Promoting a heart healthy diet during menopause

Reference: March-April 2024 | Issue 2 | Vol 17 | Page 21

“My cholesterol was totally normal until I hit menopause. I couldn’t tolerate statin medication nor did I really want to go on it, so with a few changes to my diet and lifestyle this seems to be helping.”
Katherine, aged 57

Heart health issues have generally been believed to have more impact on men than women. This is true, up to a point, but from the age of 40, a woman’s risk of heart disease and stroke increases as she moves into menopause. After the age of 50, women are seven times more likely to die from heart disease than breast cancer. The silver lining is that many cardiovascular issues take time to develop and are often preventable and manageable. Women need to focus on the diet and lifestyle factors that influence cardiovascular and hormonal health, and ideally embed these factors before and during peri-menopause, as well as after menopause. This sooner it is started, the better.

What cardiovascular changes occur during menopause?

Although menopause does not directly cause cardiovascular conditions, it raises the risk for developing them. Higher oestrogen levels prior to menopause may explain the increased risk, as oestrogen and other sex hormones regulate fundamental cardiovascular functions.¹ Although the risk of cardiovascular disease (CVD) increases with ageing, it has been demonstrated that hormone replacement therapy (HRT) provides protective effects against coronary artery calcification.² While the exact role that oestrogen plays is unclear, it is thought the hormone helps by promoting greater blood vessel flexibility, and discouraging plaque formation and inflammation in the arteries. Of course, oestrogen levels don’t instantly plummet once women enter menopause, this is why we need to look back at peri-menopause, when fluctuating hormone levels may initiate the onset of cardiac issues, at a time when heart health is not a central concern for women. Figure 1 outlines the effects of oestrogen on the cardiovascular system.

Factors increasing the risk of heart disease

While inflammation is a hot topic, it is not always associated with heart health. Chronic inflammation, the type that persists for months or years, can irritate the blood vessels, possibly promoting the growth of plaque, loosening existing plaque, and triggering blood clots that may cause a myocardial infarction (MI). Oestrogen exerts anti-inflammatory effects, leading to a protective effect on blood vessels.³

Visceral fat, or belly fat as it is sometimes known, is the fat surrounding many vital internal organs. An excess of visceral fat is linked to high cholesterol, elevated blood pressure, and type 2 diabetes, which are all well-established risk factors for heart disease. Women who carry weight around their middle have a greater chance of having an MI than women who are just heavier overall.⁴ A waist circumference of 76.2cm (30in) or more is associated with a more than two-fold higher risk of coronary heart disease⁵ and, on average, women gain 1.7 per cent fat mass per year during the menopause transition.⁶ Falling oestrogen levels have also been associated with the loss of lean body mass.

Diabetes and pre-diabetes are a major risk factor for CVD. Prolonged elevation of blood glucose levels is harmful to blood vessels and the nerves that innervate the heart. Oestrogen appears to contribute to glucose homeostasis through increased glucose transport into the cell, so a lack of oestrogen has been associated with a progressive decrease in glucose-stimulated insulin secretion and insulin sensitivity, as well as an increase in insulin resistance.⁷ Fortunately, the strategies to control diabetes are also positive for heart health.

Hypertension is an issue for many women in the menopausal or postmenopausal years, and plays a significant role in the development of coronary heart disease, chronic heart failure, and stroke in older women.⁸ The extra force created by high blood pressure may inflict damage on vessel walls that encourage plaque build-up and further narrowing of the arteries. Also, sodium sensitivity increases during the menopausal transition, frequently leading to intermittent fluid retention (oedema of the legs, hands, and lower eyelids), further contributing to higher cardiovascular risks.⁹

Lipid profile changes occur during the menopause transition, with a 10-to-15 per cent higher low-density lipoprotein (LDL) cholesterol and triglyceride levels, and slightly lower high-density lipoprotein (HDL) cholesterol levels.¹⁰ These changes begin during the peri-menopausal period.

What can women do from a dietary point of view?

Diet and lifestyle modifications can play a major role in reducing the risk for CVD; however, many healthcare professionals assume that women know what a healthy diet and lifestyle is. As dietitians, nurses, and clinicians, encouraging women to focus on what they can add to their diets to make it more heart healthy, rather than thinking they need to be on a restrictive diet, is a primary goal of care. The fact that women are bombarded with poor scientific evidence and celebrity anecdotal misinformation should also be considered.

One of the most important things for general practice nurses and other clinicians to focus on when managing this patient group is the promotion of a consistent, healthy, dietary pattern — one in line with the Mediterranean style of eating which contains: Protein sources, mainly from plants, nuts, fish, or alternative sources of omega-3 fatty acids; fat, mostly from unsaturated plant sources; carbohydrates, primarily from whole grains; at least five-to-seven servings of fruits and vegetables per day; and moderate dairy consumption.¹¹ Figure 2 provides an overview of the main characteristics of a heart healthy diet.¹¹

The scientific evidence is high, in particular, for increasing certain specific nutrients in the diet.

Omega-3 fatty acids are polyunsaturated fats that are beneficial for heart health. Eicosapentaenoic acid (EPA), docosahexaenoic acids (DHA), and alpha-linolenic acid (ALA) are the three main omega-3 fats. As a group, omega-3s have been shown to lower blood triglyceride levels, slow the growth of plaque in arteries, and have a slight effect on lowering blood pressure. EPA and DHA are found mainly in oily fish, and should be consumed once or twice per week. ALA needs to be converted to EPA and DHA, but this happens at very slow rates, which means ALA food sources like flaxseed, olive oil, walnuts, and avocado need to be consumed daily. Women who completely avoid these food sources or have raised triglyceride levels may benefit from omega-3 supplements with 200-to-500mg a day of combined EPA and DHA.¹²

The importance of fibre

Fibre plays a major role in protecting against CVD, as well as contributing to gut and general health, and there are two types of fibre that support heart health in different ways.¹³ Soluble fibre dissolves in water and binds with LDL cholesterol to help excrete it, and it also contributes to blood glucose regulation. Foods rich in soluble fibre include oats, flaxseed, chia seed, beans, and pulses (400g a week), root vegetables, and fruits like the inner part of apples, pears, and berries. Oats in particular carry a European Food Safety Authority (EFSA) health claim that the beta-glucan contained in them reduces cholesterol levels.¹⁴ However, 3g of beta-glucan is needed daily to have a positive effect.

Insoluble fibre does not dissolve in water, and therefore keeps you fuller for longer. It also helps to reduce LDL cholesterol, and is equivalent to two servings of oats or oat products in the diet daily. Insoluble fibre is found in the skins of fruits, vegetables, nuts (one handful per day), and wholegrains. Although indigestible, it undergoes fermentation in the large bowel by the gut microbiome, which produce short-chain fatty acids that have been shown to reduce cholesterol synthesis in the liver and subsequently lower blood cholesterol levels.¹⁵ Dietary fibre requirements are 25-to-30g a day¹⁶ and, to meet these requirements, at least 80 per cent of the diet needs to be made up of wholegrains, and contain more than five portions of fruits and vegetables a day.

What about soya for heart health in menopause?

As a dietitian, I get asked this question frequently by women who have heard that soya can help with both hot flushes and heart health, but that it may also increase the risk for developing breast cancer. To answer the latter first, the EFSA, the World Cancer Research Fund, and the World Health Organisation have all concluded that soya is safe to be included as part of a healthy diet. To answer the first question, there is evidence that consuming 40mg of isoflavones (equivalent to two large glasses of soya milk or 100g soya mince per day) could reduce hot flushes by 20 per cent and their severity by up to 26 per cent, and that a reduction in hot flushes may be noticed after two-to-three months of consuming soya products. With regards to heart health, Ferreira et al have shown that higher isoflavone dietary intake may be associated with a lower risk of subclinical CVD.¹⁷ This effect is thought to be related to the anti-inflammatory and antioxidant properties from the production of an active metabolite formed by the gut microbiota.¹⁸

What about reductions of certain foods in the diet?

Saturated fats from fatty meats, butter, lard, palm oil, coconut oil, as well as cakes, biscuits, pies, and pastries, need to be swapped with the prementioned foods to help prevent the elevation of LDL levels and plaque build-up in the arteries. Ideally, less than 10 per cent of total daily calories should come from saturated fat. This can also be achieved by reducing red meat intake to less than twice per week, cutting viable fat of meats, skin off chicken, and using lower fat cooking methods like grilling. It is also healthier to focus on eating less butter and cream, which are high saturated fat-containing foods. But there is good news about cheese, which appears not to raise LDL or total cholesterol. This is likely due to the complex food matrix of cheese, including the calcium in cheese binding with the fatty acids in the intestine to form an insoluble sap, resulting in inhibition of fat absorption. There is also the potential that protein in cheese could reduce inflammation, and that the probiotic microorganisms in cheese may alter cholesterol synthesis.¹⁹

Refined sugar snacks: Total sugar, added sugar, and sugar from juices are associated with higher CVD risk.²⁰ However, and importantly, fructose from fruits and vegetables, and lactose in milk, are not linked to CVD.²⁰ Encouraging women to reduce consumption to less than four refined sugar snacks per week should be a goal to keep in mind.

Salt: The guidelines suggest aiming to reduce salt to less than one teaspoon per day (5g/day).²¹ It is helpful to promote a basic rule in mind of less salt in cooking, less salt on the table, and less processed foods. The Dietary Approaches to Stopping Hypertension (DASH) diet, which is in line with the approaches of the Mediterranean Diet (with an additional focus on adding foods rich in calcium, potassium, and magnesium to lower blood pressure) is also a useful approach.

Alcohol: With the existing risk of insomnia, mood swings, hot flushes, and brain fog related to menopause, alcohol is likely to exacerbate these symptoms further. Genetic epidemiology suggests that alcohol consumption of all amounts is associated with increased cardiovascular risk, but marked risk differences exist across levels of intake, including those accepted by current national guidelines.²²

In summary

Hormonal changes during menopause can bring increased cardiovascular risk. It is well known that maintaining a healthy diet and lifestyle is the cornerstone of a healthy menopause, regardless of HRT status. The Mediterranean Diet is rich in fibre, healthy fats, antioxidants, and is a delicious way to eat for heart health and overall wellbeing.²³ Supporting women towards a balanced diet that is rich is heart-healthy foods in general practice is an integral component of menopause care provision.

FIGURE 3: The Mediterranean Diet Pyramid