It’s encouraging to see women’s experience of the menopause being discussed more openly than it used to be. In the UK currently, the topic seems to be a common one in the media, which can only be a good thing if it raises awareness of the issues that women experience, the impact it can have on their work and family life, and the options that are available to help reduce that impact by helping to reduce symptoms. These include making nutritional and lifestyle changes, and possibly hormone replacement therapy (HRT).
While much of the information available to women on how to cope with the menopause and beyond is applicable to those who participate in endurance sport, of course, the purpose of this blog to offer specific nutrition and diet-related suggestions to help you as an athlete navigate your way through this often tricky stage of life, so that you can continue to take part in the endurance sports lifestyle that you love for as long as possible, remaining in good health and having the energy to cope with training, racing, and the demands of your life outside endurance sport.
At the end, I’ve included an example of a 50 year-old ultra-runner and triathlete to demonstrate how my recommendations might work in practice.
The effects of menopause on wellbeing and performance
The age at which women start to experience menopausal symptoms varies, but typically you might start to notice these between the ages of 45 and 50, and they continue for up to 10 years. The initial period is known as the peri-menopause, when your monthly periods tend to become irregular. You are post-menopausal once you have not had a period for 12 months. Symptoms commonly experienced include hot flushes/flashes, night sweats, mood swings, “foggy brain”, vaginal dryness, reduced libido and increased anxiety or sadness. Sleep is often adversely affected, resulting in increased fatigue. It is common to see an increase in body fat around the abdomen, while remaining lean overall, or to find it more difficult to lose weight if needed. From an athletic perspective, your VO2 max gradually reduces, resulting in slower race performances, and you are likely to find that you need more recovery between training sessions. You may also become dehydrated more easily due to increased sweating. Lean muscle also starts to decrease as part of the aging process. Strength and conditioning work should become a more important part of your training mix to help maintain muscle and prevent loss of bone density. The latter is caused by the fall in your oestrogen levels that occurs at menopause and beyond
For a more detailed account of the effects of menopause on the female athlete, please do read this great blog post by endurance athlete Mel Varvel, who runs wholesome nutrition and mobile catering company www.totallywonderfuel.co.uk.
Nutrition: How to adjust your diet
The fundamentals of a healthy diet to support endurance training and racing continue to apply, namely:
- Eating enough to meet your energy needs
- Consuming mostly unprocessed foods
- Choosing a wide variety of foods to help meet your daily requirement of vitamins and minerals
- Eating at least five portions of vegetables and fruit each day (preferably 7-10)
- Including some protein in all your meals and snacks
- Having sources of mono-unsaturated and omega 3 fat regularly
- Consuming sufficient fibre to maintain a healthy digestive system and microbiome (gut bacteria)
Then there are some further recommendations that become more important for health and performance as you get older:
- Ensure that you are matching your carbohydrate intake to your training and racing needs. Too much carbohydrate, especially refined carbs and sugar, could easily lead to unwanted weight gain, particularly around the abdomen. On the other hand, insufficient carbs to support fuelling and recovery could contribute to overtraining, unwarranted weight loss and reduced performance. Include carbs (eg wholegrains, pulses, starchy vegetables or fruit) in your meals before and after every training session. If you want to go “low carb”, do this on recovery days or well away from training, eg at lunchtime where you trained before breakfast and won’t train again in the afternoon or evening.
- Increase the amount of protein in your diet to help prevent loss of lean muscle and support bone health. Collagen, a protein, is one of the fundamental building blocks of bone. Aim for around 1.4g/kg of your weight, eg 84g of protein for a female athlete weighing 60kg. This could be 20g at breakfast from yogurt, oats and nuts, 25g at lunch or dinner from a serving of meat, fish, cheese or a combination of wholegrains and pulses, and 14g from a snack such as two hard boiled eggs or a recovery drink. On your easier days, eat more protein and fewer carbs than on heavy training days.
- Don’t fear fat: it provides a source of energy for low intensity training, is important to help mitigate the effects of ageing on your skin and supports your immune system. Monounsaturated fats found in foods like olive oil and avocado, and omega 3 fats found in oily fish, walnuts, chia seeds, flaxseed and pumpkin seeds, help to maintain a healthy heart, essential to continuing in endurance sports. Some saturated fats from natural sources like butter, eggs, dairy products and meat is fine to include in your diet. The fats I would suggest avoiding, however, are the highly processed type found in vegetable oils, margarines and processed foods.
- Stay well hydrated: experiencing hot flushes/flashes and night sweats are likely to lead to you becoming dehydrated faster than usual, so I suggest you increase your fluid intake if these symptoms are an issue for you, particularly before, during and after training. You may benefit from using an electrolyte drink, containing sodium and other minerals lost in sweat, at times outside of training, eg before bed or during the night. Please read this useful blog post from precisionhydration.com about how your hydration strategy needs to change as you get older.
- Consider reducing caffeine: this doesn’t apply to all women, as our response to caffeine is at least partly genetic, but if you are experiencing hot flushes, night sweats, generally poor sleep and/or increased levels of stress/anxiety, you may find it beneficial to reduce your intake of caffeine from coffee and tea. I suggest avoiding caffeine after 2pm and starting to drink green tea. The polyphenols in green tea have been found to have several health benefits, largely due to their anti-inflammatory properties.
- Consume less alcohol: many women find that their tolerance for alcohol declines around the time of menopause and they drink less as a result. Others may turn to alcohol in response to increased stress or low mood. Decreasing alcohol intake may help to prevent hot flushes and reduce the risk of developing breast cancer (and some other cancers) in your post-menopausal years. If you do drink alcohol, support your body’s detoxification processes by including leafy green vegetables, garlic and onions in your diet. Protein foods and B vitamins from wholegrains are also needed.
An important topic: bone health
Women gradually lose bone mineral density as they age, due to reduced oestrogen levels after menopause. But this process may be more advanced in women who have a history of starting their periods after the age of 16 (late menarche) or have not had periods at all during certain times in their life (amenorrhoea). Inadequate calorie intake, disordered eating patterns or history of an eating disorder are often at the root of these hormonal disturbances. These issues are sadly not uncommon in women who have taken part in competitive sport for much of their lives, especially where a lower body weight may contribute to improved performance, eg running or cycling. Reduced bone density is recognised as part of the syndrome now known as Relative Energy Deficiency in Sport (RED-S), previously the Female Athlete Triad. Other risk factors for low bone density include a low body weight, even if menstruation was experienced, and a family history of osteoporosis. Dr Nicky Keay, a medical doctor with expertise in sports endocrinology (www.nickykeayfitness.com), suggests that “in these cases a DXA scan can be helpful to quantify bone mineral density (BMD) at skeletal sites such as femoral neck and lumbar spine.” This scan be requested via your GP. If your bone density is low, hormone replacement therapy (HRT), medication or calcium supplements with vitamin D may be recommended.
To help maintain bone density, make sure that your diet is adequate in the following nutrients:
- Calcium: useful sources are dairy products, green leafy vegetables, pulses, nuts and seeds. If you are dairy free, choose plant-based alternatives that have added calcium and increase your intake of other sources.
- Vitamin D: dietary sources include oily fish, eggs and butter. But you need sunshine to make vitamin D. Take a supplement (1000 IU daily) in the winter months and get tested at least once a year.
- Magnesium: found in plant foods, especially wholegrains.
- Vitamin K: found in green leafy vegetables.
A word on Hormone Replacement Therapy (HRT)
Although it’s not directly related to your nutrition, I asked endocrinologist Dr Nicky Keay (www.nickykeayfitness.com) to provide some up to date information on HRT, as some of you may already be taking it or considering taking it, particularly if you have low bone mineral density, but are concerned about increased risk of developing breast cancer.
Dr Keay says “The benefits of HRT are to alleviate effects of menopause: such as hot flashes, night sweats and brain fog. HRT will also prevent loss of bone mineral density which occurs in any oestrogen deficient state. Regarding breast cancer risk, according to the British Menopause Society, 23 cases of breast cancer are reported per 1,000 of the population of women aged 50-59 years over 5 years. There are an additional 4 cases in those taking HRT or the contraceptive pill. However, there are an additional 24 cases in women who are overweight and 7 fewer cases in those women taking at least 2.5 hours moderate exercise per week. So, lifestyle factors far outweigh the effects of HRT in developing breast cancer.”
She continues “There are some contraindications for taking HRT, such as a family history of breast cancer, or a history of clotting disorders. Ultimately taking HRT is an individual choice having weighed up the pros and cons. There are a range of options for HRT available on the NHS in the UK and discussing these with your GP will help in your decision process. In general terms, taking the oestrogen component of HRT via a skin route (gel or patch) reduces the dose required and therefore any side effects. The progesterone component of HRT is most effective either via tablet or coil as this is not well absorbed through the skin.”
Example: Jane *, aged 50
Jane is an ultra-runner and Ironman triathlete, who has been enjoying endurance sports since her 20s. Busy running her own business, she uses exercise as a way of helping to manage stress and takes part in several events each year at a competitive level in her age group. She is looking to maintain a reasonable endurance base and reduce the effect of aging on her performance as best she can. Jane trains for around 15 hours per week: currently 5 hours in the pool, 5 hours on the bike and 3 hours of running, plus two Bodypump® classes. She does not have a rest day.
Jane experienced disordered eating in her 20s, which continues to influence her attitude towards food. Her current diet lacks variety while being too low on calories to meet her energy needs, particularly from starchy carbohydrates and healthy fats. She does have a good intake of vegetables, fruit and plant sources of protein. She tends to snack instead of eating a proper meal in the middle of the day, and supper is often a light salad. She has been vegetarian for many years and recently decided to stop eating dairy foods for ethical reasons. She has 3-4 cups of coffee each day and little water outside of training sessions.
Jane has a family history of osteoporosis and experienced a stress fracture last year. She has suffered from iron deficiency anaemia in the last few years and had no periods for much of her adult life. She currently experiences typical menopausal symptoms such as hot flushes, night sweats and “foggy brain”. She gets around 5 hours of sleep per night due to a busy lifestyle and the demands of her training schedule, which starts with a 6am swim every weekday.
My nutritional recommendations to Jane would be as follows:
- Add more protein to breakfast, particularly after your early morning swim sessions. Greek yogurt is ideal, but a dairy free alternative would be to mix a rice or soy protein powder into porridge, as well as adding nuts and seeds. Use berries to sweeten rather than maple syrup or honey; their anti-inflammatory properties aid recovery.
- Take time for a proper meal in the middle of the day. This should include starchy carbohydrates like rice, couscous, quinoa or sweet potato if training in the late afternoon or early evening. Include both vegetables and fruit together with some protein, eg beans, chickpeas or lentils. Add avocado or olive oil to provide some mono-unsaturated fats. If having a salad, include nuts and seeds for some extra calcium and magnesium.
- Snack on natural energy bars or balls made from nuts, seeds and dried fruit before your second training session (try those available from totallywonderfuel.co.uk).
- Always include some grains or starchy vegetables with your evening meal if you have trained beforehand.
- Although you need less iron from your diet once your periods stop, it is important to avoid iron-deficiency anaemia which affects energy levels. As you do not eat red meat, have more wholegrains, nuts and pulses, alongside some fruit or vegetables as vitamin C improves absorption of iron from plant sources.
- Have a DXA scan to check bone density. If this is low, consider reintroducing dairy products from the most ethical sources you can find, to boost calcium.
- Cut back to 1 or 2 cups of black coffee per day and only drink this before 2pm.
- Try to drink water more frequently during the day and add an electrolyte tablet to the water you have by your bed during the night to replace sodium lost in night sweats before embarking on your day’s training.
I would also suggest that she gives a greater priority to sleep by dropping two of her 6am swim sessions, and takes one full rest day a week, ideally the day after a long run or bike ride. She could do Pilates or Yoga that day, which has musculoskeletal benefits.
* Not her real name
I hope that you have found this blog post useful and please do share it with other women who might benefit from my suggestions.
Jo Scott-Dalgleish BSc (Hons) is a BANT Registered Nutritionist, writing and giving talks about nutrition for endurance sport. Based in London, she also works as a Registered Nutritional Therapist, conducting one–to–one consultations with triathletes, distance runners and cyclists to help them eat well, be healthy and perform better through the creation of an individual nutritional plan. To learn more about these consultations, please visit www.nutritionforendurancesports.co.uk