As discussed in my previous blog post, Is under-fuelling making us anxious? How dieting during menopause might be the straw that breaks the camel's back, seeing the copious amount of fat loss programmes and the patriarchal narrative whereby a woman’s worth is measured by how much she weighs, I despair.
That narrative not only keeps us in chains of dieting obsession and away from doing things that we love (how many times have I heard women saying: ‘I’ll be happy/I’ll be able to start this project etc. as long as I lose X amount of weight’); but it also makes us miserable, feeling worthless and sick. Yes, sick!
The moment we hit perimenopause, all the years of under-fuelling literally smack us in the face.
Women are fragile.
Now, before you jump to conclusions, let me rephrase that statement. Women’s hormones are fragile.
The red flags of inadequate nutrition can be seen back in our reproductive years and even in pre-puberty (10 is the average age in the UK when children start dieting!).
The common red flag of Low Energy Availability is menstrual dysfunction or amenorrhea (lack of periods) altogether. Unfortunately, in many cases it is difficult to diagnose it as a lot of young females are put on an OCP (oral contraception pill) that does not regulate their menstrual cycle (as so many people still do believe!) but instead masks the symptoms and leads many women to believe that everything is fine.
When we have a low energy intake, this means we also have a low micronutrient (vitamin/mineral) intake. This means that we are not getting adequate building blocks for proper bone formation in addition to having low estrogen (related to the above-mentioned menstrual dysfunctions).
The common misconception (or lack of understanding) is that low estrogen is only associated with menopause.
But it is not the case. There are countless reasons why that can happen: genetic conditions, autoimmune disease, thyroid disfunction, but under-fuelling, disordered eating, even too much exercise can lead to low levels of estrogen and long-term health consequences – this is serious people! Cardiovascular death rates are increasing in premenopausal women (estrogen helps to keep blood vessels healthy as it is a potent vasodilator via nitric oxide production).
And the wave of osteoporosis due to long-term low level of estrogen: when do you think it starts? For those who food deprive, long before menopause!
For a woman who spent a lifetime dieting, over-exercising or simply depriving the body of adequate nutrition, perimenopause is often the time when the body says “no more”. The body is done. There is no more cheating, enough, basta! The flatlining hormones on top of years of Low Energy Availability might be just what breaks the proverbial camel’s back. (Please refer to previous blog post on that.)
Okay, so let’s look in a bit more detail about anxiety.
In the context of what has just been said, what do you think happens to an under-fed brain? Is it happy? Is it thriving?
There is absolutely no doubt that our en masse dieting and years of under-fuelling plays a vital part in the lack of our wellbeing. But this is not the only reason why there’s an influx of anxiety as we go through this transition.
The symptoms of perimenopause are tightly linked to our menstrual cycle. As we get closer to menopause, more and more cycles become anovulatory (menstrual cycle where ovulation does not occur) and this means that we do not produce progesterone. The lack of progesterone has a direct effect on our mood, as it is there to produce a calming, anti-anxiety effect on the brain and may also enhance memory function (brain fog anyone?). Progesterone also regulates the Heart Rate Variability (that affects our Autonomic Nervous System).
When we do not ovulate, and the progesterone is missing – we are prone to be in the Sympathetic Drive which makes it harder for us to relax or fall asleep. It goes without saying that when our sleep is affected, our mood is affected too, making us more disposed to mood swings and anxiety.
It seems that it would be in our best interest to delay the onset of the natural menopause. However, there is not yet enough evidence to conclusively agree on the course of an action. Nevertheless, the caloric restriction particularly during early childhood decreases the age of natural menopause as evidenced by the famous 1944-1945 Dutch famine.[1]
High intake of fruits and vegetables prolongs the reproductive lifespan because of the presence of antioxidants that counteracts the adverse effects of reactive oxygen species on the number and quality of ovarian follicles. [2]
Another reason why under-fueling intensifies anxiety is the gut-brain axis which is a direct link between the state of your gut microbiome and your mental health.
Dysbiosis of the gut is associated with central nervous system disorders (i.e., autism, anxiety-depressive behaviours) and functional gastrointestinal disorders (in particular, irritable bowel syndrome) which goes without saying, does not improve our mood in the slightest.
But it is not just the total “calories in – calories out” that this whole thing is about.
You might be consuming enough calories per day but perhaps have a tendency to skip breakfast and withdraw food till the late hours of the afternoon; bookend your meals; or simply have long periods of going ‘on empty’ during the day.
Women perform much MUCH better in a fed state, and this is even more important when we reach perimenopause. Why? For starters, long periods of running on empty elevates your cortisol levels and pushes you towards the Sympathetic Drive. The body ends up in a highly stressed state between those
meals.
Skipping meals also has an impact on insulin sensitivity (which is even worse for perimenopausal woman due to flatlining estrogen, and its effect on blood sugar levels). Symptoms of poor glycemic regulation have been shown to closely mirror mental health symptoms, such as irritability, anxiety, and worry. This should come as no surprise, as the brain runs primarily on glucose.[3]
In fact, some studies show that inconsistent blood sugar levels correlate with mood swings.
One study found that among diabetics, higher blood glucose, has historically been associated with anger or sadness, while blood sugar dips, hav been associated with nervousness.[4]
What about perimenopause? We talked a lot about low estrogen but actually, the early stages of perimenopause (provided you do not have a long history of amenorrhea) is associated with estrogen dominance and its relation to a lack of progesterone during the anovulatory cycles. As estrogen (not countered by progesterone) crosses the blood brain barrier, it hypersensitises serotonin and you get a lot of serotonin that hangs out in the brain and causes central nervous system fatigue. Once it drops off, it predisposes you to brain fog, bouts of sudden anger, anxiety & all sorts of unpredictable mood swings.
Phew!
If any of the above just went over your head, no worries.
Let’s look at what can be done instead.
1. Regular Meals
If you have been bookending most of your meals up till now, the first point of action would be to simply start eating 3 meals a day. Ideally you never go on empty unless you go to bed. But even going to bed completely empty can play havoc with your sleep. Once your blood sugar levels drop low (hypoglycaemia) you might struggle to fall asleep or even wake up during the night and then struggle to fall back asleep.
Tip! Have a little bit of food with protein in it, make sure it’s not just carbs! Any refined sugars, starch, and non-whole/refined grains are often associated with higher odds of incident insomnia. I personally like to eat my dinner early, around 6pm and sometimes, if I don’t manage to go to sleep before 10pm, I start to get hungry again. So to overcome that, I have l a teaspoon of peanut butter, no more.
2. Fuel for your exercise
Start treating yourself as an expensive car. No petrol, no go. If you are not a big breakfast eater, have half a banana with a teaspoon of peanut butter; or some protein rich drink.
3. Fuel straight after your exercise
Eating immediately after hard exercise delays decline in insulin sensitivity. That’s especially important for women in the menopausal transition, who may already be more insulin resistant because of the hormonal changes.
4. Prioritise protein!
Pre-menopausal women should aim for 30 grams of high-quality protein within 30 to 45 minutes after exercise. You also want regular doses of 30 - 40 grams of protein at each meal and 15-20 grams with your snacks.
As you reach peri and postmenopause, your anabolic resistance increases, so you want to aim to have that post-exercise protein closer to 40 grams. [5]
5. Say NO to intermittent fasting & keto
Intermittent fasting and keto both disrupt kisspeptin production. When our brain perceives we have a deficiency in nutrients, especially carbohydrate, we have a marked reduction in kisspeptin stimulation, which not only increases our appetite, but also reduces our sensitivity to insulin. Adding exercise on top elevates stress hormones, like cortisol, and it keeps your sympathetic drive high and reduces your ability to relax and predisposes you to mood swings and anxiety.
6. Choose better quality of carbs!
As we go through perimenopause, we are becoming a bit more insulin resistant but then again, as per the above point, we do not want to say good-bye to carbs altogether. Instead, choose a better quality of your carbohydrates. So, what you want to do is to avoid highly processed sources of carbohydrates such as: pizza, pasta, white rice, bread, cakes and cookies, as they most likely are going to play up with your sugar level (and we know that inconsistent blood sugar levels correlate with mood swings). Instead, focus on beans, legumes, nuts, seeds, vegetables, some whole grains, and fruits.
Let me give you an example. Just because you don’t have pasta or bread on your plate, it doesn’t mean that you don’t eat carbs. Half a can of Heinz Baked Beans and ½ head of broccoli gives you approximately 45g of carbohydrates. Another alternative would be some wonderful roasted sweet potatoes, beets, or parsnips. Carbohydrates are in all plant sources so the sky is the limit here.
7. Pair carbs with protein
Protein takes longer to digest, slowing down the absorption of glucose into the bloodstream. So, if you absolutely must consume the lesser-quality carbohydrates then make sure to add some protein to it. In fact, legumes such as beans or lentils are preferable as research show they have a second meal effect.
For example, if you have beans for dinner, their effect carries on all the way to breakfast, blunting the sugar spike effect of the toast you might have! [6]
8. HIIT training!
As much as any form of exercise is great for improving mood levels, nothing beats short bouts of high intensity. It really has to be a high intensity workout as only high intensity is a strong enough stimuli for all the body’s system to respond. That includes the increase in production of BDNF (brain-derived neurotrophic factor) that is an endogenously produced protein, which in colloquial terms is like a nourishment for the brain (helps with cognition and memory). There is not yet enough evidence to conclusively agree but some initial research done on mice show that reduced BDNF signalling displays increased anxiety behaviours.[7] As it declines as we age, it is imperative that we continue stimulating the body. HIIT training gives us those adaptations.
9. Adaptogens!
Adaptogens, as the name suggest, help you adapt to stress by blocking some of the cortisol responses, so that one experiences less stress. They are herb, roots, or other plant substances (like mushrooms).
Ashwagandha - is like the queen of adaptogens. It is more of a relaxant; however, it is not a sedative! It helps with reducing anxiety because, it decreases cortisol. It helps with cognitive impairment so that that brain fog dissipates. Is also helps with our insulin sensitivity, and thus with that blood glucose response. So, when we're talking about some of the changes that happen with perimenopause (the decrease of progesterone and not countered estrogen) as well as our tendency to be in the sympathetic drive, ashwagandha is one of the go-tos.
10. Reducing the number of steady-state long aerobic training
Now, if you are a long-distance runner or any endurance athlete for that sake, please - before you make any judgments, read on.
Long slow steady state aerobic training is not strong enough stimuli for the body to get the adaptations that we are looking for in perimenopause. But it is long enough to raise cortisol that then “hangs out” in the system for a while. If you are someone who is struggling with anxiety, and I presume you are if you ventured that far, then perhaps consider switching some of your training from long-distance steady-state to a much sharper and shorter form of running (or HIIT training) that is SII (Sprint Interval Training).
There are many benefits of High Intensity training (more on that another time) and reducing anxiety is one.
So, if you indeed struggle with heaps of anxiety, consider that maybe spending long periods of time pumping your Sympathetic Nervous System and upping your cortisol is not in your best interest.
However, there is always a caveat. If your running club is your second home, your running mates are the people that lift you up and this is something that brings you an enormous amount of joy, I’d say, continue doing it. It’s always about comparing the pros and cons, isn’t it?
Still, I’d sneak in at least one to two 10 minute sessions of sharp 20 seconds on / 10 seconds off sprint intervals into your week.
There, compromise!
11. Creatine supplementation
I know what you’re thinking – creatine is for body builders!
Hold on. A 2021 study published in Nutrients also reported that creatine might have positive effects on mood and cognition by supporting brain health, and is especially useful for menopausal women who are more susceptible to increased inflammation. [8]
Also, it can be helpful for mood swings during the menstrual cycle, especially during the high hormone (luteal) phase.
There, I think that is enough for today.
The topic of anxiety is something that I am very passionate about as I’ve been suffering from it for a very long time. It has been exacerbated tenfold once I hit my perimenopause.
Learning about female physiology gave me a motivation to implement a lot of lifestyle changes and to ultimately take life into my own hands and feel better.
[1] Elias SG, van Noord PA, Peeters PH, den Tonkelaar I, Grobbee DE. Caloric restriction reduces age at menopause: The effect of the 1944-1945 Dutch famine. Menopause. 2003;10:399–405. [2] Lifestyle and dietary factors determine age at natural menopause.
[4] Mood changes associated with blood glucose fluctuations in insulin-dependent diabetes mellitus Gonder-Frederick LA. Cox DJ. Bobbit SA. Pennebaker Health Psychol. 1989;8:45–59.
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