dietary pattern and lifestyle factors

Dietary Pattern and Lifestyle Factors Associated with Menopausal Symptoms

Maggie Chung, Alyssa Claxton, Gretchen Gibbons, Stephanie LaPlant, Taylor Wang, Lauren Zuro

Advisor: Bonnie Beezhold, PhD, MHS, CHES

Introduction

Research Question • Do women on a plant-based diet have fewer menopausal

symptoms? Are there other lifestyle factors that also impact menopause?

Hypothesis• Women who are vegetarians or vegans will report fewer

symptoms compared to those who are omnivores.

(Beezhold, Radnitz, Rinne, DiMatteo, 2015)

Overview - Menopause

• Menopause overview

• Menopause symptoms

• Hormone replacement therapy

(Grant 2015, Opatryn 2008, Shumaker 2003 )

Overview-Research Studies

• Fewer menopausal symptoms associated with higher intake of whole grains, F&V in Chinese postmenopausal women. 1

• Decreased menopausal symptoms associated with high fiber intake in women treated for breast cancer. 2

• Plant-based diets are associated with favorable metabolic profiles in pre- and post-menopausal women. 3

• Vegan diet was associated with reduced HDL-C level in pre- and post-menopausal women. 4

1. Liu, 2015; 2. Gold, 2006; 3. Karelis, 2010; 4. Huang, Y.W. 2014

Study Objectives

• To investigate whether dietary patterns and behaviors as well as specific foods were associated with symptoms that occur during menopause in aging women.

• To investigate whether demographic and lifestyle factors were related to menopausal symptoms.

Methods – Study Design

• Cross-sectional survey study

• Online delivery through convenience sampling using SurveyMonkey

• Eligibility requirements• Females, ages 45-80 years old• Willing to complete an online survey

Methods – Participant Recruitment

Methods – Survey

• Survey completion

• Survey components• Demographics• Lifestyle factors

Methods – Survey

• Frequent urination• Involuntary urination when

laughing or coughing• Change in sexual desire• Flatulence or gas pains• Aching in muscles and joints• Feeling tired or worn out• Difficulty sleeping• Aches in back of neck or head• Decrease in physical strength• Decrease in stamina• Vaginal dryness during

intercourse• Avoiding intimacy

• Hot flashes• Night sweats• Sweating• Being dissatisfied with personal life• Feeling anxious or nervous• Poor memory• Accomplishing less• Feeling depressed, down, or blue• Being impatient with others• Feelings of wanting to be alone• Increased facial hair• Changes in skin• Feeling bloated• Backaches

• Severity of menopausal symptoms; Menopause-Specific Quality of Life questionnaire (MENQOL)

Methods – Survey

• Which of the following foods do you include in your diet (at least monthly)?• Meat (beef, pork, lamb); chicken or turkey; fish or

shellfish; eggs; dairy foods; none

• Diet questions: foods, food groups, nutrients• Fruits, vegetables, beverages, omega-3 fatty acids

Methods – Survey

FRUITS AND VEGETABLES

Never or less than 1X a mo

(1)

1-3XPerMo(2)

OnceA

Wk(3)

2-4XPerWk(4)

5-6XperWk(5)

Oncea

Day(6)

2-3X per day(7)

4-5X per day(8)

6+X per day(9)

Apricots, plum, pear, apple

Berries (any type)

Citrus fruits (oranges, grapefruit, tangerines)

Grapes

Pineapple, papaya, mango (fresh)

Broccoli, Brussels sprouts, cauliflower, kale, mustard greens, radish, turnips

Orange vegetables (carrots, sweet potatoes, butternut squash, pumpkin)

Spinach, Swiss chard, salad greens

Survey Validity & Reliability

Validity• Incorporated validated scales

• Exercise and social support• Menopause-specific Quality of

Life questionnaire (MENQOL)

• Use of clear and appropriate language for survey questions

• Pilot testing and feedback

• Online delivery promoted large geographic sample.

Reliability

• Potentially unclear questions were eliminated

• Validated scales showed strong internal consistency and test-retest reliability• MENQOL – Cronbach

alpha coefficient = 0.93 (0.81 to 0.89)

Methods - Statistical analysis

• Correlational, differential analysis• Parametric statistics• Descriptive statistics• Pearson’s correlation coefficients and multiple

linear regression; Chi square tests• Independent t tests, ANOVA, ANCOVA• Significance - p < .05; SPSS version 23

Results

Menstrual Status

Postmenopausal 77.8%n=383

Peri-menopausal

22.2%n=109

Diet Pattern

OMN55.7%n=248

VG27.6%n=123

VEG16.6%n=74

Vegetarian Types• Semi-vegetarian• Pescatarian

• Ovo-vegetarian• Ovo-lacto-

vegetarian• Lactovegetarian

Canada 4.0%n=18

Other 4.3%n=19

United States91.7%n=408

Location by Country

Other 4.0%n=18

Ethnicity

White 89.4% n=398

Hispanic 3.1%n=14

Black 1.3%n=6

Asian 2.0%n=9

Normal43.9%n=168

Overweight23.0%n=88

Obese33.2%n=127

Body Mass Index (BMI)

Education

Variables nOMN

n=248VEG n=74

VGn=123

Teststat

pvalue

Mean ± SD Mean ± SD Mean ± SD

Age 44559.17

± 7.85a

58.35 ± 7.57b

55.15 ± 6.29ab F=12.28 <0.001

Country (US/non-US)

445 243 / 5ab 69 / 5a 96 / 27b X2=57.94 <0.001

Ethnicity (white/other)

445 227 / 21 65 / 9 106 / 17 X2=2.73 0.255

Education (yrs beyond HS)

4457.46

± 3.638.03

± 3.776.96

± 3.39F=2.09 0.125

BMI 39529.02

± 7.12ab

25.89 ± 5.77b

26.54 ± 6.32a F=8.23 <0.001

Same letters differ significantly

Population Characteristics by Diet Type

Principle component analysis results:

Component 1: Physical symptoms (17)

Component 2: Mental symptoms (6)

Menopausal Symptoms

Associations of Diet Type with Symptoms

Variables NPhysical

symptoms Mental

symptomsr / p value r / p value

Diet type (Omn/Vg) 371 -0.122 / 0.010 0.057 / 0.233

Total vegetables 432 -0.181 /<0.001 -0.142 / 0.003

Total fruits 431 -0.099 / 0.040 -0.100 / 0.039

Total flesh foods 431 0.173 /<0.001 -0.033 / 0.490

Beef 422 0.157 / 0.001 0.009 / 0.858

Total dairy foods 430 0.196 /<0.001 0.071 / 0.141

Total eggs 431 0.115 / 0.018 -0.043 / 0.378

Pearson’s correlation coefficients; p<.05 is significant

Multivariate Analysis – Predictors of Menopausal Symptoms

PHYSICAL symptoms MENTAL symptoms

Variable β* p value

Variable *β p value

Age -0.234 <0.001 Social support -0.246 <0.001

Vegan diet (N/Y) -0.181 0.002 Age -0.201 <0.001

BMI 0.157 0.004Berries intake freq

-0.128 0.009

Sleep hrs/night -0.106 0.040 Sweets intake freq 0.117 0.015

Sweets intake freq 0.103 0.057 Sleep hrs/night -0.096 0.046

Total exercise -0.088 0.107 Total exercise -0.086 0.090

BMI 0.083 0.097

R2 0.158 R2 0.187

Correlates with p values < .025 included in models. *Betas are standardized.

Comparison of Symptoms by Diet Groups

Symptoms n OMN n=248

VEGn=74

VGn=123

F ratioAdj

F ratio

Mean ±SD Mean ±SD Mean ±SD

Physical symptoms

445 40.46

± 17.83a

41.12± 17.78b

33.26± 14.80ab 8.33** 12.83**1

Mental symptoms

44513.64

± 6.3215.35± 7.97

13.87± 7.27

1.78 3.52*2

** p<0.001, *p<0.05; ANOVA - same letters differ significantly. 1 ANCOVA adj means: 41.62a, 40.63b, 31.83ab, pƞ2= 0.062. 2 ANCOVA adj means: 14.12, 15.40b, 12.87b, pƞ2=0.016.

Vegan diet is associated with lower severity of physical menopausal symptoms; vegans reported lower symptom severity than those who ate animal foods.

• Confirmed previously mentioned studies. 1, 2

• Vegan diet had highest dietary fiber intake vs omnivorous diet. 3

1. Liu, 2015; 2. Gold, 2006 3. Clarys, 2014

Discussion

Sweets intake

• Excess sugar consumption is linked to cell aging, negative health ailments 1-3

• Excess sugar consumption is linked to deficiencies in memory, cognitive health, and affects biological aging4,5

1. Melton, 2000; 2. Mikulikova et al 2008; 3. Crane et al 2013; 4. Cassidy et al 2010

• NIH Dietary Questionnaire II

We are interested in whether you consume any of the following specific foods or beverages and how frequently you do so.

ON AVERAGE OVER THE PAST YEAR

Never or less than

once a month

(1)

1-3 per month

(2)

Once

a week

(3)

2-4 per

week(4)

5-6 per

week(5)

Once a day

(6)

2-3 per day(7)

4-5 per day(8)

6+

per day(9)

Sweets (pastries, cakes, cookies, brownies, candy, etc.)

Soft drinks (sugar-sweetened, non-diet)

Methods

Variable n OMN VEG VG p value*


Sweets 4323.84

± 1.81a

3.44± 1.87b

2.64± 1.52ab < .0011

Soda 4241.61

± 1.28a

1.25± 0.89b

1.13± 0.55ab < .0012

* ANOVA; groups with same letters differed significantly.1 F = 18.8, pƞ2 = .08. 2 F = 8.8, pƞ2 = .04.

Results – Intake of Sweets / Soda

Variables nPhysical

symptoms(r/p)

Mental symptoms

(r/p)

Sweets intake 432 .167 / .001 .130 / .007

Soda intake 424 .118 / .015 .102 / .035

Total sweets intake frequency

423 .179 / .001 .139 / .004

Results – Associations

Pearson’s correlation coefficients; p<.05 is significant.

Results – Group Comparison

Total sweets variable

nNever or

rarelyeat sweets

Less frequentlyeat sweets

More frequentlyeat sweets

F ratio Adj F ratio

M ± SD M ± SD M ± SD

Physical Symptoms

37737.77 ±17.55a

35.53 ±13.98b

45.46 ±20.47ab 11.33* 8.82*1

Mental Symptoms

42313.73 ±

7.11a

13.06 ±5.99b

16.38 ±7.63ab 8.07* 7.21*2

* p < .01; same letters differ significantly. 1 Adj means: 36.37, 35.64, 44.51, p 2 = 0.045. ƞ2Adj means: 13.63, 13.26, 16.17, p 2 = 0.033ƞ

Eating sweets was related to increased severity of menopausal symptoms; females eating sweets more frequently had higher symptom severity than those who never or rarely ate sweets.

• Intake of sweets was positively associated with the risk of onset of menopausal symptoms5,6

• Frequency of sweets intake was associated with chills7

Discussion

5. Sabia et al 2008; 6. Herber-Gast & Mishra, 2013; 7. Ishizuka, 2008

Background – Berry Intake

• Foods that contain phytoestrogens act as antioxidants which may relieve menopausal symptoms 1

• Higher intake of flavonoids at midlife is associated with greater wellbeing in the elderly 2

1. Moreira et al, 2014; 2. Samieri et al, 2014

https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0CAcQjRxqFQoTCLj8-93ntsgCFYyrgAodeq0KUQ&url=http://www.healthy-foodforliving.com/31-superfood-for-a-healthy-and-long-life/&psig=AFQjCNGzw7xQmQCJ0pOvSyDIBYisTt1KMg&ust=1444528854129434



Never or less than

once a month

(1)

1-3 per month

(2)

Once

a week

(3)

2-4 per

week(4)

5-6 per

week(5)

Once a day

(6)

2-3 per day(7)

4-5 per day(8)

6+

per day(9)

Berries (any)

Methods

Variable n OMN VEG VGp

value


Berry intake frequency

419 3.72 + 1.65a 3.86 + 1.66b 4.54 + 1.87ab <.001*

Results – Intake of Berries

* ANOVA, F ratio = 9.036, pƞ2= 0.042; groups with same letters differed significantly.

Results – Associations

Variables nPhysical

Symptoms(r/p)

Mental Symptoms

(r/p)

Berry intake frequency

119 - .208 / .000 - .188 / .000


Results – Comparison of Groups

* p < .05; groups with same letters differ significantly. 1 ANCOVA adj means: 43.41, 38.41, 36.61, pƞ2 = 0.022 ANCOVA adj means: 15.76, 13.88, 12.87, pƞ2 = 0.02

Never or rarely

eat berries

Eat berriesweekly

Eat berries

daily

F ratio

Adj F ratio

n M ± SD M ± SD M ± SD

Physical Symptoms 373

44.84 ±21.26a

38.38 ±15.83

35.14 ±15.56a 7.39* 3.78*1

Mental Symptoms

42016.15 ±

7.85a

13.80 ±6.73

12.64 ±5.97a 6.72* 4.93*2

Discussion

Eating berries was related to decreased menopausal symptoms; females eating berries daily had lower symptoms than those never or rarely eating berries.

• Decrease in estrogen during menopause increases oxidative stress 3-4

• Berry supplementation resulted in significant improvement in symptoms5

3. Manach et al, 2004; 4. Doshi et al, 2013; 5. Schrager et al, 2015

• Omega-3 fat1 supplementation decreased depression symptoms and hot flash frequency 2

Background – Omega-3 Fats

Plant Based

Animal Based

1. Mozaffarian et. al, 2011; 2. Freeman et. al, 2011

Methods• NIH Dietary Questionnaire II format; Omega-3 questionnaire

(Sublette et al, 2011)



Never or less than

once a month

(1)

1-3 per month

(2)

Once

a week

(3)

2-4 per

week(4)

5-6 per

week(5)

Once a day

(6)

2-3 per day(7)

4-5 per day(8)

6+

per day(9)

Walnuts or walnut oil, canola oil

Flaxseeds (ground) or flaxseed oil

Variable OMN VEG VGp

value


Walnuts, canola oil

2.53 ± 1.55(n=238)

3.04 ± 1.78(n=71)

3.11 ± 1.86(n=116)

.0031

Flaxseed, flaxseed oil

1.92 ± 1.58(n=239)

2.51 ± 1.80(n=73)

3.44 ± 2.01(n=117)

<.0012

1ANOVA, F ratio = 5.86, ƞ2= 0.027; 2ANOVA, F ratio = 29.56, ƞ2= 0.122

Results: Comparison of Groups

Frequency of major ALA sources n

Physical Symptoms

(r/p)

Mental Symptoms

(r/p)

Walnuts 426 - .066 / .172 - .096 / .048

Flaxseeds 430 - .127 / .008 - .088 / .068

Total major ALA sources

424 - .132 / .007 - .120 / .014

Results: Associations with Symptoms


nNever or

rare freq of major ALA

Less freq of major

ALA

More freq of major

ALAF ratio

Adj F ratio


Physical Symptoms

42440.37 ±18.16a

39.57 ±17.46

35.40 ±15.87a 3.21* 1.56

Mental Symptoms

42414.95 ±

7.25a

14.13 ±7.08

12.63 ±6.18a 3.96* 3.47*1

* p < .05; groups with same letters differ significantly. 1 ANCOVA adj means: 14.94, 13.94, 12.86:, pƞ2= .016.

Results: Comparisons of Groups

Discussion

Eating major ALA sources was associated with decreased menopausal symptoms; those who ate them more frequently vs never or rarely reported less mental symptom severity.• Vegetarians reported better mood and higher PUFA than

omnivores 3

• High ALA intake in vegetarians lowers the LA/ALA ratio 4

3. Beezhold et al, 2010; 4. Sanders, 2009

Background

• Diets rich in monounsaturated fatty acids improved the quality of life for postmenopausal women.1

• Fast food consumption, starting in adolescents, among those following a Western diet have a stronger association with overweight/obesity, and poor dietary outcomes. 2

1. Anderson-Vasquez et. al, 2015; 2. Poti et. al, 2014

Methods

Which of the following best describes the type of meals you most frequently eat? .


Never or

rarely

2-4 times

per month

2-3 times

per week

4-6 times

per week

Once per day

2-3 times

per day

Convenience/Frozen Food

Home Cooked Meals

Eat out (fast food)

Eat at a full service restaurant

Eating habits OMN VEG VG p value*

Eat home-cook meals 241(n=243)

71(n=71)

121(n=122)

.745

Eat convenience foods

105(n=240)

23(n=72)

46(n=115)

.199

Eat fast foods 139(n=240)

29(n=72)

27(n=117)

.0001

Eat at full service restaurants

213(n=245)

58(n=72)

82(n=121)

.0022


*Chi-square; p<.05 is significant. 1X2(10, N= 429)= 44.06. 2X2(8, N= 438)= 24.41.

Results – Associations of Eating Patterns

Eating behavior patterns

nPhysical

symptoms(r/p)

Mental symptoms

(r/p)

Eat home-cooked food 437 -.041 / .387 - .017 / .729

Eat convenience/ frozen food

428 .127 / .009 .102 / .035

Eat fast food 430 .179 / .000 .132 / .006

Eat at full-service restaurants

439 -.004 / .932 - .120 / .012



nNever engaging

in eating patternM ± SD

Engaging in eating pattern

M ± SD

t statistic

F ratio ANCOVA


37.03± 16.44

41.77± 18.57

-2.95* 2.92

Mental Symptoms 428

13.44± 6.92

14.87± 6.78

-2.29* 2.14


35.85± 16.49

43.31± 18.11

-4.11* 8.15**1

Mental Symptoms 430

13.24± 6.53

15.08± 7.32

-2.91* 7.35**2

Independent t test; p < .05; ** p < .01; groups with same letters differ significantly. 1 ANCOVA adj means: 36.95, 41.97, pƞ2=0.045. 2ANCOVA adj means: 13.30, 15.01, pƞ2=0.017.

Conv

Foo

ds

Fast

Foo

ds

Discussion

Eating convenience or fast food is related to an increased severity of menopausal symptoms, and those who consumed fast foods reported more severe symptoms than those who did not.

• Those who ate fast food had less healthy dietary intake overall3

• Older women who did not eat fast foods reported fewer and less severe symptoms4

• Fast food frequency by women were lower in vitamin A, carotenes and vitamin C density5

3. Wilcox et al, 2013; 4. Moore et al, 2009; 5. Bowman, 2004

Background- Physical Activity

• Regular aerobic exercise is associated with improved menopause symptoms, including anxiety and depression 1

• Physically inactive menopausal women have more depressed mood, memory/ concentration problems, vasomotor symptoms than physically active women 2

• “Considering a 7-day period, how many times on average do you do the following kinds of EXERCISE for more than 15 minutes during your free time?” (Responses 0-20x/week)

• Total exercise: (Mild X 3) + (Mod X 5) + (Stren X 9)

Methods

Strenuous(heart beats rapidly)

• jogging, hockey, soccer, basketball,

cross-country skiing, judo, roller blading, vigorous

swimming, vigorous long

distance cycling

Moderate (not exhausting)

• fast walking, baseball, tennis, easy bicycling, volleyball, easy

swimming, alpine skiing, dancing

Mild(minimal effort)

• such as golf,

bowling, easy

walking

OMNn=248

VEGn=151

VGn=123

p value

Means ± SD Means ± SD Means ± SD

Mild 4.88 ± 3.13 5.22 ± 3.30 5.41 ± 3.54 0.314

Moderate 3.10 ± 2.36 3.35 ± 2.42 3.67 ± 2.86 0.127

Strenuous 1.61 ± 1.31a 2.28 ± 1.84 1.92 ± 1.71a 0.0031

Total 45.11 ± 22.98a 55.04 ± 28.36 49.68 ± 25.51a 0.0022

ANOVA test; groups with same letters differ significantly.1 F ratio= 6.3, ƞ2= 0.18. 2 F ratio= 6.5, ƞ2= 0.28


Results - Associations with Symptoms

Variable NPhysical

SymptomsMental

Symptoms

r/p value r/p value

Mild 459 -.086 / .066 -.032 / .490

Moderate 459 -.166 / .000 -.175 / .000

Strenuous 459 -.109 / .020 -.073 / .116

Total 459 -.177 / .000 -.140 / .003Pearson’s correlation coefficients; p<.05 is significant.

nLow

activity Medium activity

High activity

F ratio

AdjF ratio


PhysicalSymptoms

26841.18

± 17.4139.95

± 18.1934.64

± 15.93 8.33 2.11

MentalSymptoms

26815.10

± 7.13a

14.64± 6.87 b

11.81± 6.01ab 8.97* 4.62*1

PhysicalSymptoms

409 14.75± 6.75a

14.66± 7.13

12.79± 6.59a 3.96* 5.07*2

MentalSymptoms

40942.40

± 18.33abc

39.78± 17.04abc

34.95± 16.52abc 7.43* 3.26*3

ANOVA, p<.05; groups with same letters differ significantly. 1ANCOVA adj means: 14.88 , 14.77, 11.92, pƞ2= 0.038; 2ANCOVA adj means: 14.82 , 14.67, 12.71, pƞ2= 0.022. 3ANCOVA adj means: 41.12, 40.03, 35.91, pƞ2= 0.016.

Results- Comparison of Groups

Tota

l Ex

Mod

erat

e Ex

Discussion

Moderate exercise (and total) was associated with lower severity of menopausal symptoms, and those who reported not engaging in moderate exercise had more mental symptoms.

• Those who reported less total exercise had more menopausal symptom severity than those who reported more total exercise.

• Association of aerobic exercise and fewer physical and mental symptoms in menopause studies 3,4

3. Kim, 2014; 4. Gutierrez, 2012

Key Findings

• Vegans report lower severity of physical menopausal symptoms than omnivores

• Multiple factors were associated with lower severity of menopausal symptoms

Decreased Symptom Severity Increased Symptom Severity

Vegan Diet Age BMI

Sleep Hours Social Support Sweets, Fast & Convenience Foods, Grapes, Coffee, Milk, Orange/Grape Juices, Soda,

Green/Black Tea, Dark Chocolate, Beef

Physical Activity Education

Berries, Tree fruit, Spinach, Pomegranate Juice, Plant Omega-3

Strengths and Limitations

• Strengths • Large sample size• Exploration of a topic

with limited previous research

• Included many data points

• Limitations• Length and personal

nature of questions• Self-reported data• Retrospective• Food frequency only• Low generalizability• Correlational study

Conclusion

• A plant-based diet may ease the menopausal transition

• Being physically active and healthier eating habits (“slow” food) may also be beneficial

Images courtesy of sirrichards.com and tattly.com

Future Research

• Experimental study with vegan vs omnivore diet in menopausal women

• Duration of adherence to a vegan diet in menopausal women

• Investigation of premenstrual symptoms and plant-based diet

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