[Dr. Federica Amati] (0:00 - 0:15)
70,000 women when they're perimenopausal retract their symptoms. Women saw an average 35% reduction in their symptoms by changing their diet. 38% was in their brain health symptoms.

Make breakfast your most nutritious meal.

[Angela Foster] (0:15 - 0:35)
Knock it out of the ballpark. I've had women having protein and some fibre and nutrients at breakfast and say to me, my belly fat is going just with that change and they have more energy throughout the day. So powerful.

100%. When you compare the two groups of a woman who's 45 and has entered perimenopause versus one who's kind of leading up to it, will there be a difference in their metabolism?

[Dr. Federica Amati] (0:35 - 0:51)
There isn't this massive crash in base metabolic rate. Women don't just suddenly stop burning fuel. How their body responds to the same meal changes.

Your blood glucose levels stay elevated for slightly longer and your insulin levels stay elevated for slightly longer compared to a premenopausal woman.

[Angela Foster] (0:52 - 0:57)
Assuming she does manage to control and not overeat, will her body still respond differently?

[Dr. Federica Amati] (0:58 - 1:05)
Calorie quality is still important when we think about body composition. You can stay slim if you eat 800 calories of crisps. Sure.

But you're not healthy.

[Angela Foster] (1:06 - 1:33)
Dr. Ramati, you are a medical scientist, a registered nutritionist, head nutritionist at ZOE and author of the new book, The Appetite Reset, specialising in nutrition, gut health and disease prevention the course of our lives. One of the things that I hear constantly from women in their 40s and 50s is that they haven't dramatically changed what they're doing, but they feel like their body is changing. What's actually happening physiologically during this period that can make body composition so much harder?

[Dr. Federica Amati] (1:33 - 6:11)
Yeah, it's a great question to start with. And I think so my book previous to this is Everybody Should Know This. And it tracks the life course and the changes that happen, the physiology changes, metabolic changes that happen.

I think the first thing to say is that we should celebrate change because it means we're still alive. And often, often the framing is, oh, gosh, like, my body's changing. I can't eat the same things.

I can't fit the same jeans. I can't do this. And it's like, OK, that's true.

But it just means you're still alive. It means that, like, actually, you've gone from your 20s to your 30s to your 40s. Whilst it's important to stay healthy and stay fit and keep challenging ourselves, we should also accept that the change is supposed to happen, right?

Otherwise, it's not a good thing. So typically, when we think about changes, especially for women in their 40s and into their 50s, it is what you would consider the perimenopause and menopause transition. So there are lots of changes happening predominantly with our sex hormones.

And that really impacts our metabolism. It impacts how we store fat. It impacts our energy levels.

It impacts lots of things. Actually, so some of the research we've done at ZOE shows that the menopause literally changes regardless of age. This is really important.

I think the way that menopause science has moved on is to separate age-related changes with menopause-related changes. And we do this by age-matching women. So we compare physiology, metabolic response and gut microbiome composition between women who are in their 40s, those who have menopause and those who don't.

In their 50s, those who have menopause and those who don't. So what you then get is a true comparison. And we actually also compare to men of the same age.

And what you get is a true comparison of age-related, age-related to women and menopause. And I think what's now pretty widely accepted is that the menopause does have a big impact on a lot of our systems. I think sometimes it can be slightly over-egged.

So certainly these changes are real and they do happen. But your menopause doesn't completely kill your metabolism. So sometimes it's like the focus is so strong that it's disempowering.

Whereas actually what the science shows is that there are true changes, but they vary from woman to woman. So like no two women have the same serums. And they also are not always like these complete overhauls.

So there's a lot of other factors to take into account when we think about this age group. The other thing that's really worth pointing out is women in their 40s tend to have lots of caring responsibilities. So many women will have children, but they will also have ageing parents and they may have other caring responsibilities.

So in terms of like stress in the life, that's external to what you would consider stress that you might impose on yourself. So if you have a stressful career and you find your job stressful, that's something that's often a choice, not for everybody, but often is. But when you have caring responsibilities, that's external stress factors.

And they do tend to compound on women in their 40s and 50s. There's lifestyle changes. Stress is a big factor.

Sleep changes. They tangle in with menopausal changes in this age group. And those changes together then impact how much we exercise, what we eat, whether we're drinky or not, whether we're able to spend time with friends and actually doing activities that we find restorative.

So the way to sort of think about this phase of life is that it's an intertwined change period, which then throws things off kilter. And if we think of the six pillars of lifestyle medicine as supporting good health, what often happens in this age group, and this is actually speaking mostly from my experience working with women in this age group and what we see when we speak to our members at ZOE, who we have a lot of women in this age group as ZOE members. It's when life, busyness and stress and change impacts the six pillars, that then it feels like a really big shift.

If we want to look at physiology, then the simple answer is that essentially as our oestrogen levels change, the way our fat distribution, our fat is distributed in our body changes. So oestrogen is very good at helping our body store fat around our legs, our thighs, our bums, and less so around our abdomen. So often this weight distribution change, which then leads to a change in how your clothes fit and a change in how you might feel your body is, is actually very linked to oestrogen doing its job.

[Angela Foster] (6:12 - 6:18)
Interesting. So there's quite a bit to unpack there. You mentioned six pillars.

Can you just run us through what those six pillars are?

[Dr. Federica Amati] (6:19 - 9:37)
Yeah, so the six pillars of lifestyle medicine are what we understand to affect about 80% of chronic disease risk, and nutrition is one of the pillars. They're not in order, actually, I should say. They are all very interconnected and as important as each other, as we'll go through, you'll see what I mean.

So nutrition, sleep, movement, and I choose movement quite carefully because this isn't about going to specific fitness classes. It's really movement throughout the day of different types. And within movement, we think about cardiovascular, resistance, and balance.

So those are the three sort of four movement types that we think about for longevity. Avoiding risky substances. So that's not smoking, not drinking alcohol to excess, but even things like avoiding taking recreational drugs, things that put yourself at risk, essentially.

Then there's social connection, which is super important and often overlooked. But so this isn't my saying, actually. I saw someone post about this, and I thought it was so true.

They said, you never see the longevity influencers post about hanging out with their friends or volunteering at their local community centre. So we know it's a foundational pillar for longevity and it's actually one that has incredible prediction in terms of health span, is how socially connected you are. And it's rarely spoken about, which is such a shame.

And then the sixth pillar is stress management. So we can't change stress because often it's external factors that stress us. So you can't decide.

Well, I mean, some people do do this, and I don't know how healthy it is. You can't really run away from stress. If your spouse is unwell, or if you lose a parent, or if you have financial struggles, these things happen, they're external to you.

But how you deal with that, how you process that stress, and how you build a toolkit that allows you to thrive through that is fundamental to good health. And so as you can think, like those six pillars. So if you're, for example, if someone who doesn't have a very good stress management toolkit, you may turn to alcohol to help de-stress which will then impact your sleep.

And then once your sleep is impacted, you're not feeling great the next day, that may mean that you change your social behaviours. You might not see your friends, or you might avoid your family. So they all impact each other.

And so those six pillars have, you know, they're three, and they have an out-measured impact on our health and longevity. So depending on which study you look at, achieving four or five of the pillars can drastically reduce your risk of chronic disease and early death. So yeah, when we talk about, you know, what might be impacting the way people feel, the way they perform, those six pillars are foundational to be in good enough health.

Well, we can then talk about optimising on top of that. But you know, if we're focussing on the sort of what I would call the sprinkles on the cupcake, if we're focussing on things like how many times a week you can go to the sauna, but those six pillars are completely lacking, or maybe you're only getting two, it doesn't make sense.

[Angela Foster] (9:38 - 10:27)
Yeah, totally, totally. These are the foundational pillars, I suppose. So before we come back on those then, you mentioned that you'd studied women who were going through menopause and were not of identical ages and then versus men.

So if we look at, you know, I've seen studies and talked about this on the podcast before that there's a study, I think that metabolism doesn't slow down per se between the age of 20 and 60. Yet women in menopause, for the reasons you've been discussing there, including hormonal changes, do seem to have difficulties with their metabolism. So when you compare the two groups of say, a woman who's 45 or 48 and has entered perimenopause versus one who's kind of leading up to it, her ovaries are ageing a little bit more slowly, will there be a difference between those two women in their metabolism?

[Dr. Federica Amati] (10:27 - 16:28)
Yeah, so I think first thing to unpack here is that metabolic rate or metabolism, metabolism is quite a big word. It's a bit broader. It's a bit broad.

Typically what we're talking about there is like, whether your base metabolic rate changes. So whether you, how much energy you actually burn to stay alive changes. And the studies have shown that there isn't this massive crash in base metabolic rate.

Like women don't just suddenly stop burning fuel in that sense. What does change? And this is something we've shown in our study, which was published in, I believe it was 2022, is that postprandial metabolism.

So the way women respond to the same food is different if they're menopausal versus if they're not menopausal. So whilst their base metabolic rates, so how much energy they burn, how efficiently their body stores and burns energy may not change, how their body responds to the same meal changes. So what that means is that your blood glucose levels stay elevated for slightly longer.

Your blood fat levels stay elevated for slightly longer and your insulin levels stay elevated for slightly longer compared to a pre-menopausal woman. So, and actually we, in this age matched study, analysis, we looked at pre-menopausal, hairy menopausal and menopausal. So you see in the graphs in the paper, you see this like stepwise change.

So the pre-menopausal women tend to be more efficient, clearing blood glucose, clearing blood fats, insulin returning to baseline and actually inflammatory markers also. So there's after every meal, we have a very normal response, which includes postprandial inflammation. So there's an inflammatory response to eating, which helps with blood flow and with the necessary steps for digestion.

But in between these three groups of women, there is again, slightly longer postprandial inflammatory response. So whilst like the overall picture of basal metabolic rate doesn't look very different, actually how women are responding to food in every meal time is slightly different when we look at these populations and compare them to each other. So it's true that, as I said, it's true that like there isn't this massive, your entire body is ruined and menopause is doomed, which I hate that narrative.

It's so disempowering, but there are true changes in the way our body is able to adapt and respond. And listen, what we think so far, what we know so far is that this is really down to oestrogen. So oestrogen throughout our lives plays a very protective role in many factors of cardiometabolic health.

So when we look at things like blood cholesterol levels, when we look at things like even blood glucose control, oestrogen has a protective effect. And so you do see that these risks in type 2 diabetes, high blood pressure, hyperlipidemia, so high blood fats, they all go up after menopause. And that's not disputed.

You see this, your risk of having a heart attack, for example, as a woman is much lower than a man's for most of our lives. And then after menopause, we catch up. It's how we think about metabolism and how that all the different strings pull together.

What we do know is that menopause increases our risk. And the actual mechanisms by which that happens is it's complicated. It's a complex picture, but oestrogen is the underpinning mechanism because oestrogen impacts all of our organs.

We have oestrogen receptors everywhere. So, you know, from our skin to obviously like how our fat is stored, our heart health, it has an impact all over and includes metabolic responses to food. And what we found in our analysis is that some of that change, so some of the ways in which we respond to food and the change in inflammation markers and blood sugar and blood fat is mediated by changes in the gut microbiome.

So the next step in the analysis, what we're doing now is what microbes, we've identified specific strains that are very, that there's a market change from pre to post-menopause. And now we're sort of investigating, okay, well, what is their role? What is happening?

And how can we, if we can, can we intervene to meet, to sort of soften some of that change? So it's really exciting. I think we're still unravelling a lot.

Unfortunately, menopause has become very, it's a very sort of divisive topic for some reason. I think clinicians and scientists everywhere are really pleased with the advancements in research and the advancements in therapy and the way that I feel like women now have a much better toolkit to deal with the perimenopause and menopause. They have choice.

They can inform themselves and find the tools that work for them because it is highly personal. But at the same time, it's like these fights, factional fights of those who believe that it destroys their metabolism and that's all that happens. Those that think actually nothing changes.

And then there's like, oh, you should definitely take HRT, you should definitely not. And I think like with most medicine and with most health, it's highly individual. And as I said earlier, like what works for one woman might not work for another.

And in the same way that women experience periods very differently, we experience birth and pregnancy and breastfeeding. Like they're so variable, those experiences. It's the same with menopause.

So how you experience menopause or perimenopause and how you learn to deal with that and choose to go through that change is highly personalised. There's not one person that can say, well, this was going to work for everyone. So I think hopefully the fighting will die down soon on this, but at the moment, it's still a bit tense out there.

[Angela Foster] (16:29 - 18:10)
If you're getting value from this show, the single best thing you can do to help us keep bringing you the highest calibre guests is to subscribe or follow. Wherever you listen or watch, it takes 10 seconds, but it genuinely makes a difference to the quality of the guests we bring you week after week. Yeah.

And I guess some very strong views being pushed. What you've said there is really interesting and everything you're studying. If we take, if we kind of extrapolate that for someone and put it in practical terms, so a woman that's listening to this.

So we know from what you've just said that if she is menopausal, as she sits down, her blood fat is likely to stay higher for longer and her blood glucose and her insulin and her inflammation levels. And obviously inflammation increases a little bit every time we eat. So let's say that a woman sitting down, she's having a steak, which has a little bit of fat.

There's marbling in the meat. Maybe there's some vegetables tossed in olive oil. So it's a pretty healthy meal and then some form of carbohydrate alongside, right?

After that meal, if you take the woman who has a regular menstrual cycle at this stage and the menopausal woman, from what I understand what you're saying there is baseline metabolic rate hasn't changed. I've got a couple more questions on that in a moment, but baseline metabolic rate hasn't changed, but the menopausal woman is going to have those levels stay up for longer. Does that then influence the way that she burns the calories in that food such that she is now more likely to gain weight on the same calories?

Because this is the thing I hear so often is women feel like, I haven't really changed anything. And we all know that if you eat more calories, you consume more than you are burning, then that net effect is to gain weight. But will she gain weight differently to the pre-menopausal woman?

[Dr. Federica Amati] (18:10 - 26:54)
That's a really interesting question, I think. So realistically, one individual meal doesn't change the way you sort of put on weight or not. So I think it's important to frame that.

Another thing that is important to frame is in the same study, we looked at the dietary habits of these women. And what we found was that post-menopausal women were more likely to choose refined carbohydrates and to eat sweeter foods more regularly. Now, this was a cross-sexual study.

So what that means is it was one time point. So we don't know whether menopause changed food preferences. But the hypothesis is that there are actually dietary changes that also happen that perhaps aren't self-recognised.

So the women who we asked about their dietary habits, and then they also logged them, they didn't report that their diet was different. But when we compared the groups, as I said, the post-menopausal women were more likely to choose more highly refined carbohydrates, things like biscuits, pastries, how frequently they were eating those foods. So I think when we think about weight gain in general, absolutely true that if you continuously consume more calories, then you will gain weight.

But it's also super important to think about where the calories are coming from. Why? Because if you, well, lots of reasons.

First of all, foods like broccoli, kale, I mean, you have to eat a hell of a lot of spinach to get to 200 calories of spinach, for example. So there's foods that are just naturally lacking in energy, they're not energy dense. When we concentrate just on calorie intake, we missed the whole picture of how satiety signalling works, right?

Because actually the way our body tells us that we're not hungry and we can stop eating relies on the nutrients in our food. So the cells that are involved with releasing hormones like GLP-1, PYY, GIP, all these wonderful hormones that actually exist, they exist purely to help us regulate our food intake and reduce our hunger. They are all released from what we call nutrient sensing cells.

This includes the L cell, which is the most famous nutrient sensing cell. And so they don't respond to just calories, they respond to proteins, carbohydrates, fibre, because the fibre is broken down to short chain fatty acids, which are then sensed. So actually, it's really critical that we say it's not as simple as, I've eaten 1300 calories a day, that's not very much.

Let's say I've eaten 1900 calories a day and now I feel like I'm putting on weight. What's changed in the way these calories are absorbed? It's actually thinking about how is that diet supporting our satiety?

How is it supporting our metabolic health? Because when we eat a majority whole foods, high fibre, plant-based diet, doesn't have to be vegan, but plant-based, we are going to be helping our satiety signalling, but also we're going to be reducing our cholesterol levels. We're going to improve our blood glucose control.

So it's the metabolic picture for weight gain, it's more complicated than just saying calories in, calories out. How are these calories being used differently now that I have menopause? It's much broader than that.

And so what I see very often is women who come to me in their 40s and they say, I'm putting on weight and I'm not eating a lot. I'm eating hardly anything. I'm trying not to have breakfast.

Then I'll have a small lunch. Then my dinner is, I don't know, chicken breast and vegetables. And it's like, so they're severely restricting their food intake.

And then oftentimes what happens is they'll have a very late night, they'll get very hungry because they haven't eaten enough food. And they'll have like a magnum and a glass of wine. And it's actually the quality of those calories is not helping.

And you're not giving your body the nutrients it needs to feel satiated or critically the nutrients it needs to know that there isn't a famine coming. When you're regularly depriving your body of food, that our metabolism does change. And it says, okay, we don't have enough energy coming in, enough nutrients coming in.

So whenever we do get something, we need to try and store it. So what I'm saying is like, we have to take a really big step back and assess like, are you actually eating the same? Is it nutrient dense?

Do you have enough of the food you need to eat? Are you moving or how are you sleeping? So all these impact the way our body uses and stores energy.

And then usually when you dig a bit deeper, it's not actually a like for like picture. And I think sort of the positives of having lots of emphasis on perimenopause and menopause, there's always like a flip side to that. And the flip side is that a lot of women are really scared.

They're worried. They're like, I think I'm in perimenopause. I need to change everything right now because I don't want to X, Y, Z, right?

And that often, and this is just in my experience, that often results in drastic dietary restriction. Very, so it's stressing, very stressed, a lot of stress around it. And then very high impact, stressful exercise as well.

So combined. And then people feel crap. And it's like, well, yeah, I don't subscribe to this idea that I've had exactly the same diet.

I'm eating exactly the same food, exactly the same calories. And then suddenly in the past four months, it's completely changed. It doesn't happen like that.

So the same steak, I would also argue that if you're trying to like improve satiety, improve your heart health and the steak and vegetables is not the way forward, right? So like you're much better off having a piece of fatty fish, like a really lovely salmon or sardine dish with pulses and whole grains and some leafy green veg. So like that's the first thing to say.

And then that same food will be processed differently. Yes, based on medical status, according to our data, the postprandial response will be different. But there's the other factors you've got to take into account.

And remembering that it's the repeated exposures over days and weeks and months and years that have an impact. If you're worried about the sort of couple of kilogrammes that you put on holiday, what we know from sort of weight science is that you'll very likely lose those again when you go back to your normal routine. And that's true until about the age of 65 when weight elasticity, like how quickly our body returns to weight set point, starts to change.

But for most of our lives, our bodies fight hard to keep weight at the same point. So if you try and stress it into losing weight quickly, it will get you straight back up to original weight as quickly as it can. And if you put in a little bit of weight because you go on holiday or you go through a phase where you decide that you want to eat a magnum every single day or Ben and Jerry's, whatever it is, it will return back to original weight as quickly as it can.

Where that doesn't work is if the change in dietary pattern and also if you're, usually the way your brain is wired, is very different and doesn't respond to satiety in the same way and is very driven by hunger signals, which are usually external. So hunger signals from our food environment have a big role to play in how frequently we consume high energy density foods. The way that it's marketed to us, advertised to us, we encounter, you can't walk down the street in London without walking past 10 shops that are trying to sell you mocha, caramel, pistachio lattes, muffins and flapjacks and chocolate and fast foods.

There's so much food availability in our food environment and our brain is wired to pick up on that availability and make the most of it. And some of us are much more hardwired to respond yes to their signals than others. So there's, I guess what I'm saying is like there's a lot of factors and it's not as simple as saying like what is happening, what's different between a menopausal woman and a premenopausal woman with the same meal.

Some of it's got microbiome mediated, some of it is hormonally mediated but it's dietary patterns that actually change our weight and our fat distribution alongside the menopausal change. So it's not as simple as just one meal.

[Angela Foster] (26:54 - 27:48)
Yeah, it's a complex thing, isn't it? Because everything's influencing everything else and if you're not sleeping well then you're feeling a bit more stressed as well, you don't manage your blood sugar, you're more likely to eat those things, you don't move as much, like it's almost you can't separate one, you can't isolate these things. In your example, because that happens so commonly with women, right, is they try really hard and obviously discipline so high in the morning that you can kind of motivate yourself and then it wanes across the day and that's when you can fall into some of those eating habits.

Does it still need to be the case though that you need to be in a calorie excess? So if, for example, that in your example, she has the glass of wine and the magnum and this is a repeated behaviour but she's actually staying within her metabolic requirements, her nutrient sufficiency is going to be low, she may not get the signalling so it's quite hard but assuming she does manage to control and not overeat, will her body still respond differently or do you actually need that surplus?

[Dr. Federica Amati] (27:49 - 33:33)
No, so calorie quality is still important when we think about body composition and sort of health, right. If someone has a diet of Cheetos, Coca-Cola and, I don't know, sausage rolls, but they still stay within their calorie requirements, it will last for a bit, they might be able to maintain their weight, they may even be able to maintain their body comp if they are very active but that metabolic flexibility wanes with age so like you will, you get to, in your 20s, you can get away with quite a lot in terms of the lack of nutrients and also the composition of your diet, you can still stay slim. There's many people I've met who had a terrible diet for quite a long time and remained very, very, very thin but they weren't healthy so their muscle composition, like their actual body composition in terms of muscle mass wasn't very good and when you looked at the body fat, even though they were externally slim, they had more visceral fat accumulation around their organs so again, this obsession, I think one of my biggest problems with using calories as a way of like, well, should people still stay slim with that? Like, you can stay slim if you eat 800 calories of crisps, sure, but you're not healthy and so I really hate, one of the things I hate, not hate's a strong word, but I really try to change the narrative around is calories and thinness.

Can you still not put on weight? It's like, yeah, but what is going, what else is going on inside your body, right? You can be very slim, you can be wearing like size eight clothes but have the body composition of like a very unhealthy metabolic body composition, sometimes we refer to sarcopenic obesity where your muscle mass is so low that your muscle mass to fat mass ratio pushes you into this risk of metabolic disease and actually, this is one of the ways that type two diabetes can show up.

So you can have someone who externally looks very slim and they have elevated blood glucose levels because muscle is a really important metabolic organ that helps to store and use glucose. So your pancreas doesn't have to work quite as hard, pumping out insulin to help move the blood glucose out of your bloodstream and store it for later and when you have such low muscle mass, there's not that many options for your blood glucose to go to or be used by and so you can end up with an early onset, sometimes very young people, type two diabetes, which is related to that. So I really want to move away from calories as the only marker and talk about food quality.

Now calories are super useful if you are someone who needs to prepare for a competition. So perhaps you're a bikini model and you have to be a certain weight to be in your category or a boxer, right? Very calorie deficits to get you to your bracket weight will always work but here we're talking about long-term health and human performance rates.

Calories are just not going to be helpful for that. Why? Because it's also super hard.

So because we're talking about long-term dietary behaviour every single day for weeks and months and years, we're not talking about, I've got a competition in two months time and calorie labelling is imprecise. There's about 20% error on calorie labelling. So that's already difficult to track.

Calorie consumption, so how many of the calories you absorb from your food is highly variable depending on the food. So if you have whole almonds that you chew and swallow and you eat finely ground almonds or an almond paste, you're absorbing about 90% to 100% of the calories from the paste but you could be absorbing as little as 40% of the calories from the whole almonds. So the same food with the same back-of-pack labelling is giving you vastly different calories that you'll be able to absorb.

If you then layer onto that your actual dietary quality, so if you, for example, if you eat foods with lots of vegetables, if you have that steak with lots of vegetables, then some of the saturated fat in the steak essentially gets trapped into the food matrix of the vegetables so you don't even absorb it. So how you eat your food also changes how you absorb nutrients and calorie calories. So calories are an imprecise tool for long-term health.

They tell you nothing about the nutrient density, they tell you nothing about the quality of the food, the food matrix, is it intact, is it not? So how many of those calories are gonna absorb? And listen, to your point, like all nutrients stimulate insulin secretion.

So insulin is not just about blood glucose, it's about absorbing proteins, it's about absorbing fats as well. But how that nutrient is delivered, is it in ultra-processed food products or is it in whole food, makes a big difference to how much insulin will be released, how much is stimulated. And it makes a big difference to how much satiety hormones are going to be released, so how full you're going to feel and how much you can wait until your next meal.

So yeah, I just, I find like the calories, like this idea that a woman who is restricting her diet throughout the day, feeling hungry, then resorting to magnum and a glass of wine, that's not the healthy picture.

[Angela Foster] (33:33 - 34:55)
It doesn't matter if it fits in with her calories. The reason I'm so glad, the reason I sort of pushed it and I wanted to clear it up is because when you were talking about the strong views in menopause, I think unfortunately what happens is a counter view that's often put forward by, I would say pretty young personal trainers, who are not, is that it doesn't matter. No, you're only going to gain weight in a calorie surplus and it sort of doesn't matter.

And I think what I've certainly found being in perimenopause myself and working with women is that my experience of working with them and in my own body, right? And having done DEXs and things to verify it is exactly what you're saying with the science. And I think it's actually liberating and very empowering for women listening to this because if you look at those pillars and you start to take as much control of them as you are able to without making your life too restrictive, you can actually change that trajectory and the way you experience menopause so that your visceral fat is lower, you're protecting yourself against chronic disease.

And it's simple changes, like you said, which is eating whole foods, which are delicious, moving your body more, getting that kind of Goldilocks effect of not doing some high intensity, but not too much, not overdoing it, managing stress, holding onto your muscle. I think all those things make such a difference. And I think that is a very empowering message because it's one that I found has helped me a lot.

And, you know, ultimately, we're post-menopause for a very long time.

[Dr. Federica Amati] (34:56 - 35:01)
So it matters now we live longer. Yeah, exactly. It's like for many of us, it's half our lives.

[Angela Foster] (35:02 - 35:03)
Yeah.

[Dr. Federica Amati] (35:03 - 35:33)
So it's an important phase. And I think what's really what you said there is like, listen, it's not that calorie deficit is wrong, but what's your goal? If you're training, as I said, if you need to be in a bikini modelling competition, right, in sort of, as I said, two months time, you're going to have to get into some serious calorie deficit.

By the way, having also met and worked with women who do that, it's not fun. It ruins your life, right?

[Angela Foster] (35:33 - 35:38)
It's hard work after, right? Trying to like actually get back and readjust your thyroid is really difficult.

[Dr. Federica Amati] (35:38 - 40:30)
So I don't recommend it. But the PTs that say whatever happens, if you're on a deficit, you'll lose weight, yeah, sure. And for the short term, that's true.

But let's also look at weight loss science that tells us that eventually, if you are in a calorie deficit for a very long time, you reach a weight loss plateau. Why? Because our body tries to adapt to the new environment.

It senses that there's a lack of nutrients. And so it says, okay, well, we need to, this is when the basal metabolic rate does change. We need to lower energy expenditure.

So your body is extremely clever and it will literally change the chemistry in your body to lower energy expenditure as much as it can, including making you feel more tired so you move less, including reducing the amount of energy expended on absorbing nutrients in themselves. So that you end up actually running at a lower calorie output every day. And so suddenly that weight loss plateaus.

It's happening with GLP-1 medications. So it's like a short term burst of calorie restriction will get you to lose weight. Let's be honest as well.

It's a lot of it is water weight. It's a lot of it, you know, it's actually not, it's not just fat. It was preferentially fat at the beginning.

But then you also lose some lean mass too. So it's like, if the goal that we're trying to help people with here is maintain their health, optimise their health, get better, get healthier, because you can get healthier at any age. And to make sure they're well nourished, they have what they need.

Then the conversation needs to pivot away from it. It doesn't matter just being a calorie deficit. Also, because we've just talked about how imprecise it is in the science, to be honest.

And more towards what do you need to eat to support your body through this change? Now, we did another study at ZOE, where we actually tracked 70,000 women who joined ZOE when they were perimenopausal. And we tracked their symptoms before they started making any dietary changes.

And then we followed them up. And what we found is that by changing your diet, now in this case, the dietary intervention obviously was a ZOE app. So tracking their food, trying to increase their diet score, working to find out how they could add more plants and all the things we have that are integrated in the app.

But there was no extra intervention from us. It was all self-directed. So it was as much as they could do.

Right. And what we found is that women saw an average 35% reduction in their symptoms, right, by changing their diet. And that was amazing to see.

And what was really cool to see was that 38%, the highest reduction change, the highest percentage reduction was in the brain health symptoms, the anxiety, the brain fog, which is actually, according to our research, what women care about most. Like, yes, it bothers them that their body is changing. Yes, it bothers them that they notice vaginal changes.

But the one that really impacts quality of life is the brain changes. And so what we see is that the advice that we give, which is all a positive nutrition, what do you need to add to your diet? Add more plants, have some ferments, add nuts and seeds.

Like, make sure you're focussing on the food groups that are missing from your diet. That actually has an impactful change on improving quality of life. Now, on a personal level, working with women in this age group, the amount of times I've said, you're not eating enough food, you need to eat more.

And the look I get, they look at me like I've lost my mind. They're like, sorry, what? And it's because we've been brought up with such an ingrained belief.

We've been conditioned to believe that eating as little as possible is the best way forward. And actually, that's just not the case. It's just not true.

And eating as much of the right foods as possible is actually the answer. And often, one of the simplest levers, the simplest ways to do this, to start anyway, is to begin with your breakfast. So instead of being like, well, I've got really good, I feel really good.

I've got loads of willpower first thing in the morning. I'm not going to have breakfast. Make breakfast your most nutritious meal, like knock it out of the ballpark.

And often we're at home for breakfast, or at least we're home for long enough to put something together and take it with us. Make breakfast your cornerstone meal, where you get all of the things. You get really good quality protein.

You've got loads of fibre. It's high in plant chemicals. You've got healthy fats.

Like, set yourself up with breakfast. And it sounds like a simple switch, but it often sets people up and women up to then have a much better day because they're not starving. And also by the evening time, if they've also had a good lunch, they're not like, oh my God, I'm starving, I need to eat something.

[Angela Foster] (40:30 - 42:35)
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I've had women make just that one change that you mentioned there, where they're having protein and some fibre and nutrients at breakfast and say to me like within sort of an hour or so of waking, oh my goodness, I actually can't believe it, like my belly fat is going just with that change. They have more energy throughout the day. I think it's like so powerful.

I have a question for you on the studies that you've done. Where does menopause hormone therapy help this? So if we know that oestrogen is changing the way we metabolise foods and things, how does menopause hormone therapy assist in this?

[Dr. Federica Amati] (42:35 - 46:16)
I just literally, it literally protects that whole effect. So with HRT, what we see is that the protective effect of oestrogen stays. So, however, it's not a cure-all, so it doesn't completely mean that you don't have to worry about anything else.

What we find is that HRT, for some women, not for all women, but those who are successfully, like who feel a benefit, will have a reduction in their symptoms. So the Menoscale is a tool we developed as a group of female scientists and clinicians to help measure menopause symptoms. We published that in association with the British Menopause Society.

And I think it's the first female design tool, which is hilarious. So we used that, and what we see is that HRT absolutely brings down the symptoms, basically. But diet has this reduction effect, whether you're taking HRT or not.

So you basically, the way to think about it is there's a toolbox, right? Now, some women, by the way, some women, it's true, it's quite a small percentage of women, according to our science, that some women don't really feel that they have many symptoms. And they can sort of carry on as they are, which is great.

But then those who do have symptoms, having a toolbox, really, that can assist is really important. So what we see is that there is this beneficial effect of dietary change. So improving your diet is going to help you regardless.

And of course, improving your diet is going to help not just your menopausal symptoms, it's going to help with your cardiometabolic risk factors as well. And it's going to help you with your mood. So what we see in our trials that is fascinating, is that the first change people report is an improvement in energy, like you just said, improvement in mood and sleep and reduction in hunger.

So these are very subjective things, but we see that they improve across the board when people improve their diets. So it's kind of worth doing. Then you've got HRT as a tool, which is safe and effective.

And if it's something you want to explore, there's now menopause specialist GPs, which I would 100% recommend going to a specialist for this, because actually, traditionally in medical school, doctors are not equipped with how to treat a woman and her menopause symptoms. So it's worth going for that menopause specialist. And then HRT is one of the tools that's in the toolbox.

You also have, if you're someone who prefers to take, for example, just using topical oestrogen for vaginal insertion. Sometimes people use exercise. And then, of course, there's other interventions, which are gaining traction.

And this is soy isoflavones. Now, I want to be really clear here. There is a huge industry of supplements for menopause that don't have any science to back them.

So Sarah Berry, Professor Sarah Berry, who's our head scientist, the chief scientist at SAI, she always calls the menowashing. She's like, there's just menowashing. So they take like...

She's been on the show a couple of times and we've spoken about... A normal multivit, call it a menomultivit, charge 50% more. Like, it's crazy.

There isn't really evidence to support these things. I think there's more compelling evidence for eating blueberries every day than there is for taking a specific supplement. But there is emerging science for specific soy isoflavones.

So these specific soy chemicals that seem to really improve menopausal symptom severity. And the key thing is, and something we're looking at is, you need to have the right microbiome. So the specific microbes that are involved with switching that soy isoflavone into an active chemical that helps the symptoms.

So for some women...

[Angela Foster] (46:16 - 46:36)
Is it S-Equal? From when I spoke to her, I think. Is it S-Equal?

Yeah. There's only one company I found who've brought it out recently, I think, which is MitoQ that have isolated the S-Equal into a hormone balance product. Because I think Sarah was saying what you were saying, that not everyone has the gut microbiome to turn the isoflavones into the S-Equal.

[Dr. Federica Amati] (46:36 - 48:07)
Yeah. Okay, perfect. So that someone's already got ahead of it.

But what's really cool is one of the pieces of advice I give is, if you don't already have tofu and soy products in your diet, go for it. Introduce them. We know they're good for you.

They're high in protein. If you do tempeh, it's also high in fibre. It's got bioavailable iron in it, calcium.

It's probiotic. If it's tempeh, if it's tofu, it's not. But it's still really good for you.

It's low in saturated fat. What an amazing food to include in your diet. And edamame beans themselves, obviously, are wonderful.

And if in doubt, add that to your diet. You are more likely to have the microbes that break that down if you eat the food. Because they will be like, hey, this is for me.

I'm going to eat this. And if you are in the lucky group that breaks it down effectively and it helps, great. And if not, it's still going to help with your health.

So it's a win-win situation. That's an exciting area, I think. But what's really clear from our research is that improving your health helps.

HRT can be helpful, too. Again, I go back to my point earlier. You have to know what the toolbox is and then be able to personalise it to what you can do.

For some women, progesterone is a game changer to help them sleep again. So it depends what you're struggling with. It depends if working with a clinician who is going to really listen to what your background is, what your concerns are and what your goals are.

And then we can use the right tools in the toolbox to support that journey. There isn't a one-size-fits-all solution.

[Angela Foster] (48:08 - 48:29)
And have you, last question, have you seen when you look at women who are taking menopause hormone therapy, I know that, again, this kind of comes back to how it interlinks with so many things, but have you seen those women have an easier time of gaining muscle, reducing visceral fat and overall body fat than the women who are not? Or does that come down more to their diet and lifestyle changes and exercise?

[Dr. Federica Amati] (48:29 - 55:08)
In our study, in our paper, it was cross-sectional, as I said, so we didn't see whether it changed how they were able to maintain muscle mass or reduce visceral fat. What we did see is that women who were taking HRT had less of that change in post-strandial response. So they were, if you look at the different lines, they were closer to the premenopausal.

So it was protective in that sense. However, my clinical experience is that HRT can really help with some of these symptoms, but it is not the key driver to maintaining muscle mass, bone mineral density and reducing visceral fat mass. Lifestyle, exercise, nutrition, sleep is a much bigger driver.

So I would say, again, like HRT is another tool in the toolbox, but it won't increase your, like increase your muscle mass, decrease visceral fat by itself. Right. In some women, it might give them, it might give them enough sleep to have enough energy to like do the exercise, like move every day.

And so again, knock on effect, but it's not the only tool that's going to help you with that. And I think here it's important to say that women who are listening to this, who are maybe in their 20s or 30s, early 40s, really putting as much effort in now to get used to resistance training, get used to moving your body every day, really focus on like a high quality diet now is going to give you so much more buffer when menopause hits. Because the issue is that as we've discussed, menopause doesn't just suddenly mean everything falls off a cliff, but it becomes harder to build extra muscle.

It's still doable. You can still do it, but it's harder. So if you start off with a higher muscle mass, if you start off with the routine of eating and moving and sleeping in a certain way, when biology makes it a bit easier, then when the biology stops helping you so much, you're already in a better place.

So that would be my message to the younger audience. And then if you're someone who's, and I've worked with many women who are in full-blown menopause, have been for like 10 years or more, and they have transformed their health. Right.

So, as I said, it's not like a blocker, but it's just, you have to work a bit harder after. So you can either help yourself or if you're post-menopausal, there are so many things you can do to transform your health afterwards. And I want to just touch one last thing.

I know you said lifestyle medicine pillars are there and we should focus on them, but I really want to acknowledge something important, which again, I rarely see acknowledged and it's super important. They are technically free and available to us all, but in reality, we live in an obesogenic environment. So they are not that easy.

They're simple, but they're not easy to achieve. There's a reason why two thirds of the population in this country have overweight or obesity and are not in good metabolic health. Estimates are about around one in three adults having incident resistance.

And that is because the way that our work life and our feed environment and all these things are set up is not for public health. It's to maximise profit. So whilst it sounds simple, we have to acknowledge that it's not easy for everybody.

The more access you have, the easier it is. And so there is this really big divide in those who are able to achieve this and those who find it really hard. So I want to say, if it feels like you have to put your mind to it, set some time aside and really put effort in, it's because it is.

It needs effort. Unfortunately, our environment isn't set up for it to be easy. And so we need to also be kind to ourselves and actually pat ourselves on the back if we're able to really start to build these lifestyle medicine pillars into our lives, using tools to help us along the way.

So whether you use the Zodiac to help improve your nutrition, whether you're able to join a local walking group, whatever you're able to do, like, well done, because it's actually quite hard. And be kind to each other, because one of the narratives I see online a lot is like, it's easy. Just like set your alarm, like go to the gym.

Yeah, cool. If you have gym membership and you don't have caring responsibilities and you can afford to fill your fridge with healthy berries, great. But actually, that's not the case for many people.

So let's just celebrate our efforts. The most important thing is trying, finding the tools that are available to you and making the most of those. And remember that time is the only currency that you cannot buy.

So what you dedicate your time to as much as possible, really focus on where you can spend your time. So if that means blocking out your calendar for a half hour lunch break, do it. And I think people are so scared to set time aside and to actually say that I'm actually going to stop.

I'm going to get up from my desk and go to my kitchen and make a salad, right? We've got to do it. Us who are older, so those of us who manage younger people, we have to set the example.

So if you have a team, my team, I'm always like, go get a lunch break, get up and go for a walk. We have to set an example because it's very easy to get sucked into this idea that we don't have time, we don't have time, we don't have time. And again, I want to say for some of us, it can be like that with caring responsibilities and shift work.

There's lots of reasons why that might be the case. But where you can try to dedicate some time to looking after yourself, because as I said, you actually have to structure these lifestyle medicine pillars into your day if you want to be able to achieve them. One of the biggest time steps we have in our current sort of lives is social media, right?

So an average adult spends two and a half to three hours on social media, just in little snippets across the day. Take that time back. Not all of it.

I'm on social media, I put content out, right? I'm not saying we're all going to go cold turkey, but just be mindful about your time because time is precious. And if you are able to slot it in to achieve the things that you want to for yourself, it makes a big difference because it's that consistency that really pays off in the long term.

[Angela Foster] (55:08 - 56:03)
It makes such a massive difference, doesn't it? I just love that note to finish on. I think like it's so empowering.

I would say to anyone listening to this, go and look up the difference between Kronos time and Kairos time, because you start to realise that there's two ways of looking at time. There's the clock that's running and that's also ageing. And then there's also this quality of time of like, where are you putting your focus and attention?

And I think the thing I've taken away from this conversation, Dr. Amati, is that all the research is showing us that the importance of human connection, the quality of the food we eat, how we spend our lives, managing our stress, having those toolkits, and most of all, really supporting each other through that process is really, really key. And I think you've just done that in such a beautiful way. And it's just so lovely that the science shows the same thing, because I think it kind of really returns us to our roots.

I'd love for you to share how people can connect with you. I know you share a lot on social. You've written multiple books.

You're always doing research. Please share.

[Dr. Federica Amati] (56:03 - 57:33)
Yeah, so I'm Dr. Fede Amati across all the social networks. I read my messages. So if you message me, I'll look at it.

And then you can, of course, find me on the ZOE podcast. I'm in the ZOE app. So you'll see me popping up in there.

Yeah, I teach at Imperial College. So if you're a student there, you can find me. If you're a medical student, I teach there.

I even have a contact form on my website, which actually I get lovely emails through. So I always love to hear from people and hear what their challenges are. And I have a clinical practise with Well-Founded Health, which is a concierge medical company as well.

So I'm actually, I love people. So you can find me in all sorts of places. And yes, if you want to support my book, they're available on all platforms.

And the Appetite Reset really looks at how appetite works, appetite physiology and the kinds of diets that support natural appetite, as well as very detailed nutritional advice for those taking GLP-1 medications and other appetite-lowering drugs. And everybody should know this is looking at life course health. So understanding how changes in physiology, biology throughout the life course impact how we should approach health at different time points.

And then Recipes for Better Metaphors is my book that I wrote based on a lot of the science we did looking at what kind of foods actually support metaphors transition. And that has some lovely recipes in it as well. The Food for Life Cookbook with Tim Spector is another one of our babies.

The Food for Life book, big one as well. So I write, I have Substack. Basically, communication is a core part of my identity, I'd say.

[Angela Foster] (57:34 - 57:48)
I think you should do some content on how you fit all of this in as well. It's pretty amazing. Very, very inspiring.

But yeah, there's a massive, massive resource there. Thank you so much for coming on. We will link to all that in the description.

So thanks again. It's been really amazing talking to you.

[Dr. Federica Amati] (57:48 - 57:49)
Thanks for having me. It's been such a pleasure. Thank you.

ZOE nutritionist Dr. Federica Amati explains why basal metabolic rate barely changes in perimenopause, but postprandial metabolism does, glucose, fat, insulin, and inflammation stay elevated longer after meals, partly via gut microbiome shifts. She unpacks why "thin" can mask sarcopenic obesity, why calorie labels carry ~20% error, why a nutrient-dense breakfast curbs cravings, and why a 70,000-woman ZOE study saw a 35% symptom drop from diet changes alone.

WHAT YOU'LL LEARN

- Why basal metabolic rate isn't the problem in perimenopause, but postprandial metabolism is

- What's actually driving new midsection fat storage as estrogen declines

- Why calorie counting fails as a long-term strategy, from label error to the food matrix effect

- How satiety hormones like GLP-1, PYY, and GIP shift after menopause, and why breakfast is the highest-leverage meal of the day

- Why looking thin doesn't mean you're metabolically healthy, and what sarcopenic obesity reveals about muscle as an organ

- What HRT actually changes about your metabolism, muscle mass, and visceral fat, and what it doesn't

- How a 70,000-woman study found a 35% drop in menopause symptoms from diet changes alone, and why brain fog improved most