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PROMOTING HEALTHY LIFESTYLES DURING THE MENOPAUSAL TRANSITION

Benefits of Physical Activity and Nutrition

Woolf, Kathleen Ph.D., R.D., FACSM; Bushman, Barbara A. Ph.D., FACSM; Gabriel, Kelley Pettee M.S., Ph.D., FACSM; Carter, Susan M.D., FACSM

doi: 10.1249/FIT.0000000000000174
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Learning Objectives To identify the biological changes associated with the menopausal transition.

To recognize how lifestyle behaviors can optimize health for midlife women.

CONDENSED VERSION AND BOTTOM LINE Several metabolic and hormonal changes occur during the menopausal transition that can affect the health and quality of life for midlife women. As women enter this transition phase, improved lifestyle behaviors, such as nutrition and physical activity, may help prevent negative health and quality-of-life outcomes, such as chronic disease. By following healthy lifestyle recommendations set by the Dietary Guidelines for Americans, the American Heart Association, the North American Menopause Society, and American College of Sports Medicine, midlife women can help improve weight issues, heart health, bone health, and vasomotor symptoms, as well as overall quality of life.

SUMMARY STATEMENT This article provides guidance on the role of nutrition and physical activity during the menopausal transition for midlife women.

Kathleen Woolf, Ph.D., R.D., FACSM,Kathleen Woolf is an assistant professor of Nutrition at New York University Steinhardt. Her work focuses on the prevention and treatment of chronic disease through the integrated role of nutrition and physical activity. Using both cross-sectional and intervention study designs in her research, she has examined numerous parameters of health (diet, body composition, bone health, physical activity, energy expenditure, blood biochemistry) in active and sedentary women across the adult life span.

Barbara Bushman, Ph.D., FACSM,Barbara Bushman is a professor at Missouri State University, Kinesiology Department. She is the lead author of ACSM's Action Plan for Menopause, editor of ACSM's Complete Guide to Fitness & Health and ACSM's Resources for the Personal Trainer, 4th Edition, and an associate editor for ACSM's Health & Fitness Journal®. She has authored articles related to women and exercise, factors influencing exercise participation, and aqua running. She promotes health and fitness atwww.Facebook.com/FitnessID.

Kelley Pettee Gabriel, M.S., Ph.D., FACSM,Kelley Pettee Gabriel is an assistant professor of Epidemiology at the University Of Texas School Of Public Health–Austin Regional Campus. Her research focuses on 1) measurement-related issues in population-based research, including self-report and device-based strategies, and 2) epidemiology of physical activity and sedentary behaviors on health outcomes that affect women across their life spans.

Susan Carter, M.D., FACSM,Susan Carter is a practicing gynecologist in Greeley, CO. She is a sports medicine physician for the University of Northern Colorado and has years of experience with issues concerning the female athlete. She also is a fellow of the American College of Obstetrics and Gynecology and the American College of Surgeons. Dr. Carter has consulted for the International Olympic Committee and published/lectured on many topics concerning women in sports.

Disclosure:The authors declare no conflicts of interest and do not have any financial disclosures.

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INTRODUCTION

The menopausal transition encompasses a series of stages beginning with menstrual irregularity and ending with menopause, followed by the postmenopausal stages (26,49). During natural menopause, a number of biological changes occur, including a gradual loss of reproductive egg cells and changes in reproductive hormones, like estrogen and progesterone (9,53,61). Consequences include vasomotor events (hot flashes), insomnia, and weight gain. Other symptoms include mood changes, irregular menses, breast pain, depression, and discomfort associated with genitourinary atrophy (55,61). Medications to alleviate symptoms of the various conditions associated with menopause are available but are not without risk (3).

Menopause is defined by an absence of menstrual periods for 12 consecutive months when a woman transitions from a reproductive to nonreproductive status and can occur naturally as part of the normal aging process or abruptly after the surgical removal of the uterus and/or ovaries (63). The term perimenopause refers to the variable length of time from the menopausal transition through the first year of amenorrhea (26,63) and includes the first year of early postmenopause (Figure 1). Early postmenopause may last 5 to 8 years, after which a woman is considered to be permanently in the state of late postmenopause (26).

Figure 1

Figure 1

Although the onset may vary, natural menopause typically occurs between the ages of 45 and 55 years and is regarded as a midlife event (52,63). The exact age of menopause may be influenced by several factors, including geographical location, race/ethnicity, body mass index or body composition, physical activity, and diet (22,23,50). Factors that are associated with a younger age at menopause include living at high altitudes, malnourishment, low socioeconomic status, and cigarette smoking (22,52,56). Conversely, factors that are associated with older age at menopause include taller height, heavier body weight, higher number of childbirths, alcohol consumption, and oral contraceptive use (22,56).

Because life expectancy for women in developing countries is approximately 80 years, women may spend approximately a third of their life postmenopause. According to the most recent World Health Organization report (1996), approximately 467 million women were aged 50 years and older, which reflects the ages when women are typically postmenopausal (63). By 2030, the World Health Organization estimates that this number will rise to 1.2 billion women (63). In the United States, an estimated 6,000 women reach menopause every day (14). In 2011, the Baby Boom generation began transitioning into older adulthood. This process will continue until 2030, when the last Baby Boomer will turn 65, resulting in 72 million older adults aged 65 years and older in the U.S. population. Therefore, the number of postmenopausal women within the world's population is growing and will continue to grow.

During midlife, metabolic and hormonal changes occur that impact health and quality of life for women. These changes help explain the increased prevalence of chronic diseases observed in postmenopausal women, such as obesity, cardiovascular disease, type 2 diabetes, breast cancer and other reproductive cancers, osteoporosis, osteoarthritis, and autoimmune disorders (56).

However, the increased risk also could be caused by the aging process (58,59). As midlife women enter this transition phase, lifestyle behaviors, such as nutrition and physical activity, may help prevent these health challenges and will be the focus of this article (12,16,18,25,33,34,51). Although multiple products and regimens are marketed to this population, midlife women should follow evidence-based lifestyle guidelines. Health and fitness professionals can help midlife women recognize the benefit of these lifestyle behaviors.

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WEIGHT ISSUES

Weight gain and body composition changes are concerns for women during midlife. More than 70% of women aged 40 to 59 years are overweight (body mass index 25.0 to 29.9 kg/m2) or obese (body mass index ≥ 30.0 kg/m2) (48). Debate occurs as to whether the increase in body adiposity may be caused by chronological aging rather than reproductive aging or menopause (54,58,59). However, both aging and menopause seem to be involved in changes in body composition (increased fat mass and decreased lean mass) and in fat distribution (shifting from a gynoid pattern or pearlike body shape (excess fat stored in the hip and thigh areas) to more of an android pattern or apple-like shape (excess fat stored in the abdominal region)). Obesity also increases the risk of many chronic diseases and is associated with more severe vasomotor symptoms (VMS) during menopause (54). Thus, the North American Menopause Society (NAMS) recommends that all midlife women be screened for obesity by their health care providers (54).

During midlife, metabolic and hormonal changes occur that impact health and quality of life for women. These changes help explain the increased prevalence of chronic diseases observed in postmenopausal women, such as obesity, cardiovascular disease, type 2 diabetes, breast cancer and other reproductive cancers, osteoporosis, osteoarthritis, and autoimmune disorders (56).

Weight maintenance (or weight loss) through dietary modifications and physical activity should be the focus of lifestyle interventions for midlife women. Compared with younger women, midlife women have a lower total daily energy (calorie) requirement (44). This reduction may be associated with a decrease in leisure time physical activity, a gradual loss of lean body mass, and the absence of the increased energy expenditure previously occurring during the luteal phase or second half of the menstrual cycle (i.e., from ovulation to the beginning of the next menstrual period).

Energy intake should be balanced with physical activity to manage body weight. Because requirements for several nutrients, such as calcium, magnesium, vitamin D, and vitamin B6 increase with aging (27,28,45), this situation results in the challenge of reducing energy (calorie) intake but requiring more nutrients. Thus, midlife women should focus on nutrient-dense food that is lower in energy (calories). A healthy lunch might consist of a sandwich with a lean protein filling (i.e., turkey, tuna) that is loaded with vegetables (i.e., greens, tomatoes, cucumbers, peppers). Whole grain and 100% whole wheat bread and wraps provide more nutrients than white bread or buns. A piece of fruit is a healthier alternative to chips or fries. Water or low-fat/fat-free milk is a better choice than whole milk or soft drinks. To avoid weight gain during the menopause transition, the NAMS recommends that midlife women incorporate a daily calorie deficit, include physical activity, embrace a low-fat diet, and consume fruits and vegetables (54).

The Dietary Guidelines for Americans 2010 (DGAC 2010) provide guidance to achieve and maintain a healthy body weight, promote health, and prevent chronic diseases (60). The DGAC 2010 emphasize three main points: balancing energy intake with physical activity to maintain body weight; consuming more fruits, vegetables, whole grains, fat-free and low-fat dairy products, and sea food; and consuming less food with sodium, saturated fats, trans fats, cholesterol, added sugars, and refined grains. Although these guidelines are focused for Americans aged 2 years and older, these recommendations are appropriate for midlife women. The dietary guidelines are reviewed and updated every 5 years, and new guidelines were released in late 2015.

Exercise provides potential health and fitness benefits for women of all ages, especially for midlife women (31,58). More active women tend to be leaner than inactive peers, physical activity may slow the rate of change in weight across time and with menopause, and physical activity may protect against the development of obesity (59). The American College of Sports Medicine (ACSM) recommends including cardiorespiratory, resistance, flexibility, and neuromotor exercise training (Table 1) for general health benefits (20). Unfortunately, many women are not engaging in sufficient physical activity to meet current physical activity and public health guidelines. Furthermore, the percentage of women meeting guidelines decreases with age (Figure 2). This news is discouraging considering the value of regular physical activity and exercise for optimal health but presents an opportunity for health and fitness professionals to make a positive impact for midlife women.

TABLE 1

TABLE 1

Figure 2

Figure 2

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HEART DISEASE

Heart disease is the leading cause of death in women in the United States, resulting in more than 400,000 deaths each year (nearly one death each minute) (21). Although premenopausal women are at lower risk of heart disease, adverse changes in blood lipids occur during the menopause transition, increasing the risk of heart disease for midlife women (5,8,13,54). For example, total cholesterol, low-density lipoprotein (LDL) cholesterol, and triglyceride concentrations increase and high-density lipoprotein cholesterol concentration decreases in the year after menopause. The composition of the LDL changes, with a shift toward a smaller denser particle (8,38). This type of LDL is much more likely to be oxidized and can enter the lining of blood vessels more readily and form plaque. Individuals whose LDL cholesterol is predominantly small and dense (rather than large and buoyant) have a much greater risk of coronary heart disease (6). Midlife women also have an increased prevalence of metabolic syndrome and hypertension (1,11).

Unfortunately, many women (44%) are unaware that heart disease is the leading cause of death for women (41). Thus, raising awareness of the threat of heart disease is an important first step, followed by promotion of lifestyle behaviors that can play a major role in prevention, including smoking cessation, diet, and exercise (40,57). The NAMS recommends that all midlife women should be encouraged to reduce their risk by engaging in regular exercise, consuming a healthy diet, achieving a healthy body weight, and not smoking (54).

The American Heart Association (AHA) has provided updated guidelines for the prevention of cardiovascular disease in women, a disease of concern for midlife women (10,40,62). The NAMS recently reported that implementation of these AHA diet and lifestyle guidelines may decrease the risk of cardiovascular disease in midlife women (54). Similar to the DGAC 2010, the AHA recommends that women consume a diet rich in fruits and vegetables; choose whole-grain high-fiber food; consume oily fish at least twice a week; limit intake of saturated fat, cholesterol, alcohol, sodium, and sugar and avoid trans-fatty acids. The AHA recommends the pursuit of an eating pattern similar to the DASH diet (Dietary Approaches to Stop Hypertension), a plan rich in fruits, vegetables, fat-free or low-fat milk and milk products, whole grains, fish, poultry, seeds, and nuts (35,40). The DASH Diet also is consistent with the recommendations from the Dietary Guidelines for Americans (Table 2).

TABLE 2

TABLE 2

Recommendations for macronutrient distribution of the diet are the same for all healthy women (44). Midlife women should be encouraged to substitute saturated and trans-fatty acids with monounsaturated and omega-3 fatty acids. Because the strongest dietary determinants of elevated LDL cholesterol concentrations are dietary saturated fat and trans fat, intakes should be less than 7% and 1% of total energy, respectively. Protein-derived energy should come from fish, poultry, legumes, and low-fat dairy products (good sources of calcium and vitamin D). Fish, especially oily fish, should be included in the diet to get sources of omega-3 fatty acids and reduce the risk of heart disease. Added sugars and refined grains should be limited because they may increase triglyceride concentrations, decrease high-density lipoprotein cholesterol concentrations, and impact insulin sensitivity.

For the prevention of cardiovascular disease, midlife women should be encouraged to accumulate at least 150 minutes per week of moderate exercise, 75 minutes per week of vigorous exercise, or an equivalent combination of both (40). Activity can be performed throughout the day in episodes of at least 10 minutes. Additional cardiovascular benefits can be provided by increasing to 300 minutes per week of moderate-intensity aerobic activity, 150 minutes of vigorous intensity, or a combination of both. A physical activity program should be individualized and also include resistance training, training each major muscle group 2 to 3 days per week (20,40).

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BONE HEALTH

Bone health is another area of interest for midlife women. In the United States, approximately 16% of women aged 50 years or older have osteoporosis and 61% have low bone mass (37). Bone loss accelerates in the years just after menopause, and osteopenia and osteoporosis often begin thereafter (19,36,49). Concurrently, calcium absorption declines and is typically 50% below that of peak adolescent absorption, whereas the rate of bone resorption increases in midlife women (27,54). Poor vitamin D status also occurs because of decreased ingestion of vitamin D-containing food, reduced dermal synthesis of vitamin D, and decreased activation of vitamin D in the body (27).

To reduce the risk of spine, hip, and other fractures, the NAMS recommends that midlife women obtain adequate calcium and vitamin D (54). The requirement for calcium for adults older than 50 years is 1,200 mg/day (combined food and supplement sources) (27). Food sources of calcium are preferred and include dairy products (milk, cheese, yogurt), seafood (salmon, sardines), dark green vegetables (kale, collards, spinach, broccoli), and calcium-fortified products, such as orange juice, soy products, and ready-to-eat cereal (Table 3). For vitamin D, the requirement increases in a stepwise fashion for older adults (5 to 10 to 15 μg/day) (27). Because research suggests that higher doses of vitamin D are required to achieve optimal blood 25-hydroxy vitamin D concentrations, its status in the blood should be monitored for midlife women (7). Food sources of vitamin D include fatty fish, fortified milk, eggs, and fish oils (Table 4). Although calcium and vitamin D play important roles in bone health, other micronutrients (phosphorous, magnesium, potassium, vitamin C, vitamin K) seem to be important as well (2,27,28,45,46). The NAMS also recommends that midlife women should be encouraged to engage in regular physical activity, avoid smoking, and limit alcohol intake (54). Thus, a healthy lifestyle should be followed by midlife women to prevent adverse effects on bone health.

TABLE 3

TABLE 3

TABLE 4

TABLE 4

The ACSM Position Stand “Physical Activity and Bone Health” points out two strategies to make the skeleton more resistant to fracture: to maximize the gain in bone mineral density in the first three decades of life and to minimize the decline in bone mineral density after age 40 years (32). Weight-bearing and strength training exercises are recommended as strategies for bone development and maintenance (47). Weight-bearing activities can be as simple as brisk walking (although jogging or running provides impact-loading benefits to the skeleton); resistance training can be accomplished using machines, resistance bands, free weights, or barbells (47). Physical activity (including balance, leg strength, flexibility and/or endurance training) also is valuable in fracture prevention by reducing the incidence of falls (32). For an example of a comprehensive exercise program, see Box 1, which highlights the Erlangen Fitness Osteoporosis Prevention Study.

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Box 1.

Program Example: Erlangen Fitness Osteoporosis Prevention Study The Erlangen Fitness Osteoporosis Prevention Study was a long-term exercise study for early postmenopausal women with osteopenia (17,29,30). Based on their own decision, women joined either an exercise group or a control group. There were no differences between treatment groups at the beginning of the study for physical fitness, bone mineral density, pain, or nutritional status. The exercise program was low volume/high intensity and emphasized endurance, jumping, strength training, and flexibility/stretching activities using both group and at-home exercise sessions. During a period of 3 to 4 years, the women completing the low-volume/high-intensity exercise program successfully maintained bone mineral density. However, the control group women experienced a loss of bone mineral density. In addition, the exercise group had improvements in total cholesterol, high-density lipoprotein cholesterol, and triglyceride concentrations; waist-to-hip ratio; and muscular strength. Favorable changes also were found for insomnia, migraines, and mood changes. From a general perspective, this study supports the value of a comprehensive exercise program to promote health and fitness for women during the early postmenopausal years.

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VASOMOTOR SYMPTOMS

Vasomotor symptoms (VMS) (i.e., hot flashes/flushes and night sweats) have been reported in 35% to 50% of perimenopausal women and up to 30% to 80% of postmenopausal women (43). Research on VMS can be challenging to conduct and interpret because symptoms can start and stop at unpredictable times, even without therapy.

The relationship between diet, dietary supplements, and VMS has been explored by researchers. In one study, no relationship was found between dietary phytoestrogens, dietary fiber, and VMS (24). Other research suggests that phytoestrogens (soy) may relieve VMS (15). Although nonprescription remedies, such as soy, isoflavone supplements, black cohosh, vitamin E, and omega-3 fatty acids, may be marketed for relief from VMS, the NAMS recently reported that their efficacy is generally similar to a placebo (54). Furthermore, long-term risks of nonprescription supplemental hormonal therapy are not well-studied and remain controversial. Future clinical trials are needed to identify whether dietary modifications and/or dietary supplements may reduce the occurrence or frequency of VMS.

Although the relationship between physical activity and VMS has been examined, considerable uncertainty still exists. In a comprehensive literature review, more than half of the studies reported no association between physical activity and the risk of VMS (59). The remaining studies suggested a protective inverse relationship, although three reported increased VMS with higher levels of physical activity (59). Although the evidence is equivocal for a protective effect, the NAMS does suggest that maintaining a healthy body weight, avoiding smoking, and exercising regularly may provide some relief from VMS (54).

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QUALITY OF LIFE

In addition to the previously documented benefits of exercise and physical activity, both cross-sectional research and interventional research demonstrate positive changes in quality of life for physically active midlife women (4,39). Physical activity also is associated with higher levels of well-being, positive mood, and vigor and lower depression, anxiety, and perceived stress in midlife women (4,59). Given the many areas of potential positive impact, health and fitness professionals should encourage women to exercise regularly throughout their life spans.

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SUMMARY

For women, menopause is imminent and is part of the midlife experience. Health and fitness professionals who are knowledgeable about the menopausal transition and health concerns specific to midlife women are in a unique position to help women maximize health while reducing the risk of chronic disease. Midlife women should be encouraged to adopt a healthy lifestyle, including regular physical activity and a nutritious diet, while avoiding cigarette smoking and overuse of alcohol. Midlife women should focus on getting more nutrients and fewer calories by consuming a diet rich in fruits and vegetables, whole grains, and high-fiber food. Saturated and trans-fatty acids should be limited, and fatty fish incorporated twice a week to increase omega-3 fatty acid consumption and reduce the risk of heart disease. For optimal bone health, sufficient intakes of calcium and vitamin D are necessary. Physical activity in the form of a complete balanced exercise program (including cardiorespiratory, resistance, flexibility, and neuromotor training) is key for health promotion and disease prevention. The menopausal transition also should be perceived as a time for more stringent health care assessments. Adoption of these lifestyle behaviors will ensure a healthy menopausal transition and aging process.

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    American Heart Association. Go Red for Women. Available from: https://www.goredforwomen.org/
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                                    Keywords:

                                    Midlife; Perimenopause; Menopause; Lifestyle Behaviors

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