Women in midlife experience a sharp rise in their risk of type 2 diabetes mellitus (T2DM) and cardiovascular disease (CVD). This increase occurs alongside the shift in hormonal changes in perimenopause and menopause. Estrogen fluctuations start during perimenopause and drop rapidly during menopause. While younger women are often protected by higher estrogen levels, the decrease in estrogen affects how women process glucose, store fat and regulate cholesterol and blood pressure, narrowing the gap between women and men in metabolic and heart disease risk.
In fact, studies show that women with T2DM face approximately 30% higher risk of cardiovascular mortality than men with diabetes. Additionally, women with reproductive history of pregnancy-related conditions such as gestational diabetes or pre-eclampsia enter mid-life with a higher baseline risk. Together, these factors make the menopausal transition an important time to understand and address the metabolic changes that underpin long-term health.
The metabolic changes behind menopause symptoms
Perimenopause and menopause bring more than hot-flashes and sleepless nights. These symptoms are often tied to biophysiological changes that happen in the body during this stage of a woman’s life. Key changes include insulin resistance, hypertension (high blood pressure), obesity, and dyslipidemia (abnormal cholesterol and fat levels in the blood). One common marker of these changes is the accumulation of visceral fat around our organs, which is strongly linked to an increased risk of type 2 diabetes. Unlike the fat under our skin, this fat is metabolically active, which means that it releases hormones and inflammatory chemicals that interfere with insulin, making it harder for the cells to absorb glucose. This is known as insulin resistance.
This cluster of factors and others are known as metabolic syndrome. Metabolic syndrome is a combination of metabolic abnormalities including hypertension, high triglycerides, high abdominal obesity, high fasting glucose and low HDL (commonly known as the “good cholesterol”). A combination of three or more of these would diagnose metabolic syndrome which increases the risk of cardiovascular diseases (CVD). Studies have shown that postmenopausal women have a 60% higher risk of developing metabolic syndrome compared to premenopausal women. CVD is the leading cause of death for women in the U.S. It is responsible for more deaths among women than all forms of cancer combined.
What is the link with menopause?
Menopause typically occurs between 45 and 55 years of age and it is defined as the absence of a menstrual period for one year. However, irregularities, including amenorrhea (the absence of menstrual periods for an extended period) can begin in the late 30s or early 40s and may last for years. This period is called perimenopause. Hormonal changes happening during these years have somatic and physiological effect on our body and mind. In reproductive years, estrogen, especially estradiol, is central to how a woman’s body handles food and regulates blood glucose. Estrogen acts on the central nervous system, decreasing food intake and increasing satiety. It supports the pancreas in releasing insulin, and it helps muscles respond to insulin, increasing glucose uptake in cells. It ultimately supports an active metabolism. When estrogen levels decline during perimenopause and menopause, these protective effects are lost. Pancreatic cells become less effective in producing insulin and cellular uptake of glucose from the bloodstream decreases, which is known as insulin resistance. Metabolism slows, appetite often increases, and fat is redistributed toward the abdomen, leading to the accumulation of visceral fat. This fat, in turn, releases inflammatory molecules that further worsen insulin resistance.
Recommendations for supporting heart health and diabetes prevention during midlife
During the period of perimenopause and menopause, many women experience symptoms such as hot flashes and night sweats, irritability, decreased ability to concentrate, and sleep irregularities. While not all symptoms can be eliminated, lifestyle strategies such as nutrition and regular physical exercise can help to alleviate some of these symptoms. Studies show that weight loss of 10% of induced by diet alone or diet plus exercise improves insulin sensitivity and overall wellbeing in people with obesity and prediabetes. The improvement in insulin sensitivity was much greater in participants who were assigned to the exercise intervention in addition to dietary changes. The Physical Activity Guidelines for Americans recommend 150 minutes or more per week of moderate intensity aerobic activity or 75 minutes per week of vigorous aerobic activity. For increase benefits, add muscle strengthening exercises, such as resistance or weight training at least twice a week.
What are some foods that improve insulin sensitivity and heart health? High fiber foods: fiber is found in foods of plant origin, including fruits, vegetables, grains (particularly unrefined/whole grains), beans, peas, lentils, nuts, and seeds. Some general goals for vegetables, fruits, and grains include:
- Vegetables: about 3 cups per day for most women
- Fruits: 1 1/2 to 2 cups per day for most women
- Grains: 2-4 servings per day for most women. Focus on increasing your intake of whole grains, as they provide more fiber which supports glycemic control as well as heart health. Examples of one serving of whole grain include 1/2 cup cooked oatmeal or brown rice, 1 slice of whole wheat bread, or three cups of air popped popcorn.
In addition to these high fiber foods, choose:
- Lean proteins: increase your protein from plant sources, including beans (such as lima, black or cannellini beans), peas (such as chickpeas, blacked eye peas, and split peas), lentils, soy foods, nuts (such as peanuts, walnuts and almonds), and seeds (such as pumpkin, chia, or ground flax). Plant proteins have the added benefit of providing dietary fiber and cardioprotective antioxidants. Lean animal proteins include skinless chicken and turkey breast, pork tenderloin, egg whites, and white fish.
- Dairy: Choose low fat (1%) and fat free milk, yogurt, and cheese or fortified soy alternatives, like unsweetened soy milk.
- Oils: Use mostly liquid oils such as olive, canola, safflower, or avocado oil which are good sources of heart healthy mono- and polyunsaturated fats.
Limit the following foods:
- Sugar sweetened drinks like soda, sweet tea, flavored coffees with syrups and creamers, fruit juices with added sugars. Replace sugar sweetened drinks with water, unsweetened tea, or make your own infused water with lemon, cucumber, or berries.
- Sweets such as candies, pastries, cookies, cakes, sweetened cereals and other foods high in added sugars; replace them with fresh fruit, dark chocolate, or nuts for a satisfying snack or dessert.
- Red and processed meats: these often have high amounts of saturated fats. Replace with lean cuts of chicken or turkey, fish, beans, lentils, or tofu.
- Highly processed foods: these are often high in fats, sodium and refined carbs. Replace with homemade meals using fresh or frozen vegetables, low-sodium broths, whole grains, nuts, and seeds.
For more information and nutrition tips, visit the American Heart Association and American Diabetes Association.