Contributor: Hope Warshaw, MMSc, RD, CDCES, BC-ADM
In partnership with

Oh yeah, menopause! All women lucky enough to age beyond childbearing years go through menopause, yet it remains an infrequently researched and somewhat taboo topic. For women with type 1 or type 2 diabetes, symptoms like insomnia, brain fog, vaginal dryness, unexplainable weight gain, and surprising fluctuations in glucose levels may befuddle you until you and your healthcare providers realize they’re your welcome sign to menopause. The fact that menopause “usually coincides with a stage of life that in and of itself is associated with many personal and sometimes professional obligations…women sometimes think their symptoms are from something else, like stress. If you add diabetes to the mix, this confusion can increase,” says Sarit Polsky, MD, MPH.

Two of my RDN colleagues have written a valuable book, The Menopause Diet Plan: A Natural Guide to Managing Hormones, Health, and Happiness. While this book is not specific to diabetes, it contains excellent content on menopause and myriad related topics, from what’s happening in your body to reducing your risks for osteoporosis, certain cancers, and, of particular importance to women with diabetes - cardiovascular disease. I have interviewed one of the authors, Hillary Wright, MEd, RDN, who has worked with people with diabetes and has a long history with type 1. Hillary has over 30 years of experience as a nutrition educator, writer, book author, speaker, and consultant. She is the Director of Nutrition Counseling for the Domar Center for Mind/Body Health at Boston IVF in Waltham, MA, one of the largest fertility treatment practices in the United States. Hillary also works part-time as a Senior Nutritionist at the Dana Farber Cancer Institute in Boston, MA.

Hope Warshaw: I'm aware you have two siblings with type 1 diabetes. Can you share the impact this reality has had on your life, career choice, and eating habits, as well as how this impacted how you raised your three boys?
Hillary Wright: I was only 13 when my first brother was diagnosed with type 1 diabetes in 1975 at age 7 (the other was diagnosed seven years later at age 11). Fortunately, my parents had access to the Joslin Diabetes Center and Boston's Children's Hospital close by, so they were well educated on how to care for diabetes. My mom has always been a great cook, so with the guidance of a dietitian at Children's was able to figure out the diet piece with a lot of support, which I'm sure wasn't widely available at that time. My Dad was a dentist, so needles weren't intimidating. From our perspective, things remained pretty normal aside from needing to be on the lookout for signs of hypoglycemia. Dealing with diabetes just became part of our family dynamic.

As for my own eating habits, I credit my mother's influence more than anything I learned in college. I was raised in an environment where healthy family meals were a priority, but we were also allowed our sweet treats, though they were definitely more available in other people's houses! I started college without a clear career path, but my mom would often remind me how helpful the registered dietitian was at empowering them to care for their young kids with diabetes. Combining my love of science and food into a nutrition degree started to make sense, which obviously gave me a leg up when feeding my own family. My mother's healthy approach that wasn't "all or nothing" definitely shaped the food environment my three sons were exposed to. Both my husband and I cook, and now my sons all do, too – a proud accomplishment!

Hope: Can you explain what is happening with hormones in a woman's body when they observe a decline in the frequency and regularity of their menstrual cycle (perimenopause) and the onset of menopause?
Hillary: Starting in perimenopause, which lasts on average about four years, hormones, particularly estrogen, begin to fluctuate, sometimes surging but ultimately dropping, causing symptoms that can feel like a hormone rollercoaster. This declining estrogen throws off the balance with progesterone, which along with estrogen, regulates ovulation and menstruation. Menstrual periods become irregular, coming closer together or farther apart, or heavier or lighter than usual. Eventually, estrogen declines enough that ovulation and menstruation no longer occur, which after 12 months is technically considered menopause.

Hope: What is the impact of perimenopause and menopause on glucose management in women with prediabetes, type 2, and type 1? How can women lessen these challenges?
Hillary: As with any life stressor, menopausal symptoms like hot flashes and sleep issues can trigger changes in glucose management. Declining estrogen levels also shift fat storage to the abdomen, which aggravates insulin resistance, particularly if it's accompanied by weight gain in midlife. Less physical activity, relationship stress, caring for aging parents, job changes, and more eating out after the kids launch can all contribute to weight gain that makes managing diabetes more challenging. Studies show that, on average, women gain about 1.5 pounds per year in their 40s and 50s, many of which are perimenopausal years, so being aware of the weight gain risk associated with this transition long before actual menopause occurs is important. Committing to regular physical activity, including strengthening exercise to maintain muscles, will go a long way towards regulating glucose levels, particularly when paired with regular glucose monitoring so you can see how any hormone, diet, or lifestyle shifts may affect you.

Hope: What steps can all women take to prevent or minimize the typical symptoms of menopause?
Hillary: There is no "one size fits all" solution to managing all menopausal symptoms, but research suggests the same healthy diet and lifestyle strategies we advocate for diabetes management and reducing the risk of cardiovascular disease may associate with fewer menopausal symptoms. Regular exercise including strength training, not smoking, limiting alcohol, and aiming for an eating plan that includes sufficient fruit, vegetables, whole grains, legumes (including soy), nuts and seeds, seafood, and poultry, and is low in red and processed meats and added sugars, may smooth the way. Having said that, there are plenty of women who eat healthily and are active who still get hot flashes and other menopause symptoms. With diabetes, however, the cardiovascular risks are real, so good self-care around healthy eating and exercise is even more important.

Hope: Why does experiencing menopause increase the risk of developing type 2 diabetes, and what steps can women take to prevent or delay the onset of type 2 diabetes?
Hillary: The average woman transitioning through perimenopause and menopause is likely to gain at least some weight, if not a significant amount. Because insulin sensitivity is tied to weight and physical activity, midlife changes that shift our diet and activity routines can increase the risk of diabetes. This is particularly true in women with any increased risks of type 2 diabetes, such as those who enter perimenopause at a higher weight, are sedentary, have a family history or a history of prediabetes,  gestational diabetes, or polycystic ovary syndrome (PCOS).

Hope: What strategies and tactics do you suggest to help women prevent, as you say, "weight creep", or lose weight?
Hillary: It can't be emphasized enough that the number of calories you are able to consume to maintain weight in this phase of life vs. gaining weight becomes narrower and regular physical activity more important through and beyond the menopause transition. Prioritizing regular meals and snacks starting in the morning to manage hunger and stabilize blood glucose levels can help with portion control. Aiming for "balanced" meals and snacks that emphasize non-starchy vegetables, whole fruits, and a variety of lean proteins, whole grains, and healthy fats can help keep hunger at bay between meals and make portion control feel more doable.

Hope: We know that menopause can impact stress and sleep patterns and vice versa. What are some strategies to decrease the related stress and insomnia?
Hillary: Sleep disruptions are more common with age, so the best we can do is nurture a good sleep routine by getting some regular physical activity, limiting napping and caffeine during the day, and aiming for a reasonable bedtime so if you wake up at night there's still time to go back and get some shut-eye.

Hope: You present in your book "The Menopause Diet Plate." How does this differ from the usual recommendations we hear about "The Plate Method" of eating?
Hillary: In our book, we do emphasize plant-based eating but with a particular focus on the timing of food over the day. We encourage starting with a good breakfast and not skimping on lunch, with well-placed protein-containing snacks as needed between meals to manage hunger and make it easier to not overeat at dinner and beyond. This aligns eating with our natural circadian rhythms, which we now understand influence our metabolic functions, including glucose control. We do encourage readers to individualize this plan as needed and not feel bad about it. There's lots of room for flexibility!

Hope: As you realize, some think foods containing carbohydrates are an enemy in maintaining glucose management. Can you discuss, related to dealing with menopause, how women should be thinking about these foods, making healthy choices, and thinking about how much of them to eat?
Hillary: We love carbohydrates! We encourage an approach that considers the "two Q's" – aim for the best quality, which are the vegetables, whole fruits, whole grains, and the carbohydrates in milk and yogurt, and be mindful of the quantity of carbohydrates you consume at each meal and snack. Weight management is a sticking point for a lot of menopausal women, so being aware that over-restricting the amount of carbohydrates you eat earlier in the day to manage weight may only backfire and lead to overeating them at night. We recommend you proactively eat foods that contain carbohydrates when you're hungry but not starved. This may help you consume reasonable portions over the day.

Hope: How can weight management and healthy eating habits and food choices help women achieve long-term health/disease prevention?
Hillary: We all know cardiovascular disease is a major risk for those living with diabetes, and diet quality and weight management are critical to moderating this risk. By emphasizing plant-based eating, you're giving your body what it needs to protect and defend your health while you limit foods that contribute to inflammation –
like red and processed meats and added sugars – which play a major role in most chronic diseases like cardiovascular disease and also cognitive problems, and some cancers, to name just a few.

Hope: Why do women start to experience an increase in osteopenia and osteoporosis in their menopausal years? What actions can women implement to reduce or delay the onset or worsening of these conditions?
Hillary: Many women know that calcium and vitamin D are important nutrients for promoting bone health, but so is eating enough protein and exerting pressure (doing weight-bearing exercise) on our bones and muscles. Strength training is also beneficial.

Hope: Are there any nutrition supplements or OTC solutions that have sufficient scientific evidence to recommend to women to help manage menopausal symptoms?
Hillary: We wish there were! While some studies suggest eating soy may reduce hot flashes, for example, there is no clear support for this. Soy foods are healthy as a source of plant protein, but evidence for soy or any dietary supplements is lacking. Not smoking, acupuncture, relaxation therapy, and cognitive behavior therapy show more promise. It's always worth discussing menopausal symptoms with your healthcare providers, particularly if your symptoms feel debilitating.

Hope: How can our readers get a copy of your book?
Hillary: The Menopause Diet Plan is available in bookstores or through all the major online sellers.

Thanks, Hillary, for this valuable book and for taking your time to share your knowledge with DiabetesSisters.

Hope Warshaw, MMSc, RD, CDCES, BC-ADM, author of Diabetes Meal Planning Made Easy, owner of Hope Warshaw Associates, LLC, a private practice and consultancy based in Asheville NC. She has approximately 40 years of expertise in diabetes care and management and is a tireless and passionate volunteer and leader in several professional organizations, including ACDCES, ADA and the Academy of Nutrition and Dietetics. She served as president of ADCES in 2016. She is an advocate for the value of peer support and peer support communities such as DiabetesSisters and is thrilled to see these communities flourish.