Nutrition Essentials: Can Adjusting Your Diet Ease Menopause Symptoms? with Lynn Pattimakiel

Podcast Transcript

John Horton:

Hello and welcome to another episode of Nutrition Essentials, a spinoff of our Popular Health Essentials podcast. I'm John Horton, your host. Menopause is a natural stage of life, but being natural doesn't mean it comes easily. The hormonal changes that occur can bring intense symptoms. The body you've known for years may suddenly feel a bit unfamiliar. Adjusting your diet during this time may ease the transition and help your body adjust to new and different hormone levels. So today we're going to take a closer look at how what you eat can make a difference during menopause. As always, we have registered dietitian, Julia Zumpano with us to talk about the issue from the nutrition aspect. To learn more about menopause, we brought in an expert from Cleveland Clinic's Center for Specialized Women's Health. Julia, can you introduce our guest?

Julia Zumpano:

You bet, John. We're joined today by Dr. Lynn Pattimakiel, a certified menopause practitioner. As a part of her caregiving process, she helps women find the right balance between their nutritional needs and changing bodies during the menopause years. This is such an important topic that often isn't discussed. I'm looking forward to talking with Dr. Pattimakiel about how to help women find answers to their menopause questions.

John Horton:

Answers are always our goal, Julia. So let's get the conversation started. Welcome to the Nutrition Essentials podcast, Dr. Pattimakiel. Thanks for joining us to chat about how diet can play an important role as someone who works through the challenges of menopause.

Dr.  Lynn Pattimakiel:

Thank you both. It's great to be here.

John Horton:

So Dr. Pattimakiel, I've hosted a hundred plus podcasts since settling into this chair more than two years ago, and I don't think I've ever been more anxious about a topic coming into one of these. Menopause is just a sensitive issue and it doesn't feel like something that's openly talked about very often.

Dr.  Lynn Pattimakiel:

I think you're right, and as you said, menopause is a natural part of life that every woman is going to go through, but still there's some stigma that's associated with talking about it. And I think when we think about it may be due to the stigma with just natural aging, which is often frowned upon in our society. Often, I think being considered hormonal or going through the change has a lot of negative connotation associated with it. So women don't want to feel like they're being thought that they're not able to make rational decisions, more emotional, because that leads to a lot of, I think, discrimination against them and especially even in the workplace. And then again, there's a lot of misinformation that's out there, which unfortunately is from social media sources and unfortunately even from some other healthcare providers, which makes women fearful in seeking therapy. So I think that's a big challenge. And then of course, women are always the last ones to put their healthcare first because they're always so busy taking care of everybody else. So I think that's another factor that makes women kind of apprehensive about seeking care.

John Horton:

And you had mentioned the misinformation and just how it's not talked about. So today we're going to break through that and it seems like if we're going to get more comfortable talking about menopause, it would probably help to fully understand what is taking place within the body during this time. Yeah, I was really surprised when I started looking at this. I found a study that showed that 80% of women under the age of 40 had none or limited information on menopause. And I'm guessing awareness would be even less among guys. So Dr. Pattimakiel, can you give us a quick lesson, sort of a Menopause 101 to get things started?

Dr.  Lynn Pattimakiel:

Absolutely. So the average age in menopause is about age 51, but some women can go as early as early forties to as late as late fifties. During this time, again, there's also can be hormonal fluctuations that occur even before menopause occurs. The definition of menopause is technically one year without a menstrual period. So without another pathological cause. In the pre menopause or menopause transition, there can be a lot of hormonal fluctuations that occur, where women can start to see shortening of their cycle, skipping of months. Some women can go even heavier cycles and more frequent, but those do need to be investigated, because we want to make sure there's no other underlying pathological cause. And then unfortunately during this time women can also start to suffer from symptoms and everyone's different. So the severity may vary between each woman, but they could be complaining of hot flashes, night sweats, brain fog, mood, memory, concentration issues, unfortunately weight gain and other physiological symptoms such as vaginal dryness, decreased libido and painful intercourse.

John Horton:

And since you brought up weight gain, and I know metabolism and weight gain seem to be tied together here, and that always seems to be one of the more distressing aspects of menopause for many women, I imagine seeing numbers on the scale just inexplicably going up can be incredibly frustrating during this time.

Dr.  Lynn Pattimakiel:

Absolutely. And women express this frustration to me all the time that despite no change in their activity level, no change in their diet, they start to see around this timeframe a gradual increase in their weight. There are estrogen receptors all throughout the body and we know that estrogen is actually a very important regulator of adipogenesis. The decline in estrogen during this time can affect white adipose tissue distribution and fat accumulation as well. So the reported average weight gain around the menopause transition, menopause is approximately five pounds.

But with the women that we see that come to the office, we see a much higher weight gain around this time and that could also be due to compounding factors that also occur during this time of life. So things like, again, these hot flashes, night sweats, that are really disrupting their sleep, causes sleep deprivation. Unfortunately weight gain that's associated can put them at higher risk of obstructive sleep apnea, which is another medical condition that can increase cortisol levels and make it more challenging to get the weight down. So we need absolutely sleep that's essential to keep the weight down.

Another thing is that they have all these time constraints because they're caregivers, they're sometimes now caring for their elderly parents as well as their children. Other changes of life that occur, like they're empty nesters, they're trying to figure out that new schedule, where they're either carting their kids around to activities, they don't have time for themselves. This leads to unfortunately a lot of convenience types of foods during that time period. And also a decreased time for activity, which is so essential in maintaining the weight. Other things that occur during this time period as unfortunately women over the age of 60 are at higher risk of developing thyroid disease. So again, other metabolic conditions can contribute or add to weight gain during this time period.

John Horton:

That is just a lot all going on in one kind of small part of life. Julia, I'm pretty sure in your office you also see a lot of this and hear a lot of these concerns?

Julia Zumpano:

Absolutely. I do see the same as what Dr. Pattimakiel explained. We see weight gain without ... You know, minimal dietary or lifestyle changes and that can be very frustrating to a woman. We also see the distribution of weight being varied and different, so weight being more carried around the midsection, the abdominal weight gain. So definitely going from more of a pear shape to an apple shape, which we know can be more risky from a health perspective, that increased adipose tissue around the middle. So it can be very frustrating and difficult. And again, I would agree with Dr. Pattimakiel, the average may be five pounds of weight gain, but we tend to see a lot higher of a weight gain and more significant body changes that can certainly lead to being frustrated.

And also challenges when it comes to exercise. If you're gaining weight in different areas, it's not as easy to move as it was before. If you're not sleeping as Dr. Pattimakiel mentioned, you are less up to exercise, you're more likely to grab those convenience foods, reach for more caffeine, more sugar-laden foods to keep your energy level up. So it's a big picture that all interplays together. I think it's key to provide education. Again, a lot of women are not educated properly on what's happening to their bodies and how to best manage their diet and lifestyle to prevent or minimize some of the symptoms around menopause.

John Horton:

Now, everything you guys just mentioned, I can see where it would be incredibly frustrating. I mean, here you've lived all these years and all of a sudden you just start putting on pounds without changing your diet, you're still exercising maybe the same amount, this is just happening because of what's going on during this period. So from a dietary point of view, what are your options when this sort of weight gain happens? Given the hormonal changes that are taking place, I imagine it's just not as simple as cutting way back on calories.

Julia Zumpano:

No, unfortunately not. And we don't want to create more deprivation in this time of life either. So no one likes to feel deprived. It's really looking at the quality of calories where you're getting your calories from. The timing of your meals are essential. The foundation of your meals, are they balanced? Do they have proper amounts of macronutrients, meaning carbohydrates, proteins and fats? Are you spacing your meals appropriately? And then we look at other factors too, like caffeine intake and water intake. All of those simple things can be manipulated to help better serve the negative outcomes of menopause when it comes to the way your body's shaped and energy level. So it really can be ... You can make huge improvements with nutrition.

John Horton:

Dr. Pattimakiel, I know when we talked ahead of time, you had mentioned you have a whole list of things that you ask women when they first come in with this to try to figure out maybe what's going on with their eating habits and where some changes might be able to take place.

Dr.  Lynn Pattimakiel:

I try to look for areas we could target that might make it easier for them. The biggest culprits that can contribute to the weight gain, a lot of this can be associated with that time of night of eating. So the later they eat, the harder it is for them to burn the calories. And again, with this time constraints or long work days and carting the kids around, often there's meals they can tell that they're getting these calories in at 9 o'clock or 10 o'clock at night. So trying to get that earlier meal in could be very helpful. We also talk about intermittent fasting, so it doesn't work for everybody, but it is a principle that we have seen success with. Where patients we're asking them to try to get their healthy calories in, so they're not starving, they're getting their calories in, but within an 8 hour window.

And that, it's also important with the type of food that Julia discussed, we really want it from that lean proteins, the non-starchy vegetables and the fruit in moderation. Because another big culprit is those starchy carbs and they creep in everywhere. I say they're the four big Cs, the bread, the pasta, potatoes and rice. But we tend to use them because they're comfort foods. They're very convenient because again, they're sandwiches, it's on-the-go type of food. They're sometimes more cost-effective because they can do things like that bulk. And then also the cultural, like for me, my family is Indian in origin and we eat rice. So my mom thought I was crazy when I said that I'm going to try to cut back on the rice, pasta. All of these things tend to be like, it could be definitely ingrained in our diet. So it's very difficult.

John Horton:

What's hard is it seems like those are all things we're conditioned to eat regularly. I mean, they've been part of your life the entire time.

Julia Zumpano:

Great point about the simple carbohydrates and the nighttime eating. I think fasting, specifically that time restricted eating, is a great way to put structure into your eating habits. So I think it's a lot of the structured timing of your meals. I always say when you're eating after dinner you're usually not hungry. It's habitual. You're feeding to feed an emotion versus a hunger. So I think it's really key to try to get in all those high quality calories in the middle of the day and in that 8 hour window where you can kind of pack in all that nutrition. Your mind needs that food to focus, needs those calories for energy. So that is really key. And then as the evening goes along, we are less and less feeding our body nutrition but really feeding our emotion. So that's when some of those unhealthy snacks come into play. So I think that is a great tactic, is the time restricted eating.

Dr.  Lynn Pattimakiel:

And I agree with you too, Julia, that another thing I hear my patients tell me is that they're starving all day. They're starving because they're busy, they're not able to get the food in and then when it's time to eat then they go kind of very ... Like they indulge, because they've been starving the whole day. So I think your point of getting that consistent calorie intake and especially the higher proteins throughout the day, helps them to feel more satisfied and then they're not gorging at nighttime.

Julia Zumpano:

I see underfeeding a lot throughout the day too. I see that very common with women. They may be grabbing a protein bar, a banana or an apple and they're way underfeeding and then when it comes to dinner, they're eating at dinner but then they're hunger catches up with them. So it is really important to fuel throughout your active hours of the day.

John Horton:

And you had mentioned the 8 hour window, so a lot of the success that you see with that is that, I take it you start eating ... Maybe you hold off and having breakfast til about 9:00 or 10:00 AM and then you make sure you wrap up with dinner at 5:00 or 6:00?

Julia Zumpano:

I think you can adjust it based on your lifestyle. My general recommendation is not eating three hours before bed, so you can time it that way too. Everyone goes to bed at a different time. So that's where I start. I usually ask people, "What time do you lay down to go to bed?" So we'll usually subtract three hours from there and have that be the cutoff and then create that 16 hour fast from there. I also take a detailed diet history and I ask the times of their meals, so that also helps me gauge if they're saying, "Well, we always eat dinner around 8:00, 8:30, my husband doesn't get home til 7:00." So I would adjust for someone that may be their lifestyle, but I may make dinner more of a lighter meal, lunch a bit of a heavier meal and then still push the first meal a little later. So there's a lot of adjustment that can be made with time restricted eating. That's actually why I love that form of intermittent fasting is because it can be very flexible.

John Horton:

We've mentioned intermittent fasting a few times. What is it about doing this that just makes it so effective for controlling weight gain during this time?

Dr.  Lynn Pattimakiel:

I think there's multiple things that make it effective. One of the parts is that it really just holds patients accountable so that they are ensuring that they're getting their healthy calories in. They're actually tracking and then they're not grazing all throughout the day, like mindless snacking and eating. So I think that that does really have a large benefit. The other thing is that when they're truly fasting, we're thinking that their body goes into a fasting state which helps with insulin resistance and helps with their metabolic rate. So kind of boost metabolism a little bit. But they're not starving because they've hit their healthy calories within their window. And I think it gives them, again, a time of, this is your parameter, that we're done eating past that late night ... Stop that late night eating.

Julia Zumpano:

There also have been studies that show that time restricted eating, as you mentioned, can decrease insulin level but also decrease appetite. So it sounds very opposite, but fasting actually can decrease appetite because it really lowers that insulin level. It gives your body time to rest and digest. And then when you break your fast, I recommend breaking it with a high protein meal versus a carbohydrate rich meal. We want to avoid spikes in blood sugars after you've been fasting for 16 hours. I recommend really focusing on high protein, healthy fats. A little bit of carb is great, but not starting off with a carb laden meal. But really focusing on protein be the primary macronutrient in that first meal, with some fat and a little bit of carbohydrate is really key to keep that blood sugar balanced when you first do consume a meal and it will help maintain that appetite being better controlled throughout the day.

John Horton:

There's been a lot of emphasis as we've been talking this through on still maintaining a healthy diet and making sure you get enough nutrition in. I know when people start gaining weight, your instant move is to cut calories back. Why would it be dangerous, especially at this time to really restrict those calories down and where is that line where people should try to stay?

Julia Zumpano:

Well, I think it's really important when you decrease calories, you create deprivation and you also could lead to nutrition deficiencies. You could be cutting calories worth really essential nutrients that your body needs. So if cutting back calories is something you want to start doing, I usually start with cutting back calories that are not serving your body to begin with. So looking at calories from sugar or salt or snack foods or refined carbohydrates, that's where I would start cutting calories and then adding more nutrient-dense calories.

So really focusing on increasing fiber and protein and healthy fats, and that's going to create better satiety to begin with. But we don't want to lead to nutritional deficiencies and not to mention most people can survive a decreased calorie intake for maybe a week or a month, but over time that can backfire and it's not consistent, and it's hard to maintain if you're hungry. No one likes to feel hungry all day. So then we have this yo-yo effect of losing the weight and then you kind of give up because again, it wasn't a sustainable plan to begin with. And then you start to over-consume or go back to your old eating habits and regain all the weight you lost and in most times, in most cases, more. So it just doesn't lead to healthy eating habits and a healthy form of weight loss.

John Horton:

A few times here we've mentioned how this weight gain during menopause can kind of come with a shift in body shape too. I think the medical term for it that you guys have brought up is central adiposity. It was also referred to as shifting from kind of a pear to an apple shape. What's happening there that's concerning from an overall health standpoint?

Dr.  Lynn Pattimakiel:

Yes, as Julie mentioned earlier, it's that shift from that gynoid distribution, which is that pear shape and that fat is usually deposited around the hips, the thighs, the buttocks, and then it gets transitioned to more that apple shape or that android shape, which is more all cumulative around the abdomen. The danger of that is that increased deposition of fat is more a visceral type of fat, and that can be associated with higher risk of cardiovascular disease and other metabolic disorders. And we think the thought process is this lack of estrogen, there may be an increase in androgen to estrogen ratio, which kind of accumulates the fat distribution in that area. Also, that decrease in estrogen can shift the total increase in total body fat and then that visceral distribution, which again is the unhealthy fat distribution.

Julia Zumpano:

Absolutely, and I think some of the keys that we touched on here to help prevent or decrease the change in your body shape would be really where your calories come from. So really in reinforcing decreasing carbohydrate-based calories and increasing protein based calories.

Dr.  Lynn Pattimakiel:

And I think it's also a good thing to mention that we always focus on weight and pounds, but that's not the only marker of our physical health. A great example is that women, they have very skinny arms, very skinny legs, but the weight is all centralized around their abdomen, which is still again creating higher health risks. So the circumference or the inches also is very, very important and is probably something that we should be aware to monitor. So not just looking at the scale for the pounds because we don't want ... There's other things that can affect the weight, but also looking at measuring inches.

John Horton:

So from an eating point of view, when you start seeing that redistribution of weight, are there certain foods that should be limited or avoided?

Julia Zumpano:

Certainly we're starting to phase out some of those sugary foods, right? Sugar sweetened beverages, sweets, desserts, even carbohydrate based foods that are simple carbohydrate based. So things like white bread and white crackers and chips and crackers and snack foods, packaged snacks that may have a lot of added sugar or salt. Those are the first things that we try to phase out of the diet.

John Horton:

And Julia, is it important when you start doing that to do that early, during that perimenopause stage when things are just kind of starting to go?

Julia Zumpano:

Absolutely. I absolutely think that we should start this ... You know, the transition of menopause does not occur in a day, so we want to start to make these changes in the perimenopause period of time, so certainly ... And really, it's safe to do this at any time because none of those foods that I mentioned are really serving us from a nutrition perspective. Yes, they taste good ...

John Horton:

You know, if only they did, those baked goods and the pastas and everything. You want them to be good for you, but it seems like in reality they're just probably not the best thing.

Julia Zumpano:

They're not. And people will find that they don't feel very good if their diet, it consists of those because it leads to elevations in blood sugars, maybe more bloating, maybe ... You know, that central adiposity, that weight gain around the belly. Those are signs and symptoms that they're showing that ... Those symptoms, they're not feeling good on these foods. Also, the salty based snacks that are carbohydrate laden can increase blood pressure, increased fluid weight gain, make you feel more swollen. So none of those things feel good. So it's kind of an easier transition when you're recognizing and being aware of how your body reacts to cutting back on these foods, because then that can be a driving force and reinforcement for you to stay on track, that you do feel better. I think it's very important to even log your food and what you eat, but really essentially log how you feel. That is really the key, because that is what will drive change.

Dr.  Lynn Pattimakiel:

And I just wanted to take this time to highlight, I agree with everything that Julia said, but how important ... Every patient that comes to see me, I often, one of my first recommendations is to consult a nutrition therapist. Because I feel like in my talk with them, I tell them, "Don't eat this and this and this and go on your way," but I feel like to have the support from nutrition therapy is so essential to make sure that these changes are realistic. That they're realistic changes, that they don't get bored, that these are things that they can continue and they can see themselves doing for the rest of their life. Again, not a fad diet. We don't want unrealistic changes, but I do feel like people can get tired of saying, "Okay, you're not going to do this, what do I do?" So speaking with nutritionists, they have such great intuitive ideas to make this an ongoing thing that they can kind of incorporate for the rest of their lives.

Julia Zumpano:

Thank you so much for that, Dr. Pattimakiel. I really appreciate you valuing nutrition so much. I couldn't agree more. I think meeting with a registered dietitian can give you an individualized plan. And if there are some of those foods that you really want to continue to enjoy in your diet, a registered dietitian can help you figure out how to include them, how often, how much. We are not trying to deprive you of anything here. We're really trying to create better balance and provide better nutrition in the foods that you do choose, and allowing those other foods to be here and there special occasions in a controlled amount. And still seeing the positive health outcomes from dietary changes.

John Horton:

And what I love about the way that everything's been described so far, is you're not just cutting something out for no reason or just, "Oh, this is bad." It's that food starts to have a very specific effect on your body given some of the changes that have taken place. It's just you're not processing the same as what you did 10, 20 years earlier.

Julia Zumpano:

Absolutely.

John Horton:

We've talked about some of the foods that you should avoid, Julia. I know you just brought that up, the carbs, the high sugar foods, things like that. And I know one of the things that you emphasize that needs to be increased are foods that are high in protein. Why is that so important as people enter menopause?

Julia Zumpano:

Yeah, so getting that lean protein in coupled with resistance training, core strengthening exercises, is so important because as we age, we lose muscle and in menopause we might see a decline not only in bone density but also in muscle mass due to increased muscle destruction and decreased regeneration of this muscle. Our goal should really be to kind of increase that ratio of that lean body muscle mass to fat. Because that muscle to fat ratio is going to help to increase that metabolic rate and kind of help to fuel the body to keep that metabolism going. Which we often see a lot of women describe that they just feel their metabolism shuts down during this time period.

John Horton:

So with that loss of you said bone mass and muscle mass, I mean there's some things that you become more at risk for too, right?

Dr.  Lynn Pattimakiel:

Absolutely. So along with that loss of muscle mass and that loss of bone mass, it increases risk, unfortunately, of fracture, which is a whole other thing that needs to be monitored when women are in their menopausal state. Because if it's a fracture of the wrist, of course that could be unfortunate and painful, but if it's a fracture of the spine or the hip, it could lead to serious complications, even death within the first year, because of complications from that immobility, chronic pain, so many associated complications with that.

John Horton:

And then that seems to work against everything else you want too, which is the increased activity and all that. So it can just start ... It sounds like a real ...

Dr.  Lynn Pattimakiel:

A vicious cycle.

John Horton:

... downward cycle.

Dr.  Lynn Pattimakiel:

It can.

John Horton:

So if you're looking to avoid that, what's the best approach that you can take to boost protein intake?

Julia Zumpano:

So I think first and foremost, I see oftentimes women are consuming most of their protein at dinner time. I think it's really essential that we consume protein all throughout the day and spread out our protein. Protein can only be absorbed in about 20 to 30 gram increments. So you really want to try to consume multiple small servings of protein throughout the day, or regular three to four ounce portions multiple times throughout the day. So usually start including protein with each meal essentially. So really focusing on getting in anywhere from that 20 to 30, 35 grams of protein at each meal, meaning at least three times a day. Making sure that if you consume a carbohydrate as a snack or in between meals, pairing it with a source of protein that will better stabilized blood sugars. An example might be instead of just having an apple, having an apple with a little bit of almond butter or peanut butter.

And then if you are struggling getting your protein intake throughout the day, that's where, of course, meeting with a dietician can help, but also quick and easy sources of protein like protein shakes or boiled eggs or leftover chicken or turkey breast from the night before. There's a lot of easy, quick sources of protein you can include. I also think dairy is essential at this time of life. We talked about the importance of bone health and dairy also provides excellent sources of protein too. So like Greek yogurt or cottage cheese or part skim cheeses, those are great sources of protein and they're very quick and easy and convenient. So they'll give you both, they'll give you the calcium, the protein, and amongst many other vitamins and minerals that are essential for bone health.

John Horton:

So Julia, you had mentioned kind of targeting 20 grams to 30 grams of protein. For those of us who just don't ... Can't look at food and come up with those measurements, what's a good way to think about it as you're choosing items to eat?

Julia Zumpano:

Sure. So a couple examples of 20 to 30 grams of protein would look like a cup of cottage cheese, a cup to a cup and a half of Greek yogurt, a four ounce piece of chicken, turkey or fish, could be up to four eggs would give you about that much, but we want to be mindful of yolks. So usually if you're going to eat eggs every day, I recommend two whole eggs and two to three egg whites mixed together. Nuts and beans have protein as well, but it's a little bit harder to get that 20 to 30 grams from those sources alone. So generally I try to mix them and include them with other foods. So about a cup of beans will give us about 12 grams of protein and an ounce of nuts will give us between 6 to 7 grams of protein. Those are great to add to meals to help better meet that protein goal or great options for snacks because we still want snacks to contain protein.

John Horton:

And with the nuts, you're usually talking a small handful for that. I take it with the meats, the reference I always hear is it's about the size of a deck of playing cards is, I think, for beef? Does that hold for chicken and other meats too?

Julia Zumpano:

Yeah, that's about three to four ounces depending on the thickness, of course. But the palm of your hand, I always tell my patients the palm of your hand is specific to you and that's probably about what you need. I think it's an appropriate amount, thickness and palm would be a great guideline for flesh protein. So that would include things like chicken, turkey, fish, lean beef, seafood, any of those flesh meats.

John Horton:

Dr. Pattimakiel, I mean, when people come in and ask you, are there suggestions that you give out too?

Dr.  Lynn Pattimakiel:

Yeah, so again, I'm always amazed when I have my patients meet with nutritionists how they come back with their total protein goal for the day and I'm always blown away because it's much higher than what we're getting. I think that the average person gets ... They always are trying to find ... So I think that was excellent, all those examples of how to get that protein in. Because they're like, "I can't do anymore. I've maximized how much protein I can get." And then we offer the protein shakes or the protein bars. But I think a main concern when we're doing that, there's so many brands that are out there, and there's so many different things that ... They're marketed for different things. So really looking at the ingredients at these protein bars or these protein shakes, and making sure that they're just not glorified chocolate bars with protein added because ...

John Horton:

Some of them are. They do. They are like candy bars, they taste like them too.

Dr.  Lynn Pattimakiel:

They taste like them and I can see why ...

John Horton:

And you think they're good ...

Dr.  Lynn Pattimakiel:

... but we're not getting what we want. We're definitely getting excessive caloric intake. So looking for ones that are really more, I'm going to say whole ingredients, not processed, things that are going to be lower in calorie count, higher in protein just like Julia had said. And then also lower sugar and maybe increased fiber because I think that's going to also help make them feel more full and help with gut transit as well.

Julia Zumpano:

Dr. Pattimakiel, I can't agree with you more because I commonly give my patients a protein goal and they are often shocked. Generally I recommend ... The general guidelines are between 1 to 2 grams of protein per kilogram. I personally think we should shoot for a little closer to 1.5 grams of protein to 2 grams of protein per kilogram, depending on your activity level, if you're weightlifting, et cetera. That's where a dietician can really help. But if a patient focuses on just protein, most of their day will be set aside to focus on protein, and they won't even have time or calories left over to be consuming other things, because we are so under consuming protein.

It's essential. If you start off with meeting your protein needs and then sometimes I just, instead of even going to calories ... Less and less often, am I providing calorie controlled meal plans, I'm really focusing on giving them a protein goal and a fiber goal. Those are the two I focus on. So it mainly looks something like 90 grams of protein a day, 30 grams of protein per meal and shooting for 30 grams of fiber a day, 10 grams of fiber a meal. If they can try to meet those targets, they will be very full, very satisfied, and they won't even be thinking about calories because they'll be so full and satisfied and that's enough of a job to begin with.

John Horton:

Julia, you'd mentioned that the 1.5 grams per kilogram, and that's by your own weight too, right?

Julia Zumpano:

Current body weight, yes.

John Horton:

Okay. Right. And just for those who aren't into the metric system, one kilogram is about a little over 2 pounds, correct? With a lot of what you guys have talked about here as far as tracking this, it does seem like a food log would be critical. Because I don't know how anybody else goes, but I'd have a hard time just knowing how many grams of protein I had a day. Is that usually something that you recommend for people?

Julia Zumpano:

I do. I do consider a food log as a great option. I also give lists of what would be 30 grams of protein and what would be 10 grams of fiber. I also create a plan and give them resources. If logging is not for you ... Because again, it's not for everyone. Some people really don't enjoy that consistent need to log. But I do find that people who log have much greater success when it comes to weight loss. You could do an old school paper notebook log. There's apps that are great. The Cleveland Clinic diet app is a phenomenal way to get some of that logging in. There's voice logging, there's photo recognition. So there's a lot of great technical tools that you can use to make logging a lot easier and it will track all that information for you, which is ideal.

John Horton:

Let's talk about some other ways that food choices and nutrition therapy can affect issues that come with menopause, including dealing with hot flashes and night sweats.

Dr.  Lynn Pattimakiel:

Yeah, so we know that unfortunately for women who are experiencing moderate to severe hot flashes, night sweats, there are a lot of triggers they probably can identify, especially in their diet. So if targeting those and trying to eliminate, they may get a significant response. So common things, and unfortunately they're all the good things again, so I get patients very angry with me. They're suffering, I'm telling ... But spicy food is one of the things that can sometimes trigger hot flashes. Women ... With caffeine, and again, they're drinking increased caffeine because they're not sleeping.

They're having this disruptive sleep, so they're doing whatever they can to increase their ... Keep their energy levels up. But caffeine can stimulate hot flashes and night sweats as well. Alcohol, and some women enjoy a glass of wine at night. But again, trying to cut back on that because we do see it trigger hot flashes. And then even things like hot beverages, because that thermostat is so offset in our brain during this perimenopause menopause transition that even a small increase in ambient temperature, they experience it almost like a 10 degrees fold. So they experience that as well. And then other things, of course, like nicotine or smoking, those are things that can increase hot flashes and night sweats, so avoidance of that.

Julia Zumpano:

Sure, additional foods are, salty foods and sugary foods can really trigger those. So a high salt diet, again, as we mentioned, a lot of sweets, desserts and sugary beverages can also lead to some of those increased symptoms.

John Horton:

In general, is there a particular eating plan that's recommended during menopause and after? Are there foods that should definitely always be on your shopping list?

Julia Zumpano:

Absolutely. We've talked a lot about protein and calcium and fiber. So really those are the key components here. But we want to focus on more of an anti-inflammatory style of eating that really ties in everything we've discussed thus far. So really whole food sources of protein. So food firs, we always want to focus on food first and getting in our nutrients. Things like lean meats, fish, eggs, tofu, beans, Greek yogurt and cottage cheese, phenomenal sources of protein. Varying all those proteins throughout the day and throughout the week is really essential to avoid boredom and to maximize nutrient intake. Because, of course, all those foods provide many other nutrients that are serving our bodies. We want to focus on getting in enough Omega-3 fatty acids. So we would get those through fatty fish like salmon, tuna, herring, or mackerel.

They're also found in plant-based foods such as chia seeds, ground flax seeds, hemp seeds, pumpkin seeds, avocado oil are some good sources there too. I always provide unlimited amount of non-starchy vegetables, so free beyond the veggies all day long, unlimited amounts. Right? So you never have to weigh, measure, count, vegetables ever. All day, every day with every meal. And varying. Huge benefits to varying the amounts of fruits and vegetables you consume because again, you're going to maximize those phytonutrients, vitamins, minerals, fiber content, et cetera. So just simple examples here are lettuce, greens, celery, cucumbers, tomatoes, peppers, eggplant, broccoli, cabbage, cauliflower, the list goes on and on and on. So no bad vegetable. I always say there's nothing bad that comes from the ground. So we always want to consume foods that are plant-based.

John Horton:

Yeah, I take it you don't have a lot of issues with people overeating their green beans and carrots and all of that stuff.

Julia Zumpano:

No, that's usually the area that we're, of course, encouraging a greater consistent intake of. You have the fresh fruits. So fruits, I think ... You know, I get questions about fruits all the time. Well, isn't that sugar? Well, we are not concerned with natural sugars. Natural sugars are important. They actually help serve that sweet tooth that you might have. They're giving you essential vitamins and minerals, fiber. I think fruit is essential and shouldn't necessarily be avoided. If you find yourself consuming way too much fruit, we may need to put a serving size or serving goal to that.

And more importantly, pairing your fruit with sources of protein. As I mentioned before, nuts and seeds are very beneficial for an Omega-3 fatty acid, but those that aren't high in Omega-3, all those other nuts provide other phenomenal sources of nutrition. And then extra virgin olive oil has been shown to have a lot of antioxidant power, and again, gives you great anti-inflammatory benefit as well. So that's really the foundation of the diet. Now that doesn't mean that there's other foods that cannot be included in moderation, but those are the foods we want to have on our grocery list.

John Horton:

That's a pretty big list that you just gave us. I mean and it all seems like food that people enjoy and that you can really build a sustainable diet around.

Julia Zumpano:

Absolutely. And they serve ... You know, we're talking specifically about menopause, but this diet serves all ages. So a lot of women who are going through menopause are feeding their family, and their family are all different ages and stages of their life. But we know that this foundational core of foods will serve all stages of life and will help all stages of growth and nutrition support. So it's really important too to know that you're feeding your family these nutrient-dense foods as well.

John Horton:

Well, it sounds very similar to the Mediterranean diet, which we talk about all the time. It's just kind of an ideal long-term eating plan.

Julia Zumpano:

Absolutely. I mean, we know that Mediterranean diet is an anti-inflammatory diet, so certainly that's another great route to go too. And they're very, very similar.

John Horton:

So Julia, I know ahead of time when we were talking, you also wanted to get into was it phytoestrogens? What are those and how can they possibly help out?

Julia Zumpano:

Sure. So phytoestrogens are foods that mimic the form of estrogen in our body. And some food sources include soy products, ground flaxseed, peanuts, some fruits and vegetables, chickpeas. Some people have noted that their symptoms of menopause may be improved by consuming some of these phytoestrogens, but I know that the research is not extremely strong in this area. And I'll let Dr. Pattimakiel speak more from the clinical side, but you do want to talk to your healthcare provider about increasing some of these foods if you're doing it specifically for the purpose of controlling symptoms.

Dr.  Lynn Pattimakiel:

I think all the options that you mentioned are excellent because there are also added health benefits with a lot of this stuff. So trying to get, again, that increased soy. The only thing is that we would recommend, just like you said, from natural sources. And I think that if it's going to help, it's going to help. And if not, it may not help. But to try to avoid the supplementation of soy supplements because we're worried about the quality of the grade. We don't know where they're getting the material from and that could worsen ... Or put them at negative health effects otherwise. And then with the soy, there is studies that show that not everyone has the isoenzyme that actually converts the phytoestrogen that you get from these products to estrogen. So again, it may or may not be beneficial, but women can try. I think it could be very helpful and again, provide a lot of other nutritional supplement and benefit.

Julia Zumpano:

And as Dr. Patty Mackle mentioned, these foods are whole foods and if you stick to the whole food version, and you provide variety and getting other sources like the chickpeas and the peanuts, then you're adding so much more nutrition to your diet and hopefully maybe lessening some symptoms along the way.

John Horton:

Dr. Pattimakiel, I know you mentioned earlier that you view nutrition as just really a key component during this stage and in possibly dealing with some of these symptoms. But I imagine it's one of those things that also doesn't just 100% work and solve all your problems. It has to be kind of one piece of an overall puzzle as you're looking to find some answers.

Dr.  Lynn Pattimakiel:

Yes, absolutely. So again, it's that well-balanced lifestyle that we're looking for. So that nutrition is a huge key to not just menopause, but to so many chronic medical conditions that can negatively impact the way they experience these life changes. So getting that balance, again, nutrition, with that balance in activity, making sure they're getting that moderate intensity activity. Our goal is about 150 minutes per week, getting their heart rate up, breaking a sweat, not comfortably able to hold a conversation. And then focusing on that resistance training, core strengthening exercises to help prevent that muscle mass loss, to try to build as much muscle to fat ratio as we discussed. Again, getting the sleep, how important that is. It was so important in this whole picture as well. But then I think it is important also that women don't suffer, that there's a lot of other options that are out there during this menopause transition. And again, knowing that there is a lot of FDA approved, both hormonal and non-hormonal options that are out there that can be individualized and tailored for each woman depending on their needs.

John Horton:

And it sounds like one of the big keys is just to talk about it. It seems like there's so ... People, they kind of hide everything and they internalize it and don't really share a lot. It sounds like you can get a lot out of just being open about what's going on and trying to find some solutions that would work for you.

Dr.  Lynn Pattimakiel:

Yes, absolutely. Unfortunately, maybe as providers we're at fault as well because we may not ask if they're not sharing. So it's also important for providers to start asking these questions to kind of create an environment that they feel comfortable sharing these symptoms. But a lot of the time the women may not bring it up because they're apprehensive of the response. They think it's a normal natural thing that they just have to suffer through or they're worried about the potential risks of seeking treatment.

John Horton:

And it sounds like one of the key things too, as you hit this stage, it is a change that you're going to have for the rest of your life. So a lot of these dietary changes that you might make, these are things that you're going to carry onward as you age gracefully.

Dr.  Lynn Pattimakiel:

Absolutely, and that's why we want to make sure it's as realistic and sustainable as possible.

Julia Zumpano:

And I want to mention, John, these changes don't have to happen overnight, so we don't want to ... That can be very overwhelming and daunting. So gradually making these changes as soon as possible. If you are in the premenopausal range of your life, really looking at starting to make these changes now. Really, any woman in her thirties or forties should be considering making some dietary changes, adding some resistance training, getting enough sleep, getting enough calcium, getting enough protein, getting enough fluid, which we didn't talk about, is extremely essential from an overall health perspective.

But looking at small gradual changes, and if you start early and start to build upon the changes that you make, once you get to that menopause time of your life, you've already made some changes. And even if you are in that stage of your life, again, slowly building upon the changes. It doesn't have to change overnight. I usually recommend start with what food group or what you think will be the easiest for you to change. So start with the easiest food goal you can make and I help my patients set that. But setting goals and then again, consistently trying to build upon those goals. And slowly as you're focusing on improving your food choices and improving your intake of protein and fiber, then you start to take away some of those foods that aren't necessarily serving that goal.

John Horton:

Julia, you mentioned hydration, and you're right, we did not address that earlier. So can you give us a little bit as to maybe what targets should be? Is it more important to make sure you're hydrated during the stages of menopause?

Julia Zumpano:

I think in general, hydration is key. I think as women get busier and busier in their lives, they tend to forget to drink water unless it's around. And a lot of times we perceive our thirst as hunger. So I think it's important that you look at, am I consuming enough fluid? Am I getting in enough water? Am I adequately hydrated? Because that can affect, again, like I mentioned, your perception of hunger. It can affect your stooling and your bowel movements and your urination and expelling. Certain toxins come out through your urine. So I think it's very important to be hydrated. It also affects your blood pressure, so we want to really be focused on getting enough fluid throughout the day. And if you are going to incorporate some exercise, that's where it's really key to also be very mindful of getting in enough fluid, because you are going to lose more fluid through sweating.

John Horton:

So this has been just a fascinating and interesting discussion, and hopefully it will help people feel a little more open about talking about menopause and maybe how to use diet to ease the transition. Before we say our goodbyes and head our separate ways though, is there anything else you'd like to add regarding the menopause and that stage of life?

Dr.  Lynn Pattimakiel:

So again, just emphasizing that again, once you're in menopause, you are in menopause. So symptoms may start to get better for the hot flashes and night sweats, but with time there are other changes that can occur the longer you're in menopause. So that bone health still needs to be monitored, vaginal health still needs to be monitored. So even if they're having just mild symptoms of the hot flashes, night sweats, and those get better, it's still important to seek care to make sure that they're being treated appropriately.

Julia Zumpano:

I couldn't agree more. Really just shedding light on this topic that is not addressed enough. So if you are a woman struggling with any of these symptoms, whatever stage you're in, really seeking help from a healthcare provider.

John Horton:

Well, that's a great way to wrap things up. I want to thank both of you for just offering so much fabulous information, and I appreciate your time today.

Julia Zumpano:

Thanks so much, John.

Dr.  Lynn Pattimakiel:

Thank you.

John Horton:

There's no question that menopause brings changes to bodies, with many of them being uncomfortable. Adjusting your diet during this time by following the tips suggested by Dr. Pattimakiel and Julia might help ease the process and it may even leave you healthier and happier as you move forward. If you liked what you heard today, please hit the subscribe button and leave a comment to share your thoughts. Until next time, eat well.

Speaker 4:

Thank you for listening to Health Essentials, brought to you by Cleveland Clinic and Cleveland Clinic Children's. To make sure you never miss an episode, subscribe wherever you get your podcasts or visit clevelandclinic.org/HEpodcast. This podcast is for informational purposes only and is not intended to replace the advice of your own physician.