Menopause is associated with metabolic changes in our bodies. How does this affect your future health as a woman, and what can you do to about it? It is helpful to explore a time beyond symptoms of menopause and consider your metabolic health. You cannot see it, it isn’t a sexy topic, but it is one which could affect the quality of life in your future. What is metabolic syndrome and how is it linked to menopause? How do we reduce your risk of metabolic syndrome? At Rowena Health Menopause Specialist Clinic we take your metabolic health seriously, we know it can affect your future health, and we want to teach you all about this.
Oestrogen and metabolic health
Oestrogen has a number of protective effects on your metabolic health, it is involved in glucose transport into cells, it increases your basal metabolic rate, it reduces your insulin resistance, it increases your HDL and decreases your LDL and it reduces central body fat. When we go through the menopause, oestrogen falls and you may see adverse metabolic changes, and as a consequence some, but not all women will progress to develop metabolic syndrome.
What is Metabolic Syndrome?
Your body works well when everything is in balance. When things consistently rise, like blood pressure, or body fat, or blood lipids, or insulin levels this is a problem and can lead to increases in your risk of Heart Disease, Stroke and Type 2 diabetes.
Metabolic Syndrome is a collection of ‘health risk factors’, having three of these usually suggests you have metabolic syndrome. Insulin resistance is pivotal to metabolic syndrome.
- Insulin resistance – where your body has become resistant to the hormone insulin, leading to high blood sugar levels
- High blood pressure – either one of your systolic or diastolic BP levels are greater than 130/80
- Overweight or obesity – especially around your waistline, in Europe this would be a waist circumference greater than 80cm
- Unhealthy levels of blood fats – usually with high triglyceride levels greater than 1.7 mmol/l and low HDL levels less than 1.3mmol/l
This diagnosis of Metabolic Syndrome is associated with endothelial dysfunction and atherosclerosis resulting in an increased risk of Cardiovascular Disease (heart disease and stroke) and Type 2 Diabetes Mellitus. There are around 3.5 million women living with a heart or circulatory disease (including heart disease and stroke) in the UK. Heart attacks kill an average of more than 70 women every day. Behind these numbers are real people living their lives with heart disease. People from some ethnic backgrounds are more prone to insulin resistance and metabolic syndrome. For example, those with a South Asian or black Afro-Caribbean background.
What is Insulin?
When you eat a high carbohydrate meal your body breaks down the carbohydrate (like pasta, bread, rice or cakes or sweets) in the gut and then absorbs the glucose into your blood stream, resulting elevation in your blood glucose.
Insulin is a hormone, released by your pancreas. Insulin’s role is taking this glucose out of your bloodstream. It goes into your cells to make energy, into the liver and the muscles where it is stored as glycogen, or into the fat cells where it is stored as fat. This is very important, as high blood glucose levels over time are harmful to your body, damaging blood vessels, kidneys and brain cells and increasing your risk of cardiovascular disease, eye problems, nerve damage and kidney damage, which can all be very serious.
Insulin’s main job is to keep your blood sugar/glucose between 4 and 6 mmol/l, any higher and it is toxic to your tissues. The pancreas produces as much insulin as is required to achieve this level of blood glucose. The pancreas works hard to keep you safe from toxic blood glucose.
Insulin, as part of it’s role, stops fat break down for energy, so if you have stored fat in your body and you have high levels of insulin, due to insulin resistance or you are frequently eating carbohydrates, then you won’t be access your own fat stores for energy. This has implications for weight loss and for carbohydrate craving.
The Science bit
Insulin activates the rate of cellular respiration (glycolysis, pyruvate oxidation, the krebs cycle and oxidative phosphorylation), so that glucose can be used in the cells to produce energy for the body. Insulin can increase the rate of conversion of glucose into glycogen, by glycogenesis in the liver and muscles. Glycogen can be stored in the liver and muscles and can be converted back to glucose when needed, for example if you are fasted, to keep your blood sugar in that stable 4-6mmol/l range. 100g of glycogen can be stored in the liver, at one time. If you are fasting and your glycogen stores are depleted, and your body needs glucose, for a stable blood sugar then then glucose can be made by gluconeogenesis, using non-carbohydrate sources like glycerol and amino acids. The body works hard to keep a stable blood sugar.
If there is extra glucose in the blood, with the help of insulin, this can be converted into fatty acids, and stored in adipose tissue, and this causes you to gain weight. If there is too much fatty acid, some of this builds up in your liver, causing a non-alcoholic fatty liver, which can lead to serious liver damage.
It is all to do with blood sugar stability, no matter how hard insulin has to work, it tries to keep your blood sugar stable and store any glucose to be used for energy when you need it. If you become resistance to insulin then that is when problems can start.
Insulin resistance
If you are insulin resistance your tissues are resistant to the action of insulin, in response the pancreas produces more and more insulin to compensate. Over time, when you follow a standard typical Western diet high in carbohydrates, your fat cells can become inflamed. They become resistant to the signals from insulin to take up glucose from the blood and store it as fat. The insulin keeps going and encourages the body starts to store the glucose as fat in the liver, as fatty liver. This process can go on for years before the pancreas becomes tired of working so hard to release insulin and eventually insulin can no longer keep a control on your blood glucose levels, and your blood glucose levels rise measure out of range showing that you have become pre-diabetic or diabetic.
When blood sugar is consistently raised, it can lead to many chronic health conditions, including Cardiovascular Disease, Stroke, Type 2 Diabetes, Renal failure, Blindness, and Neuropathy. Obesity, Type 2 Diabetes, metabolic syndrome, hypertension, PCOS, corticosteroid excess, non-alcoholic fatty liver disease, and certain forms of cancer are associated with insulin resistance. The effects of acute and long term stress and the stress hormones cortisol and adrenalin, can increase insulin resistance and acute sleep deprivation, certainly common in menopause, has been reported to raise blood sugar.
Clues that you might be insulin resistant
Generalised tiredness, this is common, central weight gain, carbohydrate cravings. You may feel that you need to eat something, or you will pass out. Mid-morning or mid-afternoon hypoglycaemic symptoms, sudden fatigue, light headedness, shakiness or tremor are possible due to eating, then a sudden release of insulin. Symptoms of hypoglycaemia are seen when glucose is in the normal range.
Why are some people more prone to insulin resistance?
Unfortunately the simple answer is genetics and epigenetics. Some people are more genetically prone to insulin resistance and weight gain than others even when consuming the same diet and living the same lifestyle. The modern western diet may make us all prone to insulin resistance, as it is so carbohydrate rich.
A story
Imagine your body is a fireplace, you don’t want the fire to go out, so you need energy which simply you get from carbohydrates and fat. Imagine your carbohydrates are small sticks, they burn quickly on your fire, so you need to frequently put them on to keep the fire going. Imagine your fat stores are large logs, they burn for longer to keep your fire going. You get energy from carbohydrate and fat.
If you are not insulin resistant and you have metabolic flexibility, then you have a mixture of sticks and logs by your fire to keep your fire going for energy, you can use both carbohydrates you eat and your body fat for energy.
If you are insulin resistant, your insulin levels are high and your cells are resistant to the effects of insulin. You cannot use your logs (fat) which burn slower for longer for making energy, (as the insulin locks your fat stores). In order to keep your fire going you must keep adding sticks to make energy (eating carbohydrate). Your fire burns fast when you add sticks (eat carbohydrates), they give you energy, but quickly your fire burns out, your blood sugar drops, your energy drops, and you need to add more sticks (eat more carbs) to keep your fire going. Consequently you are hungry often with fluctuating energy and blood sugar is fluctuating up and down. When insulin levels rise, it puts the brakes on burning fat for fuel, and it encourages the storage of incoming food, mostly as fat. There is no point in trying not to eat as your body is craving, and needs energy.
How can we reduce insulin resistance?
This is done by reducing the carbohydrates in your diet and using techniques including timed eating windows. You will need support to do this, but it can be done. HRT can help, as can certain medications to improve insulin sensitivity.
How can we reduce our risk factors for metabolic syndrome?
Reducing central weight?
Lifestyle measures: regular physical activity and eating a low carbohydrate, real food diet can help to to lose central weight. Taking Hormone replacement therapy, HRT, can also reduce central fat accumulation. Oestrogen reduces abdominal fat deposition, by increasing fat oxidation, and breaking fat down to produce energy.
Normalising our lipids?
Want to understand more about cholesterol? Lifestyle and eating a diet rich in healthy fats may help. You can do this by taking medications like statins, fibrates, PCSK9 inhibitors. All forms of HRT, oral and transdermal lower total cholesterol and LDL cholesterol. Depending on the way in which oestrogen is taken and the type of progesterone or progestogen is taken, HRT also can have a beneficial effect on HDL (oral can increase HDL more than transdermal), and triglycerides (transdermal reduces TG’s more than oral). Androgenic progestogens blunt the HDL increase, but they do reduce triglycerides. In simple terms you can address your blood lipids in a number of ways.
Reduce insulin resistance
You could use a medication like Metformin, as drug which increases your body’s response to insulin. HRT also lowers insulin resistance. The trials found that the most favourable results were with oral HRT, using the oestrogen, Estradiol 17 beta, in comparison to transdermal application. Oestrogen acts directly on muscle, liver and fat cells reducing insulin resistance. Progestogens can blunt the effect of beneficial oestrogen in insulin resistance. Different progestogens have specific glucocorticoid (anti-inflammatory) and mineralocorticoid (regulation of salt and water) action, both of which can affect insulin resistance. Androgenic progestogens can increase insulin resistance. Natural progesterone, Utrogestan, a micronised progesterone and dydrogesterone are felt to be the best and have a neutral effect on insulin resistance, so will not affect the beneficial effect of oestrogen. HRT can be tailored individually, to a women depending on her needs. Oestrogen may also be able to act on the pancreas to stimulate insulin secretion.
Reduce blood pressure
In clinical practise this does happen as you loose weight. You can also take antihypertensives drugs. HRT can have a beneficial effect on blood pressure. If you want to understand more about blood pressure, please click the link.
What healthy lifestyle changes can we make to reduce the risk of metabolic syndrome?
Diet
Carbohydrates – both starch and sugar = blood glucose
Carbohydrates are not all the same, if you have some metabolic flexibility then choosing low glycemic index (GI) carbohydrates is be best, and may help to keep your blood sugars more stable, avoiding high blood glucose spikes and subsequent surge in insulin levels. If you are really struggling with insulin resistance then eating a low carbohydrate, real food diet can be really effective in reducing insulin levels. This is best done with advice and support but it can be beneficial if you are trying to reduce body fat.
The glycemic index (GI) rates carbohydrates from 0-100 based on how quickly they release glucose into our bodies.
High GI index carbohydrates
These are foods such as such as pasta, bread, rice, processed foods, sugary drinks, fast food, sweets, and cakes, have a GI number over 70, these are high glycemic index foods. Be aware that fruit is a natural sugar, and if consumed in excess can cause high blood sugar peaks. consequence of eating these foods is a rapid release of glucose into the bloodstream, a surge in blood glucose, followed by a rapid fall in blood glucose, leaving you tired and hungry quickly. Eating food with a high GI index is linked to an increased risk of Type 2 Diabetes, cardiovascular disease, and obesity. It is also linked with Age-Related Macular Degeneration and colorectal cancer.
Low GI index carbohydrates
These are foods such as such as whole grain rice, vegetables, fruits, legumes, dairy products, and nuts give a lower and slower rise in blood sugar and have a GI number below 70. Replacing your high GI carbohydrates with low glycemic index ones may keep your blood sugars more stable and avoid high sugar spikes which lead to a surge in required insulin levels.
Healthy fats
Studies show that eating foods with fat and fibre produce a more gradual rise in blood sugar. Choosing healthy fats is best. Eat enough fibre. This can be found in fruit, vegetables, pulses, nuts and whole grains feed healthy bacteria.
Feed your microbiome
Eat a wide range range of colourful, plant based foods, this will help to feed the good bacteria in the gut. Plants that grow above the ground generally are lower in carbohydrates. Eating highly processed foods are high in sugar, which will encourage weight gain and also detrimentally affect the gut microbiome. It is better to cook using fresh ingredients. Eating fermented foods like natural live yogurt, might encourage more microbes to grow in the gut.
Hydration
Drink plenty of water. often the body send signals that you are hungry, when you are actually thirsty.
Alcohol
Alcohol should be mentioned here, this is rich in sugar and can have an affect on the gut microbiome, it seems to be less well tolerated by many women as they go through the time of menopause.
Weight
Keeping a BMI in the healthy range of 20-25 is best. However, that said, it is possible to have a slightly higher BMI and still be metabolically healthy. Dress size and subcutaneous fat deposition does not always correlate with metabolic health. Fat can be deposited around the organs in someone who looks ‘thin’. These people are called TOFI.
Aerobic exercise
Exercise can reduce insulin resistance. The benefits of regular exercise seem endless. All adults should aim to do at least 150 minutes of moderate-intensity activity a week or 75 minutes of vigorous-intensity exercise over the course of a week. This can be broken up into smaller manageable chunks, mix and match. Do what you love to do, what is fun, you’re much more likely to continue do it. If it’s a sociable exercise it will help with cognition, as will good sleep hygiene and cognitive exercises. It will help to reduce depression and anxiety. if it’s a solitary exercise it could incorporate mindfulness and meditation, both of which are wonderful ways to self care and reduce stress.
Strength exercise
Strength training can also be very useful. It increases lean muscle as well as improving insulin sensitivity. Simple bodyweight exercises such as press ups, step ups and squats can be highly effective.
Stress reduction
Being acutely stressed leads to insulin resistance so that blood glucose remains high and there is immediate energy to ‘run away from the bear,’ or in modern life to juggle the children, the work email and sick relative. The body sees no difference in these things, a stress response occurs and if this stress is long term it can increase insulin resistance and lead to weight gain. How resilient we are to deal with stressful events can affect our future health.
Sleep
Sleep balances many things including our ghrelin and leptin hormones. These affect our appetite and our feeling of fullness, which in turn affects our weight. Sleeping well can be important in weight management. There are many things we can do to improve sleep.
Psychology
There are many reasons for us to eat and to gain weight, which can lead increase our risk of metabolic syndrome. Talking to someone about these might help to support you to make some changes.
In summary
In summary, your food choices, your exercise schedule, your weight and your hormones will have a role to reduce your risk of metabolic syndrome, and of some the common chronic health conditions that are now affecting our increasingly older population.
If you have metabolic syndrome we can help you manage this and support you in making the lifestyle changes what will help. Managing metabolic syndrome includes reduction of central body fat, normalising lipids, a reduction of insulin resistance and a reduction in blood pressure. With the right diet and lifestyle you can reverse fatty liver, lower insulin levels and improve insulin sensitivity, loose weight which may reduce blood pressure and reverse metabolic syndrome. You may then change the path of your future health.
Women at midlife would benefit from a blood pressure check, weight, girth and a blood fasting lipid assessment. What better time to discuss this with women than at their menopause assessment. If you are high risk for the development of insulin resistance and metabolic syndrome, then it gives you a chance to make early changes. You will have the knowledge and the ability to make an informed choice, in order to reduce your risk of chronic illness and give yourself time to enjoy a healthy future.
Please book an appointment at Rowena Health Menopause Clinic for a metabolic health check including blood tests, a QRISK assessment and a discussion about metabolic syndrome.
Last updated September 2023 Dr Carys Sonnenberg Rowena Health