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Complementary and Alternative Medicine Series

A Dietary Prescription for Menopause and Beyond

Greg Hottinger, MPH, RD; Tracy Gaudet, MD

Menopause can be a perfect time to explore lifestyle issues that can significantly affect both menopausal symptoms and long-term health. Given the magnitude of this life transition, this can be a once-in-a-lifetime opportunity to discuss significant behavioral changes.

One essential area to address in this regard is nutrition. Many patients have a limited understanding of how nutritional choices—far beyond the calories consumed—can have a major impact on perimenopausal and postmenopausal health. Indeed, the patient should know that her dietary choices can be far more important than any decision regarding HT. Nutritional advice can be provided in the form of a "prescription"—ie, a critical part of a treatment plan, like pharmaceuticals or adjunct therapies—to further emphasize its critical role.

DIETARY INFLUENCES

The modern American diet can exacerbate menopausal symptoms and contribute to disease by failing to provide an adequate level or ratio of nutrients, including fiber, vitamins, minerals, fatty acids, and phytochemicals. The regular consumption of processed foods, the omission of unprocessed alternatives, and a low intake of fruits and vegetables are largely responsible for these nutritional deficiencies. A healthy, balanced nutritional program can help alleviate menopausal symptoms by lowering blood pressure, supporting weight loss, maintaining healthy blood glucose levels, and reducing the synthesis of inflammatory compounds. In addition, dietary modification has been shown to reduce the risk or progression of numerous conditions common in postmenopausal patients, including cardiovascular disease (CVD), diabetes, osteoporosis, and certain cancers.

Dietary changes alone can significantly lower blood pressure and cholesterol and triglyceride levels.^1,2 A higher intake of fruit, vegetables, legumes, fish, poultry, and whole grains is inversely associated with diabetes, stroke, and serum levels of C-reactive protein (CRP) and other inflammatory markers, compared with a "Western" diet high in red and processed meats, sweets, fried foods, and refined grains.³ In addition to the general dietary recommendations to consume at least five servings of fruits and vegetables daily, more whole grains, and less saturated fat, the physician can recommend a higher intake of green, leafy vegetables, fish, soy products, other legumes, and nuts and seeds to significantly improve women's overall health status.

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LEAFY VEGETABLES

A single, daily serving of green, leafy vegetables is inversely associated with major chronic disease (relative risk [RR] = 0.95) and CVD (RR = 0.89).⁴ In addition, regular consumption lowers hemoglobin A1C levels, improves blood sugar metabolism independent of fiber,⁵ helps maintain regular bowel function, and provides nutrients such as calcium, magnesium, vitamin K, vitamin C, and folate that are important for maintaining bone mineral density (BMD).

Green, leafy vegetables are the most concentrated dietary source of vitamin K, which mediates the γ-carboxylation of osteocalcin and other bone proteins. Low serum levels of vitamin K are associated with lower BMD and increased risk of hip fracture; women consuming < 109 mcg/d of vitamin K had a 30% higher risk of hip fracture compared with those consuming at least 109 mcg/d (Table 1).⁶ In addition, green, leafy vegetables are a good source of folate, a deficiency of which is linked to lower BMD,⁷ elevated homocysteine levels, and possibly an increased cancer risk due to higher uracil misincorporation and chromosomal break rates.⁸ It is estimated that 10% of all Americans are folate-deficient,⁹ while surveys show that 30% of the elderly population are not meeting the US recommended daily allowance (USRDA) of 400 mcg for folate.¹⁰

Table not available online

TABLE 1. Nutrient Content of Green, Leafy Vegetables Source: US Department of Agriculture, Agricultural Research Service. Nutrient Database for Standard Reference, Release 17 (2004). Available at: http://www.nal.usda.gov/fnic/foodcomp/.

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FISH

Compared with the ideal of a 1:1 ratio of omega-6 fats to omega-3 fats, the Western diet has 16 times more omega-6 than omega-3 fats.¹¹ This imbalance alters prostaglandin synthesis/metabolism and may promote the pathogenesis of CVD, cancer, inflammatory disease, and autoimmune disorders.¹² The menopausal patient can significantly improve her dietary ratio of fatty acids by replacing red meats with fish—particularly oily, cold-water fish.

Women with a higher intake of omega-3 fats have significantly lower serum levels of CRP and other inflammatory markers.¹³ Reducing inflammation may be partly responsible for the reduction in CVD risk associated with fish intake. Consumption of one to two servings per week of fish rich in omega-3 appears to reduce the risk of coronary disease mortality by 25%.¹⁴ The benefits associated with fish intake can be profound for the dyslipidemic patient, particularly when consumed in place of red meat or fried foods. Many practitioners recommend that patients consume two to three servings of oily fish per week.

Another option for increasing omega-3 intake is "designer" eggs. These special eggs have a much higher omega-3 content than regular eggs due to the type of chicken feed. Four designer eggs contain the omega-3 equivalent of a 3.5-oz serving of salmon (Table 2).

Table not available online

TABLE 2. Fat Content of Fish Source: US Department of Health and Human Services and Environmental Protection Agency. Mercury Levels in Commercial Fish and Shellfish. Available at: http://www.cfsan.fda..gov/~frf/sea-mehg.html.

Increasing vitamin D intake is another reason to add oily fish into the diet. Vitamin D enhances calcium absorption and reduces parathyroid hormone-mediated bone resorption. The usual reference range for serum vitamin D levels (25-hydroxyvitamin D₃) is 50 to 80 nmol/L. However, there is emerging evidence that a level < 80 nmol/L is associated with reduced calcium absorption, osteoporosis, and increased fracture risk.¹⁵ Increasing serum levels from 50 to 80 nmol/L improves calcium absorption by nearly 66% and reduces fracture risk by 33%.^16,17 It is estimated that older individuals need a supplemental vitamin D intake of 1,300 IU/d to reach the 80-nmol/L threshold.

Long-term observational studies positively correlate vitamin D intake (but not total calcium or milk intake) with a reduced hip fracture rate.¹⁸ A 3.5-oz serving of salmon, tuna, or sardines provides 200 to 400 IU, while 1 c of fortified milk has 100 IU. In addition to fish intake, low-fat milk consumption, and 10 to 20 min/d of summertime sun exposure, a supplement should be recommended to the menopausal patient to reach a daily vitamin D intake of at least 1,000 IU.

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SOY PRODUCTS AND OTHER LEGUMES

Soybeans are a concentrated source of isoflavone phytoestrogens that may alleviate menopausal symptoms and protect against certain cancers, including breast cancer, as well as heart disease and osteoporosis. Soybeans are also a good source of protein that can be used to replace animal foods containing higher levels of saturated fat and cholesterol, effectively improving cardiovascular health.

Isoflavones and other components of soy appear to reduce menopausal hot flashes, although there may be a strong placebo effect.¹⁹ Most studies that have shown a benefit used 40 to 80 mg/d of isoflavones. Isoflavones can exhibit weak estrogenic or antiestrogenic activity, influence transcription and cell proliferation, and modulate signal transduction. Preliminary research suggests that soy intake among premenopausal women may reduce breast cancer risk.²⁰ However, there are safety concerns regarding the use of isolated isoflavone supplements, and the current consensus is to obtain isoflavones from soy foods. Women who have had breast cancer are advised against soy consumption pending further research.

While the direct relationship between soy intake and osteoporosis prevention is unclear, findings from 15 trials suggest that isoflavones reduce bone loss in younger postmenopausal women.²¹ Skeletal benefits have been seen at a moderately high dose of 80 mg/d of isoflavones, and two glasses of soy milk (76 mg/d of isoflavones) can prevent lumbar spine loss in postmenopausal women.²² Adequate protein intake is also important for BMD, and adding nonanimal protein to the diet may offer additional protection; women consuming low protein levels (17 to 51 g/d) had a reduced BMD and increased osteoporosis risk, whereas a moderate intake (4 to 8 oz/d of animal protein) was associated with the lowest BMD loss at all sites.²³ Desirable levels of isoflavones and protein from soy-based foods can be attained by consuming one to two servings of soy foods daily (Table 3).

Table not available online

TABLE 3. Protein and Isoflavone Content of Soy-based Foods*24 *Protein and isoflavone content varies widely between type and manufacturers of soy milk; consult label.

Few studies have examined the relationship between legume intake (other than soy) and menopausal symptoms. Legumes contain very small amounts of isoflavones relative to soy, but like soy they are an excellent source of soluble and insoluble fiber, magnesium, and folate--all of which are associated with a reduced risk of CVD, cancer, diabetes, and osteoporosis (Table 4).

Table not available online

TABLE 4. Nutrient Content of Nonsoy Legumes Source: US Department of Agriculture, Agricultural Research Service. Nutrient Database for Standard Reference, Release 17 (2004). Available at: http://www.nal.usda.gov/fnic/foodcomp/. Source for soluble fiber: Food Processor Nutrition Analysis Software package, version 7.60 (ESHA Research, Salem, OR).

Magnesium is a cofactor in several enzymes critical for carbohydrate metabolism. A recent survey found that black women consume only 55% of the USRDA of 320 mg/d, while white women consume 69%.²⁵ Dietary magnesium intake is positively correlated with less bone loss at the hip²⁶ and a significantly lower risk of diabetes, particularly in overweight women.²⁷ Other good dietary sources of magnesium include whole grains, nuts, and green, leafy vegetables.

The average menopausal patient consumes roughly 13 g/d of fiber--ie, 50% of the USRDA. A 1/2-c serving of legumes provides 6 to 8g of fiber. Higher fiber diets are associated with lower cholesterol levels, lower heart disease risk, reduced blood pressure, enhanced weight control, better glycemic control, reduced risk of certain forms of cancer, and regular bowel function.²⁸ A 19-year prospective cohort study found a 22% lower risk of heart disease among individuals eating legumes four or more times each week.²⁹

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NUTS AND SEEDS

Regular consumption of nuts and seeds correlates with a reduced risk of heart disease and diabetes. Women consuming five or more servings of nuts per week have a 35% reduced risk of heart disease³⁰ and a 27% reduced risk of diabetes³¹ compared with those rarely consuming nuts. Nuts and seeds are a good source of nutrients that have been shown to independently support cardiovascular health (eg, monounsaturated fats, vitamin E, folic acid, magnesium, copper, arginine).

Consuming single, handful-sized servings of nuts and seeds as part of a healthy diet can support weight loss by increasing satiety and reducing overall food intake. Nuts and seeds offering health benefits include almonds, almond butter, Brazil nuts, cashews, filberts, macadamias, peanuts, peanut butter, pecans, pine nuts, pistachios, pumpkin seeds, sunflower seeds, walnuts, and flaxseed.

Flaxseeds are a concentrated source of phytoestrogens called lignans that have chemoprotective effects in animal and cell studies. A flaxseed-enriched diet reduces serum concentrations of 17Β-estradiol and estrone sulfate,³² and are as effective as oral estrogen-progesterone in decreasing menopausal symptoms and lowering glucose and insulin levels.³³ Preliminary results suggest that flaxseed exerts a chemoprotective effect in postmenopausal women,³⁴ and intake does not alter markers of bone formation and resorption.³⁵ Flaxseed is a rich source of α-linolenic acid, a short-chain omega-3 fat that may protect against coronary heart disease.³⁶

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CONCLUSION

The patient who improves the quality of her diet may experience fewer menopausal symptoms. In addition to the recommendations discussed, reducing the intake of alcohol, caffeine, refined sugars, spicy foods, and hot beverages may reduce hot flashes and associated problems. More importantly, these same changes will help the patient to maintain a healthier body weight and lower her risk of heart disease, cancer, diabetes, and osteoporosis.

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References

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