Metabolic and heart health in menopause

Metabolic and heart health in menopause

Women in midlife and heart health

As women transition into menopause, they experience a multitude of hormonal changes that can significantly impact their health. One notable concern during this phase is the risk to cardiometabolic health, which can show up as elevated cholesterol levels, waist circumference, blood pressure, fasting glucose levels and insulin resistance. Although hormonal changes are justifiably a leading cause of concern, there's generally a lot more going on during this time as well! Understanding the causes of cardiometabolic risk is crucial for women to take proactive steps toward maintaining their cardiovascular health.

Some of the risks to hear health in midlife will surprise you!

(Firstly, some you may have heard of)

Hormonal changes

One of the primary factors contributing to increased blood pressure and cholesterol during menopause is the decline in oestrogen levels, as oestrogen has a protective effect on the cardiovascular system. As oestrogen decreases, women may notice an increase in abdominal or central fat deposition, and this elevated visceral fat (around the organs) which the liver must deal with increases pro-inflammatory cytokines affecting the immune system. Over time this inflammation becomes chronic and systemic, and may show up in the cardiovascular system as vasoconstriction of arteries, making women prone to cardiac issues and issues with insulin resistance. 

Changes in Body Composition

Menopause often brings about changes in body composition, such as an increase in central, or abdominal fat and a decrease in lean muscle mass, but did you know your waist:hip ratio (WHR) is a more accurate predictor of Type 2 diabetes and heart disease than overall body weight or BMI? In Australia, a waist-hip ratio (WHR) above 0.85 for women and 0.9 for men is associated wwith an increased risk of meatabolic complications including Type 2 diabetes. A waist circumference above 88cm for women and 102 cm for men is another way of measuring the increased risk of metabolic complications, and is easy to measure with a tape measure.

Socioeconomic, Diet and Lifestyle Factors

As women age, their dietary habits may also alter, affected by stress and mood swings, lack of sleep, obligations with work and family, access to affordable health services or food security to name a few! Factors such as increased consumption of overly processed foods, a diet low in healthy fats, smoking, alcohol and decreased physical activity (due to above reasons!!) can worsen the risk of disease.

Family History

Do you have parents or grandparents with Type 2 diabetes, heart disease or high cholesterol? Genetics plays a crucial role for cardiometabolic health in menopause. It's important to be aware of your family's health history and discuss it with healthcare professionals when assessing your risk factors.

Now for some less conventional risks it's good to know about!

Maternal nutrition, gestational age and weight

Was your mother over/undernourished when pregnant with you? This can affect cardiometabolic health later in life as can being born prematurely or being large for gestational age (1) 

Do you have PCOS or endometriosis?

Women with PCOS have a higher risk of visceral adiposity, hypertension and insulin resistance but even women with PCOS who are lean have an increased risk of cardiac disease, making early detection and treatment so important! 

Women with endometriosis are more prone to chronic systemic inflammation, an altered gut microbiome (more on this later) and an ‘atherogenic lipid profile’ (2)  that is, problematic cholesterol levels!

Did you gradually enter menopause or was it hard and fast?

Generally, women go through peri/ menopause gradually during the ages of 45-55 with the average age being 51 in developed countries, for women experiencing surgical menopause however, this can happen much younger and surgically induced menopause before the age of 40 is associated with many mental and physical challenges, including an increased risk of cardiovascular disease (3). HRT, if advised and directed by your medical practitioner, may be beneficial here.

Autoimmunity

Autoimmune diseases such as systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), and systemic sclerosis (scleroderma) preferentially affect women, often in their midlife and are characterised by systemic inflammation, and the use of glucocorticoids to manage this inflammation may lead to an accelerated cardiovascular disease risk in this group of  women (4). Glucocorticoids are also hormones secreted by the adrenal glands as an endocrine response to chronic stress!

The Imbalance of Calcium with Vitamin D, Vitamin K and Magnesium 

Calcium is essential for bone health, and is often taken by women in midlife if they are at risk of osteoporosis. Excessive intake however, particularly as a supplementation without adequate Vitamins D, K2 and magnesium, can increase the risk of heart disease by promoting arterial calcification, that is, the buildup of calcium deposits in the walls of blood vessels making them less flexible (5). 

Vitamins D and K are both fat-soluble vitamins and play a central role in calcium metabolism. Vitamin D regulates calcium metabolism by increasing calcium absorption from the intestines into circulation as well as promoting the production of vitamin K-dependent proteins. Vitamin K2 helps direct calcium from arteries to bones, and magnesium plays a vital role in maintaining heart health as it helps reduce the risk of atherosclerosis (plaque buildup in arteries), improves blood sugar control, and protects against inflammation. Vitamin K2 is primarily found in organ meats such as liver (a great reason to eat chicken pate!) and certain fermented foods, with natto, fermented soybeans, sauerkraut, and hard cheeses being excellent sources. 

Magnesium also affects calcium metabolism by influencing its absorption, retention, and overall homeostasis. It acts as a natural calcium antagonist, regulating calcium's effects in the body, especially in muscle cells. Additionally, magnesium is essential for vitamin D activation, which is critical for calcium absorption. 

A balanced intake of these nutrients is crucial for cardiovascular health.

This information is for educational purposes only, always follow the advice of your medical practitioner. If you are on calcium supplementation, do not add Vitamin K2 to your dosage without consulting with your medical practitioner as K2 can interfere with some blood. thinning medications such as warfarin.

The gut and the oral microbiome play a role in heart health!

Did you know you have one hundred trillion gut bacteria, from many hundreds of species, living in your digestive tract? Recently, there has been much interest in the role the gut microbiome plays in heart health including cholesterol levels, blood pressure and the likelihood of a heart attack.

In clinic I often recommend my clients complete a CDSA (Complete Diagnostic Stool Analysis) as it gives a highly in-depth assessment of each individual's gut microbiome and how it is impacting your health and wellbeing now and in the future.

Here are some ways your microbiome could impact your heart health:

Dysbiosis, or an imbalance  in ‘good’ and ‘bad’ bacteria are associated with increased risk of cardiovascular diseases due to increased inflammation, altered metabolism, and damage to the lining of the gut wall, can all contribute to the development of heart disease.

‘Hexa LPS’ producing bacteria such as Salmonella, Klebsiella pneumoniae, Pseudomonas aeruginosa, and Helicobacter pylori are highly inflammatory microbes that can trigger inflammation and immune activation when they cross the gut barrier. This inflammation and intestinal permeability will present as high Secretory IgA on a Complete Diagnostic Stool Analysis (CDSA).

The gut microbiome produces a variety of metabolites that influence cardiovascular health:

Short-chain fatty acids (SCFA's) such as butyrate, produced by gut bacteria when fermenting dietary fibre and resistant starch, contribute to improved gut barrier function, reduced inflammation, and enhanced nutrient absorption. SCFA's also play a role in regulating metabolism, blood sugar control, and may potentially reduce the risk of colon cancer and type 2 diabetes. 

On the other hand, an excess of trimethylamine-N-oxide (TMAO), also a gut microbiota-derived metabolite, has been linked to inflammation and heart disease. Previous studies have revealed that elevated plasma BCAA levels correlate with the severity of insulin resistance, one of the most important characteristics during T2DM development. 

The metabolism of branched-chain amino acids (BCAA’s) is also significantly influenced by the gut microbiota and elevation of these products due to dysbiosis of bacteria such as Clostridium symbiosum, can influence host metabolism, impacting conditions like obesity and type 2 diabetes.

Elevated plasma BCAA levels also correlate with the severity of insulin resistance, one of the most important characteristics during T2DM development (6). 

The collection of microbes in the mouth collectively referred to as the oral microbiome is increasingly being recognised for its impact on cardiovascular health.  This connection is primarily due to bacteria from the mouth entering the bloodstream and potentially damaging the heart. 

Dysbiosis of oral bacteria including Porphyromonas gingivalis and Treponema denticola, Streptococcus salivarius and Streptococcus anginosus are linked to inflammation and the development of heart disease including endocarditis, hypertension, atherosclerosis and aortic aneurysm.

Dysbiosis of the oral microbiome is often observed with the intake of proton pump inhibitors (PPI’s), used for relief of acid reflux. In clinic we work to balance stomach acid and investigate the root cause of reflux as it is not only painful, but because the long term use of PPI’s can cause many health issues!

As a clinical nutritionist, it is incredibly useful to read and interpret my clients CDSA reports and apply appropriate microbiome insights to enable strategic use of prebiotics (fibre used as food for beneficial bacteria) and probiotics with other dietary and lifestyle modifications to impact the microbiome and heart health.

What are some tips for improving cardiovascular outcomes during Menopause?

Adopt a Heart-Healthy Diet

For many this may be a Mediterranean-esque diet (depending on your culture and ancestry, budget, time and individual nutritional needs). A heart healthy diet is built with high-fibre nutrient-dense foods including vegetables, fresh fruits, legumes, and whole grains, fish and lean meat

Heart-healthy fats include olive oil, avocados, nuts and seeds.

Quality protein from dairy, poultry and fish and some red meat is also consumed.

Olive oil as a good quality fat is incorporated into many meals as it contains tocopherols, polyphenols, and a balanced linoleic/alpha-linolenic acid profile, which is beneficial for the immune system and inflammatory response.

Plant sterols can help lower cholesterol by blocking the absorption of some of the cholesterol in food.

Fibre has several health benefits including weight management and lower blood pressure and comes from foods such as fruits, vegetables, nuts, and whole grains. Soluble fiber from foods including oats, almond butter, broccoli and apples has been shown to improve glycemic control and lower cholesterol.

As well as focusing on healthy foods, the Mediterranean diet emphasises sharing meals with family and friends, promoting social connection and reducing stress.

No naked carbs and meal sequencing for improved glycemic response 

Pairing carbohydrates in a meal with healthy fats and adequate protein helps regulate insulin resistance, where cells in the muscles, fat and liver do not respond to insulin, a hormone essential for regulating blood sugar levels. Insulin resistance is a major risk factor for type 2 diabetes, and cardiovascular disease (CVD) 

With each meal, eat the fat and protein first then the carbohydrates, this meal sequencing, i.e., consumption of protein and/or fat before carbohydrate, may promote secretion of glucagon-like peptide-1 (GLP-1) from the gut. GLP-1 is an appetite suppressant, and may enhance insulin secretion 

Going for a walk after the meal, even a 10 minute walk as ‘postprandial’ exercise is an important tool for improving the glycemic response to a meal!

Regular physical activity, in particular strength training and aerobic exercise

This is one of the most effective tools we have for strengthening the heart, and regulating blood sugar levels! Thirty minutes a day, five times a week when possible helps build muscle mass, which can boost metabolism and burn more calories, contributing to a healthier weight. It also improves overall cardiovascular health by making it easier to perform daily activities and aerobic exercises without getting fatigued (7).

Exercise is however a physical stressor, and prolonged or excessively intense exercise can raise cortisol and systemic inflammation so work hard but don’t overdo it too often and be careful with the HITT!

Manage Stress: 

Chronic stress can lead to increased inflammation throughout the body including the arteries, as well as elevated blood pressure, and changes in cholesterol levels, all of which are major risk factors for heart disease.

Stress also triggers unhealthy behaviors like smoking, overeating, and lack of physical activity, further exacerbating the risk. Engaging in stress-reducing activities such as yoga, meditation, or spending time in nature can have a positive impact on overall health.

Support through targeting appropriate supplementation 

Targeted nutritional supplementation under the guidance of a health care professional may be of benefit including:

Cardiovascular support with magnesium, omega 3 fatty acids, and B vitamins in particular B3

Nervous system and adrenal support with magnesium glycinate, glycine, taurine and L-theanine

Reduce inflammation and oxidative stress with antioxidants such as CoQ10, resveratrol, curcumin NAC, glutathione and quercetin.

Support the liver (it has a central role in cholesterol production,  metabolism, and elimination) with milk thistle, betaine, taurine and trimethylglycine).

Support insulin sensitivity to reduce the risk of metabolic syndrome with magnesium, taurine, inositol chromium and alpha lipoic acid 

Optimise the health of the gut and oral microbiomes

The benefit of assessing a client's unique CDSA is that we have evidence of where dysbiosis exists and can treat it, for example if bacterial infections such as Campylobacter, Shigella, Salmonella, Yersinia enterocolitica, and Candida species, or parasites like Borrelia burgdorferi, Ehrlichia, and Babesia spp we can perhaps treat the microbiome with an antimicrobial.

We know that other microbes such as Akkermansia muciniphila can enhance the gut barrier, which helps prevent harmful substances from entering the bloodstream and potentially reducing inflammation. 

Butyrate-producing bacteria are crucial for maintaining the gut's integrity and preventing the progression of atherosclerosis, a major factor in coronary heart disease. Studies have shown that these bacteria help regulate cholesterol balance, reduce inflammation, and prevent the formation of atherosclerotic plaques.

Depending on the low levels, we may give probiotics, as fermented foods or supplements. Probiotics don't necessarily repopulate the  gut microbiome, but they do communicate with the immune system, and help produce metabolites that reduce inflammation and improve gut health. 

Before we give probiotics however, it is important to supply the microbiome with prebiotics, a type of fibre that your body cannot digest but that  is readily used by beneficial bacteria in your gut. They are essentially food for the good bacteria, helping them to thrive and improve gut health. Examples of prebiotics I prescribe depending on what my clients individual microbiomes needs include  include inulin, pectin, galacto-oligosaccharides (GOS),fructooligosaccharides (FOS) , beta-gluten and ellagic acid 

Changes to cardiometabolic health such as elevated blood pressure, cholesterol and insulin resistance during menopause is a complex issue influenced by hormonal changes, socioeconomic factors, lifestyle, genetic factors and some surprising newly researched risk factors!.

By understanding these causes and taking proactive steps to manage cholesterol levels, women can support their cardiovascular health during this significant life transition.

If you would like to discuss any of these strategies I mentioned above, please book an appointment on my website, www.bespokenutrition.com.au 

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