Download - 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*
Mean ± SD Mean ± SD Mean ± SD
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
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)
Berries (any)
Methods
Variable n OMN VEG VGp
value
Mean ± SD Mean ± SD Mean ± SD
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
Pearson’s correlation coefficients; p<.05 is significant.
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)
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)
Walnuts or walnut oil, canola oil
Flaxseeds (ground) or flaxseed oil
Variable OMN VEG VGp
value
M ± SD M ± SD M ± SD
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
Pearson’s correlation coefficients; p<.05 is significant.
nNever or
rare freq of major ALA
Less freq of major
ALA
More freq of major
ALAF ratio
Adj F ratio
M ± SD M ± SD M ± SD
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? .
ON AVERAGE OVER THE PAST YEAR
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
Results – Comparison of Groups
*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
Pearson’s correlation coefficients; p<.05 is significant.
Results – Comparison of Groups
nNever engaging
in eating patternM ± SD
Engaging in eating pattern
M ± SD
t statistic
F ratio ANCOVA
Physical Symptoms 379
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
Physical Symptoms 383
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 – Comparison of Groups
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
Mean ± SD Mean ± SD Mean ± SD
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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