Is the Mediterranean Diet a good diet to address menopause symptoms?
What do we actually know so far? You'd be surprised!
In the UK it is now early summer with an abundance of fresh produce that can also be found in the Mediterranean region and the promise of al fresco dining (temperamental weather permitting!). With this in mind I thought it was apt to start exploring how much we really know about the Mediterranean Diet (AKA MedDiet) and menopause symptoms in particular.
What actually is the Mediterranean Diet?
We should start with a very fundamental question – What actually is the MedDiet? You might have spent some time holidaying (or even living) in countries around the Mediterranean and found that actually, they all eat quite differently! I also remember talking about this topic to a cohort of Master students and I talked about the composition of the ‘Mediterranean Diet’, when one of my students, who was Greek, piped up and said “but this is not how we eat in my country”!
Things can get really confusing when trying to define what the MedDiet is, and there is a health/nutrition a cultural traditions dimension to this.
Let’s start with cultural traditions – In 2013 UNESCO declared the MedDiet to be an intangible cultural heritage, meaning that the traditions of eating and food preparation habits are deemed to be important knowledge and skills that need to be protected for future generations. This refers in particular to Croatia, Cyprus, Greece, Italy, Morocco, Portugal and Spain, which jointly submitted the application to UNESCO.
These countries did not view their ways of eating as part of an overall Mediterranean dietary pattern until a physician named Ancel Keys highlighted the common ground of the foods and dietary habits in the Mediterranean basin. Keys was interested in this from a health perspective. He conducted a number of large-scale studies and analyses on the links between diet and heart disease between the 1950s and ‘70s. Some of these are a bit controversial these days in terms of their methods (e.g. cherry-picking data), but we are not going to get into this here! The important thing for the purpose of today’s post is that Keys deemed the traditional diet of Greece and Southern Italy as people were still consuming it in the 1960’s as extremely healthy. This was a diet low in saturated and high in unsaturated fats with olive oil being the main source of fats. He called this the Mediterranean Diet or MedDiet, which has now turned into a household phrase.
Since those early days there has been continuing interest in this way of eating and its impact on health and disease. In nutrition science we have a method called dietary pattern analysis, which means that a certain way of eating is defined by the different types of foods/food groups (and their contained nutrients) and how frequently and in which amounts these are being eaten. A dietary pattern allows for us to consider the effects of the combination of these different foods rather than focusing on a single food and or nutrient alone. The food matrix is an important concept here that in essence means that there are synergistic effects between different nutrients and that effects cannot not be explained by individual nutrients alone. The whole is greater than the sum of its parts, or 1+1 = 3.
These days there are different methods to define and characterise a particular dietary pattern when trying to understand its impact on our health. Two important methods that are often used in nutrition research are:
It has been established before the study that certain foods and dietary habits form part of a dietary pattern, such as the MedDiet, and the study uses a scoring system that checks how closely participants stick to that one. This is called a priori dietary pattern analysis. (It is decided before-hand which and how much each food someone should eat to be classed as consuming a MedDiet.)
The whole diet of the participants is being analysed, and it is found that those who are the healthiest consume certain foods and ingredients (in varying quantities) that are traditionally linked to the Mediterranean region. This is called a posteriori dietary pattern analysis. (We define the dietary pattern based on the food that study participants have actually been eating. This means that it might not be 100% like a traditional MedDiet)
I appreciate that at this stage this probably sounds rather boring and abstract, but this is quite important for later on in this post, so bear with me!
The MedDiet that we talk about today and which is consistently being voted one of, if not the best diet in the world is actually a consensus definition. Over time the amount and frequency of consumption of specific food groups traditionally consumed in the Mediterranean have shown to be beneficial for health. This means that we have a Mediterranean Diet pyramid (see below) representing this consensus, but each individual country around the Mediterranean also has their own dietary guidelines. There can be differences between individual countries in terms of specific types of food, but it is fair to say that the overarching food groups are very, very similar.
Image source: https://www.mdpi.com/1660-4601/17/23/8758
Why am I going on about this? Because within the context of research looking at the impact of the MedDiet on health (and disease) in general and on menopause-related symptoms in particular, it might matter, which form of the MedDiet has been consumed by the participants and how the study team defined a MedDiet in the first place. Remember what I said last week about a not one size fitting all approach?! The foundations of how the research was conducted and how a MedDiet was defined might matter for the individual.
What is the consensus on what a MedDiet is?
As you can see from the pyramid, this is by no means a vegan or even vegetarian lifestyle, but plant-based foods clearly form the foundation here and should be eaten at every single meal. This includes vegetables, fruits and whole grains coming from a diversity of sources, making for colourful plates. A range of cooking methods is also being used. Other plant foods, such as nuts/seeds, olives, legumes, garlic, herbs and spices should be eaten daily. The only animal-based food that is recommended for daily consumption are dairy products. In the upper part of the pyramid, we find other animal products with recommendations on the number of servings of these per week. Preference is given to fish and seafood, white meat and eggs. Red meat (for example beef, lamb, pork) and processed meats (for example ham, bacon, sausages) should be consumed far less often. Sweets are allowed, but only as occasional treats during the week, not in form of the daily chocolate bar after lunch!
The main fat is extra-virgin olive oil and as you can see the pyramid is very generous here, with the recommendation being for this to be included in each meal. This one takes many people by surprise, and they can struggle with it.
Very often we think about wine as well with regards to the MedDiet (to the delight of many people), but as there are countries around the Mediterranean basin that do not drink alcohol for cultural or religious reasons, the MedDiet pyramid makes this discretionary.
As I have said, this is a consensus and individual countries around the Mediterranean have their own recommendations that are deemed to be more in line with their specific traditions and preferences.
This could be one of the reasons why we find discrepancies in the scientific literature regarding the proportions of the different macronutrients (carbohydrates, proteins and fats) derived from these food type amounts and frequencies of consumption. Some studies therefore describe the diet as having what would be classed as high carbohydrate content with 55%, others would class the MedDiet as being of moderate carbohydrate content (40-45%) with a higher proportion of fat (which comes from healthy fats).
It can be very confusing!
What does the research tell us about the impact of the MedDiet on specific menopause symptoms?
There are a number of publications from official bodies that praise the MedDiet as a really good diet for menopause, one of these is the 2020 European Menopause and Andropause Society (EMAS) position statement on The Mediterranean diet and menopausal health. These publications look at the available scientific evidence at the time to come to an overall conclusion that they then base their recommendations on. Many of these seem to take a long-term approach when it comes to health and future health risks. The information on shorter-term menopause symptoms falls a bit short in my opinion. Of course, I 100% agree that we need to be aware of the long-term consequences of the changes to our bodies (and I spoke about this in my previous posts here and here) and be in a position to take appropriate action. However, this can be somewhat difficult if you are fighting with symptoms that are very much affecting your daily quality of life right now and that are potentially preventing you from becoming more proactive and organised when it comes to the long-term stuff.
Once I started searching for concrete evidence that can tell us more about the MedDiet and menopause symptoms, I quickly realised how frustratingly little we yet again know. This leaves us with a lot of guess work and therefore trying to work with the next best bits of available information as you will see. This is also what guidelines tend to do, if there is no information on the population of interest (in our case us peri- and postmenopausal chicks), they look at what we know in more general terms about the potential approach to a particular issue.
The MedDiet and menopause symptoms overall
The EMAS position statement that I just mentioned therefore cannot tell us much about studies available before 2020 that directly explored these pesky, annoying symptoms of the menopause.
Since the 2020 position statement a 2021 Italian cross-sectional study (meaning it took a snapshot of one point in time in the study population) described how 100 women with obesity who were in postmenopause fared by following a MedDiet with regards to menopause symptoms overall and in more specific symptom categories. The women were asked to complete a brief questionnaire asking about the daily or weekly consumption of 14 items classed as typical of or undesirable in the MedDiet The original questionnaire can be found here.
Interestingly, although 15 of the women had a (self-reported) high-adherence to the MedDiet, only 11 reported no or moderate menopause symptoms. There also seems to have been a small number of cases that did not seem to have high MedDiet adherence but nonetheless presented with no or moderate symptoms. The research team also measured other lifestyle factors, such as no smoking and engaging in physical activity and these also seemed to have a beneficial impact. We therefore need to be mindful that following a healthy diet is not the only factor that women in the menopause transition should try and integrate into their lives.
The researchers in this study also looked at individual food items in the questionnaire that they were using and found that the consumption of at least 3 150g-servings of legumes (beans, peas and pulses, fresh or dried) per week was associated with lower severity of menopause symptoms overall. This shows that whilst someone might be classed as having a high adherence to a particular diet, in this case the MedDiet, it might be very specific key ingredients that make a big difference, and if the evidence for this becomes stronger over time, we then therefore should ensure to incorporate these into our diet.
The MedDiet and hot flushes/night sweats (AKA vasomotor symptoms)
When the 2020 EMAS statement was published, they could only refer to two different studies with regards to the MedDiet and vasomotor symptoms, although the diets that were described in those two studies were strictly-speaking not true MedDiets, but classed as ‘Mediterranean-style’ or a ‘dietary pattern with high plant intake similar to the MedDiet’.
The first of these two studies was a nine-year study in Australian women published in 2013. At the beginning of data collection, the 6040 women who started the survey were between 50 and 55 years old. Participants completed a questionnaire on their dietary intake over the previous 12-months period at the very beginning and were then asked every three years whether they experienced vasomotor symptoms. Fifty-seven and a half percent said that they did. Interestingly, a small number of women included in this cohort were classed as premenopausal yet reported hot flushes and/or night sweats. This particular study did not use a particular questionnaire to assess adherence to a MedDiet, but instead used the method that grouped certain foods together to identify different types of dietary patterns, one of these called a Mediterranean style diet. Interestingly, when looking the foods that were identified as essential part of this pattern, beans were a factor, olive oil was not mentioned. Bean sprouts, which I am assuming would not spring to mind if I asked you to name one typical Mediterranean vegetable, also made it into this list. The study found that those who fit better into the Med-style diet at the beginning reported a lower occurrence of vasomotor symptoms in the years that followed. This study did not dig further into whether there might be particular food items that might be specifically linked to this, although it did highlight that intake of more fibre and of low-glycaemic index foods might play a role. It is fair to say that in this case olive oil was not on the radar, and it is not clear whether any of the women involved consumed this. Another weakness of this study is as well that we do not know whether dietary habits might have changed over a nine-year period. The researchers also highlighted that the women eating these types of foods also had healthier lifestyles overall.
The second study cited by EMAS was large-scale trial conducted at a similar time in the US which included over 6000 postmenopausal women being asked to follow a specific diet. I think it is worth highlighting here that whilst the dietary prescription did indeed include plenty of fruits, vegetables and wholegrains, participants were also advised eat a low-fat (20% fat) diet, which is unlike the habitual MedDiet. Those who experienced mild vasomotor symptoms and followed the prescribed diet were more likely to reduce these after 12 months, but this was not the case for those with moderate or severe symptoms.
Whilst I am of course pleased for any woman who manages to reduce or even eliminate hot flushes and night sweats, as a nutritionist I am somewhat frustrated that these two studies are being quoted as evidence that the MedDiet is good for vasomotor symptoms. This is because I feel like these two dietary patterns were comparable to the MedDiet consensus in some ways but not in others, namely with regards to olive oil (and subsequent intake of beneficial fats). If you were to eat a more traditional MedDiet would you therefore be able to achieve the same results? In my eyes this is a bit like comparing apples with oranges.
A more recent Australian cohort study undertaken in 207 participants in perimenopause or early postmenopause, which used a validated questionnaire including foods and dietary habits traditional to the MedDiet (including olive oil!), did not find any links between adherence to the MedDiet and vasomotor symptoms. Although it is fair to say that not many participants actually really followed the MedDiet. This might have had an impact on the findings. We don’t know.
At this stage it might be worth adding that a number of studies looking at diet and vasomotor symptoms concluded that weight loss in women carrying excess weight had a greater impact on the reduction of severe hot flushes or night sweats that any healthy dietary pattern itself.
The MedDiet and sleep
We do not seem to have studies that focus on adherence to a MedDiet and impact on sleep in peri- or even postmenopausal populations. Studies in other populations or where participants also include men and had a wider age range overall seem to show promising results, although some of the findings can be inconsistent.
The analysis of the large-scale US National Health and Nutrition Examination Survey 2007-2008 that did look at diet and sleep duration and specifically reported on peri- and postmenopausal women, did not look at the MedDiet in particular but at specific foods instead. Unfortunately, the perimenopausal women got lumped in with the pre-menopausal women, i.e. no consideration could be given to the fact that one of the more common perimenopause symptoms are sleep disturbances! The questionnaire only asked whether participants had had a period in the previous 12 months and therefore no further differentiation was possible before postmenopause. Consumption of fewer foods and lower intakes of some particular macro- and micronutrients were linked to sleep lasting less than five hours per night. Consuming a MedDiet with its diversity of foods could therefore potentially ensure sufficient intakes of namely carbohydrates, protein and some of the B-Vitamins and the minerals, which this analysis found to be important.
The MedDiet and cognition
Surprise, surprise! At this point in time scientific studies looking at potential links between the MedDiet and cognitive menopause symptoms, such as brain fog in women still in the menopause transition, don’t seem to exist either. There are some studies in postmenopausal women, and the overall conclusion seems to be that studies of shorter duration did not find any or only limited beneficial effects, whilst studies of longer duration did.
We have plenty of evidence out there that in ageing and older adults the MedDiet and individual components (such as fish, olive oil, fibre) can have a positive impact on brain health, memory and learning. The MedDiet is therefore being recommended by many health and nutrition organisations and professionals as a long-term health strategy. For the purpose of this particular section, where I focus on the improvement of brain fog, we simply don’t know whether the MedDiet can help. The evidence one way or another is just not there.
The MedDiet and joint and muscle pain
Unfortunately, this is also an area that has not been widely researched and what little there is has focused on postmenopause and none of the nutrition studies conducted seem to have used a MedDiet. Studies have investigated the links between the MedDiet and arthritis, but this is a medical condition, not a symptom, such as the joint and muscular pain that can occur during the menopause transition.
The MedDiet and mood, depression and anxiety
Whilst there are a number of studies investigating the impact of following a MedDiet on mood, anxiety and depression, yet again we hardly have any research on women in the menopause transition in particular.
The Italian study in 100 postmenopausal women that I mentioned earlier also looked at psychological symptoms and found that consumption of at least 4 tablespoons of (extra) virgin olive oil per day reduced psychological symptoms (depression, irritability, anxiety, physical and mental exhaustion). There were no links between the MedDiet overall and psychological symptoms, however.
Overall, it can be said that we do have some evidence that the MedDiet can have a beneficial effect on mood, anxiety and depression but there is a distinct lack of scientific evidence whether this is also the case for women going through the menopause transition in particular.
The MedDiet and weight or body composition
Analysis of the UK Women’s Cohort Study found that over a four-year period high adherence to a MedDiet (again legumes but not olive oil as a food item were included in the scoring system that was used) in postmenopausal women was associated with lower gains in waist circumference and a lower risk of developing a waist circumference size that increases the risk of cardiometabolic diseases. In this one women also only reported their food intake at the beginning of the study, and it is therefore not clear whether their diet might have changed over time. Furthermore, participants supplied their own measurements, these were not taken by independent researchers.
A 2018 study of 481 postmenopausal women in Greece assessed self-reported adherence to the MedDiet over the previous 12-months period, using another scoring system based on a range of foods and dietary habits consistent with a healthy Mediterranean Diet. The researcher wanted to find out whether there is a link between consuming a MedDiet and BMI, waist circumference and waist-to-height ratio, the latter being a measure to see whether someone is too large around the waist for their height. This is indicative of increased health risks. Women had been in postmenopause by an average of nearly 9 years at the time the data was being collected. The analysis seems to indicate that those consuming a MedDiet as such were not much different to the rest of the cohort in terms of BMI and waist. They did however identify a more specific dietary pattern where high consumption of legumes and unrefined cereals (both of which are important foods in a traditional MedDiet) was linked to lower BMI, lower waist circumference and low waist to height ratio. Unfortunately, we do not know what ‘high consumption’ means, so I cannot comment any further on this.
It is also worth noting that a number of studies that prescribed the MedDiet to menopausal women in order to reduce weight, recommend calorie reduction and/or physical activity as well. In these cases, it is hard to determine whether the MedDiet alone would have had the desired effect.
Overall conclusion
As I said before it can be somewhat frustrating trying to untangle the potential evidence that we currently have regarding the MedDiet and whether it might help to address symptoms of the menopause that affect our daily quality of life acutely.
Probably the first thing to say is that there is simply hardly any evidence out there that is relevant to us as women in the menopause transition to begin with! There are some studies looking at the MedDiet and postmenopausal women, but often these are conducted in older cohorts that are most likely in the latter stages of the postmenopause when oestrogen and progesterone levels have already flat-lined. There are literally no studies conducted in women that are right in the thick of the menopausal transition!! Why is this? My guess is that we are still classed as being too messy in terms of our erratically fluctuating hormone levels, which makes it quite hard to determine potential effects. We very well know from our lived experience how much havoc this can cause! Researchers traditionally have therefore shied away from us. We do need more studies!
I am afraid to say that very often the studies conducted are of what the scientific community would class as medium to low quality. Some of the issues being measurements and adherence being self-reported by women and studies observing women rather than giving them very specific study conditions. All this makes findings from these studies less reliable.
Please don’t get me wrong! We do have a lot of evidence that the MedDiet is a very healthy dietary pattern with respect to long-term health conditions that impact women, especially postmenopause, such as cardiovascular health, bone health, brain health to name a few. For the purpose of long-term health, it is a pattern and lifestyle that is well worth adopting if you feel that you are able to do this. (Although there are other dietary patterns out there that are also beneficial in this regard and might suit some people better. More on these in future posts.) However, my post today was focused specifically on the bothersome, clearly felt menopause symptoms.
Maybe the best solution to this dilemma is to adopt a MedDiet anyway and if you can accept that this might not do much for your immediate symptoms (but you might be amongst the lucky ones where it works – You never know!!) you can take solace in the knowledge your future self will thank you for it. Another thing to bear in mind is that there were certain foods in some studies that seemed to have beneficial effect in those who clearly consumed them! Bring on the beans and stock up on some good-quality olive oil!
Your call to action this week
This is therefore my call to action for you this week. Let’s start with the legumes, which the consensus of the MedDiet recommends should be consumed every single day. (Although some of the scientific studies show that a few times a week is already very beneficial!) How could you integrate these into your daily diet? Where could you add them to dishes? (Maybe a handful thrown onto a summer salad? Or a nice chilli that can keep the whole family happy? That chickpea hummus that you could have as a snack with vegetable sticks or wholegrain crackers in work?) In most households we tend to not eat enough legumes, let’s try and change that!
Do I hear you say - Eating legumes every day? Are you crazy? Okay – remember what I said about steps and about not trying to be perfect? Start there! If you don’t eat legumes at all, start eating them. If you eat them sometimes, start eating them more often! The research does tell us that at least a few servings per week can make a difference.
Your long-term health will benefit and hopefully, you will see a positive impact on your menopause symptoms!
See you next week!