ESPEN Congress Cannes 2003 Organised by the Israel Society for Clinical Nutrition

Education and Clinical Practice Programme

Session: Dietitian Symposium: Nutrition throughout the woman life cycle

Nutrition and the Menopause Ms. Gaynor Bussell St. Albans, United Kingdom

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What is the menopause? Menopause is the name given to the time when women’s ovaries slowly stop working. This leads to a fall in levels of the oestrogen and is thought to be related to a variety of symptoms such as hot flushes, irritability and joint pains.

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Why is diet important during the menopause • • • • •

Osteoporosis Heart disease and blood pressure Weight gain Menopausal symptoms Certain cancers

Top 10 tips for menopause 1 Have a varied, balanced diet and keep an interest and enjoyment in eating. 2 Eat the right amount for you 3 Watch fats 4 Include fruit, veg and wholegrains 5 Have enough calcium and vitamin D 6 Eat some oily fish

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Top Ten Tips: Nutrition for the Menopause (cont..) • • • •

7 Eat plenty of starchy foods 8 Watch alcohol and caffeine 9 Watch salt 10 Feel free to try alternatives such as soya

Eat a variety of foods; This will ensure your body gets a mixture of all the nutrients you need Don’t forget to take an interest in food and enjoy your food.

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Weight issues • A BMI of 25-26 is fine. • Metabolic rate may be lower at middle age so less food is required than when younger. • Some causes of extra weight: – fall in metabolic rate – less active – creeping obesity – HRT does not lead to weight gain per se

Does reaching the menopause have to equal central adiposity? No! • Physical activity alone can offset central weight gain as measured by waist circumference • Maintaining a normal weight will help

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Physical activity: the 3 S’s Stamina: an extra 2000 steps a day will burn up 100 calories which is responsible for creeping obesity. Buy a pedometer! Suppleness: if you don’t use it you loose ittry Yoga, Pilates, Stretching Strength: pump it up with those baked bean cans

Fats! Benefits of reducing fat in the diet: – improved lipid profile – reduced incidence of heart disease – weight loss – possible reduced incidence of dementia – reduced breast tenderness

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Types of fats • Benefits are seen with following the Mediterranean diet- fruit and vegetables, olive oil, fish and some wine! • Monosaturated fats are termed ‘good fats’and include rapeseed oil (canola), olive oil, avocado oil, linseed oil, hempseed oil (these are also good vegeterian sources of omega 3 oils) • Avoid trans fats

4.Fruit and Vegetables It is recommended to eat at least 5 portions of fruit and vegetables daily. Fruit and vegetable intake is associated with increase BMD, increase antioxidant levels and provides the mood regulating mineral, magnesium, which is often low in menopausal women.

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What is osteoporosis?

“It is a progressive systemic skeletal disease characterised by low bone mass and microarchitectural deterioration of skeletal tissue. It results in bone fragility and an increased susceptibility to fracture. It is a silent disease, such that the deterioration of skeletal tissue occurs with no outward sign until fracture occurs”

Diet for osteoporosis • A balance of nutrients is important, including fruit and vegetables. • Have a diet rich in calcium with enough vitamin D to help you absorb the calcium. Calcium is found in dairy foods, tofu, green vegetables, beans and fish that contain edible bones.

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Calcium supplements • Most benefit seen for calcium in late menopause and in elderly. • Seems little effect during peak of the menopause. • 500mg supplement is sometimes recommended if there is osteoporosis (UK NOS) • May be best taken with Zn, Cu, Mn, Mg and vitamin D • A soluble form of calcium is best • Do not exceed 2000mg calcium from diet and supplement

Other factors affecting bone health • • • • • •

Vitamin A Coffee Phytates Protein Salt Alcohol

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Vitamin D and oily fish

• UK recommendation is to eat 2 portions of fish a week, one of them should be oily. This will provide some vitamin D and essential fatty acids that help protect the heart. • Vitamin D is found also in eggs, butter and margarine and fortified breakfast cereals. • 10-15 mins sun on face and forearms during summer months is also recommended • In the UK, people over 60 are recommended to take a 10 mcg supplement daily.

Benefits of fish oil • Reduces CVD risk, especially beneficial for reducing subsequent heart attack after first, and in Type 11 diabetes. • Reduces heart fibrillation. • Reduces blood pressure. • Reduces triglyceride level. • Anti-coagulatory (will help prevent clotting). • Anti-inflammatory (especially beneficial to raise ratio of omega 3 to omega 6). • May help to reduce symptoms of rheumatoid arthritis. • May help reduce risk of age-related macular degeneration and dry eye syndrome.

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7.Eat more starch! • Dietary advice for maximum health benefits include the recommendation to eat 50% of calories as carbohydrate, with as much as possible coming from unrefined sources. • A starchy and fibre rich carbohydrate should be eaten at each meal. This will help keep bowels healthy, will provide a long lasting supply of energy and may help reduce cholesterol levels.

8. Alcohol! Excess alcohol is associated with:. • hot flushes • osteoporosis • weight gain. • Cancer, especially of the breast Moderate drinking seems to be cardioprotective after the menopause.

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Caffeine Excess caffeine during the menopause may be associated with : • sleep problems • anxiety • reduced bone density • blood pressure • Parkinson’s disease (taken with HRT)? • breast tendernes Black coffee seems to be the main concern

9. Salt! • Salt can lead to high blood pressure. • Salt may cause hypercalciurea, thus predisposing to osteoporosis. • A high salt diet may also exacerbate bloating and fluid retention. To cut down: Reduce the amount of processed foods you eat and don’t add salt to your food (use more herbs and spices).

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10. Phytoestrogens Shown Benefit: • Some menopausal symptoms e.g. hot flushes ß Prostrate cancer ß Cholesterol lowering Some evidence: ß Bone health ß PMS ß Breast and endometrial cancer, ß Cognitive function ß Blood pressure ß CVD in postmenopausal women

Isoflavone content • • • • • •

Soya milk 10mg/100ml Soya yogurt 10mg/100ml TVP 33mg/100g Soya cheese 7mg/100g Tofu 27mg/100g Red clover supplement 40mg 40-60mg required /day for any effect

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Food Sources of phytoestrogen • Soya and soya products such as soya milk, tofu, soya yogurts • Vegetables and fruit

• Seeds especially flax seeds (linseed). • Nuts • Peas, beans and lentils

Other alternatives to HRT • Menopause designer supplements: Expensive and may not be the best. • Herbals e.g. Black Cohosh, Chinese angelica, Agnus Castus, Don quoi, Wild yam, St john’s wort, Hops, Ginseng: May have a role, but watch safety and seek medical advice if on other medication. • Isoflavone supplements e.g. Red clover: Not as effective as dietary sources • Other supplements e.g. vitamin E, EPO, vitamin B6: may be helpful for symptoms such as breast tenderness and bloating. • Healthy lifestyle- raises the threshold above which symptoms appear

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THE MENOPAUSE EXCHANGE Tel: 020 8420 7245 Fax: 020 8954 2783 E.mail:[email protected]

References • Baer DJ, Judd JT, Clevidence BA, Muesing RA, Campbell WS et al. Moderate alcohol consumption lowers risk factors for cardiovascular disease in postmenopausal women fed a controlled diet. Am J Clin Nutr 2002; 75(3):593-9 • Bingham S et al. Flawed research methods may mask a link between dietary fat and breast cancer • Burckhardt P, Dawson-Hughes B, Heaney RP. Nutritional Aspects of Osteoporosis. 2001; London: Academic Press • Davidson MH, Maki KC, Karp SK, Ingram KA. Management of hypercholesterolaemia in postmenopausal women. Drugs Aging 2002; 19(3): 169-78 • Department of Health: Report on Health and Social Subjects (49): Nutrition and Bone Health. London: The Stationary Office; 1998 • Feskanich D, Singh V, Willett WC, Colditz GA. Vitamin A intake and hip fractures among postmenopausal women. JAMA 2002; 287(1):487-54 • Fowke JH, Longcope C, Hebert JR. Brassica vegetable consumption shifts estrogen metabolism in healthy postmenopausal women. Cancer Epidemiol Biomarkers Prev 2000; 9(8): 773-9 • Friedenreich CM. Weight gain, waist-hip ratio identified as risk factor for breast cancer. Int J Cancer 2002; 99:445-452 • Horn-Ross P et al. Regular phytoestrogen consumption reduces endometrial cancer risk. J Nat Cancer inst. Aug. 6 2003 • Key T Obesity boosts cancer-causing hormones J. National Cancer Inst, August 19 2003

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• McTiernan A. Exercise ‘prevents breast cancer’ JAMA Sept. 10 2003 • Moroney JT, Tang MX, Berglund L. Low–density lipoprotein cholesterol and the risk of dementia with stroke. JAMA 1999; 282:254-260 • North American Menopause Society. The role of isoflavones in menopausal health. Menopause 2000 Jul-Aug;7 (4):215-229 • O’Shea B et al. For the Osteoporosis Research Advisory group. A meta-analysis of calcium supplementation for the prevention of postmenopausal osteoporosis. Osteoporosis nt. 200;11:S114 • Scientific Advisory Committee on Nutrition (SACN) Draft report on salt. [cited 2002 November 4]. Available from: URL: http://www.sacn.gov.uk • Teede H et al. Soy protein with isoflavones has favourable effect on lipids in postmenopausal women. Clin Endocrinology 2003;58:704-709 • Teede H et. Al. Isoflavones reduce arterial stiffness in healthy men and women. Arterioscler Thronb Vasc Biol 2003; 23: 1066-1071 • Tice J Phytoestrogen supplements bot useful for menopause symptoms. JAMA 2003;290:207214 • Washburn S, Burke GL, Morgan T, Anthony M. Effect of soy protein supplementation on serum lipoproteins, blood pressure and menopausal symptoms in perimenopausal women. Menopause 1999; 6:7-13 • Whiteman MK. Smoking and Obesity Increase risks of severe Hot Flashes. Obstet Gynecol 2003; 101:264-272 • Genistein has similar effects to oestrogen Am J Med. 2003 Apr 15;114 (6):470-6

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