Thickening waist, spare tyre, muffin top or meno belly; call it what you will, but body fat changes can be an alarming feature of the mid-life hormone shift for even the most body-positive woman.
“It is the number one symptom that will trigger a woman to call me,” says nutritional therapist Rachel Graham. “She may be dealing with a host of other symptoms, but it is weight gain that is really frustrating and annoying.” This is not just about appearance; excess abdominal fat is a health concern.
Menopause is, technically, only a moment in time: the 12-month mark after a woman’s last period. The average age of menopause in Ireland is 51. But fluctuating levels of oestrogen and progesterone begin to disrupt the menstrual cycle years before that, during the perimenopause. Symptoms can include hot flushes, anxiety, disturbed sleep, reduced sex drive and brain fog, as well as weight gain. Some of these may wane or disappear post-menopause, but from then the impact of low oestrogen on long-term health is of increased concern.
The end of fertility often coincides with other midlife challenges, such as juggling work with caring for children or teenagers and possibly parents too. As stress, anxiety and disturbed sleep morph into continual fatigue, women are bombarded with conflicting social media advice on everything they should be doing to future proof their bodies. If only they had the time and the energy.
“A stressed body is a perfect environment for fat storage,” says Graham, whose mantra is “nourish your body, don’t punish it”. Doubling down on efforts to cut calories is unlikely to work and can backfire, she warns.
“When you restrict, your body reads this as a threat. It is going to hold on to fat rather than releasing it. What your body needs now isn’t less, it’s more of the right things – optimised levels of nutrients.”
Graham did not initially recognise signs of her own perimenopause. At age 43, she was working in the food business but also studying nutritional therapy at the College of Naturopathic Medicine. Frustrated at her inability to concentrate, as well as noticing a sharp increase in appetite while studying, she started to apply some of what she was learning to herself.
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“I was really optimising all of the nutrients and foods that support brain function. It genuinely worked.” On completion of her nutritional therapy course, she trained to be a medicinal chef, learning about required dosages of nutrients and how to use food in the management of lifestyle-related health issues.
“I poured all of that experience into writing my own menopause cookbook.” What was intended to be a short e-book for her clients “grew legs” into a 400-page document, which she self-published. It then came to the attention of Irish publisher Gill Books, which has now brought out a paperback edition of Nourish for Menopause.
Nutritional therapist Rachel Graham: ‘A stressed body is a perfect environment for fat storage.’ Photograph: Dara Mac Dónaill
Dr Louise Fitzgerald, a GP at Grafton Medical in Dublin with a special interest in women’s health and the menopause, regards diet as an essential part of managing the menopause transition. She too likes to look at what can be added in, particularly fibre, rather than focusing on what might come out.
“The average weight gain in perimenopause is 1.5kg per year – so in perimenopause, you gain on average 10kg,” she says, acknowledging this will not be the case for all women. Doctors can prescribe hormone replacement therapy (HRT) and non-hormonal medications to ease symptoms, but this “is not going to have a direct impact on dropping those kilos”. However, it will help if the treatment improves mood and energy levels. Aside from menopausal symptoms, there is also the long-term effect of underlying changes to consider, such as a rise in cholesterol, higher blood pressure, and increased fragility.
Take five: top tips from menopause nutritionist Rachel Graham
Prioritise protein at every meal. Most importantly, start your day with breakfast rich in protein and fibre. Skipping breakfast is the biggest mistake you can make.
Eat phytoestrogens. These are plant compounds that mimic the effect of oestrogen and are found in foods such as soy, flaxseed, beans and lentils.
Feed your gut with fibre. This will support digestion, improve mood and is important for brain health.
Ensure sufficient intake of calcium and magnesium. These minerals work together to protect bone health. Supplements may be necessary but professional advice is recommended.
Stop restricting and start nourishing. Ditch the calorie counting and concentrate on the body’s need for optimised nutrition.
“Oestrogen is our superpower,” says Fitzgerald. Once women go through menopause, they have much lower levels of oestrogen, and are at a higher risk of heart attacks and strokes, as well as osteoporosis, a disease that weakens bones.
She will always point out to patients that a dual approach is needed: what they can do, around diet, lifestyle, exercise, and what she can prescribe. Muscle loss, which not only reduces physical strength but also impairs calorie-burning ability, accelerates through menopause and beyond. This can be slowed down through resistance training, and doctors should cover this in consultations, she says.
“I was at a talk recently, and the doctor rather shockingly said, ‘Who tells people about diet, lifestyle, exercise any more? That’s so old-fashioned’.” The implication was that prescribing the new generation of weight-loss drugs looks after that now.
Fitzgerald might prescribe these if appropriate for a menopausal patient who asks about them, but she would rarely suggest them. For a start, to counteract muscle loss, people at this stage of life need to eat at least 1g of protein per kilogram of their weight every day, which is a huge amount for somebody with a suppressed appetite.
Dietician Gillian McConnell welcomes how some GPs now refer patients to a dietitian before prescribing weight-loss medication. Photograph: Nick Bradshaw
Eating sufficient fibre is also a challenge for those on weight-loss medication, says Gillian McConnell, a dietitian registered with the health regulator Coru. Furthermore, lack of desire for liquids as well as food compounds the problem of constipation.
McConnell works at a specialist menopause and women’s health clinic, Rose Clinic Bray in Co Wicklow, and runs Inside Out Nutrition in Sandyford, Dublin. She welcomes how some GPs now refer patients to a dietitian before prescribing weight-loss medication, because overall nutritional adequacy is a big issue.
In managing menopause, Graham is not averse to HRT, which she uses herself, but regards as the “icing on the cake”. It needs the firm foundation of good nutrition, as well as lifestyle measures of protecting sleep, managing stress, staying active, getting daily sunlight, drinking enough water and staying connected socially, she says.
So what should the nutritional priorities be at this stage of life? In her book, Graham outlines “the meno eight”. For every category, she suggests recipes, each of which comes with a breakdown of the 16 main nutrients it contains – and no mention of calories.
Dr Louise Fitzgerald of Grafton Medical takes a special interest in women’s health and the menopause. Photograph: Nick Bradshaw
“When you take calories out of the conversation entirely and replace them with the nutrients, the calories essentially take care of themselves,” she argues. The theory is that nourishing food is naturally more filling and satisfying. “You will find that you will be able to maintain a healthy weight and/or lose weight, if that is your goal.”
Even if life might seem way too busy for much cooking, never mind tracking nutrients, being aware of food types to focus on for menopause wellbeing is a good start. Here are Graham’s eight:
1. Protein
Why: to counteract muscle loss that is accelerated not only by increasing age but also reduced oestrogen. Protein is slower to digest and dampens down the hunger hormone. McConnell stresses it should be part of every meal and any snack in between. She suggests aiming for between 1g and 1.6g of protein per kilo of bodyweight a day.
Good sources: a small chicken fillet, steak or salmon darne will provide at least 25g; suggested choices for breakfast include eggs (7g each) and Greek yogurt (10g in a 100g serving). Graham recommends increasing plant rather than animal protein; think, for instance, tofu (10g in 125g portion), quinoa, black beans, kidney beans and lentils. For a snack, combine fruit with a handful of nuts.
2. Fibre
Why: to improve gut and heart health, as well as blood-sugar regulation. It not only eases movement of food through the gut but also boosts beneficial intestinal bacteria. As oestrogen drops, lubrication in the gut dries up and the bowel is more sluggish, increasing the likelihood of constipation and bloating, says McConnell. Prolonged transit time of faecal matter “also extends exposure to various toxins, waste and cancer-causing compounds in the intestines”, says Graham. Fibre is key to lowering cholesterol, while its “filling” effect helps in weight management.
Good sources: an estimated 80 per cent of people in Ireland do not eat enough fibre, with up to 35g a day recommended. That’s the equivalent of eight apples (with the skin on) but meals should be built around a variety of high-fibre options such as whole grains, beans, nuts, seeds, other fruits and vegetables. If increasing from a low base, take it slowly.
3. Phytoestrogens
Why: these are plant compounds that mimic the effects of oestrogen and can help regulate body temperature. They also have a mild binding effect on the body’s oestrogen receptors, which “weakens the cancer-causing potential of old circulating oestrogen”, says Graham.
Good sources: soybeans, alfalfa sprouts, flaxseed (also known as linseed), nuts and wholegrains.
4. Omega-3
Why: these essential fatty acids are “good fats” and an important part of a healthy diet. Omega-3 is particularly linked with brain health; it can also reduce inflammation and reduce the risk of heart disease.
Good sources: oily fish such as salmon, mackerel and sardines; aim for two helpings a week. Also flaxseed, a “superfood” with other benefits.
5. Antioxidants
Why: to “deal with the ‘exhaust fumes’ of life: pollution, toxins, chemicals, nutritional deficiencies and even stress”, says Graham.
Good sources: this is where “eating the rainbow” comes in. Differently coloured plants have different phytochemicals, which help to protect against cancer, so choose a variety of fruit and vegetables by their colours. Other antioxidant foods include nuts, seeds, green tea and even chocolate – the higher the percentage of cocoa solids the better for flavonoids.
6. Probiotics
Why: to boost beneficial bacteria in the gut. Fermentation of foods enhances nutrient content and makes them easier to digest.
Good sources: live yogurt, sourdough bread, kombucha, apple cider vinegar and sauerkraut.
7. Calcium and magnesium
Why: these very important minerals work together to protect bones. Insufficient calcium contributes to osteoporosis and high blood pressure. Symptoms of magnesium deficiency are similar to those of the menopause, says Graham. They include muscle cramps and twitches, fatigue, anxiety and constipation.
Good sources: in addition to dairy, plant foods with beneficial levels of calcium include seaweed, leafy greens and legumes. Magnesium is found in dried seaweed and herbs, nuts, seeds and grains.
8. Brassicas
Why: eating vegetables that belong to the cruciferous family helps to reduce the severity of symptoms such as hot flushes and night sweats. A higher intake is linked to lower rates of cancers, such as those of the colon, breast and lung, as they contain compounds that can boost the effect of enzymes on counteracting carcinogens.
Good sources: cauliflower, broccoli, kale and cabbage.