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Nutrition and Women

In June 2009, our guest experts were three dietitians from some of the nutrition programs offered at Women’s College Hospital in Toronto.

Kinga Balogh, RD is a registered dietitian who has been working at Women's College Hospital since graduating three years ago. Kinga counsels patients with multiple health concerns, including endocrine, digestive and metabolic conditions. She also works at the Henrietta Banting Breast Centre raising awareness about dietary strategies for breast cancer prevention, and provides nutrition counselling in the Wellness for Independent Seniors program. Kinga is involved in endocrinology research on optimizing dietary recommendations for women living with polycystic ovary syndrome.

As the clinical dietitian for the Multidisciplinary Osteoporosis Program and the Women’s Cardiovascular Health Initiative at Women’s College Hospital, Helen Emanoilidis, MSc, RD, specializes in a number of clinical areas including osteoporosis, osteoarthritis, cholesterol, blood pressure and weight management. Helen obtained a master of science degree in nutrition from the University of Toronto and a bachelor of applied science in food and nutrition from Ryerson University. In addition to her role as a clinical dietitian, Helen has made several media appearances and has delivered a number of nutrition workshops to community and corporate groups in Toronto.  

Carolyn Christo, RD, CDE, has been a registered dietitian for the past 11 years, seven of them at Women’s College Hospital. Her work experience includes nutrition counselling for diabetes, heart health, weight loss, pregnancy and pediatrics. In addition to patient counselling, Carolyn presents to community groups and teaches physicians, nurses, allied health-care professionals and students. She collaborated with the Canadian Diabetes Association in the development of education materials for the public. She currently works at TRIDEC – the Diabetes Management Centre at Women’s College Hospital.

Here are their answers on Nutrition and Women.

Q: The Better Bones website lists 20 essential bone-building nutrients for adults and women. Do you agree with these recommendations, or should one just eat a balanced diet following Canada’s Food Guide and take a multivitamin? There are so many different opinions on the Food Guide and multivitamins that it's really difficult to know what action to take when you read recommendations like this.

A: When it comes to bone health, calcium and vitamin D top the chart. Although there is convincing evidence for the use of other vitamins and minerals, such as vitamin A, vitamin K, magnesium, phosphorus, zinc, boron, manganese and copper in bone health, more research is needed to fully understand the supplementation effects of these nutrients on bone health. However, most of these nutrient needs can be met by consuming a healthy, well-balanced diet.

With the exception of vitamin K, you can also find most of these nutrients in a multivitamin and mineral formula, to complement your healthy diet. It is too early to recommended taking a daily vitamin K supplement as a way to boost overall bone health. However, a diet that includes vitamin K is encouraged for individuals who are at a higher risk of bone fractures. Vitamin K is found in dark green leafy vegetables (kale, collards, spinach, beet and turnip greens, mustard and dandelion greens, and green leaf lettuce), brussels sprouts, broccoli, parsley and asparagus. It is important to note that a vitamin K supplement is not suggested for people with a history of blood clots or those on blood-thinning medications.

Magnesium is also an important nutrient for bone health. However, most of the studies supporting the use of magnesium supplements found they were primarily effective in individuals who were magnesium depleted, such as elderly people with poor diets, individuals with intestinal disease, alcoholics and those with hyperthyroidism. Although magnesium recommendations can be easily met by following a healthy diet – which includes whole grains, dairy products, legumes, fruits, vegetables, fish and nuts – intake of this nutrient still appears to fall below recommended levels. If their diet is considerably lacking in the foods previously mentioned, women may consider taking a magnesium supplement up to 320 milligrams. Any higher amounts of supplemental magnesium can lead to diarrhea.

There is mounting evidence to suggest that higher potassium intake, primarily from consuming a diet high in fresh fruits and vegetables, not only limits urinary calcium losses, but is also associated with higher baseline bone mineral densities and less bone loss. This is yet another reason to increase your vegetable and fruit intake.


Q: What types of food should I eat if I have high cholesterol and suffer from acid reflux? I also have a family history of heart disease.

A: Lifestyle modification has been noted as a way to decrease symptoms associated with acid reflux or GERD (gastroesophageal reflux disease). Lifestyle modifications include:

  • elevating the head of the bed
  • maintaining an upright position while eating and for at least 45 minutes after eating
  • avoiding high-fat meals
  • eating small, more frequent meals throughout the day (instead of three large ones)
  • controlling your weight
  • reducing intake of alcohol, tobacco and caffeine
  • avoidance of possible trigger foods such as spices, high-fat foods, chocolate, peppermint and citrus fruits or juices

Although these strategies may have limited effectiveness and are usually ineffective in severe cases of GERD, some of these strategies may provide other health benefits, such as a more heart-healthy diet.

Below is a list of heart-healthy dietary strategies you may consider adopting.

  1. Limit unhealthy fats such as those found in butter, lard (often found in baked goods), meat, poultry, higher-fat milk and cheese, palm and coconut oil.
  2. Incorporate healthy fats in moderation. The key here is ‘moderation.’ but healthy fats such as those found in avocados, canola or extra virgin olive oils, nuts, seeds and all-natural peanut butter can raise your good cholesterol while lowering your bad.
  3. Choose plant-based proteins more often. This includes foods like soy, nut butters, nuts and seeds, and legumes.
  4. Eat more fruits, veggies and whole grains.
  5. Increase your intake of Omega-3 fatty acids. Try eating fish two or three times per week. Preferred choices include salmon, trout, sardines and herring. Other plant sources include walnuts, canola oil, flax seed and foods fortified with Omega-3.
  6. Increase your intake of soluble fibre. Opt for legumes, oat products, barley, foods with added psyillium, and pectin-rich fruits like apples, pears, citrus fruits, and berries.
  7. Limit your salt intake. Try to avoid adding salt to any of your dishes, and read the label when purchasing foods. Your daily sodium intake should be less than 1,500 milligrams (most individuals consume three times this amount).
  8. Drink alcohol in moderation. Yes, this includes wine. Too much alcohol can not only increase your weight, but can also increase your blood cholesterol and blood pressure.
  9. Achieve a healthy body weight.
  10. Plan ahead by creating daily or weekly menus.


Q: What specific food items would you recommend that would assist with overall stress management? I'm looking for ideas that could be easily implemented on a daily basis?  Should I take daily supplements of vitamins B12 and D? If so, how much?

A: It seems everyone is talking about being stressed these days. As our schedules get busier and our leisure time becomes almost non-existent, it’s no wonder people are feeling stressed-out. The good news is there are dietary strategies for helping to alleviate stress.

  1. High-carbohydrate diet. Studies have shown that during stressful periods, an increased supply of a brain chemical known as serotonin can induce a calming or relaxing effect. Serotonin is referred to as the ‘feel-good’ brain chemical, and the best way to increase your serotonin levels is to consume a high-carbohydrate diet. Eating foods like pasta, breads, cereals, grains, legumes, fruits and vegetables are great ways to boost your serotonin levels. Be sure to choose whole-grain options.
  2. Limit caffeine. Several studies have shown that combining stress with caffeine has negative effects. Not only does the caffeine produce an agitating effect, it can also affect your blood pressure levels.
  3. B vitamins. During stressful times, B vitamins (along with many other nutrients) help by facilitating the conversion of stored energy into blood glucose for immediate fuel. Vitamin B6 specifically is also important in the production of serotonin. Foods high in B vitamins include kale, collards, swiss chard, bok choy, broccoli, green beans and several fortified breads and cereals. You may consider taking a B complex supplement and a regular multivitamin. The combination will help to increase your vitamin B intake.
  4. Magnesium. This nutrient is also involved in the production of serotonin. Foods like nuts and seeds contain magnesium and B vitamins.
  5. Vitamin C. Some animal studies have found low blood vitamin C levels during stressful times. Food rich in vitamin C include citrus fruit, strawberries, bell peppers, broccoli, cabbage, tomatoes, potatoes, kiwis and brussels sprouts.
  6. Alcohol. One would think alcohol relieves stress, but it instead induces the stress response by stimulating stress hormones. Try to limit your alcohol intake to no more than one drink per day.


Q: I am allergic, intolerant and/or sensitive to many foods. I have different reactions depending on the food. Thank goodness none of this has been life-threatening. Do I still benefit and get nutrients from things that I am allergic, intolerant and/or sensitive to when I consume the food?

A: A food allergy is a negative immune system reaction that occurs soon after eating a certain food.

A food intolerance or sensitivity is a negative reaction (often delayed) to a certain food/drink or ingredient. The intolerance could be related to the absence of specific chemicals or enzymes needed to digest a food item (such as lactose intolerance).

It is difficult to comment on whether or not you absorb nutrients from foods you are allergic, intolerant or sensitive to without knowing more about you and your health, but regardless of this, eating should be a positive experience. I would suggest consulting a registered dietitian to develop an individualized eating plan that would maximize your nutrient absorption and your enjoyment from eating. You can find a registered dietitian at the Dietitians of Canada website.

It might also be a good idea to ask your primary care physician to check your blood levels of vitamin D, B12, magnesium and iron. These are key nutrients you might be at risk of deficiency for.


Q: Can you please explain what the statement “your diet should consist of 40/40/20 per cent protein, fats and carbohydrates” means?  Note that I might not have the right order.

A: First let me clarify that the healthy daily recommendation is 45-65 per cent of calories from carbohydrates, 10-35 per cent of calories from protein and 20-35 per cent of calories from fat. These are the Dietary Reference Intakes (DRIs), which are the Canadian and American nutrition recommendations for healthy adults. Some popular fad diets adjust these percentages, which may be where you heard 40/40/20. However, it is important to note that the DRIs were based on extensive critical review of the evidence relating amounts of carbohydrate, protein and fat intake to reduced risk of chronic diseases (such as Type 2 diabetes and heart disease) and levels required to maintain good health, and the information in diet books may have little to no scientific evidence to back it up.

For an average healthy adult eating 2,000 calories per day, the DRI percentages would look like this:

  • 900-1,300 calories from carbohydrate

(divide by four calories per gram = 225 to 325 grams of carbohydrate)

  • 200-700 calories from protein

(divide by four calories per gram = 50-175 grams of protein)

  • 400-700 calories from fat

(divide by nine calories per gram = 44-78 grams of fat).

Canada’s Food Guide (CFG) was designed with the DRIs in mind. If you are eating the recommended number of servings from each of the four food groups stated in CFG, your percentage of calories from carbohydrate, protein and fat should fall into the recommended amounts. For more information on Canada's Food Guide visit Health Canada’s website.

If you would like to find out your individual calorie and nutrient requirements, a registered dietitian is the ideal professional to help.


Q: I have recently been diagnosed with interstitial cystitis. Are there any foods that I should avoid? Are there any foods that might help? Any foods that will not aggravate the condition

A: A review of the literature suggests that no scientific evidence links diet with interstitial cystitis. However, many doctors and patients find that alcohol, tomatoes, spices, chocolate, caffeinated and citrus beverages, and high-acid foods may contribute to bladder irritation and inflammation. Some people also note that their symptoms worsen after eating or drinking products containing artificial sweeteners. Eliminating various items from the diet and reintroducing them one at a time may determine which, if any, affect a person’s symptoms. However, maintaining a varied, well-balanced diet is important.

I would strongly recommend a book entitled Confident Choices by Julie Beyers. The author is a registered dietitian, highly trained and experienced in providing dietary strategies for the management of interstitial cystitis. This easy-to-use workbook can help you determine your personal food triggers and get you on your way to feeling better.

For further information on the condition and dietary management strategies, please visit the Women’s Health Matters Interstitial Cystitis Health Centre.


Q: I am 54 years old and perimenopausal. I am not taking any hormones. I find that I have gained weight, especially around the abdomen. What foods should I be eating to make sure that I don’t gain too much weight as I approach menopause?

A: Perimenoupause and menopause are high-risk times for weight gain in women. Although the average weight gain during menopausal transition is two to five pounds, it can be much greater. The hormonal shift our female bodies experience with menopause increases the likelihood of gaining weight, especially around the waist. Also with age, our metabolic rate drops significantly.

To reduce the risk of weight gain, one needs to reduce daily caloric intake to compensate for the drop in their metabolic rate. Lifestyle factors such as diet, exercise and weight control are important in preventing menopausal weight gain and facilitating weight loss.

When it comes to preventing weight gain, overall caloric intake is more important than the types of foods consumed. No food is fattening unless consumed in excess of your body’s caloric requirements.

Following Canada’s Food Guide and being physically active will not only help you achieve and maintain a healthy body weight, but will also lower your risk of heart disease – a risk that increases after menopause.

Choose vegetarian protein options – including tofu, beans, chickpeas and lentils – more often over animal proteins. Include a good variety of low-fat and no-sugar-added dairy products. Pick whole-grain and high-fibre grain products over refined and processed options.

Choose a variety of non-starchy vegetables and limit your fruit intake to a few servings daily to reduce your overall sugar intake.

Be mindful of hidden sources of calories from snacks, desserts, specialty coffee beverages, juices and alcoholic drinks.

Eat small and frequent meals to help boost your metabolic rate, and ensure you’re well hydrated with sugar- and caffeine-free beverages throughout the day.


Q: I have heard that in women, iron is poorly absorbed by the body. Why? I have low iron and am taking supplements and doing my best to eat foods that are iron-rich. But I'm wondering how I can do a better job. What foods really help to absorb iron?

A: While women have greater need for iron, it is usually due to certain life stages such as adolescence, pregnancy and premenopause, when women need additional iron.

Iron is readily available in our food supply. It is important to distinguish between two sources of iron. Heme iron is very easily absorbed by our body, and is found only in meat, fish, seafood and poultry.

Non-heme iron is not absorbed as well as heme iron. Good sources of non-heme iron include fortified breakfast cereals (check the label to ensure iron fortification), whole grains, enriched breads and pasta, dried beans, lentils, nuts and some dried fruits.

I would suggest three easy steps to get more iron:

  1. Go for heme: choose meat, fish or poultry more often. These foods will also help your body use non-heme iron. If you’re vegetarian, consider eating non-heme iron foods regularly.
  2. Include vitamin C-rich foods (citrus fruits, papaya, melons, leafy vegetables, potatoes, peppers and broccoli) with your meals. Foods that contain vitamin C help your body absorb iron.
  3. Avoid tea and coffee during meals. Tea and coffee contain polyphenols which lower the amount of non-heme iron your body can absorb.

For further information please refer to the U.S. National Institute of Health’s Dietary Supplement Fact Sheet.


Q: Why do milk and dairy products inhibit iron absorption? I eat whole grain cereal with milk for breakfast. Is it true that the milk negates the benefit of the whole grain?

A: Milk and dairy products contain calcium. It is wise not to consume iron foods or iron supplements with calcium-containing foods or supplements because calcium and iron compete for absorption in the body. A source of vitamin C should be consumed with iron supplements or a meal containing iron. This will enhance the body’s absorption of iron.

To answer the second part of your question, no, milk does not negate the benefit of whole grains. In fact, some grains – due to their phytate and fibre content – can affect calcium absorption. However, most individuals do not consume enough foods that contain phytates and fibre. But if you are someone who does include a variety of whole grains, legumes, and other plant-based foods in your diet throughout the day, be sure you are getting enough calcium by eating a variety of calcium-containing foods.


Q: I have low iron levels. Will they improve once I hit menopause (I'm 48 now) and am no longer losing blood every month?

A: It is likely that your anemia will resolve gradually with the loss or infrequency of your menstrual cycles. Iron requirements drop by about 50 per cent with the cessation of cycles.

However, adequate iron intake is still necessary, especially among athletes, vegetarians, those with chronic malabsorption, and those with chronic infectious, inflammatory, or malignant disorders such as arthritis and cancer.

For additional information on how to get adequate iron sources in your diet, please refer to the answer I have provided for question number eight.


Q: I am 51 years old and have never been overweight. But I quit smoking in February, and have been putting on a lot of weight. I walk five days a week for two miles, and work out at the gym at least three days a week. I eat a healthy diet: almonds (11), walnuts (three), five servings of fruit, two or three servings of vegetables, a couple of crackers with cheese (1-inch cube), yogurt, and chicken or steak with salad for dinner. I drink plenty of water. Since I quit smoking, I have gained weight like crazy – 15 pounds. I am always bloated and feel obese by the end of the day. Can you tell me what I could do differently?

A: Congratulations on quitting! Although weight gain is unpleasant, don’t let that deter you.

I just want to first explain the metabolic changes that you may be experiencing so that you fully appreciate the challenges you’re facing.

First of all, smoking increases your metabolism, so when you stop, your metabolism slows too. This means that your body burns less food to function, and more is stored in the body, leading to weight gain. Furthermore, the nicotine in cigarettes has an appetite-suppressant effect – when you quit you have to have even more willpower to eat less.

Another consideration is change in metabolism after the age of 50. Your metabolic rate slows down with the hormonal changes around menopause.

Even though you face these challenges, I am confident you can stabilize your weight and hopefully even lose the 15 pounds you’ve gained since quitting.

A combination of strategies may help you, including exercising, continuing to watch food choices, and keeping a food diary.

  • Exercising is a great way to combat slowed metabolism and also get your mind away from cravings. Continue with the exercise routine you have described.
  • Regarding your food choices, here are some additional suggestions: since fruit contains a lot of sugar, try having one to two servings of fruit and more servings of vegetables per day instead. Celery sticks and carrots are convenient and portable snacks. Fruit-flavoured yogurts contain a considerable amount of sugar, so try low-fat plain yogurts instead. You can add mixed berries to your plain yogurt for extra sweetness. Choose cheeses with less than 20 per cent MF (milk fat) more frequently. Also, try using leaner cuts of meat and skinless chicken prepared using low-fat cooking methods, such as baking, broiling, barbecuing or stir-frying. If you use salad dressings, try to replace creamy dressings with vinaigrettes and control the amount you put onto your salad. Watch for toppings on salads as well.
  • I would strongly encourage keeping a physical activity and food journal as well.
    Early on in a person's quit, the urge to smoke is frequent and uncomfortable. It's natural to look for something to ease the discomfort, and food is often used as a replacement.
  • Lastly, a word on alcohol: not only is alcohol high in calories, it can be a huge trigger to smoke. For many people, smoking and drinking go together like a hand in a glove. Avoid the empty calories in alcohol, but more importantly, don't put yourself at risk of relapse by drinking early if your quit.


Q: I am a woman in her mid-forties who has the opposite problem of many women.  I have difficulty maintaining my weight of 110 pounds (my height is 5-4). Can you suggest a daily diet that would help me maintain my weight? I have no other health problems.

A: It is important to maintain weight in a healthy way, so having balanced, high-energy, nutrient-dense foods from all four food groups in Canada’s Food Guide is important. It is also important to be physically active in order to help build muscle. Try to get enough sleep too, since inadequate amounts of rest can affect weight. During a meal, try having high-energy foods first, and salads and soups last. Have three meals a day, plus snacks in between. Having fluids during meals can make you feel too full, so try drinking between meals instead. Try having a protein and carbohydrate source in all your meals and snacks. Some high-energy, nutrient dense snacks include: crackers with peanut butter and apple slices, granola with fruit and yogurt, smoothies, trail mix with dried fruits and nuts, energy bars, and peanut butter with banana sandwiches.


Q: I'm 45 years old and I have been trying to conceive for about three years. I have fibroids. Are there any foods that would help or hinder me from getting pregnant? I am being treated in a fertility clinic.

A: Although the majority of studies that focus on diet and infertility are primarily observational, the following dietary strategies appear to be associated with a lower risk of infertility.

  1. Limit or omit any trans fats from your diet. These fats are usually found in fast foods, commercially baked goods and packaged or processed foods like ice cream, crackers, cookies, waffles, pies, chips and frozen dinners.
  2. Try to eat only good quality carbohydrates like whole grains and limit you intake of any refined grains. This will also help to increase your intake of fibre and low glycemic carbohydrate which may be beneficial.
  3. Increase your intake of mono-unsaturated fats like extra virgin olive oil, avocados, nuts and seeds.
  4. Limit your intake of animal protein while increasing your intake of plant proteins such as peas, dried beans, lentils, tofu, nuts and seeds.
  5. Contrary to what you typically hear, higher-fat dairy products are a good choice. One to two servings per day of whole milk or foods made from whole milk (full fat yogurt, cheese and ice cream) may offer some benefit.
  6. Be sure to take your multivitamin. Higher frequency of multivitamin use is associated with higher fertility rates.
  7. Focus on a healthy body weight. Infertility rates are higher in underweight (BMI below 20) and obese (BMI over 35) women.
  8. There is some preliminary research to suggest that a nutritional supplement containing vitamin E, vitamins B6, B12 and folate may improve fertility. However, more studies are needed before specific recommendations are warranted.
  9. Limit your caffeine intake. There is plenty of evidence showing a decrease in fertility with caffeine intake. This includes colas, coffee, black tea and chocolate.
  10. Limit your alcohol intake.



Q: What foods do you recommend for controlling flatulence and stomach distension?

A: There could be many reasons why you feel bloated, so it’s difficult to give you specific advice. I’d start by making sure that you’re not frequently constipated, as this is one of the most common causes of bloating and discomfort. If constipation is a problem, gradually increase the amount of fibre-rich foods you eat such as fruits, vegetables, whole-grain cereals and bread, whole wheat pasta, brown rice and beans. Also, try to drink up to eight glasses of water per day, as a lack of fluids can make constipation worse, especially if you’re eating lots of fibre.

Some foods are also known to cause bloating so you might want to eat fewer of these. Typical culprits include beans, broccoli, cauliflower, cabbage, sprouts, onions and garlic – however, remember these are good sources of fibre and most people are able to build up their tolerance to these foods with frequent exposure.

Swallowing too much air can also give you a bloated tummy and, surprisingly, there are several habits that can result in this. Simple things such as talking while eating, using a straw or sports bottle, chewing gum, eating when you’re on the move, drinking from a water fountain and eating when you’re upset are all common culprits, so try to eliminate as many of these things as possible.

You may also find it helpful to cut out carbonated beverages, including sparkling water. These beverages contain gas which then ends up in your stomach. It’s also worthwhile to avoid too many ‘diet,’ ‘sugar-free’ or ‘low-carb’ products that contain sorbitol, mannitol or maltitol. These sweeteners, which are used in place of sugar, have a laxative effect which can leave you feeling uncomfortable and full of wind.

Some people blame bloating on an intolerance to a certain food such as wheat or dairy products. However, food intolerances are notoriously difficult to diagnose as the symptoms can be so wide-ranging, including everything from bloating, fluid retention, headaches and tiredness, to constipation and diarrhea. If you really think you might have an intolerance I suggest you keep a food and symptoms diary to see if there’s any pattern, and then see your doctor or dietitian for a proper diagnosis.


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