Optimizing lifestyle at the menopause Irene Lambrinoudaki Endocrinologist

Optimizing lifestyle at the menopause Irene Lambrinoudaki Endocrinologist Associate Professor of Gynecological Endocrinology University of Athens, Greece

Women in Europe live on average 85 years http: //www. who. int accessed April 2015

Older women face on average 10 years of disability http: //www. who. int accessed April 2015

How is menopause connected to disability? The iceberg of menopause – related morbidities • Menopausal symptoms Immediate implications • • Intermediate implications Muscle atrophy Sarcopenic obesity CV risk factors Bone loss • Cardiovascular disease • Osteoporosis • Frailty Cancer Long-term implications

Risk management in menopause • Lifestyle modification • Medical treatment • Surgery • Healthy eating • Physical activity • Quit smoking

Beneficial eating patterns Harmful eating pattern DASH diet (Dietary q «Western» diet Approaches to Stop q. Rich in red and processed Hypertension) meat q. Rich in fiber (whole grain q. Rich in saturated fat cereals) q. Rich in sugar and salt q. Rich in fruits, vegetables and low fat dairy q. Low in saturated and trans fat, cholesterol q. Mediterranean Diet q Guallar-Castillon et al Nutr Metab Cardiovasc Dis 2010; Nettleton et al Atherosclerosis 2010, Liese et al Br J Nutr 2010, Nettleton et al Am J Clin Nutr 2009; Romaguera et al Am J Clin Nutr 2010, Lee et al Br J Nutr 2010

Original aspect of Mediterranean diet: a combination of foods

Mediterranean lifestyle today Communal meals (family, friends) Bach-Faig et al Public Health Nutrition 2011

Weight loss Waist circ change Change in DBP BMI change Change in SBP

Adherence to the Med diet is associated with lower cardiometabolic risk and CVD mortality

Diet and cancer prevention Risk factor Cancer Obesity breast, endometrial, colorectal, renal Red or processed meat colorectal Alcohol Breast, GI, mouth, larynx Protective factor cancer Dietary fiber Breast, colorectal Fruits and vegetables All cancer

Diet and cancer prevention

Adherence to diet guidelines and cancer • WHI observational study • 65, 838 postmenopausal women • Follow-up 12. 6 years incidence Cancer RR (adherent vs nonadherent) All cancer 0. 83 (0. 75 -0. 92) breast 0. 78 (0. 67 -0. 92) colorectal 0. 48 (0. 32 -0. 73) endometrial 0. 73 (0. 49 -1. 09) mortality Cancer RR (adherent vs nonadherent) All cancer 0. 73 (0. 68 -0. 78) breast 0. 67 (0. 43 -1. 03) colorectal 0. 39 (0. 24 -0. 63) endometrial 0. 59 (0. 26 -1. 37)

Diet and osteoporosis prevention Daily allowance • Calcium: 1000 -1200 mg elementary calcium • Vitamin D: 800 IU Food Calcium content Milk, yogurt 1 serving 200 -300 mg White cheese 40 gr 25 -150 mg Yellow cheese 40 gr 300 -450 mg Small fish 100 gr 350 mg Tahini paste 1 sp 65 mg Sesami seeds 1 sp 92 mg

Diet for postmenopausal women to prevent sarcopenia Ensure adequate protein intake to avoid loss of muscle mass • 25 -30 gr of high quality protein per meal • Low proportion of carbohydrates (negative effect on protein turnover) Protein sources • Poultry, eggs (the white) • Fish • Skimmed dairy products Benton MJ. Curr Opin Endocrinol Diabetes Obes. 2013 Oct; 20(5): 412 -9 Li Z, Heber D. Nutr Rev 2012; 70: 57– 64.

Exercise delays the aging process Regular physical activity is associated with 30% reduction of all-cause mortality in both healthy and patients with CVD Positive health outcomes Energy balance through integrated program of both healthy eating and exercise

Protective effects of exercise on the cardiovascular system

Independently of weight loss exercise improves • Triglycerides • LDL-c and HDL-c • Systolic BP • Diastolic BP • Waist girth Influence of a walking program on the metabolic risk profile of obese postmenopausal women. Roussel, Michel et al Menopause 2009; 16(3): 566 -575

Exercise improves cardiovascular disease risk factors in community-based menopausal transition and early postmenopausal women in China. Intervention: moderate intensity aerobic/endurance exercise, 3 days / week , 45 -60 min for 6 months Wu, Liping et al. Menopause 2014; 21: 1263 -1268

Exercise against frailty Intervention: resistance training programme for 4 months Increase in muscle mass and strength, no change in weight Variables Control group Δ% Resistance training group Δ% BM (kg) Pre 64. 25 ± 5. 03 Post 64. 90 ± 5. 13 1. 01 Pre 64. 58 ± 9. 22 Post 64. 07 ± 9. 18 − 0. 79 BMI 25. 26 ± 1. 81 (kg/m 2) % body fat 35. 80 ± 5. 71 25. 53 ± 2. 11 1. 07 26. 22 ± 3. 26 26. 00 ± 3. 11 − 0. 083 36. 58 ± 4. 61 2. 15 33. 68 ± 3. 93 31. 41 ± 4. 86* − 6. 75 Lean body 41. 05 ± 2. 43 mass (kg) 41. 01 ± 2. 49 − 0. 09 42. 54 ± 4. 23 43. 59 ± 3. 93* 2. 46 Fat body mass (kg) 23. 20 ± 4. 95 23. 88 ± 4. 37 2. 93 22. 04 ± 5. 35 20. 48 ± 5. 66* − 7. 06 Bench press (kg) Leg press (kg) 35. 50 ± 5. 13 37. 40 ± 6. 60 5. 35 38. 20 ± 7. 89 48. 60 ± 7. 66* 27. 23 134. 00 ± 24. 29 150. 60 ± 21. 89 12. 39 128. 60 ± 12. 71 181. 70 ± 42. 98* 41. 29 *p < 0. 05 between pre- and post excercise. Clin Interv Aging. 2013; 8: 1221– 1228.

Can exercise reduce body weight? Lifestyle change (diet + physical exercise) leads to sustained weight loss and reduced abdominal obesity, even after the completion of the intervention Stop of intervention WOMAN Study Women on the Move through Activity and Nutrition Kuller et al Obesity 2012

• EPIC: 217, 000 participants > 50 years / 11 years follow-up • Women more inactive than men • Women from Greece, Italy and Spain most inactive • Women from the Netherlands and Denmark most active Ekelund U et al. Am J Clin Nutr. 2015 Mar; 101(3): 613 -21

EPIC study: 7. 4% of all deaths could be averted if all inactivity was removed Ekelund U et al. Am J Clin Nutr. 2015 Mar; 101(3): 613 -21

EPIC study • Lean active: 40% lower mortality rate compared to lean inactive • Obese active: 20 -30% lower mortality rate compared to obese inactive Ekelund U et al. Am J Clin Nutr. 2015 Mar; 101(3): 613 -21

Physical activity and cancer risk • 65, 858 women in WHI observational study • Follow-up: 12. 6 years • Women with the highest activity score: 17% lower cancer risk compared to women with the lower activity score Thomson Ca et al. Cancer Prev Res (Phila). 2014 Jan; 7(1): 42 -53

Physical activity and osteoporosis risk • All forms of exercise, including brisk walking confer benefit to the skeleton • Direct effect on bone strength • Indirect effect through increases in muscle mass • Reduction in the risk of falls (agility and balance improvement) Osteoporosis Prevention and Management: Nonpharmacologic and Lifestyle options. CHRISTIANSON, MINDY; SHEN, WEN; MD, MPH Clinical Obstetrics & Gynecology. 56(4): 703 -710, December 2013. DOI: 10. 1097/GRF. 0 b 013 e 3182 a 9 d 15 a

Physical activity recommendations Exercise acts as a drug; the pharmacological benefits of exercise Vina, F et al. Br J Pharmacol. Sep 2012; 167(1): 1– 12.

Intensity X Duration X Frequency = Score Total CAMBRIDGE PHYSICAL ACTIVITY INDEX FOR SPORTS Score Activity Evaluate your current exercise program by selecting your score for each category. Intensity 5 Sustained heavy breathing and perspiration 4 Intermittent heavy breathing and perspiration, as in tennis 3 Moderately heavy, as in cycling and other recreational sports 2 1 Moderate, as in volleyball, softball Light, as in fishing 4 Over 30 minutes 20 to 30 minutes 10 to 20 minutes Less than 10 minutes Duration 3 2 1 Frequency 5 4 3 2 1 6 to 7 times per week 3 to 5 times per week 1 to 2 times per week A few times per month Less than once a month Score Total = Intensity X Duration X Frequency

Evaluation of Activity Score Evaluation Activity Category 81 to 100 Very active lifestyle High 60 to 80 Active and healthy Very good 40 to 59 Acceptable but could be better Fair 20 to 39 Not good enough Poor Under 20 Sedentary • Tennis, 60 minutes 3 times per week = 64 Very good • Walking, 45 minutes, 3 times per week = 48 Fair • Cycling, 20 minutes, 2 times per week = 27 Poor

Exercise programmes for CV conditioning and muscle strengthening in menopause Type of exercise frequency walking daily swimming 4 -5 times / week Running 3 -4 times / week Resistance training 3 -4 times / week intensity duration 40 -60% maximal 45 -60 minutes heart rate mild 30 -60 minutes 40 -60% maximal 20 -40 minutes heart rate 50% maximal heart rate reference Menopause, 2013, Vol. 20 No. 11, pp. 1216 -1226 Am J Cardiol. 2012 Apr 1; 109(7): 100510 Med. Sci. Sports Exerc. , Vol. 45, No. 4, pp. 706– 713, 2013 45 -60 minutes Clin Interv Aging. 2013; 8: 12218

Sedentary behavior (too much sitting, avoiding routine daily activities such as stair climbing or walking) is an independent cardiometabolic risk factor apart from lack of exercise

Take-home messages • Menopause is associated with obesity, sarcopenia, cardiovascular disease and osteoporosis • Lifestyle modifications can dramatically reduce the risk for these conditions • Women should consume whole grain products, fruits and vegetables and avoid red and processed meat • Physical activity should be incorporated in the daily routine and should include at least 150 minutes moderate activity or 75 minutes vigorous activity exercise per week

Thank you very much for your attention!