol
Large portions
The most practical and accurate way to gain an understanding of woman’s dietary habits is a 3-day food and activity diary. This should be completed by the woman prior to the consultation. The diary should also be accompanied by guidance supporting accurate completion. Mobile phone applications such as My fitness Pal and Nutricheck are also easy to use, accurate and inexpensive (www.myfitnesspal.com/; www.nutracheck.co.uk/CaloriesIn/).
It can be useful to quantify regular excess calories in the context of a cumulative, weekly proportion of a woman’s daily recommended calorie allowance, e.g. ‘Your wine intake over the week equates to more than an entire day’s worth of calories (Table 17.1). Is that something you think you could reduce?’
Table 17.1 Calories contained within popular snacks/drinks
| Excess calories | Per item | Typical daily intake | Equivalent in daily calorie allowance 1800 Kcals |
| 175 ml glass of wine | 159 cals | 2 glasses per night × 7 days | 2226 = 1.2 days’ worth of calories |
| 34.5 g bag of crisps | 180 cals | 1 bag × 5 days | 900 = 0.5 days’ worth of calories |
| 36 g peanuts | 216 cals | 1 × 5 days | 1080 = 0.6 days’ worth of calories |
| Garlic bread slice | 204 cals | 3 slices × 2 days | 1224 = 0.7 days’ worth of calories |
| Twix | 142 cals | 1 × 5 days | 710 = 0.4 days’ worth of calories |
| Mayonnaise 36 g | 246 cals | 1 × 5 days | 1230 = 0.7 days’ worth of calories |
Agreeing on 2–3 dietary changes to achieve a total saving of 3500 calories over a week is a good and effective starting point. The weight loss plan is based on adjusting the woman’s existing diet – not a prescriptive, ‘one-diet-fits-all’ approach.
TIP: It can also be helpful to put individual daily dietary changes into a check list to formalize the personal plan of action the woman is agreeing to undertake.
The diet plan has four changes for the woman to focus on
Reduce wine to one glass per night (1113 calories saved)
Cut out crisps at lunchtime (900 calories saved)
Cut out mayonnaise (1230 calories saved)
Only have garlic bread 1 day/week (612 calories saved)
Total calories saved 3855
Other Calorie-Saving Considerations
Portion Sizes
It is well documented that large portion sizes can often be a contributory factory for people who are overweight. It’s difficult to visualize portion sizes in a clinical setting; however, it can be useful to ask a patient if their main meal of the day would ‘fit into their cupped hands’ (a rough guide to the amount of food you need to satiate hunger). If the woman thinks her meal is larger than that, suggest using a smaller plate or taking a modest first helping and then assessing if she wants more after the first helping has been eaten. She should allow around 5–10 min after completing her first helping before going back for more. These are helpful, effective ways to reduce portion sizes.
Snacks
There is confusion about whether snacking is a helpful part of a healthy eating plan. Three modest-sized meals plus two small snacks per day can be perfectly healthy and in some instances helps prevent unconscious grazing. The reality is that it’s usually more important to establish what someone is snacking on and why – rather than changing whether they do or don’t snack at all.
Skipping meals and avoiding whole food groups, specifically carbohydrates, have both been identified as behaviours which tend to increase snacking. If someone is snacking and grazing unconsciously they will be more inclined to choose foods which satisfy hunger quickly – these foods are high in fat and sugar, such as confectionery, crisps and biscuits.
A planned snack mid-morning or mid-afternoon should provide around 100–150 calories (Table 17. 2). It’s useful to suggest women keep snacks with them when they are away from the home.
Table 17.2 Suggested snacks that have low calorie content
| Snack | Calorie value < 100 |
| Slice of malt loaf | |
| Small pot of low-fat fromage frais | |
| 2 tablespoons fresh fruit salad | |
| 1 tablespoon low-fat hummus and crudités | |
| Large rice cracker with low-fat cheese spread or peanut butter | |
| 1 crumpet with a low-fat spread | |
| Scotch pancake | |
| Calorie value < 150 | |
| Around 20 almonds | |
| 100 g edamame beans | |
| 15 Pringles | |
| 3 Jaffa cakes | |
| Baby Bel light or Laughing Cow cheese light with a Ryvita | |
| 25 g baked ready salted crisps |
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