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A practical nutritional guide for the management of sleep disturbances in menopause
Daniela Laudisio , Luigi Barrea , Gabriella Pugliese , Sara Aprano , Bianca Castellucci , Silvia Savastano , Annamaria Colao & Giovanna Muscogiuri
ABSTRACT
Sleep disturbances (SD) represent one of the main symptoms of menopause and they are caused by several factors. Hormonal changes such as the reduction of estrogen levels and the consequent vasomotor symptoms (VMS) along with psychiatric disorders such as depression and anxiety could contribute to the onset of SD. Furthermore, obesity per se or through the obstructive sleep apnoea (OSA) could blunt sleep. Moreover, in menopause is usually a reduction in melatonin, that could contribute to SD. Nutritional strategies are paramount because they could contribute to managing menopause-related SD, in particular tackling obesity and overweight. Furthermore, some foods, such as soy, fish, whole grains, vegetables, and fruit could decrease symptoms like depression and VMS, correlated with SD in postmenopausal women. Therefore, the aim of this review is to provide an overview of the current evidence on SD in menopause and to provide nutritional strategies for managing SD in this context.
Introduction
Currently, sleep disturbances (SD) represent a common concern among the general population; in fact, about 35% of individuals have problems falling asleep, staying asleep, awakening early, or not feeling refreshed after sleep. SD has a significant impact on the quality of life and is associated with numerous adverse health outcomes. In fact, SD and the consequent sleep loss may have detrimental effects on the cardiovascular, endocrine and nervous systems, determining an increased risk of cardiovascular diseases, hypertension, obesity, type 2 diabetes and impaired glucose tolerance, anxiety and depression (Barrea, Pugliese, Framondi et al. 2020; Leger and Bayon 2010; Kohli et al. 2011; Vogtmann et al. 2013; Thurston et al. 2017). Among SD, insomnia, characterised by difficulty falling asleep or staying asleep, accompanied by daytime impairment of mental and/or physical function and irritability (Bianchi 2017) is estimated to be more frequent in women (Ohayon 2002; Krystal 2003). Furthermore, the prevalence of SD among women is variable and increases with age (Kravitz and Joffe 2011). It ranges from 16% to 42% in premenopausal women, from 39% to 47% in perimenopausal women, and, it affects 35% to 60% in postmenopausal women (Kravitz and Joffe 2011). Menopause is a physiological event in the woman’s life characterised by the cessation of spontaneous menstrual cycles caused by a reduction in the sex hormones oestrogen and progesterone and a consequent increase of follicle-stimulating hormone (FSH) and luteinizing hormone (LH), which occurs when the ovarian reserve ends (Nelson 2008). In addition to insomnia, the most commonly SD founded in menopausal women, include nocturnal breathing disturbances, of which obstructive sleep apnoea (OSA) is the most common, restless leg syndrome, periodic limb movement syndrome, depression and anxiety (Guidozzi 2013). The aetiology for SD in menopausal women is still unknown, but, however, it seems that is caused by the contribution of several risk factors that commonly occur in menopause such as decreased oestrogen levels and the consequent vasomotor symptoms (VMS), depression, weight gain (mostly the increase of visceral adiposity) (Guidozzi 2013). Several studies showed an improvement of VMS after phytoestrogens intake (Hachul et al. 2011; Franco et al. 2016). This could be due to their chemical structure that is similar to that of oestradiol, therefore, mimicking oestrogen-like properties and relieving menopausal symptoms (Britt et al. 2005; Cano et al. 2010; Lambert et al. 2017); also, evidence indicates that high fibre and low glycemic index foods intakes may be associated with a reduced risk of depression (Gangwisch et al. 2015; Daneshzad et al. 2020). In fact, postprandial hyperglycaemia and resultant compensatory hyperinsulinemia from high dietary glycemic load can result in reactive hypoglycaemia (Seaquist et al. 2013), triggering the secretion of autonomic counterregulatory hormones such as adrenaline, cortisol, glucagon, and growth hormone, and these hormones responses can cause symptoms such as depression and anxiety (Ludwig 2002). Moreover, high fibre and low glycemic index foods intakes could contribute to weight loss and to a reduction of waist circumference (WC; Appling et al. 2007; Dormire and Howharn 2007). In particular, visceral adipose tissue is an important source of proinflammatory cytokines could be associated with sleep regulation (Perrini et al. 2017; Muscogiuri et al. 2019). Furthermore, a high intake of omega-3 has been reported to decrease depression and anxiety that in turn could contribute to worsening VMS. In fact, omega-3 play a role in mental health as it reduces neuronal damage by oxidative stress, hindering inflammatory processes and diminishing cytokine circulation and cellular infiltration and also may improve tryptophan transport, a serotonin precursor (Laye et al. 2018; Liao et al. 2019; Tsujiguchi et al. 2019; Godos, Currenti et al. 2020). Thus, the aim of this review is to provide an overview of the current evidence on SD in menopause and to provide nutritional strategies for managing SD in this context.
Menopause and sleep disturbances
Ovarian hormonal changes: oestrogen decrease
Overweight and obesity
Melatonin reduction
Nutritional advice for the management of sleep disturbances in menopause
Phytoestrogens
Low glycemic index foods, fibre, fruits, vegetables and whole grains
Polyunsaturated fatty acids
High glycemic index foods: carbohydrate, sugars, refined cereals
Tryptophan
Nutritional assessment of postmenopausal women with sleep disturbances
Clinical evaluation of body composition
Clinical evaluation of sleep disturbances
Dietetic intervention
Particular attention should be paid to particular dietary rules:
1. It is recommended adequate protein intake for the maintenance of muscle mass and strength and for the prevention of sarcopenia. The current DRI is 0.8 g protein/kg body weight (Trumbo et al. 2002; Morais et al. 2006; Arentson-Lantz et al. 2015). It is recommended the high consumption of animal protein alternatives such as legumes, tofu and soybeans, and it is recommended at least 3 servings of fish per week and lean cuts of meat;
2. It is recommended intake of phytoestrogens, in particular, isoflavones can be abundantly found in soybeans, instead, lignans are found in legumes, vegetables such as carrots and cabbage, fruits such as strawberries, nuts, flax seeds and whole grains;
3. Fish rich in PUFA omega-3 is preferable, such as anchovies, herring, mackerel, salmon, sardines, sturgeon, trout and tuna;
4. It is recommended intake of complex carbohydrates such as fibre, non-juice fruit, vegetables and whole-grain and limit intake of carbohydrates with a high glycaemic index such as sugars, glucose, sucrose, fructose, starch;
5. Prefer fruit and vegetables rich in vitamins C, E, B and folate, such as strawberries, lemon, kiwi, avocado, artichokes, broccoli, asparagus, spinach, chard, black cabbage, endive, lettuce, beetroot, brussels sprouts; 6. It is recommended intake of foods rich in tryptophan (Table 1); estimated to be between 250 mg and 425 mg, which results in a dietary intake of 3.5–6.0 mg/kg of body weight per day (Richard et al. 2009).
Conclusions
The menopause is associated with an increase SD such as insomnia or difficulty falling asleep, which negatively impacts the quality of life. The aetiology for SD in menopausal women is still controversial, but, the key players seem to be the decrease of oestrogens levels that in turn contribute to the onset of depression, VMS, weight gain and mostly the increase of visceral adiposity could account for the onset of SD in postmenopausal acting directly through the secretion of cytokines or indirectly through OSA. Moreover, melatonin plays a very important role in circadian rhythm, especially in sleep onset and in sleep maintenance. The decline of melatonin secretion which physiologically occurs with age could be a further player that could contribute to SD in menopause. Although data available on SD and nutrition in postmenopausal women are few, they overall suggest that nutritional management strategies could represent a useful tool to treat SD in postmenopausal women. Therefore, adequate management of SD seems to be essential, and it should involve dietary. Increased intake of phytoestrogens could relieve menopausal symptoms, in particular, VMS, high intake of fibre and low glycemic index foods may be associated with a reduced risk of VMS besides, high intake of fibre could contribute to weight loss and to the reduction of waist circumference. Furthermore, a high intake of omega-3 has been reported to decrease depression and anxiety that in turn could contribute to worsening SD. Consumption of tryptophan, a precursor of melatonin, could improvements in sleep parameters. Therefore, adequate nutritional management and a Clinical evaluation of SD should be mandatory in the clinical practice, and it should involve a tailored diet based on the patient’s habits.
Considering that, there are no specific dietary guidelines that are directly related to menopause and SD, this manuscript provides a practical guideline that could be useful for the management of SD in menopause.
Daniela Laudisio , Luigi Barrea , Gabriella Pugliese , Sara Aprano , Bianca Castellucci , Silvia Savastano , Annamaria Colao & Giovanna Muscogiuri
ABSTRACT
Sleep disturbances (SD) represent one of the main symptoms of menopause and they are caused by several factors. Hormonal changes such as the reduction of estrogen levels and the consequent vasomotor symptoms (VMS) along with psychiatric disorders such as depression and anxiety could contribute to the onset of SD. Furthermore, obesity per se or through the obstructive sleep apnoea (OSA) could blunt sleep. Moreover, in menopause is usually a reduction in melatonin, that could contribute to SD. Nutritional strategies are paramount because they could contribute to managing menopause-related SD, in particular tackling obesity and overweight. Furthermore, some foods, such as soy, fish, whole grains, vegetables, and fruit could decrease symptoms like depression and VMS, correlated with SD in postmenopausal women. Therefore, the aim of this review is to provide an overview of the current evidence on SD in menopause and to provide nutritional strategies for managing SD in this context.
Introduction
Currently, sleep disturbances (SD) represent a common concern among the general population; in fact, about 35% of individuals have problems falling asleep, staying asleep, awakening early, or not feeling refreshed after sleep. SD has a significant impact on the quality of life and is associated with numerous adverse health outcomes. In fact, SD and the consequent sleep loss may have detrimental effects on the cardiovascular, endocrine and nervous systems, determining an increased risk of cardiovascular diseases, hypertension, obesity, type 2 diabetes and impaired glucose tolerance, anxiety and depression (Barrea, Pugliese, Framondi et al. 2020; Leger and Bayon 2010; Kohli et al. 2011; Vogtmann et al. 2013; Thurston et al. 2017). Among SD, insomnia, characterised by difficulty falling asleep or staying asleep, accompanied by daytime impairment of mental and/or physical function and irritability (Bianchi 2017) is estimated to be more frequent in women (Ohayon 2002; Krystal 2003). Furthermore, the prevalence of SD among women is variable and increases with age (Kravitz and Joffe 2011). It ranges from 16% to 42% in premenopausal women, from 39% to 47% in perimenopausal women, and, it affects 35% to 60% in postmenopausal women (Kravitz and Joffe 2011). Menopause is a physiological event in the woman’s life characterised by the cessation of spontaneous menstrual cycles caused by a reduction in the sex hormones oestrogen and progesterone and a consequent increase of follicle-stimulating hormone (FSH) and luteinizing hormone (LH), which occurs when the ovarian reserve ends (Nelson 2008). In addition to insomnia, the most commonly SD founded in menopausal women, include nocturnal breathing disturbances, of which obstructive sleep apnoea (OSA) is the most common, restless leg syndrome, periodic limb movement syndrome, depression and anxiety (Guidozzi 2013). The aetiology for SD in menopausal women is still unknown, but, however, it seems that is caused by the contribution of several risk factors that commonly occur in menopause such as decreased oestrogen levels and the consequent vasomotor symptoms (VMS), depression, weight gain (mostly the increase of visceral adiposity) (Guidozzi 2013). Several studies showed an improvement of VMS after phytoestrogens intake (Hachul et al. 2011; Franco et al. 2016). This could be due to their chemical structure that is similar to that of oestradiol, therefore, mimicking oestrogen-like properties and relieving menopausal symptoms (Britt et al. 2005; Cano et al. 2010; Lambert et al. 2017); also, evidence indicates that high fibre and low glycemic index foods intakes may be associated with a reduced risk of depression (Gangwisch et al. 2015; Daneshzad et al. 2020). In fact, postprandial hyperglycaemia and resultant compensatory hyperinsulinemia from high dietary glycemic load can result in reactive hypoglycaemia (Seaquist et al. 2013), triggering the secretion of autonomic counterregulatory hormones such as adrenaline, cortisol, glucagon, and growth hormone, and these hormones responses can cause symptoms such as depression and anxiety (Ludwig 2002). Moreover, high fibre and low glycemic index foods intakes could contribute to weight loss and to a reduction of waist circumference (WC; Appling et al. 2007; Dormire and Howharn 2007). In particular, visceral adipose tissue is an important source of proinflammatory cytokines could be associated with sleep regulation (Perrini et al. 2017; Muscogiuri et al. 2019). Furthermore, a high intake of omega-3 has been reported to decrease depression and anxiety that in turn could contribute to worsening VMS. In fact, omega-3 play a role in mental health as it reduces neuronal damage by oxidative stress, hindering inflammatory processes and diminishing cytokine circulation and cellular infiltration and also may improve tryptophan transport, a serotonin precursor (Laye et al. 2018; Liao et al. 2019; Tsujiguchi et al. 2019; Godos, Currenti et al. 2020). Thus, the aim of this review is to provide an overview of the current evidence on SD in menopause and to provide nutritional strategies for managing SD in this context.
Menopause and sleep disturbances
Ovarian hormonal changes: oestrogen decrease
Overweight and obesity
Melatonin reduction
Nutritional advice for the management of sleep disturbances in menopause
Phytoestrogens
Low glycemic index foods, fibre, fruits, vegetables and whole grains
Polyunsaturated fatty acids
High glycemic index foods: carbohydrate, sugars, refined cereals
Tryptophan
Nutritional assessment of postmenopausal women with sleep disturbances
Clinical evaluation of body composition
Clinical evaluation of sleep disturbances
Dietetic intervention
Particular attention should be paid to particular dietary rules:
1. It is recommended adequate protein intake for the maintenance of muscle mass and strength and for the prevention of sarcopenia. The current DRI is 0.8 g protein/kg body weight (Trumbo et al. 2002; Morais et al. 2006; Arentson-Lantz et al. 2015). It is recommended the high consumption of animal protein alternatives such as legumes, tofu and soybeans, and it is recommended at least 3 servings of fish per week and lean cuts of meat;
2. It is recommended intake of phytoestrogens, in particular, isoflavones can be abundantly found in soybeans, instead, lignans are found in legumes, vegetables such as carrots and cabbage, fruits such as strawberries, nuts, flax seeds and whole grains;
3. Fish rich in PUFA omega-3 is preferable, such as anchovies, herring, mackerel, salmon, sardines, sturgeon, trout and tuna;
4. It is recommended intake of complex carbohydrates such as fibre, non-juice fruit, vegetables and whole-grain and limit intake of carbohydrates with a high glycaemic index such as sugars, glucose, sucrose, fructose, starch;
5. Prefer fruit and vegetables rich in vitamins C, E, B and folate, such as strawberries, lemon, kiwi, avocado, artichokes, broccoli, asparagus, spinach, chard, black cabbage, endive, lettuce, beetroot, brussels sprouts; 6. It is recommended intake of foods rich in tryptophan (Table 1); estimated to be between 250 mg and 425 mg, which results in a dietary intake of 3.5–6.0 mg/kg of body weight per day (Richard et al. 2009).
Conclusions
The menopause is associated with an increase SD such as insomnia or difficulty falling asleep, which negatively impacts the quality of life. The aetiology for SD in menopausal women is still controversial, but, the key players seem to be the decrease of oestrogens levels that in turn contribute to the onset of depression, VMS, weight gain and mostly the increase of visceral adiposity could account for the onset of SD in postmenopausal acting directly through the secretion of cytokines or indirectly through OSA. Moreover, melatonin plays a very important role in circadian rhythm, especially in sleep onset and in sleep maintenance. The decline of melatonin secretion which physiologically occurs with age could be a further player that could contribute to SD in menopause. Although data available on SD and nutrition in postmenopausal women are few, they overall suggest that nutritional management strategies could represent a useful tool to treat SD in postmenopausal women. Therefore, adequate management of SD seems to be essential, and it should involve dietary. Increased intake of phytoestrogens could relieve menopausal symptoms, in particular, VMS, high intake of fibre and low glycemic index foods may be associated with a reduced risk of VMS besides, high intake of fibre could contribute to weight loss and to the reduction of waist circumference. Furthermore, a high intake of omega-3 has been reported to decrease depression and anxiety that in turn could contribute to worsening SD. Consumption of tryptophan, a precursor of melatonin, could improvements in sleep parameters. Therefore, adequate nutritional management and a Clinical evaluation of SD should be mandatory in the clinical practice, and it should involve a tailored diet based on the patient’s habits.
Considering that, there are no specific dietary guidelines that are directly related to menopause and SD, this manuscript provides a practical guideline that could be useful for the management of SD in menopause.
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