After my recent post on keto for women, I got a lot of feedback. One of the most common themes: “But what about menopause?” I heard from dozens of women in both the comment section and in emails who were having trouble losing weight and dealing with the varied symptoms of menopause. Was keto the answer? Was Primal? Were they doing something wrong?
Rather than start with the assumption that going keto or Primal is the best way to deal with menopause, I figured I’d start from ground zero, drawing on the extensive scientific literature on diet and menopausal symptoms to see if I could arrive at some general trends and make recommendations.
But first, why do we even experience menopause? In the big picture, menopause is rather rare. Besides humans, orcas and pilots whales are the only other species where the females live significantly beyond their reproductive age. The average age of menopause hovers around 50, and most women can expect to live another 30 years or so. That indicates its importance. It wouldn’t have been uniquely established and preserved in just a couple species if it didn’t provide huge benefits to those species. And sure enough:
They provide childcare so parents can be more productive, whether it’s going back to work in the office or foraging for nuts and tubers in the bush.
They impart wisdom to the youngsters—and to the community as a whole.
And, though parents probably wouldn’t count this as a positive, they spoil grandkids rotten.
To boot, many women I know say menopause ushers in the most focused, creative time of their lives. If their reproductive years (particularly perimenopausal ones) were characterized by hormonal chaos, they often find themselves grateful to be free of the perpetual fluctuation. But mostly they say they’ve entered a time of life when they feel more confident and self-possessed. (Joan Erikson, author, psychologist, teacher, artisan, and wife of noted psychologist Erik Erikson, writes insightfully about this transition.)
All this said, menopause can also present its share of physical difficulties for many, if not most, women at some point. But do these effects need to be as unpleasant as they often are? I’d venture to say no. I have a few posts in mind here, but let’s dig into dietary strategy today.
First, let’s establish what changes physiologically during menopause. What are the most common symptoms of menopause? And what does the evidence say about how diet affects those symptoms?
This might be the most common complaint women have during and after menopause: Weight goes on more easily and is harder than ever to scale back. Nothing seems to work, even the dietary interventions that previously did.
Why is weight loss so hard after menopause?
Energy expenditure and basal metabolic rate both drop with menopause.
What really does seem to work is the classic paleolithic diet: lean meat, fruit, nuts, vegetables, eggs, berries, and fish with no grains, legumes, sugar, dairy, potatoes, or added salt. 40% of energy from fat, 30% from protein, 30% from carbohydrate. Over 24 months, menopausal women on a paleo diet lost more fat, more waist circumference, and more triglycerides than those on a standard “healthy” diet.
Perhaps it’s the protein. Another study found that postmenopausal women who ate the least protein (under 0.8 g protein per kg bodyweight) had the most body fat and were physically weak. Those who ate the most (over 0.8 g per kg, 1.1 g/kg on average) had the least body fat and were more physically capable.
What’s clear is that weight loss has beneficial effects on menopause symptoms. It reduces inflammation, improves cancer biomarkers, regulates sex hormones, and improves endothelial function—to name a few. What’s also clear is that weight loss can have negative second-order effects in menopausal women, like bone mineral loss and loss of lean mass. So, it’s worth doing, and doing right. You have to strike a fine balance between losing weight and avoiding muscle loss. As your satiety signaling is likely thrown off, you might have to make a more conscious effort to track your food intake and make sure you’re not overdoing it.
Before menopause, most women are protected against heart disease, at least compared to men. Once menopause sets in, a woman’s heart disease risk goes way up. A good diet for menopause, then, would have to reduce heart disease risk. What does the evidence say?
In overweight post-menopausal women, high-fat diets (where the fat came from cheese or meat) improved atherogenic biomarkers compared to a high-carb diet. Both the cheese-based and meat-based diets increased HDL and Apo-A1; the high-carb diet did not.
Meanwhile, high-carb diets were persistently linked to chronic low-grade inflammation and an elevated risk of heart disease in postmenopausal women.
Moving beyond broad macronutrient ratios, are there any specific foods or nutrients that play an outsized role in menopasual women’s heart health?
Dark chocolate may help with reduced endothelial function, another risk factor for heart disease. Postmenopausal women who consumed high-cacao chocolate saw their endothelial function improve in one study.
Green tea appears to help postmenopausal women reduce fasting insulin, a major but underappreciated risk factor for heart disease (and a host of other bad conditions).
As estrogen plays a big role in the maintenance of bone mineral density and overall bone health, bones get weaker and lose density during menopause. A woman’s risk of osteoporosis, fractures, and other bone-related incidents skyrocket during and after the transition.
Intake of long-chain omega-3 fatty acids—found in fish, shellfish, and fish oil supplements—is associated with higher bone mineral density at the hips and spine (the most crucial parts for aging people) in osteopenic women. Osteopenia is lower than normal bone mineral density. It isn’t quite osteoporosis, but osteopenia can often progress into it.
Glucose loading actively impairs bone remodeling in postmenopausal women. The problem doesn’t go away just because you exercise, either. And it gets worse the higher your postprandial blood glucose goes.
The normal bone-relevant nutrients become even more relevant after menopause:
One study in postmenopausal women found that yogurt fortified with vitamin D3 improved bone mineral density, while regular yogurt without the vitamin D3 worsened it.
Another found that a gram of calcium a day wasn’t enough to stave off bone mineral loss in menopausal women during weight loss; they needed at least 1.7 grams per day.
Another study found that a collagen supplement increased bone mineral density in post menopausal women.
Everyone’s heard of “pregnancy brain.” There’s also “menopause brain.” It’s characterized by brain fog, memory loss, lack of focus, and other cognitive symptoms.
Some research also suggests a role for micronutrient supplementation in menopausal cognitive symptoms:
Vitamin C can help. In one study, postmenopausal women who took 500 mg of vitamin C a day improved verbal recall, naming, and repetition. These improvements were accompanied by reductions in beta-amyloids linked to Alzheimer’s disease.
Resveratrol may help. In one study, it increased cerebral blood flow and improved overall cognitive performance during a series of tests, particularly in verbal memory.
Both fish oil and soy isoflavoneshave been shown to reduce hot flash occurrence, with soy acting faster on severe hot flashes and fish oil doing a better, but slower job of targeting both moderate and severe hot flashes.
Folic acid supplementationreduced the severity, duration, and frequency of hot flashes. A better source for folic acid are folate-rich foods, like leafy greens or liver.
A woman’s risk of breast cancer rises after menopause. After menopause, the inflammatory status of the breast goes up almost as a general rule. This explains at least part of the elevated risk for breast cancer postmenopausal women exhibit, and it’s true whether or not the woman is overweight or not. Menopausal breast fat is inflammatory fat.
Among Japanese women, those who ate the most noodles and other carbohydrates had higher levels of estradiol, which other studies have found correspond to a higher risk of postmenopausal breast cancer. Those who ate the most fish, fish fat, and saturated fat had lower levels, which correspond to a lower risk. Of course, the authors opine that this suggests eating more fish and say nothing about saturated fat, but we can’t really expect them to contradict decades of propaganda—I mean, evidence.
Menopause is generally inflammatory; along with waist circumference, menopause status is an independent predictor of low-level inflammation and elevated hs-CRP (one of the most fundamental markers of inflammation). There’s a low level simmer going on, and it can cause a lot of problems. Diet can make it worse, or make it better.
High-glycemic diets—also known as diets high refined carbohydrates—are associated with more oxidative stress in post-menopausal women (for what it’s worth, the same is true in premenopausal women). Intakes of insoluble fiber and PUFA, including omega-3s and healthy sources of omega-6s like nuts, were linked to lower levels of oxidative stress.
Genetics matter, of course. A growing body of evidence indicates that various genetic variants can influence the effects of some of these dietary interventions on the symptoms and risks associated with menopause.
There’s more to managing menopause than just diet, of course. Lifestyle decisions matter too. But that’s beyond the scope of today’s post. Maybe in the future.
So, can we make any recommendations? What are the takeaways? We see some trends emerge.
Avoid Refined Carbohydrates
Pretty much every study that looked at fast-digesting, low-nutrient sources of carbohydrates found they have a negative effect on most concerns of menopause, including bone health, breast cancer risk, heart health, weight gain, inflammation. Now more than ever, don’t eat them.
Limit Carbs To Only What You Use
If you’re an incredibly active woman, someone who CrossFits and runs sprints and swims laps and plays with grandkids, you can get away with more carbohydrates, and may even thrive with a few extra. But make sure you actually need those carbs.
Menopause isn’t easy for most women. Things are changing, hormones are in flux, and eating strategies you once employed may no longer work the same way. There’s no magic diet that fixes everything, but there are lots of little changes that can tilt the scales in your favor.
Try them out and let me know what you think.
In the meantime, I’d love to hear how you’ve handled menopause via diet. Thanks for reading, and take care, everybody.
Mark Sisson is the founder of Mark’s Daily Apple, godfather to the Primal food and lifestyle movement, and the New York Times bestselling author of The Keto Reset Diet. His latest book is Keto for Life, where he discusses how he combines the keto diet with a Primal lifestyle for optimal health and longevity. Mark is the author of numerous other books as well, including The Primal Blueprint, which was credited with turbocharging the growth of the primal/paleo movement back in 2009. After spending three decades researching and educating folks on why food is the key component to achieving and maintaining optimal wellness, Mark launched Primal Kitchen, a real-food company that creates Primal/paleo, keto, and Whole30-friendly kitchen staples.