Tips from an MS dietitian to navigate menopause and the impact of diet

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Jess: Hi and welcome to the MS podcast series. My name is Jess, and today I'm speaking with Julie Orr, who's an accredited dietitian here at MS Plus. And so, we're going to be speaking about perimenopause and menopause and the effect that diet has on this. So, thank you so much for being able to speak with me today, Julie.

We'll get straight into it. Is diet something that can impact on menopause?

Julie: Yes, it does impact on us during this time. However, there isn't anything particularly specific that would be a game changer. As a dietician, I promote the benefits of healthy eating, focusing on whole foods and minimizing processed foods and all the literature and evidence would support this.

Jess: We know that diet is such an important factor for many chronic health conditions and just overall wellbeing. Is there any research or thoughts on the role that diet can play in menopause or even things like the onset of menopause?

Julie: Certainly, there's some evidence that suggests that diet plays a role in the onset of menopause, and they've shown that high intakes of oily fish are associated with a delayed start of menopause, while large intakes of refined pasta and rice consumptions may lead to an earlier onset. And this was information that was gained by a study in the University of Leeds. But unfortunately, this is an area that requires more work, more additional study, like many areas of nutrition.

Jess: Yeah, okay. So, we know that lifestyle changes such as, making changes to our diet is really common for people with MS as well as, people with other health conditions. Is there any research or evidence for particular foods to be included in our diet to help manage the symptoms of menopause or be beneficial in some way?

Julie: Yeah, sure. At this point in time, a healthy diet is what we need would promote. And so, the current Australian Dietary Guidelines and the Australian Guide to Healthy Eating provide us evidence-based advice on the amounts and the kinds of foods that we need for health and wellbeing. So, the dietary patterns recommended in the Australian Guide to Healthy Eating will provide adequate nutrients for good health and also minimise the risk of developing chronic diseases.

It will also assist you during this time in your life, so perimenopause and menopause. By following the recommendations I'm hoping that you'll feel better, enjoy life, and live longer and healthier. So, we know that most Australians, we need to eat more fruits and vegetables and the current recommendations are to aim for two fruit and five serves of vegetables each day. With an aim to have brightly coloured foods and there's a new concept around eating the rainbow. Also trying to add legumes and lentils or the dried peas and beans into your way of eating. The Australian Dietary Guidelines focuses on the five food groups, so it might be a nice idea, Jess, if we just go through the five food groups.

We've just discussed the fruits and vegetables. In terms of the grain or the cereal foods, there should be a focus on enjoying those foods, but aiming for the whole grain, whole grain breads, whole grain breakfast cereals, and then using oats and rice and pasta.

Jess: That doesn't include, you know, like white bread when they say whole grain, does it?

Julie: It does, it would form part of the grains, but a better choice or a healthier choice would always be the whole grain, wholemeal versions of the bread.

When choosing dairy, look for, including adequate amounts of dairy and their recommendations or their number of serves will vary depending on the age and the sex of the person, but certainly women in the perimenopause age group, we're looking at four serves of dairy a day and that's quite a large volume of dairy and certainly we're promoting the use of low fat milks, yogurt and cheese in the dairy group.

Also, it's important to include regular intakes of your lean meats, poultry, fish, eggs, nuts, and seeds as a protein source and so we typically refer to that as the meat, chicken, and fish group and or alternatives to those if you choose a non-meat way of eating. And then where you can including water as a drink of choice.

We put all of that together in terms of a, way of eating or a diet as such is the Mediterranean diet, so we know that this is really healthy dietary pattern, and the characteristics of the Mediterranean diet would follow the Australian guide to healthy eating. So, it promotes the consumption of lots of vegetables and lots of fruit, whole grain cereals and legumes and with small amounts or reduced intake of your saturated fats and the Mediterranean way of eating would have a preference for the unsaturated or vegetable fats.

Jess: Yeah, and I think we're all becoming more aware of the Mediterranean diet. It's certainly one that is more frequently heard about through research in the news. You know, I've noticed even just in the recent year. So, it's good to know that it follows the Australian guidelines.

Julie: Yes, and I think it's just another way of saying the same sort of information.

Jess: I know that I certainly hear from talking with people with MS, and I'm sure that you do too, is people may be cutting out or restricting entire food groups. So, cutting out things like maybe say dairy or meat or, some other entire sort of food group. Is there any recommendations or views, particularly in the context of menopause of foods that should be completely avoided or limited in someone's diet?

Julie: That's the interesting part of the Australian Guide to Healthy Eating, it is not a way of eating that excludes any foods. It's looking at encouraging more of the better choices and reducing what's termed as discretionary choices. We could probably rename discretionary choices to what we would usually refer to as junk food or lollies, chocolates, those types of things.

So, the discretionary choices are something that as all Australians and particularly during the time of menopause when you're wanting to improve the way of eating, is to reduce those types of foods. So, we typically refer to those as the highly processed foods, and foods that provide low amounts of nutrition and usually lots of calories.

So, it's just some common examples there just would include most things from the bakery except for the whole grain bread. So, pie, sausage rolls or hot chips. Snack foods such as potato crisps or cakes and biscuits. Things like cakes, muffins, sweet biscuits and often muesli bars fall into that category as well. Ice creams and desserts, cream, and butter and then the highly sweetened foods such as jams and honeys and, soft drinks, cordials, energy drinks, sports drinks. And a lot of times we would put juice into those highly sweetened drink category as well. But I think what's important to think about here is that it's okay to include those foods in small amounts and so typically we would describe them as sometimes foods or trying to limit the inclusion of those.

So, a healthy eating plan is not one that excludes those exclusively. It's looking at minimising the intake of those. And I think it's good to remember that we don't have a good or a bad food. We have a good or not so good way of eating. And I think all of us at some point in time can make better choices. And so certainly promoting that idea that if you can make a better choice, then that's a good way to go. I'm sure many of our listeners will understand that as soon as you start to say, I can't have something, that's when your brain starts to think about those foods more often than you would have normally thought about them and the desire to have them. And then we start falling into the habit of saying that I don't have willpower. I'm not strong enough. It's none of those things. It's just your body wanting those foods once you say that you're not allowed to have them.

So, it's trying to keep all things in moderation and maximizing the better choices.

Jess: Yeah, that's definitely a more balanced way of looking at it. You know, instead of, I can't have this, or I shouldn't be eating that. It's just thinking about the amounts that you're consuming.

So, Julie, one food that seems to be a bit controversial is soy. So, is this something that people should avoid if they're menopausal? What's their current thoughts on soy?

Julie: You're absolutely correct, Jess. It's polarizing, isn't it? You'll find as much information about the benefits as you will of the negatives in terms of soy and hormones. I think perhaps let's go back a step and talk about what is soy? So, soy is a part of the legume family and it's found in many foods today such as edamame snacks or the soybean in its natural form, right through to soy milk and a whole range of fermented soy foods. So, some common examples there would be miso, tempeh, and soy sauce. And even more recently soy has been added into burgers as tofu burgers, soy milks, yogurts and even soy cheese.

Soy is a good food. It's really high in protein and it makes it a good alternative to meats, chicken and fish. So, it becomes a protein alternative if you are wanting to stay away from the animal products. But the research has shown a very large study was completed in 2019, and it was an umbrella type of study, so it looked at a whole range of different studies, and this particular one included 114 different studies, and looking at the outcomes of soy foods.

And during that well, I guess the outcome of that study was that there had been a beneficial link with menopausal symptoms, such as hot flushes with the inclusion of soy. And there's also been some positive benefits or links with other lifestyle type diseases such as cancer, cardiovascular disease, bone health and even some improvements with cognitive function if by including soy or soy products.

And out of this group of studies, they were only able to show a negative link with one study and that was a slightly higher risk of gastric cancer, but that was in men so not our, current cohort and from drinking lots of miso soup. So, I guess the overall is that soy is a positive and certainly when we're talking about menopause, there may be some reduction in menopausal symptoms.

And there was a more recent study Jess, a Canadian study that were the research was just released recently that combining a reduced fat vegan diet and daily soybeans was associated with a reduction in hot flushes and also some weight loss. So, there is some positive benefits around including soy.

Jess: Right. I found it interesting from that study. They were talking about finding significant weight loss and There's so much information about how weight gain during this time in a woman's life is important. Is such a common issue. What do we know from the research about weight gain during menopause and perimenopause?

Julie: Yes, weight gain is an issue. And we certainly know that from recent studies that around 1. 5 kilograms per year is usual or typical. And then by the time you've gone through perimenopause through to menopause, you may have increased your weight by around 10 kilograms. So, for most of us women that's significant.

And due to the reduction in estrogen levels, where the body accumulates that weight tends to change. So more of the weight is deposited around the abdomen area and less around the hips and thighs. So, there's not a lot of knowledge around the mechanism driving the weight gain. Certainly, it's known that many women are susceptible to weight gain during this time, but we really unclear about the reasons. And so, there's some thoughts around the hormones change and that might be part of the issue. We certainly know that it's often a time of change in women's lives and whether that has something to do with it. And we certainly know as all of us age that our muscle mass starts to decrease and any reduction in muscle mass will just slow your metabolism and then a slowed metabolism makes weight gain easier. So, during this time, you often need to be eating less calories, but still nutrient dense type of foods to counteract all of those body changes.

Jess: Yeah, it sounds like a complex process, you know, with so many factors involved, a weight gain of 10 kilos sounds like a pretty significant increase. And we know the research around, the impact of being overweight or obese on MS and its role in progression. And it's no wonder that we hear a lot about all of these different trends and things.

So, intermittent fasting, you know, where you might go certain periods of time without eating is a really popular, I guess, trend or way of eating that we hear about. Is there any sort of evidence or view on this for the management of menopause or, even say just generally its role in managing weight?

Julie: Certainly, the information is out on intermittent fasting as a lifestyle or a dietary change. Can you believe this was first introduced in 2012 by Dr. Michael Moseley and unfortunately, it's increased in its popularity with several celebrity endorsements. But we know for weight loss, some individuals will lose weight and others don't. And it doesn't seem to be any better or worse than other types of dieting or eating changes. We know that the weight loss is usually caused by a deficit in calories or just by eating less. And so, some people find the structure around eating or intermittent fasting, having the rules of when, you can and can't eat actually helps eat less and that's what's facilitating the deficit in calories and then weight loss.

At the moment, the evidence is poor, and it doesn't show us that one type of calorie restriction is any better than another form of calorie restriction. And the people who follow intermittent fasting don't seem to be able to maintain it as a lifelong lifestyle change like most other diets that people have tried. But I guess summing that up, if it works for you, you feel better, it helps you make better decisions around eating then it might be helpful for you. As a dietitian, I would prefer the normalization of eating and trying to adopt a way of eating that you can do from now until ever, and that involves regular meals and lifelong eating habits. I also prefer a way of eating that's avoids rules around eating. And I think as soon as we start introducing rules, we make it perhaps harder than it needs to be. And healthy eating needs to be a way of life and it shouldn't be hard. As soon as it's hard, it's hard to continue doing it. But interestingly, there are some newer research looking at the use of intermittent fasting as a dietary tool. And there's been some positive benefits for helping with blood pressure levels and blood fat levels, but this is still contained to research and in laboratory animals and certainly a long way to go before we could say that it's a way of treating these conditions in people.

Jess: Yeah, it does sound like it'd be quite restrictive and really hard to sort of live your life with an eating pattern that doesn't let you, eat at certain times and things like that. It's sort of opens up another door of difficulties.

Julie: Yes, yeah.

Jess: So, we were talking a little bit before about how the weight gain can change your body composition and things like that and we know that as you age, you lose muscle. So, does protein intake have a role in managing menopause, you know, perimenopause, weight gain, what sort of role does that play?

Julie: I think here that Jess what's important is that achieving adequate dietary protein is important at all stages of our life, particularly for maintaining that muscle mass. And as we were just talking about unfortunately as we age the muscle bulk decreases. And so, we do know that dietary protein is the only dietary aspect of maintaining adequate muscle bulk. And so, we're trying to preserve our muscle bulk for obvious reasons for function but also to help maintain our metabolism. And by doing so it makes it easier to keep your weight stable. As soon as you start losing your muscle bulk, not only do you start to find functional movement more difficult, but it also makes weight gain easier.

Jess: And I guess that's probably something that's especially important for people living with MS, wanting to maintain as much good function as you age as possible. So doing all the things that are going to give you the best chance of that.

Julie: Yes. And not to minimize the input of regular activity or regular exercise in that as well.

Jess: Yeah, and so it's so interesting because with menopause and perimenopause, these changes in a woman's life, they come along with a range of other health factors. So even, you know, having an impact on things like our heart health. So how does diet play a role in this.

Julie: Yeah, I was going to say lucky, but maybe lucky is the wrong choice of words. We understand that estrogen is protective against heart disease. And so, while our bodies are producing good levels of estrogen, so as we do before we go through perimenopause and menopause that is helps us minimize our risk of heart disease.

So once our body stops producing the same levels of estrogen, then our risk of heart disease increases. We know that dietary saturated fats also increase our risk of heart disease. So, it's an important time to really start thinking about the dietary fat choices that you're making and to help minimize your blood cholesterol levels and decrease your relative risk for heart disease, then further reducing the saturated fats in diet. And certainly, that links in with M S as well. There's certainly some thinking that restricting saturated fats is protective there as well. So, the saturated fats, as we know, are found in your animal fats and also the coconut oils. So, the easiest and quickest way to remove saturated fats from your diet are to just remove any of the white visible fat from your red meats to not eat the chicken skin, to choose low fat dairy products and to avoid coconut oils.

But more importantly our food industry uses saturated fat as its primary fat source. So, trying to minimize the use of processed foods, particularly processed foods that would be higher in fat.

Jess: So, Julie, what would be, I guess, a good alternative for unsaturated fat?

Julie: So, the strongest evidence or the best oils are the olive oil, extra virgin olive oil, and then any of your unsaturated fats, so your monounsaturated fats, which tend to be vegetable fats or seed fats, and polyunsaturated fats, again, are seed fats. And you'll see those words listed on the oils and margarines. And so, I look for a polyunsaturated or monounsaturated. But if we're thinking back to the Mediterranean diet, then olive oil is the oil of choice.

Jess: Yeah, absolutely. And it was interesting at the start of our discussion, we were talking about the number of serves of dairy that's recommended in the Australian guidelines. And so, thinking about menopause, is dairy a really important factor to consider? Because it has an impact on our bone health, doesn't it?

Julie: Yes, again, estrogen or the lack thereof of oestrogen increases our risk of fractures and our bone health can start to decline during that time. So, bone health in terms of dietary influences is vitamin D and dietary calcium. Dietary calcium found in our dairy products, milk, cheese, and yogurt, is the most easily absorbed calcium that we can eat.

However, if you choose a non-dairy milk, so the soy, oat, almond varieties, please look for a calcium enriched option. Not all of the milk alternatives are fortified with calcium because they're not naturally high in calcium like a dairy milk, so it needs to be a choice that will have added calcium in it.

Jess: So, is there anything else that sort of has an impact on our bone health, you know, particularly with perimenopause, menopause?

Julie: yeah, interestingly, Jess, there's been some thinking that a high salt diet has been linked with a lower bone density and so if your bones aren't as dense or as strong, then you're certainly more at risk of poor bone health or osteoporosis. And so, the best way to reduce the salt is to avoid adding salt when you're doing the cooking and also always taste your food. If you, one of the people that add salt to the table, then taste it prior to adding the salt, so you're not just automatically adding salt to the table. And also, now it's very easy to choose a whole range of low salt food versions. And most of the common high salt foods, like many of our commercial sauces or foods like that will have a low salt option. And I think the best way to reduce the salt intake is to choose non processed foods. Unfortunately, all processed foods are high in dietary salts.

So, I feel like we just keep going back to more fruit more vegetables and your whole grain breads and cereals because they're the lowest processed, the best choices for us. And then also the whole meats and meat alternatives rather than the processed version of those foods.

Jess: Yeah, we are sort of circling back to those guidelines, but it's good to actually hear the reasoning behind it. It's good to know that our guidelines are just so evidence based and promote good health for everyone really.

So, we know that with menopause, perimenopauses just these alone, you know, excluding MS, come with a whole host of symptoms and things that we stereotypically know are associated with menopause. When you say the word menopause, I think of hot flushes and seeing the woman, you know, sitting there in front of their fans, just absolutely melting down. So, thinking about symptoms like hot flushes, which are, seem to be so prevalent for any woman going through menopause, are there any sorts of nutritional changes or foods that can really help relieve any of these symptoms?

Julie: Again, this is one that will be beneficial for some and not beneficial for others. There is some evidence that foods rich in phytoestrogens will help reduce hot flushes but not enough to promote that as a way of eating. Still the focuses is just on eating well for overall health. But if we think about the phytoestrogens as a group, then they're found in the highest concentrations in flaxseed followed by the soybean and tofu, but also in your fruits, particularly dried fruits, and vegetables, especially the green leafy vegetables, and then again, the benefits of legumes and lentils, and there's some phytoestrogens in tea. But if we think about that in context of eating again your fruits and vegetables and a plus for the soy there is as particular useful inclusions in your way of eating.

Jess: Right. Okay. So, I guess little bit in reverse, what's the research sort of say around foods that might actually worsen symptoms like hot flashes.

Julie: I think certainly individuals will be able to tell you that's caffeine, alcohol and spices is something that they've identified as being a contributor to hot flushes and the British Menopause Society will specifically mention those. The research is not strong, as is there's some benefit of having fruits and vegetables will again minimise the symptoms of hot flushes. But I think the most important thing here Jess, is to think about how these foods may or may not impact on you. And if they are, if it's something like caffeine. We can absolutely exclude that from our way of eating and not have any negative consequence. Again, would be true with alcohol. So, if there's something that interfere or worsen the symptoms, then they're, foods that can be avoided without any negative consequence.

I think when we start restricting foods in a diet, then potentially run ourselves into a risk of minimizing a whole group of nutrients is important. So, it's not something you would ever look to encourage avoiding whole food groups but individual types of foods, if they have a link, then it's certainly okay to be avoiding those.

Jess: Okay. And so, I guess if you had maybe like a top tip or advice to help someone who's listening and thinking, you know, how can I put all of this into practice for myself? Like what's the best way to take control over your eating and maybe getting it back to more in line with the guidelines that are recommended for every person and putting it into practice. How can people go about that?

Julie: I think the thing that I've found mostly by working with people is to restore structure around eating. So, re-implement a regular breakfast, lunch, and dinner, if you're not already doing so, and looking at having a morning tea, afternoon tea and supper. And by planning those meal types, then you plan better choices. And then so I always think it's good to get the structure right and then looking at improving the choices. So, if you're someone that doesn't eat breakfast then it's important to start having a regular breakfast and then you can look to have a whole grain breakfast cereal or have some low-fat yogurt with some fruit and grains or nuts on that. So, it's hard to go straight to that if you're not a person that eats breakfast. So, I think the meal structure is important and then looking at the choices that you're making. But hopefully through this whole time that we've been speaking Jess, reiterating the importance of whole foods, lots of fruits and vegetables and anywhere that you can increase those. Changing from lower fibre or lower grain cereals to higher fibre, higher grain cereals is another way. And then just making sure that you're choosing adequate protein rich foods and choosing adequate calcium, whether that's via dairy option or a non-dairy option that's fortified with calcium.

Jess: Absolutely. It's been really good to chat with you, Julie, about all of these things and sort of go through a bit of almost myths and misconceptions around menopause and diet and other sort of topical things. So, thank you so much.

It's been really helpful. If people wanted a bit of support and maybe feel that they can't do this by themselves or need a bit of guidance. How do people get support with managing their diet?

Julie: Certainly, I'd encourage everyone to access the services of a dietitian with a trained health professionals in terms of talking about healthy ways of eating. I'm certainly available here at MS Plus and I'm based in Blackburn and available for individual consults or if you're not from Melbourne, certainly you can access the dietician service myself included by telehealth and that's an option for you as well.

There's also a lot of good information around on the internet and certainly I've referred back to the Australian Dietary Guidelines a lot during this session. And certainly, there's a whole website, Eat for Health, that's available with good information. And also, I really like the Thinking Nutrition podcasts that are presented by Dr. Tim Crow, and you can certainly access those from all good podcasts avenues. But certainly, I guess my number one promotion here would be to find your own dietitian and to have a discussion around your own eating and then individualised recommendations that you might like to implement.

Jess: Absolutely. Thank you so much, Julie. And I guess, in wrapping it all up back to people who are, you know, women who are going through menopause, perimenopause, or even approaching this stage in their life, what would your final take be on the impact of nutrition, particularly on menopause and perimenopause.

Julie: I guess the impact is similar to all stages of our life, nutrition is important. The focus shifts slightly, but the underlying message of adequate fruits, vegetables, whole grain cereals good protein, choosing good fats, and then coupling that with levels of exercise that you're able to maintain or activity that you're able to maintain is the best recommendation.

Jess: Thank you so much for that Julie, it's been such a pleasure speaking with you today.

Julie: Thanks, Jess.

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