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Nutrition & Hydration - Considerations in Menopause

Let's talk about nutrition and hydration for active menopausal women. Athletic women of all ages chronically undereat. (I'm describing anyone who regularly exercises on purpose as an athlete...from those who regularly take brisk walks with their friends to those training for competition.) Some women undereat because they have body image issues but others because they don't realize how much food they need. For example, a 140-pound woman needs to eat about 2300-2500 calories on most of her training days. Surprised? In fact, most athletic women barely eat enough calories to meet their basic metabolic needs. This state of being underfed is called Low Energy Availability (LEA). After only 4 days of LEA, thyroid function and bone formation start to be disrupted. If you continue in a state of LEA, you may develop a multi-system condition known as Relative Energy Deficiency in Sport (RED-S), which is a cascade of hormone disruption that results in a serious medical condition.

So what is happening inside your body when you have LEA? Energy deficiency impairs the anterior pituitary release of gonadotropins (that is to say, the hypothalamus in your brain doesn't work right). As a result, in reproductive age women experiencing LEA, estrogen production crashes, causing functional amenorrhea (loss of menstruation) and decreased bone mass. Moreover, LEA alters other hormonal pathways, causing physiological consequences like alteration of the thyroid hormone signaling pathways, the hypothalamic-pituitary-adrenal (HPA) axis, leptin levels, carbohydrate metabolism, the growth hormone/insulin-like growth factor-1 axis, and sympathetic/parasympathetic tone. Or stated more succinctly, it messes up your entire body. Women with LEA experience GI distress and often weight gain (despite their restricted food intake). Their blood lipids, particularly LDLs, and cholesterol levels increase, which can cause cardiovascular issues. Stress-independent over-activity in the HPA axis (increased circulating cortisol), when prolonged, also may increase the risk for cardiovascular disease. Underfed female athletes also develop vascular intolerance, which affects the body's cooling system, the ability of muscles to receive blood quickly during exercise, and can lead to high blood pressure.

Ever wondered why your training plateaus or even decreases despite putting in more training? Did you also have no menstrual period, stress fractures, always seem to have a head cold, reduced coordination, hangriness, and/or GI issues? You almost certainly were experiencing the consequences of LEA and depending on the number and severity of your symptoms, you may have had RED-S. The most tell-tale sign of RED-S for reproductive age women is irregular or no menstrual periods. Unfortunately, women taking hormonal birth control or who are peri-menopausal can miss this symptom since hormonal birth control causes a withdrawal bleed regardless of underlying hormone levels, and peri-menopausal women can attribute the disruption to menopause instead. And, of course, menopausal women don't have this symptom as an early warning since they no longer have periods. Stress reactions and fractures are much more common in female athletes with LEA because bone health is negatively affected. LEA lowers immunity, worsens coordination, and produces chronic hangriness. Gut distress is also typical - LEA can cause IBS symptoms, bloating, gassiness, and nausea. Women in a state of LEA also experience more depression and anxiety.

As menopausal athletic women, LEA is compounded (and masked) by other physiological changes happening in our bodies. As we have discussed in earlier blog posts, the reduction of estrogen in menopausal women affects the muscle breakdown/protein synthesis balance, which causes the body to use muscle protein as fuel. According to studies, this situation is worsened because menopausal women chronically undereat protein - typically only 75% of the RDA for sedentary women. At the same time, menopausal women use less fat for energy which leads to a greater reliance on carbohydrate stores and increased fat storage, but the menopausal body also has an impaired ability to utilize carbohydrates. With less estrogen, menopausal women also have difficulty managing cortisol, which results in increased fat storage, mostly around the midsection and upper back.

Many menopausal women respond to their increased fat storage by dieting. You can see the problem, right? An already underfed menopausal woman restricting her calories even further will cause even more fat storage and make everything worse. Menopausal women also are more hungry - it's not in your head. Lack of estrogen disrupts release of the protein kisspeptin, whose job it is to blunt appetite. Low estrogen also results in increased sensitivity of your body to the hunger hormone (ghrelin) and reduces production of the protein leptin, resulting in a feeling of hunger. To make matters worse, menopausal women often suffer from sleep disruption which compounds the increased ghrelin and lower leptin. Other menopause symptoms overlap many of the symptoms of LEA (increased fractures, depression & anxiety, diabetes, cardiovascular issues, reduced vascular response), which makes diagnosis difficult, in part because few women report to their doctor that they undereat since they either don't know it or, if they have an eating disorder, hide it.

That all sounds bad, but the good news is that you can counteract some of the impact by eating the required amount and types of food that will work for your menopausal body. We discussed carbohydrates and proteins in previous blog posts. If you like math and measuring your food, Dr. Stacy Sims, author of Next Level, recommends 2-3.5 grams of carbohydrate/kg of body weight/day and 2.2-2.4 grams of protein/kg of body weight/day for menopausal women (e.g., a 140 lb. woman should eat approximately 1250 calories each of carbs and protein per day). I confess that I am too busy (and lazy) to measure my food or count calories so here's the shortcut: eat 3 meals a day, and at each meal fill 1/2 of your plate with fruits and vegetables,1/4 of the plate with lean protein (salmon, chicken, shrimp, turkey, peanuts, cheese, eggs, cottage cheese, scallops, Greek yogurt, almonds, sunflower seeds, walnuts, cream cheese), and 1/4 of the plate with whole grain foods (brown rice, black rice, quinoa, sprouted grain bread, bean-based pasta). I talked more about portion size here. You also should eat before, during, and after exercise. Snacks before and after a workout should include carbohydrates and proteins (e.g., banana w/ peanut butter, whole grain toast & nut butter, veggies with quinoa, boiled eggs, whole wheat crackers with tuna, Greek yogurt with granola, toast with eggs, salmon with brown rice, veggie & hummus pita, grilled chicken salad). The timing of the after-exercise snack is crucial since studies show that menopausal women only have 20-30 minutes once a workout ends to best use calories for building muscle. During exercise lasting more than 1 hour, experts say that you should consume 1 cal/hr/body weight if you are doing a high impact sport like running or 1.5 cal/hr/body weight if your exercise is lower impact like cycling. (e.g., a 140 lb. woman needs 140 calories/hour for high impact activities and 210 calories/hour for low impact activities.) Menopausal women are less efficient at processing carbohydrates so realize that if you eat a sizable portion of a simple carbohydrate like a bagel or pasta as your snack, your blood-sugar levels will skyrocket and then crash in a much more dramatic way than when you were younger. If possible, choose real food (like rice cakes or date balls – check out Scratch Labs for recipes) over processed ones (like energy gels and chews.) Be particularly careful with the sugar fructose since studies show that menopausal women can't digest it well. During exercise, you should avoid any product that contains any version of the word fructose (e.g. high-fructose corn syrup), honey, agave syrup, invert sugar, maple-flavored syrup (but maple syrup is ok), molasses, palm or coconut sugar, sorbitol, reconstituted (or concentrated) fruit juice, or sorghum. Interestingly, fructose in fruit does digest well for menopausal women so eat all the fruit that you want.

Since we are talking about eating, we should say a few words about hydration. Water absorbs into your blood through your gut (mostly your small intestines). The transport system works via osmosis, which basically is when water molecules travel from a place with low concentration to a place with high concentration. Therefore, if your blood is more concentrated than the fluid you drink, your small intestines will allow the water into your bloodstream, hydrating you. But if you ingest a fluid with a higher concentration than your blood, water will travel from the blood into the intestines, dehydrating you and possibly causing stomach upset. The transport system works best if water has a small amount of sugar and some salt in the right amounts such that the concentration is less than that of your blood. The sugar also acts as a co-transporter to help the sodium from the salt to enter the blood. (Read more about absorption here.) Most commercially available sports drinks have too much sugar and cause water from the blood to move into the gut to dilute the sugars. Stated plainly, many sports drinks dehydrate you. Plain water leaves the gut better than sports drinks but more slowly than if it had some (but not too much) sugar and salt in it. So, what's the right amount? According to Sims, you should add approximately 4 teaspoons of maple syrup and 1/8 teaspoon of salt to 16 oz. of water to encourage absorption of the water into your blood. A word about artificial sweeteners - ok, three words - don't use them. Artificial sweeteners pull water into the intestines from the blood and can cause dehydration and possibly diarrhea. Sucralose is particularly problematic because the body perceives it as sweet, so it releases insulin in response, which signals glucose release, which causes more insulin release, and so on. No one wants their blood glucose rising and crashing over and over while trying to exercise. As if that's not bad enough, long term use of sucralose can lead to insulin resistance which can cause diabetes.

One study looked at sweat rates of women of different ages. The menopausal women sweated the least, were least thirsty, and most overheated. Menopausal women tend to have a higher core temperature than younger women, and it can make it harder for them to perform in the heat. Without sweating for cooling and thirst to encourage drinking, it's no wonder menopausal women have difficulty with athletic performance, particularly in hot conditions. Some studies show that menopause hormone therapy (MHT) can increase the ability of the body to retain body water. Whether on MHT or not, menopausal women should aim to drink 0.12 oz/lb. of body weight (e.g., a 140 lbs. woman needs 17 oz/hr), ideally spread out in 10-15 minute intervals. If temperatures are above 75 degrees, you should increase your fluid intake to 0.16 oz/lb. of body weight (e.g., a 140 lbs. woman needs 22.4 oz/hr) Set your watch alarm and drink whether you think you need to or not - given all of the disruptions of menopause, you need to drink enough even more than when you were younger.

In summary, it is far too common for athletic women to undereat. Unfortunately, LEA results in decreased performance and numerous problematic symptoms that can turn into a serious medical condition, RED-S, if not addressed. Menopause masks some of LEA's symptoms and compounds the problems of LEA. It is critical that athletic menopausal women prioritize eating and hydrating at levels high enough to support their physiological needs. See your doctor if you feel that you may be experiencing issues associated with LEA. She can determine the underlying cause(s) of your symptoms and suggest treatments. If you have additional questions about nutrition, your doctor can refer you to a registered dietician to help design a plan specific to you and your needs.

Disclaimer - Information on this website is provided for informational purposes only. The information is a result of years of practical experience and formal training by the author. This information is not intended as a substitute for the advice provided by your physician or other healthcare professional or any information contained in any product label or packaging. Do not use the information on this website for diagnosing or treating a health problem or disease, or prescribing medication, or other treatment. Always speak with your physician or other health care professional before taking any medication or nutritional, herbal, or homeopathic supplement, or using any treatment for a health problem. If you have or suspect that you have a medical problem, contact your healthcare provider promptly. Do not disregard professional medical advice or delay in seeking professional advice because of something you have read on this website. Information provided on this website and the use of any products or services mentioned on this website by you do not create a doctor-patient relationship between you and any of the physicians affiliated with this website. Information and statements regarding dietary supplements have not been evaluated by the Food and Drug Administration and are not intended to diagnose, treat, cure, or prevent any disease.

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Christy Lippert
Christy Lippert

Very thorough and interesting info. Thanks!

Dr. Rochelle Bernstein
Dr. Rochelle Bernstein

Thanks for the feedback. I'm glad it was helpful. Please let us know if there is a specific topic you'd like for us to discuss. -RB

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