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FINAL PRESENTATION 2015
1. Dietary Pattern and Lifestyle Factors
Associated with Menopausal Symptoms
Maggie Chung, Alyssa Claxton, Gretchen Gibbons,
Stephanie LaPlant, Taylor Wang, Lauren Zuro
Advisor: Bonnie Beezhold, PhD, MHS, CHES
2. Introduction
Research Question
• Do women on a plant-based diet have fewer menopausal
symptoms? Are there other lifestyle factors that also
impact menopause?
Hypothesis
• Women who are vegetarians or vegans will report fewer
symptoms compared to those who are omnivores.
(Beezhold, Radnitz, Rinne, DiMatteo, 2015)
4. Overview-Research Studies
• Fewer menopausal symptoms associated with higher intake
of whole grains, F&V in Chinese postmenopausal women. 1
• Decreased menopausal symptoms associated with high fiber
intake in women treated for breast cancer. 2
• Plant-based diets are associated with favorable metabolic
profiles in pre- and post-menopausal women. 3
• Vegan diet was associated with reduced HDL-C level in pre-
and post-menopausal women. 4
1. Liu, 2015; 2. Gold, 2006; 3. Karelis, 2010; 4. Huang, Y.W. 2014
5. Study Objectives
• To investigate whether dietary patterns and behaviors
as well as specific foods were associated with symptoms
that occur during menopause in aging women.
• To investigate whether demographic and lifestyle factors
were related to menopausal symptoms.
6. Methods – Study Design
• Cross sectional survey study
• Online delivery through convenience sampling using
SurveyMonkey
• Eligibility requirements
• Females, ages 45-80 years old
• Willing to complete an online survey
9. Methods – Survey
• Frequent urination
• Involuntary urination when
laughing or coughing
• Change in sexual desire
• Flatulence or gas pains
• Aching in muscles and joints
• Feeling tired or worn out
• Difficulty sleeping
• Aches in back of neck or head
• Decrease in physical strength
• Decrease in stamina
• Vaginal dryness during
intercourse
• Avoiding intimacy
• Hot flashes
• Night sweats
• Sweating
• Being dissatisfied with personal life
• Feeling anxious or nervous
• Poor memory
• Accomplishing less
• Feeling depressed, down, or blue
• Being impatient with others
• Feelings of wanting to be alone
• Increased facial hair
• Changes in skin
• Feeling bloated
• Backaches
• Severity of menopausal symptoms; Menopause-Specific
Quality of Life questionnaire (MENQOL)
10. Methods – Survey
• Which of the following foods do you include in your
diet (at least monthly)?
• Meat (beef, pork, lamb); chicken or turkey; fish or
shellfish; eggs; dairy foods; none
• Diet questions: foods, food groups, nutrients
• Fruits, vegetables, beverages, omega-3 fatty acids
11. Methods – Survey
FRUITS AND VEGETABLES
Never or
less than
1X a mo
(1)
1-3X
Per
Mo
(2)
Once
A
Wk
(3)
2-4X
Per
Wk
(4)
5-6X
per
Wk
(5)
Once
a
Day
(6)
2-3X
per
day
(7)
4-5X
per
day
(8)
6+X
per
day
(9)
Apricots, plum, pear, apple
Berries (any type)
Citrus fruits (oranges, grapefruit,
tangerines)
Grapes
Pineapple, papaya, mango (fresh)
Broccoli, Brussels sprouts,
cauliflower, kale, mustard greens,
radish, turnips
Orange vegetables (carrots, sweet
potatoes, butternut squash,
pumpkin)
Spinach, Swiss chard, salad greens
12. Survey Validity & Reliability
Validity
• Incorporated validated scales
• Exercise and social support
• Menopause-specific Quality of
Life questionnaire (MENQOL)
• Use of clear and appropriate
language for survey questions
• Pilot testing and feedback
• Online delivery promoted large
geographic sample.
Reliability
• Potentially unclear
questions were eliminated
• Validated scales showed
strong internal consistency
and test-retest reliability
• MENQOL – Cronbach
alpha coefficient = 0.93
(0.81 to 0.89)
13. Methods - Statistical analysis
• Correlational, differential analysis
• Parametric statistics
• Descriptive statistics
• Pearson’s correlation coefficients and multiple linear
regression; Chi square tests
• Independent t tests, ANOVA, ANCOVA
• Significance - p < .05; SPSS version 23
23. Associations of Diet Type with Symptoms
Variables N
Physical
symptoms
Mental
symptoms
r / p value r / p value
Diet type (Omn/Vg) 371 -0.122 / 0.010 0.057 / 0.233
Total vegetables 432 -0.181 /<0.001 -0.142 / 0.003
Total fruits 431 -0.099 / 0.040 -0.100 / 0.039
Total flesh foods 431 0.173 /<0.001 -0.033 / 0.490
Beef 422 0.157 / 0.001 0.009 / 0.858
Total dairy foods 430 0.196 /<0.001 0.071 / 0.141
Total eggs 431 0.115 / 0.018 -0.043 / 0.378
Pearson’s correlation coefficients; p<.05 is significant
24. Multivariate Analysis – Predictors of
Menopausal Symptoms
PHYSICAL symptoms MENTAL symptoms
Variable β*
p
value
Variable β*
p
value
Age -0.234 <0.001 Social support -0.246 <0.001
Vegan diet (N/Y) -0.181 0.002 Age -0.201 <0.001
BMI 0.157 0.004
Berries intake
freq
-0.128 0.009
Sleep hrs/night -0.106 0.040 Sweets intake freq 0.117 0.015
Sweets intake freq 0.103 0.057 Sleep hrs/night -0.096 0.046
Total exercise -0.088 0.107 Total exercise -0.086 0.090
BMI 0.083 0.097
R2 0.158 R2 0.187
Correlates with p values < .025 included in models. *Betas are standardized.
25. Comparison of Symptoms by Diet Groups
Symptoms n
OMN
n=248
VEG
n=74
VG
n=123
F ratio
Adj
F ratio
Mean ±SD Mean ±SD Mean ±SD
Physical
symptoms
445
40.46
± 17.83a
41.12
± 17.78b
33.26
± 14.80ab 8.33** 12.83**1
Mental
symptoms
445
13.64
± 6.32
15.35
± 7.97
13.87
± 7.27
1.78 3.52*2
** p<0.001, *p<0.05; ANOVA - same letters differ significantly.
1 ANCOVA adj means: 41.62a, 40.63b, 31.83ab, pƞ2= 0.062.
2 ANCOVA adj means: 14.12, 15.40b, 12.87b, pƞ2=0.016.
26. Vegan diet is associated with lower severity of physical
menopausal symptoms; vegans reported lower symptom
severity than those who ate animal foods.
• Confirmed previously mentioned studies. 1, 2
• Vegan diet had highest dietary fiber intake vs
omnivorous diet. 3
1. Liu, 2015; 2. Gold, 2006 3. Clarys, 2014
Discussion
27. Sweets intake
• Excess sugar consumption islinked to cell
aging, negative health ailments 1-3
• Excess sugar consumption is linked to
deficiencies in memory, cognitive health, and
affects biological aging4,5
1. Melton, 2000; 2. Mikulikova et al 2008; 3. Crane et al 2013; 4. Cassidy et al 2010
28. • NIH Dietary Questionnaire II
We are interested in whether you consume any of the following specific foods or beverages and how
frequently you do so.
ON AVERAGE OVER THE PAST YEAR
Never or
less than
once a
month
(1)
1-3 per
month
(2)
Once
a
week
(3)
2-4
per
week
(4)
5-6
per
week
(5)
Once
a day
(6)
2-3
per
day
(7)
4-5
per
day
(8)
6+
per day
(9)
Sweets (pastries, cakes, cookies,
brownies, candy, etc.)
Soft drinks (sugar-sweetened, non-diet)
Methods
29. Variable n OMN VEG VG p value*
Mean ± SD Mean ± SD Mean ± SD
Sweets 432
3.84
± 1.81a
3.44
± 1.87b
2.64
± 1.52ab < .0011
Soda 424
1.61
± 1.28a
1.25
± 0.89b
1.13
± 0.55ab < .0012
* ANOVA; groups with same letters differed significantly.
1 F = 18.8, pƞ2 = .08. 2 F = 8.8, pƞ2 = .04.
Results – Intake of Sweets / Soda
31. Results – Group Comparison
Total
sweets
variable
n
Never or
rarely
eat sweets
Less
frequently
eat sweets
More
frequently
eat sweets
F ratio Adj
F ratio
M ± SD M ± SD M ± SD
Physical
Symptoms
377
37.77 ±
17.55a
35.53 ±
13.98b
45.46 ±
20.47ab 11.33* 8.82*1
Mental
Symptoms
423
13.73 ±
7.11a
13.06 ±
5.99b
16.38 ±
7.63ab 8.07* 7.21*2
* p < .01; same letters differ significantly. 1 Adj means: 36.37, 35.64, 44.51, pƞ2 = 0.045.
2Adj means: 13.63, 13.26, 16.17, pƞ2 = 0.033
32. Eating sweets was related to increased severity of
menopausal symptoms; females eating sweets more
frequently had higher symptom severity than those
who never or rarely ate sweets.
• Intake of sweets was positively associated with the risk of
onset of menopausal symptoms5,6
• Frequency of sweets intake was associated with chills7
Discussion
5. Sabia et al 2008; 6. Herber-Gast & Mishra, 2013; 7. Ishizuka, 2008
33. Background – Berry Intake
• Foods that contain phytoestrogens act as
antioxidants which may relieve menopausal
symptoms 1
• Higher intake of flavonoids at midlife is
associated with greater wellbeing in the
elderly 2
1. Moreira et al, 2014; 2. Samieri et al, 2014
34. We are interested in whether you consume any of the following specific foods or beverages and how
frequently you do so.
ON AVERAGE OVER THE PAST YEAR
Never or
less than
once a
month
(1)
1-3 per
month
(2)
Once
a
week
(3)
2-4
per
week
(4)
5-6
per
week
(5)
Once
a day
(6)
2-3
per
day
(7)
4-5
per
day
(8)
6+
per day
(9)
Berries (any)
Methods
35. Variable n OMN VEG VG
p
value
Mean ± SD Mean ± SD Mean ± SD
Berry intake
frequency
419 3.72 + 1.65a 3.86 + 1.66b 4.54 + 1.87ab <.001*
Results – Intake of Berries
* ANOVA, F ratio = 9.036, pƞ2= 0.042; groups with same letters differed significantly.
36. Results – Associations
Variables n
Physical
Symptoms
(r/p)
Mental
Symptoms
(r/p)
Berry intake
frequency
119 - .208 / .000 - .188 / .000
Pearson’s correlation coefficients; p<.05 is significant.
37. Results – Comparison of Groups
* p < .05; groups with same letters differ significantly.
1 ANCOVA adj means: 43.41, 38.41, 36.61, pƞ2 = 0.02
2 ANCOVA adj means: 15.76, 13.88, 12.87, pƞ2 = 0.02
Never or
rarely
eat berries
Eat berries
weekly
Eat
berries
daily
F
ratio
Adj
F ratio
n M ± SD M ± SD M ± SD
Physical
Symptoms
373
44.84 ±
21.26a
38.38 ±
15.83
35.14 ±
15.56a 7.39* 3.78*1
Mental
Symptoms
420
16.15 ±
7.85a
13.80 ±
6.73
12.64 ±
5.97a 6.72* 4.93*2
38. Discussion
Eating berries was related to decreased menopausal
symptoms; females eating berries daily had lower
symptoms than those never or rarely eating berries.
• Decrease in estrogen during menopause increases oxidative
stress 3-4
• Berry supplementation resulted in significant improvement
in symptoms5
3. Manach et al, 2004; 4. Doshi et al, 2013; 5. Schrager et al, 2015
39. • Omega-3 fat1 supplementation decreased
depression symptoms and hot flash frequency 2
Background – Omega-3 Fats
Plant Based
Animal Based
1. Mozaffarian et. al, 2011; 2. Freeman et. al, 2011
40. Methods
• NIH Dietary Questionnaire II format; Omega-3
questionnaire (Sublette et al, 2011)
We are interested in whether you consume any of the following specific foods or beverages and how
frequently you do so.
ON AVERAGE OVER THE PAST YEAR
Never or
less than
once a
month
(1)
1-3 per
month
(2)
Once
a
week
(3)
2-4
per
week
(4)
5-6
per
week
(5)
Once
a day
(6)
2-3
per
day
(7)
4-5
per
day
(8)
6+
per day
(9)
Walnuts or walnut oil, canola oil
Flaxseeds (ground) or flaxseed oil
41. Variable OMN VEG VG
p
value
M ± SD M ± SD M ± SD
Walnuts, canola
oil
2.53 ± 1.55
(n=238)
3.04 ± 1.78
(n=71)
3.11 ± 1.86
(n=116)
.0031
Flaxseed,
flaxseed oil
1.92 ± 1.58
(n=239)
2.51 ± 1.80
(n=73)
3.44 ± 2.01
(n=117)
<.0012
1ANOVA, F ratio = 5.86, ƞ2= 0.027; 2ANOVA, F ratio = 29.56, ƞ2= 0.122
Results: Comparison of Groups
42. Frequency of
major ALA sources
n
Physical
Symptoms
(r/p)
Mental
Symptoms
(r/p)
Walnuts 426 - .066 / .172 - .096 / .048
Flaxseeds 430 - .127 / .008 - .088 / .068
Total major ALA
sources
424 - .132 / .007 - .120 / .014
Results: Associations with Symptoms
Pearson’s correlation coefficients; p<.05 is significant.
43. n
Never or
rare freq of
major ALA
Less freq
of major
ALA
More freq
of major
ALA
F ratio
Adj
F ratio
M ± SD M ± SD M ± SD
Physical
Symptoms
424
40.37 ±
18.16a
39.57 ±
17.46
35.40 ±
15.87a 3.21* 1.56
Mental
Symptoms
424
14.95 ±
7.25a
14.13 ±
7.08
12.63 ±
6.18a 3.96* 3.47*1
* p < .05; groups with same letters differ significantly.
1 ANCOVA adj means: 14.94, 13.94, 12.86:, pƞ2= .016.
Results: Comparisons of Groups
44. Discussion
Eating major ALA sources was associated with
decreased menopausal symptoms; those who ate
them more frequently vs never or rarely reported
less mental symptom severity.
• Vegetarians reported better mood and higher PUFA than
omnivores 3
• High ALA intake in vegetarians lowers the LA/ALA ratio 4
3. Beezhold et al, 2010; 4. Sanders, 2009
45. Background
• Diets rich in monounsaturated fatty acids
improved the quality of life for postmenopausal
women.1
• Fast food consumption, starting in adolescents,
among those following a Western diet have a
stronger association with overweight/obesity,
and poor dietary outcomes. 2
1. Anderson-Vasquez et. al, 2015; 2. Poti et. al, 2014
46. Methods
Which of the following best describes the type of meals you most frequently eat? .
ON AVERAGE OVER THE PAST YEAR
Never or
rarely
2-4
times
per
month
2-3
times
per
week
4-6
times
per
week
Once
per
day
2-3
times
per
day
Convenience/Frozen Food
Home Cooked Meals
Eat out (fast food)
Eat at a full service restaurant
47. Eating habits OMN VEG VG
p
value*
Eat home-cook meals
241
(n=243)
71
(n=71)
121
(n=122)
.745
Eat convenience
foods
105
(n=240)
23
(n=72)
46
(n=115)
.199
Eat fast foods
139
(n=240)
29
(n=72)
27
(n=117)
.0001
Eat at full service
restaurants
213
(n=245)
58
(n=72)
82
(n=121)
.0022
Results – Comparison of Groups
*Chi-square; p<.05 is significant. 1X2(10, N= 429)= 44.06. 2X2(8, N= 438)= 24.41.
49. Results – Comparison of Groups
n
Never engaging
in eating pattern
M ± SD
Engaging in
eating pattern
M ± SD
t
statistic
F ratio
ANCOVA
Physical
Symptoms
379
37.03
± 16.44
41.77
± 18.57
-2.95* 2.92
Mental
Symptoms
428
13.44
± 6.92
14.87
± 6.78
-2.29* 2.14
Physical
Symptoms
383
35.85
± 16.49
43.31
± 18.11
-4.11* 8.15**1
Mental
Symptoms
430
13.24
± 6.53
15.08
± 7.32
-2.91* 7.35**2
Independent t test; p < .05; ** p < .01; groups with same letters differ
significantly. 1 ANCOVA adj means: 36.95, 41.97, pƞ2=0.045.
2ANCOVA adj means: 13.30, 15.01, pƞ2=0.017.
ConvFoodsFastFoods
50. Discussion
Eating convenience or fast food is related to an increased
severity of menopausal symptoms, and those who
consumed fast foods reported more severe symptoms
than those who did not.
• Those who ate fast food had less healthy dietary intake
overall3
• Older women who did not eat fast foods reported fewer
and less severe symptoms4
• Fast food frequency by women were lower in
vitamin A, carotenes and vitamin C density5
3. Wilcox et al, 2013; 4. Moore et al, 2009; 5. Bowman, 2004
51. Background- Physical Activity
• Regular aerobic exercise is associated with improved
menopause symptoms, including anxiety and depression 1
• Physically inactive menopausal women have more
depressed mood, memory/ concentration problems,
vasomotor symptoms than physically active women 2
52. • “Considering a 7-day period, how many times on average do
you do the following kinds of EXERCISE for more than 15
minutes during your free time?” (Responses 0-20x/week)
• Total exercise: (Mild X 3) + (Mod X 5) + (Stren X 9)
Methods
Strenuous
(heart beats rapidly)
• jogging, hockey,
soccer, basketball,
cross-country
skiing, judo, roller
blading, vigorous
swimming,
vigorous long
distance cycling
Moderate
(not exhausting)
• fast walking,
baseball, tennis,
easy bicycling,
volleyball, easy
swimming, alpine
skiing, dancing
Mild
(minimal effort)
• such as golf,
bowling, easy
walking
53. OMN
n=248
VEG
n=151
VG
n=123
p value
Means ± SD Means ± SD Means ± SD
Mild 4.88 ± 3.13 5.22 ± 3.30 5.41 ± 3.54 0.314
Moderate 3.10 ± 2.36 3.35 ± 2.42 3.67 ± 2.86 0.127
Strenuous 1.61 ± 1.31a 2.28 ± 1.84 1.92 ± 1.71a 0.0031
Total 45.11 ± 22.98a 55.04 ± 28.36 49.68 ± 25.51a 0.0022
ANOVA test; groups with same letters differ significantly.
1 F ratio= 6.3, ƞ2= 0.18. 2 F ratio= 6.5, ƞ2= 0.28
Results – Comparison of Groups
54. Results - Associations with Symptoms
Variable N
Physical
Symptoms
Mental
Symptoms
r/p value r/p value
Mild 459 -.086 / .066 -.032 / .490
Moderate 459 -.166 / .000 -.175 / .000
Strenuous 459 -.109 / .020 -.073 / .116
Total 459 -.177 / .000 -.140 / .003
Pearson’s correlation coefficients; p<.05 is significant.
55. n
Low
activity
Medium
activity
High
activity
F
ratio
Adj
F ratio
Mean ± SD Mean ± SD Mean ± SD
Physical
Symptoms
268
41.18
± 17.41
39.95
± 18.19
34.64
± 15.93
8.33 2.11
Mental
Symptoms
268
15.10
± 7.13a
14.64
± 6.87 b
11.81
± 6.01ab 8.97* 4.62*1
Physical
Symptoms
409
14.75
± 6.75a
14.66
± 7.13
12.79
± 6.59a 3.96* 5.07*2
Mental
Symptoms
409
42.40
± 18.33abc
39.78
± 17.04abc
34.95
± 16.52abc 7.43* 3.26*3
ANOVA, p<.05; groups with same letters differ significantly.
1ANCOVA adj means: 14.88 , 14.77, 11.92, pƞ2= 0.038; 2ANCOVA adj means: 14.82 , 14.67, 12.71,
pƞ2= 0.022. 3ANCOVA adj means: 41.12, 40.03, 35.91, pƞ2= 0.016.
Results- Comparison of Groups
TotalExModerateEx
56. Discussion
Moderate exercise (and total) was associated with lower
severity of menopausal symptoms, and those who
reported not engaging in moderate exercise had more
mental symptoms.
• Those who reported less total exercise had more
menopausal symptom severity than those who reported
more total exercise.
• Association of aerobic exercise and fewer physical and
mental symptoms in menopause studies 3,4
3. Kim, 2014; 4. Gutierrez, 2012
57. Key Findings
• Vegans report lower severity of physical menopausal
symptoms than omnivores
• Multiple factors were associated with lower severity of
menopausal symptoms
Decreased Symptom Severity Increased Symptom Severity
Vegan Diet Age BMI
Sleep Hours Social Support Sweets, Fast & Convenience
Foods, Grapes, Coffee, Milk,
Orange/Grape Juices, Soda,
Green/Black Tea, Dark
Chocolate, Beef
Physical Activity Education
Berries, Tree fruit, Spinach, Pomegranate
Juice, Plant Omega-3
58. Strengths and Limitations
• Strengths
• Large sample size
• Exploration of a topic
with limited previous
research
• Included many data
points
• Limitations
• Length and personal
nature of questions
• Self-reported data
• Retrospective
• Food frequency only
• Low generalizability
• Correlational study
59. Conclusion
• A plant-based diet may ease the menopausal
transition
• Being physically active and healthier eating
habits (“slow” food) may also be beneficial
Images courtesy of sirrichards.com and tattly.com
60. Future Research
• Experimental study with vegan vs omnivore diet
in menopausal women
• Duration of adherence to a vegan diet in
menopausal women
• Investigation of premenstrual symptoms and
plant-based diet
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