One For The Ladies
At various times of our lives, we women encounter certain challenges with regards to our hormones and the symptoms we may experience due to their fluctuation. But does it have to be this way? Lifestyle interventions such as nutrition and exercise can play a huge role in mitigating the deleterious effects that hormone changes can evoke.
Conditions such as Polycystic Ovarian Syndrome (PCOS) are becoming more widespread and, although the cause is not definitive, one strong theory is that insulin resistance plays a big role. In addition, studies have shown that insulin resistance is a high predictor for non-alcoholic fatty liver disease (NAFLD) in women with PCOS, which shows the correlation between insulin resistance and PCOS.
PCOS is a condition that is affecting many young women today, causing them to experience symptoms such as:
- Irregular periods
- Cessation of periods
- Excessive hair growth on face, chest, back and buttocks
- Weight gain
- Thinning head hair
- Oily skin
A diagnosis of PCOS can affect future health because such women are at higher risk of developing depression, type 2 diabetes (this is related to the insulin resistance), high blood pressure, heart disease, stroke, sleep apnea and endometrial cancer (cancer of the womb).
How Does Nutrition and Exercise Fit Into This Equation?
Well muscle mass plays an important role in health generally, and is found to be a critical element in determining cardiovascular and metabolic risks associated with PCOS.
A few studies have now demonstrated that progressive resistance training can improve hyperandrogenism, reproductive function and body composition by decreasing visceral fat and increasing lean muscle mass. Combined with the right nutrition, this can have a powerful impact on the health of young women suffering with PCOS. One study in particular implemented a program of progressive resistance training (PRT) 3 times a week, for 4 months for women with PCOS. The results showed an increase in muscle strength, improved hyperandrogenism, and better body composition because body fat was reduced and lean muscle mass was increased. The authors concluded “it is suggested that resistance exercise programs could promote health and fitness in women of reproductive age, especially functional capacity of strength those with PCOS”.
A review of 10 studies looking at resistance training and women with PCOS stated that it was necessary to look at the bigger picture, taking nutrition into the equation before definitive answers could be found. I would agree with this as I believe that both diet and exercise together hold the key to success.
Low carbohydrate diets and ketogenic diets have been found to be helpful in the treatment of PCOS. Because this way of eating addresses insulin resistance (and is proving to be very effective in the treatment of type 2 diabetes), it is a powerful tool to reduce weight, lower inflammation, improve biomarkers such as lipid profiles and restore insulin sensitivity.
On a personal note, a client I worked with a couple of years ago came to me with a diagnosis of PCOS and was unable to get pregnant. She and her husband were waiting for IVF treatment, but she had been told to get her BMI down before they would be considered. We worked together on changing her nutrition and implementing a training program. We did a body composition analysis at the start and end of the 8 week program to determine what changes had taken place. All her markers had changed for the positive – BMI had come down, there was significant fat loss, increase in skeletal muscle tissue, her fitness had improved considerably, but the most important change of all was that she was pregnant! No IVF had been necessary, just the change in lifestyle had been what was necessary. She went on to have a successful and healthy pregnancy and gave birth to a bouncing baby boy!
Menopause, Diet and Exercise
For women going through menopausal transition, the challenges faced can be overwhelming. The body is starting to move away from reproduction and oestrogen starts to decline. This can induce a cascade of symptoms such as:
- Weight gain
- Hot flushes
- Night sweats
- Vaginal dryness
- Vaginal itching
- Mood swings
- Breast tenderness
Health related fitness (HRF) consists of body composition and bone strength (known as morphological fitness), muscle endurance, strength and flexibility (known as musculosketetal fitness), postural control (motor fitness), aerobic ability and power and blood pressure (cardiorespiratory fitness) and lipid and carbohydrate metabolism (metabolic fitness). The onset of menopause is often accompanied by changes in body composition that includes a decrease in lean muscle tissue, increase in fat mass and decrease in aerobic fitness and strength. Along with the hormonal decrease in oestrogen, these changes can have a dramatic effect on the overall metabolic health of women during menopause, causing them to experience the typical symptoms described above. Mental health issues are also very common in women undergoing menopause, with tension, irritability, moodiness, anxiety and emotional instability being stated as the main symptoms experienced.
Often the only treatment offered is hormone replacement therapy (HRT), but it could be that this may not be necessary if a nutrition and exercise strategy is implemented early on. Other conventional therapies for hot flushes include cognitive behavioural therapy (CBT), plant-based therapies, and specific naturopathic interventions such as evening primrose oil, flaxseed, ginseng, wild yam, black cohosh, progesterone creams, medicinal Chinese herbs, reflexology, and magnetic devices, acupuncture. However, these are either ineffective or their efficacy remains to be proven in large clinical trials.
Lack of oestrogen can result in a progressive decrease in muscle mass, strength and bone density – all of which are associated with conditions such as sarcopenia (muscle wasting) and osteoporosis (bone crumbling). This inevitably becomes a vicious circle of not being able to exercise because of pain or degeneration, and then a further worsening of the condition. Loss of muscle mass leads to loss of muscle functionality, which in turn results in restriction of mobility, functional impairment and eventually physical disability. The final outcome is a loss of independence and reduced quality of life. Retaining a good level of lean body tissue, reducing the accumulation of fat mass (particularly visceral fat) through lifestyle practices such as proper nutrition and a regular exercise program can make a difference to the severity of the symptoms, perhaps alleviating them altogether.
Muscle mass starts to decline in our 30’s, 40’s and 50’s and continues as we age. This is why a strength program started early can be preventative, although it is never too late to start. Muscle and bone health is also linked to protein intake and calcium and vitamin D availability, as well as a decrease in physical activity. Resistance training, in particular is important for muscle protein synthesis, but it is essential to consume adequate protein, otherwise the body will simply break down muscle tissue to create new tissue – not an ideal situation! Women, especially, seem to consume far less protein (particularly from red meat) than their male counterparts, and will typically opt for a skinless chicken breast and salad with low fat dressing. This is not an optimal eating pattern for someone aiming to preserve, or increase, muscle mass. But talking about muscle mass often frightens women as they immediately assume they will turn into the next Ms Olympia overnight! This is such a far cry from the truth. It takes a significant, committed program to become a bodybuilder – one that many bodybuilding women struggle to achieve, even when they are trying their hardest! What we are talking about here is simply maintaining (and increasing where necessary) the muscle tissue and preventing further decline, becoming stronger and therefore more functionally able-bodied and maintaining strong and healthy bones. What we want to prevent are the falls and breaks that are associated with growing old.
Vitamin D contributes to calcium and phosphorus regulation and has beneficial effects on both bone and muscle mass. Although vitamin D is synthesised through the skin via sunlight, many of us live in countries that don’t have enough sun for much of the year, and so it is critical to obtain this vital vitamin through the diet as well as getting outside as much as possible. Vitamin D plays an important part in the uptake of calcium in muscle cells and regulates many other cells functions, but interestingly it is also being touted as having a positive effect on skeletal muscle mass and strength. As we age we are also unable to produce as much vitamin D and so dietary sources of both vitamin D and calcium become much more essential. This means eating foods such as salmon, liver, egg yolks, cheese on a regular basis. Calcium rich foods include liver, fish such as sardines where you eat the bones, cheese, yogurt, whey protein, leafy greens. (For those who dislike the taste or texture of liver I have several recipes that are a great way to include liver regularly but disguise the taste and texture).
Collagen is a protein, but does not contain all the amino acids, however it is extremely important for bone health, ligaments, joints, tendons, cartilage, as well as our skin and hair. It is also great for gut health and can help to heal intestinal permeability (leaky gut). As we age we start to produce less of it ourselves, so it is helpful to add it into our daily nutrition. This can be done through drinking bone broth, which is easy to make, or a collagen supplement such as Primal Collagen, which mixes into drinks without any taste.
During the ageing process, our skeletal muscle tissue has a reduced ability to synthesise protein. This can result in sarcopenia (muscle loss). Chronic low grade inflammation, which is linked to the decrease in oestrogen and increase in visceral fat, leads to an increased demand for muscle protein synthesis (MPS). Although current recommendations for protein intake sit at around 0.8g per kg of bodyweight per day, the increased protein demand for older people means that the amount should be increased to 1.0-1.2g per kg bodyweight per day as recommended by the European Society for Clinical Nutrition and Metabolism. It is also important to recognise that physical activity places an extra demand on the body for MPS, particularly with regard to resistance training. Most women are under-consuming protein even at the 0.8g level (remember that this is the MINIMUM requirement). A study done with a sample of healthy post-menopausal women showed that those consuming protein below the recommended RDA demonstrated an impaired upper and lower extremity functionality that those consuming a higher level of protein. When you have impaired muscle metabolism you are far more likely to gain a higher fat mass and the possibility of insulin resistance, both of which are associated as being precursors of frailty. Protein is also a requirement for healthy bones, aiding intestinal calcium absorption. Protein should be included at every meal – so, for example, eggs at breakfast, fish or chicken at lunch and lamb, steak or pork in the evening.
A review looking at the role of protein and vitamin D supplementation combined with exercise training stated “Hormonal replacement therapy is effective in osteoporosis prevention, but concerns have been raised with regard to its safety”. The conclusions drawn were that protein, vitamin D supplementation and progressive resistance exercise training are capable of directly targeting both sarcopenia and osteopenia and could delay or halt the cycle leading to the deterioration of bone and muscle.
WHAT We Eat And WHEN We Eat.
Fasting can have many beneficial effects on health as I have written about in a previous blog. For women intermittent fasting (IF)/time restricted feeding (TRF) has been shown to improve reproductive and mental health, musculoskeletal disorders, as well as decreasing the biomarkers related to cancer.
A recent study revealed that women with PCOS who fasted reduced the chronic sympathetic overactivity experienced with PCOS, reducing the neurohormone levels and therefore improving both physical and mental health. An increase in leutenising hormone in obese women with PCOS corrected ovulatory problems. Even a small weight loss has been shown to have significant clinical effects, improving psychological issues, menstrual cycles, ovulation, fertility, insulin resistance and risk factors for heart disease and type 2 diabetes.
Metabolic dysfunction can be prevented by practicing intermittent fasting due to the significant protective actions such as reduction of fat mass, lowered blood pressure and resting heart rate, and improvements in lipid profiles.
The mental health benefits of fasting have been widely acknowledged, reducing the symptoms of anxiety and depression and improve social functioning. Fasting is associated with greater clarity of mind, increased alertness and mood improvement. Changes in neurotransmitters due to fasting can improve quality of sleep and synthesis of brain derived neurotrophic factors (BDNF). Evidence confirms that there are significant cardioprotective actions of IF/TRF such as weight loss, reduced fat mass, reduced blood pressure and heart rate, improved lipid profiles, and prevention of metabolic dysfunction.
Fasting induces the state of autophagy, an evolutionary recycling pathway that degrades, recycles and renews cellular proteins, organelles and mitochondria. This process has been reliably linked to the aging process. When we eat 3 meals a day, with snacks, and nibbles in the evening in front of the TV, we are never allowing our bodies to enter the state of autophagy. When we eat we stimulate mTOR (mechanical target of Rapamycin), which is a growth pathway. This is a necessary pathway to stimulate muscle synthesis and cell growth, but when it is constantly switched on, with no autophagy to break down any damaged cells, there is a higher risk of abnormal growth in cells, which can lead to cancer. The opposite pathway is AMPK (adenosine monophosphate-activated protein kinase), which is an enzyme. Its role is to activate glucose and fatty acid uptake and oxidation when cellular energy is low. So when you haven’t eaten a meal for a few hours, or have done a bout of exercise, AMPK is activated. When this pathway is activated, autophagy is also activated. A study demonstrated the benefits of AMPK is mice, with and without non-alcoholic fatty liver disease (NAFLD), whereupon levels of fat in the liver dropped when AMPK was activated. New fat production was slowed and existing fats were metabolised for energy.
As we age, there is a natural deterioration of tissues and organs due to oxidative damage, and an age-related decline of autophagy. IF/TRF, resulting in lower insulin levels, may slow down many of these age-related processes, and extend lifespan. Calorie restriction through intermittent fasting prevents the age-dependent decline of autophagy by stimulating the process for several hours during the day and improving the sensitivity of liver cells. This stimulation has anti-ageing effects.
But as well as fasting inducing the process of autophagy, exercise also plays a role. Exercise is a form of physiological stress, and causes adaptations to occur within the body. Autophagy is a necessary process for the adaptational response to exercise to occur. Improvements in neurological function, maintaining tissue integrity and activation of different pathways for adaptation occur via autophagy during exercise.
Exercise induced mTOR and the autophagy required for adaptation shares a common signalling pathway with calorie restriction (through IF/TRF), and although exercise-induced skeletal muscle autophagy is currently the most studied, there is evidence to suggest that there is enhanced autophagic activity stimulated in other tissues, such as heart, liver, pancreatic cells and adipose tissue.
The symptoms of menopause are caused by a down-regulation in the production of oestrogen. In a study to investigate whether the effects of exercise training on muscular autophagy could be beneficial in the absence of oestrogen, mice were given an ovariectomy, which disrupts oestrogen production, to mimic low oestrogen in menopausal women. Deficiency of oestrogen following the ovariectomy showed a suppressed muscular autophagy pathway, which was posited could lead to a disruption of intracellular homeostasis involved in anabolic and catabolic processes (building up and breaking down of tissues). Their study found that there was a dose respondent trend in exercise time per training session on muscular autophagy, with 90 minutes appearing to be optimal. Exercise training effectively counteracted the negative influences on the expression levels of mTOR, prevented fat accumulation, and increased muscle mass, despite the lowered levels of oestrogen.
Another study, also in ovariectomised rodents, demonstrated that the effects of jump training produced positive changes in bone mineral density, bone mechanical properties and bone formation and resorption markers. The authors concluded that jumping exercises was effective to prevent bone loss – even when osteopenia had already been established. A jump rope is one of the most inexpensive pieces of equipment you can buy, is totally portable and, once you have re-discovered the joy of skipping (remember when you used to do it as a child with joyful abandonment?), you will wonder what took you so long to take it up again!
Exercise has beneficial effects on muscle mass, strength and bone density, as well as physical performance, cardiovascular health and mental health. It has been shown to delay the onset of osteoporosis, improve balance and reduce the risk of fractures.
Progressive resistance training (PRT), in particular, is most effective in increasing muscle mass, improving strength and increasing endurance. It also benefits cardiovascular health due to the demand placed on the body when lifting a heavy object. Menopause coincides with the onset of sarcopenia (muscle loss), which indicates that non-physically active menopausal women should take up exercise as soon as possible at this time to prevent both sarcopenia and osteopenia (bone loss). Women who are already osteoporotic should include PRT regularly to improve their bone density and reduce the risk of fractures and breaks.
For women experiencing weight gain that they just can’t seem to shift, high-intensity interval training was shown to improve visceral adiposity tissue (that’s the dangerous fat surrounding the organs which can result in conditions such as NAFLD). One study demonstrated that including HIIT improved both visceral fat and inflammatory markers in obese postmenopausal women. HIIT is also a very time-efficient way of training compared to traditional hours of cardio, and is much more effective at targeting visceral fat in particular. Another study showed that an 8 week sprint interval training program increased total lean mass, decreased fat mass and increased aerobic fitness of postmenopausal women after only 8 hours of actual exercise during an 8 week period.
Moderate levels of physical activity have been associated with reduced psychosocial and physical menopause symptoms in peri-menopausal Korean women.
Cardio versus Resistance Training
Reading through the various research, looking specifically at women experiencing typical symptoms of menopause, such as hot flushes, here’s what I found to be particularly interesting:
One trial took postmenopausal women who were experiencing at least 4 moderate or severe hot flushes or night sweats per day and randomized them to either a 15 week resistance training intervention, or unchanged physical activity. They had not been exercising prior to starting the trial and were not taking any therapies for treating the hot flushes. They performed resistance training three times per week, with the routine containing 8 exercises with 8-12 reps done in 2 sets. The training was also set per individual with regard to load and progression. The result was that the hot flushes decreased more in this intervention group than the control group who were not exercising. The authors stated that this type of intervention “could be an effective and safe treatment option to alleviate vasomotor symptoms.
But here’s the interesting part. Another study took a total of 174 women experiencing hot flushes and night sweats, and assigned them to regular aerobic exercise such as walking, aerobics and swimming. They had to complete exercise diaries (although 65 participants did not complete a single diary). One group received a menopause specific DVD and written materials to encourage regular exercise whilst the other group was offered attendance at exercise social support groups in their local communities. A control group continued as usual with no exercise intervention. Both the exercise interventions lasted for 6 months. The result was that NEITHER group reported any significant reduction in hot flushes or night sweats compared to the control group. The authors stated “This trial indicates that exercise is not an effective treatment for hot flushes/night sweats. Contrary to current clinical guidance, women should not be advised that exercise will relieve their vasomotor menopausal symptoms”. Personally, I think that the type of exercise undertaken was probably not intensive enough, and that low-moderate intensity cardio exercise does not induce the benefits that resistance training offers.
A systematic review of randomised controlled trials found that post-menopausal women benefitted from 30 minutes of daily moderate intensity walking combined with a resistance-training program twice a week. They also recommended that diet should be taken into consideration and combined with the training to maintain a healthy weight, preserve bone mineral density, and increase muscle strength. The authors concluded “such exercise might also improve flexibility, balance and coordination, decrease hypertension and improve dyslipidemia”.
On A Personal Level
I have followed a low carb way of eating for many years now, changing from a 27 year vegetarian, to a Paleo template and then to a low carb Paleo protocol. I have also been training for many years – particularly strength training within the past 8 years. I had also been implementing intermittent fasting for about a year and a half prior to onset of menopause. When I entered peri-menopause I didn’t find myself experiencing any deleterious symptoms. I had a few hot flushes for about a week, but then I changed my diet completely to the carnivore protocol, after which all the hot flushes disappeared, and I have not had one since. My periods basically dwindled away over a timeframe of a year and half. I have maintained (and improved) body composition by combining a targeted nutrition and exercise approach and feel the fittest and healthiest I have ever felt. My muscle mass has increased, my bone density is good, I am strong and am rarely ill.
It seems to me that there is a real lack of research in the area of menopause, nutrition and exercise. The reason that this blog has come out later than usual is that I have spent so much time trawling through the research, looking for as much evidence as I could find. It is my belief that evolutionarily women did not suffer the kinds of debilitating symptoms that they are now frequently experiencing in the modern world prior to, during and post-menopause. I think we have strayed so far from foods that are compatible with our DNA, and that support optimal health and wellbeing, that we are now exposing ourselves to all kinds of chronic ailments. With regards to training and physical activity, I think that many women opt for cardio-type exercise as they age – some not even performing exercise that really raises the heart rate, choosing gentle options such as Pilates and walking (strolling as opposed to vigorous hill walking etc), all of which are not going to produce the adaptations required for muscle, bone, mental and heart health – which all contribute to better body composition, and reduced risk of metabolic conditions. Many young women do not do any training at all, or, again, opt for the more cardio end of the spectrum. I am not dismissing cardio as a good form of exercise, but I believe that resistance training plays a far more important role in health than we currently give it credit for.
Eating a diet that is more in line with our natural, human requirements, seeking out bioavailable sources of protein and eating nutrient rich whole foods, in conjunction with committing to a training program to improve vital health markers, should be the first line of intervention for helping women avoid the so-called “inevitable” symptoms that are associated with ageing. I don’t believe that menopause should be a miserable affair, filled with debilitating conditions, or that younger women should have such problems trying to conceive, experiencing symptoms that can send them into depression with a higher risk of future ill health. These are modern day problems that we are experiencing unnecessarily, and can largely eradicate through implementing positive changes in lifestyle.
If you are a young woman, start now – protect your future health, be in your best shape before you are considering having a baby. For older women, it is not too late. Changing your dietary and exercise habits can be challenging, but so worth it to experience the vast improvements in health that are yours for the taking. Ask yourself how much better could you feel?
If you would like to schedule a consultation to discuss how to safely, and effectively, implement changes such as fasting, dietary protocols and training programs contact me here.