" \
WOMEN'S AWARENESS, PERCEPTIONS AND ATTITUDES OF
MENOPAUSE AND THEIR DIETARY INTAKES IN MANAGING
MENOPAUSAL SYMPTOMS:
A CASE OF MARAGUA TOWN, KENYA //
BY:
~WAIR~G7SUSAN WAMBUI
H60/8650/99
A thesis submitted in partial fulfillment of the requirement for the degree of Masters of
Science in Foods, Nutrition and Dietetics in the School of Health Sciences of Kenyatta
University.
2006
Wairegi, Susan Wambui
Women's awareness,
oerceptions and
IIIIIIIIIIII111I
, 2001/302096
~ENYATTAUNIVERSITY LIBRARY
II
DECLARA TION
This thesis is my original work and has not been presented for a degree in any other
university or any other award.
SIGNITURE __ ~~===-~ __ DATE
WAIREGI SUSAN WAMBUI
This thesis has been submitted with our approval as University Supervisors.
,,-:SIGNITURE_=j'--..,.....l-"--_"'-_•..•....:;;..;::~~__ DA TE
JUDITH N. WAUDO
Department of Foods, Nutrition and Dietetics
Kenyatta University.
SIGNITURE_---'~ · DATE
ELIZABETH N. KURIA
Department of Foods, Nutrition and Dietetics
Kenyatta University.
111
DEDICATION
This thesis is dedicated to my beloved mother Njeri and my dearest son Michael.
IV
ACKNOWLEDGEMENTS
Compilation of this thesis could not have been realized without the collaborative support
of lecturers, professors and other members in the Department of Foods, Nutrition and
Dietetics, Kenyatta University. More so, I wish to acknowledge the contributions of my
supervisors; Prof. Judith Waudo and Dr. Elizabeth Kuria, both of Kenyatta University.
Without their regular inputs, guidance, encouragement and tireless dedication, the
writing of this thesis would not have been achieved.
I acknowledge the inputs of all the women particularly, Elizabeth Njoroge, Rose
Kimani, Sr. Sophia Nduta, Evalyne Kagunda and Ceckia Mwangi who in one way or the
other worked tirelessly and dedicated their time for the data collection in Maragua
town.
My gratitude is also to my colleagues Mr. Mwaura G., Ms Kariuki, Mr. Maina. Mrs.
Mugoro and the rest for their support throughout my academic years. I am grateful to
Peter Chege for his meticulous guidance in data analysis and to Mr. Bojana for the keen
editing of the final thesis. Lastly, I sincerely wish to thank my entire family; my mother
Njeri, my sisters Magiri and Waithera and brothers Maina and Mwangi for their
boundless support, prayers and love throughout my academic years.
vABSTRACT
Menopause manifests itself through hot flashes, insomnia, night sweats and loss of
libido among other symptoms. Recent researches have established that with the use of
Hormone Replacement Therapy, there is an increased risk for hormone related cancers.
Diet is now seen as one of the primary and safest methods of managing menopausal
problems. The significant problem was women's lack of factual information about
menopause and the role nutrition can play in managing menopausal symptoms. The
purpose was to establish women's awareness, perceptions and attitudes to menopause
and their dietary intakes in managing menopausal symptoms. A cross-sectional
descriptive survey approach was used where a multi-stage sampling technique was
employed to purposively sample 121 menopausal women of between 40 and 59 years,
living and working in Maragua Town, Kenya. Instruments used to facilitate data
collection were interview schedules, Likert scales and focus groups. Quantitative data
were analyzed using the scientific package for social sciences (SPSS). Pearson Product -
Moment Correlation (R) technique was used to establish the relationships between
nutritional knowledge for menopause with hot flush and between consumption of
kilocalories and selected nutrients with presence of symptoms associated with
menopause. Spearman Rho correlations technique was used to establish the relationships
between levels of nutrition knowledge for menopause with frequency of foods rich in
isoflavones in the diets. Regression analysis was used to establish the probability of a
symptom associated with menopause being explained by the change in the total intakes
of kilocalories and the selected nutrients and nutritional substances. Qualitative data
were transcribed, grouped into categories, themes developed and presented in textual
form. It was found that menopause was a culturally welcomed and accepted
phenomenon. Menopausal symptoms were prevalent but not well-understood. Though
women's diets were of plant origin, they were inadequate in isoflavones, kilocalories,
dietary fiber, vitamin A, magnesium and calcium in reference to the World Health
Organisation's Recommended Dietary Allowances. This led to the observation that less
intake of kilocalories, isoflavones and selected nutrients were accompanied by presence
of symptoms' associated with menopause. There was no significant relationship between
nutritional knowledge for menopause and consumption of foods rich in isoflavones,
kilocalories and selected nutrients. It was concluded that culture greatly influenced
women's perceptions and attitudes of menopause. Types and quantities of nutrients
consumed by women at menopause had significant influence on presence of menopausal
symptoms. Therefore, there should be increased counseling and sensitization for both
women and men and up-to-date information about menopause made readily available to
women. Nutritional education Programme on menopause should be undertaken to bring
about change in dietary intakes. The Ministry of Education should be sensitized to
incorporate nutrition knowledge for menopause into school's curriculum and in adult
education Programmes. The findings will benefit the policy makers, nutritionists,
educationists, menopausal women and the whole population in general.
vi
TABLE OF CONTENTS
Declaration .ii
Dedications iii
Acknowledgement. .iv
Abstract. v
List of tables xi
List of figures xiii
Abbreviations and symbols xiv
CHAPTER 1: INTRODUCTION
1.1 Background jnformation 1
1.2 Statement of the problem 3
1.3 Purpose of the study 4
1.4 Objectives of the study 4
1.5 Significance of the study 5
1.6 Conceptual framework. 6
1.7 Limitations of the study 7
1.8 Assumptions 7
1.9 Operational definition of terms 8
1.10 Organisation of the thesis 9
CHAPTER 2: LITERATURE REVIEW
2.0 Introduction 10
2.1 Entering menopause 10
2.2 Endocrinologic changes at menopause 11
2.2.1 Changes in menstrual cycle patterns 11
2.2.2 Changes in pituitary gonadotropins releasing factors 12
2.2.3 Changes in sex steroid hormones 12
2.3 Menopausal symptoms: 14
2.3.1 Physiological symptoms of menopause '" 15
2.3 .2 Vasomotor complaints 16
2.3.3 Vaginal dryness 18
vii
2.3.4 Urinary tract infections 19
2.3.5 Weight gain 19
2.3.6 Other common symptoms 21·
2.3.7 Long-term complications 21
2.4 Psychological aspect of menopause 26
2.4.1 Connection between body and mind during menopause 27
2.4.2 Factors contributing to adverse psychological symptoms
at menopause 28
2.5 Socio-cultural factors and menopause 30
2.6 Dietary management of menopausal symptoms .31
2.6.1 Recommended foods for menopause .31
2.6.2 Foods to be avoided during menopause .36
2.7 Exercises during menopause 38
2.8 Herbal therapy 38
2.9 Sununary : 39
CHAPTER3:METHODOLGY
3.0 Introduction 40
3.1 Research design 40
3.2The study area 40
3.3 Population 41
3.4 Sampling process 41
3.5 Research instruments 43
3.6 Ethical considerations 44
3.7 Data collection procedures 44
3.7.1 Interview schedules for the clinical officers and nutritionists 44
3.7.2 Interview schedules for the women .45
3.7.3 Focus groups discussions .46
3.8 Pre-testing 46
3.9 Data analyses 47
3.9.1 Quantitative data 47
VIII
3.9.2 Qualitative data 48
3.10 Operational definition of variables .48
3.10.1 Independent Variables .48
3.10.2 Dependent Variables 49
CHAPTER 4: RESULTS AND DISSCUSSION
4.1 Introduction 51
4.1 Socio-economic data 51
4.2 Women's reproductive factors 54
4.3 Symptoms associated with menopause among the Maragua menopausal
women 58
4.4 Women's awareness of menopause 60
4.4.1 Women's awareness of menopausal symptoms 61
4.4.2 Societal constriction in the information dissemination about menopause ..64
4.5 Women's perception of menopause 65
4.5.1 Coping with the symptoms 67
4.5.2 Treatments of menopausal symptoms at the District Hospital 71
4.5.2.1 Clinical Officers' recommendations 72
4.5.2.2 Nutrition therapy at hospital 74
4.6 Women's attitudes towards menopause 75
4.6.1 Women's levels of satisfaction by various factors during
the menopausal transition 77
4.6.2 Women' attitudes towards changes experienced at menopause 82
4.7 Women's dietary intakes 84
4.7.1 Meals distributions 84
4.7.2 Food portions 86
4.7.3 Food frequency 88
4.7.3.1 Frequency of consumption of different classes of foods in
the diet. 88
4.7.3.2 Frequency of foods rich in isoflavones 89
4.7.4 Foods commonJy consumed by the women 9J
ix
4.7.5 Nutrients adequacy 97
4.8 Vitamins and mineral supplementation 101
4.9 Women's physical activities 102
4.9.1 Types of physical activities 102
4.9.2 Women's levels of exercising 104
4.10 Nutritional knowledge for menopause and its influence on food consumption 104
4.10.1 Women's nutritional knowledge for menopause 104
4.10.2 Responses given to the test on nutritional knowledge for menopause 105
4.10.3 Relationship between nutritional knowledge for menopause
and consumptions of foods rich in isoflavones 109
4.11 Relationships between dietary intakes and presence of menopausal symptoms
associated and those associated with menopause .113
4.11.1 Relationships between total amount ofisoflavones in the diets and
presence of hot flushes 113
4.11.2 Relationships between consumption 0 of kilocalories and selected
nutrients with the presence of menopausal symptoms associated with
menopause 114
4.11.3 Regression analysis 117
CHAPTER 5: SUMMARY, CONCLUSIONS AND RECOMMENDATIONS
5.1 Introduction 119
5.2 Summary of the findings 119
5.3 Conclusions 125
5.4 Recommendations 127
5.5 Suggestions for further research 128
REFERENCE 129
APPENDICES
Appendix 6.1 Map of Kenya showing population of main towns 134
Appendix 6.2 Kegel exercise 135
xAppendix 6.3 Interview schedule for menopausal women 136
Appendix 6.4 Nutritionist interview schedule 153
Appendix 6.5 Physician (clinical officers) interview guide 156
Appendix 6.6 Focus groups discussion guide ]58
Appendix 6.7 Calibration table ]59
Appendix 6.8 Women's responses to the nutritional test at menopause 162
Appendix 6.9 Actions taken to relieve symptoms associated with menopause
among menopausal women ofMaragua Town-Kenya 166
~Appendix 6.10 Isoflavones content in foods 169
xi
LIST OF TABLES
Table 2.1: Tests to determine menopause status 13
Table 4.1: Socio-economic characteristics of menopausal women of Maragua Town 52
Table 4.2: Reproductive factors and menopausal status among menopausal women of
Maragua Town, Kenya 55
Table 4.3: Types of symptoms associated with menopause and their degree of severity
among menopausal women ofMaragua Town-Kenya 59
Table 4.4: Perceived attributes associated with menopause among menopausal women of
Maragua Town, Kenya 62
Table 4.5: Preference in sharing of menopausal experiences among menopausal
women of Maragua Town, Kenya 65
Table 4.6: Perceptions of symptoms associated with menopause among
menopausal women in Maragua Town, Kenya 67
Table 4.7: Complaints necessitating hospital visits among menopausal women
ofMaragua Town, Kenya 71
Table 4.8: Treatments given for symptoms associated with menopause at
Maragua District Hospital. 72
Table 4.9: Reasons for the insipid attitude towards managing symptoms associated
with menopause among menopausal women ofMaragua Town, Kenya 75
Table 4.10: Measurement of attitudes at menopause (%) among menopausal women
ofMaragua Town-Kenya 78
Table 4.11: Attitudes towards changes experienced at menopause among menopausal
women ofMaragua Town, Kenya 83
Table 4.12: Meal distributions among menopausal women of Maragua Town-Kenya.84
Table 4.13: Reasons for skipping meals among menopausal women of Maragua Town,
Kenya 85
Table 4.14: Women's usual food portion sizes against the recommended portion sizes
based on pyramid of health diet 87
Table 4.15: Foods taken for lunch among the menopausal women ofMaragua Town,
Kenya 88
xii
Table 4.16: Intakes ofisoflavones rich foods in a period of3 months among
menopausal women ofMaragua Town, Kenya 90
Table 4.17: Foods consumed by menopausal women of Maragua Town, Kenya 93
Table 4.18: Nutrient intakes of kilocalories, isoflavones and selected nutrients among
menopausal women of Maragua Town-Kenya 98
Table 4.19: Physical activities and exercises among menopausal women of Maragua
Town, Kenya 102
Table 4.20: Performance in the nutritional knowledge for menopause test among
menopausal women of Maragua Town-Kenya 105
Table 4.21: Relationships between levels of nutritional knowledge for menopause and
frequency intakes of foods rich in isoflavones among menopausal women of
Maragua Town-Kenya 110
Table 4.22: Relationships between scores in nutrition knowledge for menopause test and
amount of kilocalories and selected nutrients among menopausal women of
Maragua Town, Kenya 112
Table 4.23: Relationships between amount of kilocalories and selected nutrients
consumed with the presence of symptoms associated with menopause among
menopausal women of Maragua Town, Kenya .1'15
Table 4.24: Kilocalories and selected nutrients as predictors of menopausal symptoms
among menopausal women ofMaragua Town, Kenya 118
KENYATTAUNIVER\,ITY LIBRA!!!
xm
LIST OF FIGURES
Figure 1.1: Nutrition and other related fuctors that contribute to menopausal symptoms 6
Figure 4.1: Breakfast dishes among the menopausal women of Maragua Town 91
Figure 4.2: Micronutrients supplementations among the menopausal women ofMaragua,
Town 102
xiv
ABBREVIATION AND SYMBOLS
GnRF - Gonadotropic releasing hormones
LHRF - Luteinizing hormone releasing factor
FSH - Follicle stimulating hormone
LH - Luteinizing hormone
DHEA - Dehydroepiandrosterone
CNS - Central nervous system
LDL - Low density lipoproteins
HDL - High density lipoproteins
HRT - Hormone replacement therapy
SHBG - Sex hormone binding globulin
EFA - Essential fatty acid
FGD - Focus group discussion
PMS - Pre-menstrual syndrome
CBS - Central bureau of statistics
RDA - Recommended dietary allowance
WHO - World Health Organisation
< - Less than
> - Greater than
.:s - Equals or less than
~ - Equals or greater than
= - Equals
+ - Plus
± - Plus or minus
1CHAPTER 1
INTRODUCTION
1.1 Background information
Menopause marks the end of women's reproductive years. The follicle stimulating
hormone (FSH) and luteinising hormone (LH) produced by pituitary glands no longer
stimulate the ovaries to produce estrogen and progesterone needed for release of ovum.
Council of Affiliated Menopause Societies (CAMS) states that natural menopause is
recognized to have occurred after 12 consecutive months of amenorrhea (lack of
menstrual cycle for at least three consecutive months), for which there is no pathological
or physiological cause (Hasler, 2001). Menopause occurs at a median age of 51.4 years
with some women reaching menopause as early as in the thirties and a few in the sixties
(Hasler, 2001; Kingsley, 2001; Henkel, 2001).
Marked drop of estrogen and progesterone in the blood stream, results to emergence of
wide variety of menopausal symptoms. Hot flashes, night sweats, anxiety, irritability,
depression, loss of libido and crying spells are some of these symptoms (Beckham,
2002; Kimmel, 1990).
Endocrinologic, physical and clinical features of menopause starts immediately prior to
menopause and ends during the first year after menopause (perimenopause) and lasts for
four years in most women (North American Menopause Society, 2001). An estimated
20 million American women with menopausal problems have had therapeutically
hormonal replacement of estrogen to substitute what their ovaries no longer provide
(Smith & Shimp, 2000). Many women have similarly been using hormone replacement
2therapy (HRT), to alleviate menopausal symptoms. However, the emerging studies
linking HRT use to increased risks to hormone-related cancer, have led to women
looking for safer alternative methods.
Unhealthy food practices and lifestyles such as heavy smoking, excessive drinking of
alcohol, fatty foods and lack of exercise accentuate these symptoms during menopause
(Kelliher, 2000). Diets rich in animal protein such as meat and milk should be taken
sparingly (Ludington & Diehl, 2000). Vegetarian diets that include soy, peanuts and
sweet potatoes contain plant hormone, phytoestrogen, which mimics body's estrogen
when levels decrease, easing symptoms of menopause and osteoporosis (Omoni s:
Aluko, 2005). High fiber diets found in whole meal cereals, pulses and vegetables are
beneficial in preventing many ailments including menopausal symptoms (Ludington &
Diehl, 2000). Other recommended nutrients during menopause include vitamins A, B, C,
D and E, magnesium, calcium, zinc and boron.
Nutritional knowledge at menopause is "limited" among older population (Posner &
Levine, 1991, pp. 424) because of the lack of necessary information on health arid
nutrition. Also culture, socio-economic factors, family, health, attitude and
psychological concerns, determine if women will experience a crisis during menopause
or not.
31.2 Statement of the problem
Research reveals that Negroid women are more susceptible to physical and estrogen-
related menopausal symptoms than other ethnic groups (ALLBAH, 2002). In spite of
this, a majority of Negroid women lack mastery of menopause, leading to making
uninformed choices (ALLBAH, 2002). As a result, they suffer through menopausal
period alone afraid to talk about what is happening to them. Depending on severity of
the symptoms, the repercussion is significant stress noted on women's health, families
and marital unions in particular (Henkel, 2001).
Hormone replacement therapy (HRT) has been prescribed to millions of women to
relieve menopausal symptoms and reduce risk of osteoporosis. However, recent
researches show a 10 - 20 percent higher risk of endometrial cancer among women on
the HRT drug (Hasler, 2001). This has led to scientists including gynecologists to
caution against long-term use ofHRT.
Diet is now being considered as one of the safe alternatives to menopausal problems
(Beckham, 2002; Hasler, 2001; Kirschman & Kirschman, 1996). However, studies
indicate that older population shows limited nutritional knowledge (posner & Levine,
1991). Inadequate nutritional knowledge, coupled with cultural heterogeneity, affluence
and modernity have attributed to the rapid changes in African diets and lifestyles.
Modernization has paved ways to new food habits and a falsified perception that some
traditional African diets are inferior and unacceptable; consequently being replaced with
highly refined processed foods (K'Okul, 1991). Yams, nuts, sweet potatoes and soy are
some traditional vegetable foods, which offer natural protection against problems
4associated with menopause and its complications, but are no longer common in local
diets (Pamplona-Roger, 2000 b; K'Okul, 1991). Therefore, the concern is that, there is a
general lack of mastery of menopause among African women and limited nutritional
information that show the link between nutrition and menopause.
From the available literature, hardly any studies on nutritional management of
menopause have been undertaken in Africa and particularly in Kenya. It is important to
study this phenomenon within the Kenyan cultural context, in order to have a clear
picture on Kenyan women's cultural perception and the existing knowledge of local
foods that help alleviate menopausal symptoms. This study therefore investigated
Kenyan women's perception of menopause and dietary practices during menopause as
pertains to managing menopausal symptoms.
1.3 Purpose of the study
The purpose of this study was to establish women's perceptions of menopause and
dietary practices at menopause among menopausal women of Maragua Town, Kenya.
1.4 Objectives of the study
The study aimed to:
1) Identify the symptoms associated with menopause that were experienced by women.
2) Investigate women's awareness, perceptions and attitudes of menopause.
3) Determine the dietary intakes of women during menopause.
4) Investigate women's physical activities during menopause.
55) Determine the relationship between dietary intakes and presence of symptoms
associated with menopause.
6) Investigate women's nutritional knowledge of menopause and its influence on their
food consumption.
1.5 Significance of the study
Women in some cases confuse menopausal symptoms such as hot flashes and headaches
with diseases such as typhoid or malaria. The study's insight into women's views and
interpretations of menopause and the subsequent symptoms will enlighten the medical
personnel on women's perceptions of menopause and thus facilitate appropriate
treatment and counselling to the affected women.
The study has established the types as well as the quantity of nutrients intake by the
menopausal women. Nutrients found effective in controlling menopausal symptoms are
also noted. Therefore, nutritionists will establish diets and forms of nutrient
supplementation for menopausal women. These measures will help menopausal women
go through menopause transition with ease. Finally, the study being a pioneer research in
the field of menopause and nutrition in Kenya, will act as a baseline study for further
research in the field.
61.6 Conceptual framework
Menopause
Functions
• Healthy bones & tissues
• Balancing body chemistry
• Moistens membranes &
skin
(J Socio-
economic
factors
(J Socio-
cultural
factors
(J utritional
knowledge
during
menopause
Nutrition
• utrients intake e.g.
vitamins A,C, D, E
Isoflavones, fiber,
magnesium and
calcium
• Exercise
• Herbal therapy
Symptoms
• Hot flashes
• Night sweats
• Mood swings
• Insomnia
• Vaginal dryness
• Fatigue. etc.
Figure 1.1:Nutrition and other related factors that contribute to menopausal symptoms
The hypothesized model (figure 1.1) highlights the relationship between nutrition and
menopause. The model was primarily used to show the inter-relationship of the variables
used in the study. At menopause, there is a marked drop in levels. of estrogen and
progesterone produced by ovaries. Estrogen being an anabolic agent for protein is
needed for production of strong bones and tissues, in maintaining moistness of mucous
7membranes, as well as balancing body chemistry. Before the body adjusts itself to the
new changes, menopausal symptoms such as hot flushes, insomnia, depression, sweats,
among others may occur. The absence of healthy diet before the onset of menopause
accentuates menopausal symptoms (Beckham, 2002; Grayson, 2002).
Socio-economic factors such as income levels, occupation, education levels as well as
nutritional knowledge for menopause, coupled with women's socio- cultural perceptions
of menopause and cultural dietary dynamism may deter women from upholding healthy
eating practices and lifestyles (K'Okul, 1991).
1.7 Limitations of the study
Since the study is a case of Maragua Town menopausal women, generalization of the
findings to women of other areas should be done with caution. The study was also
limited in inadequacy of funds and time.
1.8 Assumptions
Since symptoms associated with menopause are similar to symptoms found in other
typical diseases; the study assumed that in the absence of disease, the symptoms were
due to menopause. The study also assumed that women's dietary intakes and practices
contributed to symptoms associated with menopause. Data from the 24-hour recall was
assumed to have reflected a normal dietary intake and practices.
81.9 Operational definition of terms
• Age: Measured from the first birth date to the current year, in years.
• Marital status: State of being married, single, divorced or separated.
• Education levels: Education levels as per the highest award attained through the
formal education system in the country. These include class 8/7, '0' level, 'A' level,
college level and university level.
• Income levels: These refer to women's net incomes per month.
• Occupation: Activity or job that under-taken the purpose of generating income.
• Gynecological problems: These refer to presence of hysterectomy and
oophorectomy.
• Food: Any substance the women eat or drink for life, health, growth and
refreshment.
• Exercise: Refers to physical activity that women engage in. For example, a brisk
walk or just a job demanding heavy exertion.
• Attitudes: Women's way of thinking and/or feelings towards menopause.
• Perceptions: Women's ability to understand menopause / quality understanding of
menopause and of symptoms associated with menopause.
• Awareness: Refers to having knowledge or being well-informed about menopause
and symptoms associated with it.
• Symptoms associated with menopause: These refer to symptoms due to menopause
such as hot flushes, night sweats, mood swings, insomnia, vaginal dryness, fatigue
etc.
9• Menopause transition: This refers to the period between pre-menopause, through
menopause to 12 months after cessation of menses.
1.10 Organisation of the thesis
This chapter gives the background information of the undertaken research. The problem
of the study, the purpose and the objectives of the study are given in details. Related
literature is reviewed in chapter two and methods in chapter three. The research fmdings
are reported and discussed in chapter four and chapter fives 'give the conclusions of the
research, recommendations and suggestions for further research in the related areas.
10
CHAPTER 2
LITERATURE REVIEW
2.0 Introduction
Literature related to menopause and dietary management of menopausal symptoms is
reviewed under the following sub-topics: Entering menopause, endocrinologic changes
at menopause, menopausal symptoms; physiological, psychological and socio-cultural
aspects of menopause, dietary management of menopause, exercises during menopause
and herbal therapy.
2.1 Entering menopause
The diagnosis of natural menopause is by definition retrospective. The Council of
Affiliated Menopause Societies (CAMS), International Menopause Society (IMS),
define natural menopause as the permanent cessation of menstruation resulting from the
loss of ovarian follicular activity (Hasler, 2001).
Menopause occurs at the age of between 48 and 52 years in a wide variety of population,
with some women reaching menopause as early as in their 30s and a few in their 60s
(Hasler, 2001; Kirschman & Kirschman, 1996; Kimmel, 1990). Onset of natural
menopause is recognized to have occurred after 12 consecutive months of amenorrhea
(Hasler, 2001; Beckham, 2002). Amenorrhea is lack of menstrual cycle for at least three
consecutive months, for which there is no other obvious pathological or physiological
cause. This may not come as a surprise, but may be preceded by irregular cycles and
menses, a period termed as perimenopause (Hasler, 2001).
11
Changes associated with menopause are evident during this period, signalling the
approaching cessation of menses. At this period, the body readies itself to switch to non-
reproductive stage. Menopause onset can be prematurely triggered by surgical removal
of uterus (hysterectomy) or by the removal of ovaries (oophorectomy) (Parihar & Shar,
2001; Kimmel, 1990). Removal of both ovaries is preceded by rapid decrease in plasma
estradiollevels. Follicle stimulating hormone (FSH) is significantly elevated in 2 days
and Luteinizing hormone (LH) by the 3fd day (Parihar & Shar, 2001). A woman without
menstrual periods for a period of 1 year after menopause is said to be post-menopausal
(Henkel, 2001).
2.2 Endocrinologic changes at menopause
2.2.1Changes in menstrual cycle patterns
Female reproduction is influenced by three hormones. These are Gonadotropic releasing
hormones (GnRH), which include luteinizing hormone releasing factor- (LHRF) and
follicle stimulating hormone (FSH); Pituitary gonadotropin, which are FSH and
Luteinizing hormone (LH) and sex steroids which include estrogen, androgen,
progesterone, produced by ovary, adrenal glands and extra-glandular tissue metabolism
Menstrual cycles vary throughout the reproductive span: Within, between individuals
and among cultural groups (Chaubal & Vaishwanar, 2001). As menopause approach,
menses become irregular and in general less frequent (Henkel, 2001). However, prior
anovulation, (2 - 8 years before menopause) menstrual cycle length increases and in
each cycle, few follicles grow until finally they are depleted (Parihar & Shar, 200]).
12
2.2.2 Changes in pituitary gonadotropins and releasing factors
Prior menopause an increase or decrease of GnRH productions is influenced by positive
or negative feedback induced by two centres of hypothalamus; tonic centre and cyclic
centre (Parihar & Shar, 2001). Tonic centre is responsible for production ofFSH and LH
while cyclic centre responds to actual demand by release of FSH and LH. These centres
are influenced by ovarian steroids and peptides.
At menopause, this mechanism is slightly altered. By 34 years FSH production is
increased but statistically significant at approximately 40 - 44 years (Smith & Shimp,
2000). With increased FSH, there is an increase in LH by 45 - 50 years. But as long as
follicular growth and development does not cease, estradiol levels remain the same.
During post-menopause there are elevated levels of FSH and LH to indicate ovarian
follicle failure (Beckham, 2002). However, FSH level are higher than LH as LH is
cleared faster in the blood stream (30 minutes for LH and 4 hours for FSH).
2.2.3 Changes in sex steroid hormones
By}5 years ovary begin to decrease in weight and size and contain fewer oocytes and
follicular structures and more atretic and degenerative follicles. During reproductive
years, 90 % of the estradiol occurs from the ovary. A gradual increase is noted
throughout the cycle to a late follicular peak (Luteal maximum) and then a progressive
decrease until start of next cycle (Parihar & Shar, 2001).
However, during perimenopause, menses become irregular and vaginal bleeding occurs
at end of inadequate luteal phase or after a peak of estradiol without subsequent
13
ovulation or corpus luteum formation. Estradiollevels remain the same at normal range
until follicular growth and development ceases but luteal progesterone decline (Smith &
Shimp, 2000). The transition is characterized by periods being no longer neither regular
nor predictable (Beckham, 2002). The egg follicle in the ovaries does not mature
consistently. Cycles may be ovulatory, with a mid-cycle estrogen surge followed by
progesterone release or anovulatory, with corresponding rise and falls of estrogen levels
and progesterone secretion which has come from a ripened egg case. Thus, fewer
follicles are available and so, less estrogen is produced.
In an effort to keep the ovary functioning, pituitary send more FSH and LH hormones to
stimulate the ovaries (Henkel, 2001; Kimmel, 1990). It is 'recognized in the medical
world that a high level of FSH is the true marker that signals a woman has entered
menopause. FSH test reflects the brain exposure to estrogen and is seen as the best
marker for total exposure to estrogen. It is now considered the standard test for
menopause.
Table 2.1: Tests to determine menopause status
Blood levels of FSH Status
~ <40ml Not menopausal
~ 40 - 100 ml In transition period
~ > 100 ml Through menopause
Additional tests used by practitioners
Vaginal smears
Estrogen levels in blood
Source: Henkel, 2001.Menopause Sourcebook: 3fd edition.
KENYATTA UNIVERSITY LIBRARY
14
Some physicians maintain that measuring estrogen level in the blood and vaginal tissues
can also be an indicative point of reaching menopause (Henkel, 2001). Total circulating
estrogen substantially becomes reduced during post-menopause (Henkel, 2002).
Production of estrone is also reduced. The available estrogen is a result of peripheral
conversion by aromatization of plasma androstenedione. Circulating estradiol level after
menopause is 10 - 20 pg/ml (40 - 70 pmol/I) mostly derived from estrone (parihar &
Shar, 2001).
Androgen: estrogen ratio change due to marked decline in estrogen and there is onset of
mild hirsutism. With increased age, there is decreased DHEA (dehydroepiandrosterone )
and DHEAS, but circulating levels of androsteredione, testosterone and estrogen remain
relatively constant ( Parihar & Shar, 2001). Percentage of conversion of androsteredione
to estrogen correlates with body weight: Increased estrogen production with increased
body weight (Beckham, 2002). This is due to the body's ability to aromatize androgens.
At post-menopause, ovanes which contain islands of thecal cells are stimulated to
secrete androgens. Eventually the ovarian stroma is exhausted and no further stimulation
can result to gonadal activity. Adrenal contribution of precursors of estrogen proves
inadequate. Estrogen insufficiency can not sustain secondary sex tissues, hence
symptoms related to decreasing ovarian follicular competence (parihar & Shar, 2001).
2.3 Menopausal symptoms
Manifestation of menopause varies among different women and within an individual
woman. Depending on individual binding sites for estrogen, hormone dependent
15
symptoms may predominate or lack altogether. Researches show that 50 % of the
women go through menopause without showing signs of menopause (Alford & Bogle,
1982). Also, the symptoms may occur concurrently or sequentially and may depend
upon psychosocial, cultural and environmental factors (Chaubal & Vaishwanar, 2001)
2.3.1 Physiological symptoms of menopause
A decade before becoming menopausal, changes begin happening in the body that set
the beginning of the transition from reproductive to non-reproductive. Most of them
revolve around declining estrogen levels. Estrogen affects many organs in the body from
uterus to ovaries, fallopian tubes, vagina, urinary tract, breast and skin. Central nervous
system (CNS) notably pituitary and hypothalamus, spinal cord, gastro-intestinal system
(colon, pancreas and liver), the adrenal gland, the circulatory system (heart and arteries)
and the skeletal system are also affected (Parihar & Shar, 200 I; Smith & Shimp, 2000;
Kirschman & Kirschman, 1996).
When blood estrogen falls, the target organs are no longer exposed to the same levels of
the hormone. The body therefore begins to manifest some signs. The exception is often
the rule when it comes to menopausal symptoms. Some women will not notice their
entry into menopause, while other experience very severe symptoms (Hasler, 2001;
Henkel, 2001). According to Alford and BogIe, (1982), 50% of women go through
menopause without symptoms. This is explained by individual variation of estrogen
binding cites or any other factors (Henkel, 2001; Alford & Bogle, 1982).
16
2.3.2 Vasomotor complaints
Some researchers group hot flashes and night sweats together as vasomotor complaints
(Henkel, 2001). Hot flash is related to the body adjustment to changes in the hormone
system, among them dropping estrogen and progesterone levels and fluctuations of FSH
and LH. As result not all women experience signs of estrogen deprivation. A minority
may even experience excess estrogen, one of the signs being dysfunctional bleeding due
to uterus fibroids or cancerous growth of uterine lining (Henkel, 2001). Excess estrogen
due to heavy use of estrogen both in oral contraceptive and estrogen treatment during
menopause is most common in women (Cataldo, De Bruyne and Whitney, 1995).
Spontaneous bruising or bleeding and appearance of tiny bumps in the skin and mucous
membranes characterize this condition, commonly known as purpura.
Elevated LH during ovulation was previously thought to be the cause of hot flashes
(Henkel, 2001; Kimrnel, 1990). Current theory proposes that certain brain chemicals
notably; catecholamines and opiates may mediate hot flashes (Henkel, 2001).
Hypothalamus, one of the glands affected by estrogen decline, somehow releases a
trigger substance that results in thermoregulatory instability (Henkel, 2001). The body
signals get mixed, triggering a warming and sweating sequence in an effort to stabilize
what is perceived as change in body temperature.
Around two years after menses stop, at least 40 to 58 percent of the women in
menopause will continue to experience hot flashes, and a 112 to V4 of these women may
continue to experience these hot-flashes for longer periods than 5 years. Studies vary in
their estimates of hot flashes frequencies. Most of these studies show the symptoms
17
frequencies to range between 70 and 85 % (Henkel, 2001; Polit & La Rocco, 1980). Hot
flashes can range from mild to moderate or severe. An average hot flash can last 3.3,
minutes; some can be as short as Yz a minute while some can last one whole hour.
Research has shown that women who are overweight tend to show fewer hot flashes. It
is reasoned that their bodies metabolize some additional estrogen from fat tissues. So
estrogen withdrawal is somewhat mitigated (Henkel, 200 I).
There are some practical tips that women can follow to manage hot flashes. They should
limit or better still eliminate substances that may act as triggers (Henkel, 2001;
Kirschman & Kirschman, 1996). Such substances include caffeine, alcohol, hot and
spicy foods. To modulate body temperature and prevent dehydration, plenty of water
and fluids should be taken. Clothing should also be chosen wisely. Layered clothing
preferably cotton, which can be shed when one gets hot and put back when chill
approach are more convenient. Use of light blankets at night or having a fan near the bed
can deal with night sweats and flashes (Henkel, 2001). These measures can help women
get restive and comfortable nights.
Newer approaches to copmg mechanisms that are helpful are "coping behaviours".
Regular, practiced deep breathing reduces hot flashes by 50 percent (Henkel, 2001). In a
recent research, deep slow abdominal breaths 6 to 8 a minute instead 0f the usual 14 to
16 help prevent arousal of central nervous system (CNS) which plays a major part in
causing hot flashes (Beckharn, 2002; Henkel, 2001). Other behavioural methods include
practising self- acceptance, tracking the emotions and situations that precede a flash, and
18
thus putting some degree of self-control. Keeping a sense of humor is medicinal to the
body as well as the soul.
2.3.3 Vaginal dryness
Besides the normal aging, estrogen depletion causes pH balance of vaginal mucosa to
change resulting to atrophic vaginal symptoms, vaginal dryness, vaginal itching or
burning and pain with intercourse (dyspareunia) (Smith & Shimp, 2000). After
menopause, the lining of the vagina become thinner, less elastic and vagina becomes
shorter and narrower. The natural vaginal secretions and lubrication dwindles. This
condition prompts recurrent yeast infections, painful and uncomfortable sex. Women
desire for sexual intercourse diminishes with every painful act. There follows reduced
sexual activity among these women, which only exacerbate the problem (Henkel, 2001;
Woodruff & Birren, 1983). These problems are less pronounced among women who
remain sexually active (Smith & Shimp, 2000). The solution lies in seeking medical
attention that could effectively resolve the lubricating problem. To keep the vaginal
tissues moist, women can use the recommended topical creams, to include jells and
creams or insatiable Estring that deliver low amounts of estrogen to the affected areas
(Beckham, 2002).
Women are also advised to keep their vaginal muscle toned by use of exercise such as
Kegel exercises (See appendix 6.2). This exercise controls the vagina and bladder
muscle, preventing and managing stress incontinence, common at menopause (Henkel,
2001).
19
2.3.4 Urinary tract infections
Women at menopause experience more infections of urinary tract, more frequent
urination and more uncontrolled urination. At the age of 40, the body's ability to
regenerate nephrons seems to diminish and the number of nephrons gradually declines
(Kimmel, 1990; Kermis, 1984). In the resting state the kidney can maintain fluid and
electrolyte balance. During stress however, the response of kidney declines (Smith &
Shimp, 2000). Diminished regulatory mechanism such as hormonal control is the
primary factor in limited response to stress (Henkel, 2001; Alford & BogIe, 1982).
Urinary tract organs- kidney, bladder and urethra are sensitive to estrogen (Henkel,
2001; Kimmel, 1990). Bladder tone, for instance, is dependent on estrogen. With
estrogen depletion, the muscles become lax. This effect combined with stress produced
by childbearing can cause stress incontinence (Henkel, 2001). If this condition is not
treated, it can become a grave problem to the affected woman. Exercises such as Kegel
can be used to control stress incontinence by toning the lax muscles (La Haye 1998)
(Appendix 6.2). Menopausal women should also limit their caffeine intake, train
bladder to hold more urine and use biofeedback where possible to monitor body
changes. Biofeedback is a technique of controlling the involuntary nervous system by
using monitoring devices that give one the feedback, usually a sound or a tone, when
changes in blood pressure, brain waves and muscle contractions occur (Henkel, 2001).
2.3.5 Weight gain
Weight gradually increases as a woman enters her 40s. Metabolism is slower at
menopause, and due to certain extra stresses apt to be present at menopause, extra
20
feeding can be indulged, necessitating the weight gain. Being obese or 20% above the
recommended weight gain is an independent factor for heart diseases (Henkel, 200];
Kirschman & Kirschman, 1996). Most of the weight is gained around the middle, and is
very difficult to shed. Some thin women who have abnormally high levels of
cholesterol, a condition clinically referred to as Familial hypercholesterolemia is also at
risk. On the other hand, a woman with a thin frame is more susceptible to fragile bone
disease.
When a woman has a history of being overweight it would be less likely that she can
manage to get it down to what is recommended for her height. In such a case, she should
learn to live with the weight gain (Henkel, 2001). However, moderate weight losses are
useful in terms of improving health. Changing of dietary habits can be a good starting
point. Diets high in dietary fiber, 3 to 5 servings of fruits and vegetables every day, high
complex carbohydrates such as whole grains, brown rice and whole pastas, and low fatty
and sugary foods should be taken (Grayson, 2002). Fermentable dietary fiber is
associated with the inhibition of carcinogenic events and exhibition of low glycemic
effect, preventing a sharp rise in blood sugar after consumption (Beans for health
alliance, September, 2005).
Exercise can contribute to weight loss through "burning" of the excess fat. Regular
weight bearing activities and aerobics contribute to a sense of wellbeing in addition to
increasing stamina, bone and muscle strength and reducing hot flashes (Kirschman &
Kirschman, 1996; Cataldo, De Bruyne end Whitney, 1995).
21
2.3.6 Other common symptoms
Many other symptoms observed during menopause may occur coincidentally.
Headaches often increase in menopause and in post-menopause (Henkel, 2001). Some
scientists believe they are estrogen-related, since estrogen acts almost like an opiate in
the brain (Kimmel, 1990). Tenseness and irritability are also observed. Issues that
previously were not bothersome would seem too ominous and irritating. Other
symptoms include heart palpitation, dizziness, tiredness especially on walking and
feeling of "pins and needle" particularly in extremities, a condition referred to as
"restless legs". More symptoms include depression, forgetfulness, loss of muscle pain-
myalgia or joint pains - arthralgia, itching of labia and vaginal discharges. Most of these
symptoms are characteristics of under active thyroid (Hypothyroidism) and is quite
common in middle aged women (Beckham, 2002). For the above symptoms to qualify to
be categorically menopausal, one should rule out the possibility of them being symptoms
of another medical condition. For instance, beart palpitations and shortness of breath can
be signs of heart diseases. Tiredness, insomnia, lack of self-confidence may be linked to
clinical depression.
2.3.7 Long-term complications
Osteoporosis
Osteoporosis is commonly known as the bone loss disease. Bones are living tissues and
thus go through constant remodelling. Estrogen is the precursor required in the
remodelling process through aiding absorption of calcium from food to contribute to
bone mineral content (Chaubal & Vaishwanar, 2001).
22
Most of the bone mass is built during childhood and adolescence years, and steadily
increases till mid-30s after which it decreases at about 1 to 3 percent per year (Henkel,
2001). Not all bone loss progresses to osteoporosis, although osteoporosis is a major
health problem in women. It is more common than arthritis and three times more
prevalent than diabetes (Chaubal & Vaishwanar, 2001).
In normal adults, arm span is equal to height, but in osteoporotic adults arm span is
greater than height; thus the difference between arm span and height can be used as
means of estimating vertebral bone loss (Alford & Bogle, 1982). When estrogen level is
decreased, bone remodelling shifts to the breaking down of bone, a condition referred to
as resorption. With decreased estrogen, adrenal glands start to make both estrogen, and
androgen, and take up many other actions of ovarian hormones (Beckham, 2002).
Calcium needed for bone remodelling at this time is absorbed less and excreted more
(Kirschman & Kirschman, 1996). Individual who have had larger bone frames such as
athletics, lose their bone density at slower rate than those with thin bone frames (Henkel,
2001). They also possess better reserves and can tolerate bone loss more.
The National Osteoporosis Foundation has come up with several risk factors to
osteoporosis. Men suffer less bone loss than women do (Beckham, 2002; Alford and
BogIe, 1982). Only about 10 percent of male develop osteoporosis (Henkel, 2001).
Females, particularly those above 50 years are more susceptible to bone and hip
fractures. It's argued that males usually have big bones and thus do not lose their density
at a faster rate than women. Moreover estrogen decline at menopause accelerates bone
loss especially if the affected woman is not under hormone therapy (Beckham, 2001).
23
Early menopause implies decreased estrogen levels at an earlier age than perceived
normal. Estrogen being an anabolic agent of protein in conjunction with calcium is
required in remodelling of bones. Low blood estrogen translates to a disruptive of the
remodelling process where by the process is tipped towards bone resorption (Beckham,
2002). Lean Caucasians and Western Asians are more susceptible than other races,
probably due to their smaller bones (Ludington & Diehl, 2000).
Calcium is needed at high dose at menopause and post menopause. Some researchers
suggest that a life-long dietary habits may be important than estrogcn treatment in
maintaining bone structure (Cataldo, De Bruyne & Whitney, 1995). Increased dietary
calcium promotes protein retention and activation of osteoblast needed in restructuring
of the bone (Cataldo, De Bruyne & Whitney, 1995). With reduced estrogen production,
calcium is absorbed less efficiently and excreted more (Kirschman & Kirschman, 1996).
At menopause, the initial acceleration of bone loss in women reflects loss of endogenous
estrogen and has little to do with dietary calcium (Beckham, 2002). As early effects of
estrogen deficiency subsides, compensatory mechanism for accommodating diet~
deficiency becomes less efficient. This results in a secondary hyper-secretion of
parathyroid hormones, leading to support of plasma calcium at expense of aggravated
bone loss. At this time, dietary supplementation and calcium and vitamin D supplements
are vital (Beckham,2002). Eating balanced diets rich in vitamin D and magnesium, will
aid in calcium absorption. Approximately 1000 mg a day for pre-menopausal and 1500
mg / day for post- menopausal is recommended especially if the woman is not under
hormone therapy (Henke1,2001; Alford & BogIe, 1982).
24
Calcium absorption at menopause is also interfered with by changes in f1C digestive tract
(Henkel, 2001). Many middle aged women become lactose intolerant, a condition that
prohibits women to have calcium intakes from the dairy products one of the best sources
of dietary calcium. Women who develop lactose intolerance should s eek other food
sources, or choose commercially made foods without lactose, or replenish their calcium
with calcium supplements (Pamplona- Roger, 2000 b).
High diets in protein, salt and phosphoric acid accentuate bone loss too (Beckham, 2002;
Ludington & Diehl, 2000). These cause calcium to be leached from bones and excreted
in urine. Excessive use of animal proteins, salt and phosphorous in meat and certain soft
drinks override any amount of calcium consumed or swallowed (Ludington & Diehl,
2000).
Engaging in weight bearing exercises 2 to 3 times a week for at least 20 minutes at a
time helps retain bone density (Beckham, 2002). These activities include, walking,
jogging, dancing, aerobics and racquet sports (Henkel, 2001).
Women of under weight for whatever reasons, have thin bone structure. These persons
are susceptible to bone disease. Osteoporosis has genetic links. Women whose close
family members have suffered from the disease are automatically at higher risk. Women
who smoke cigarette set into menopause 2 years earlier before the average age
(Beckham, 2002; Henkel, 2001). Smoking is believed to interfere with calcium
absorption, through reducing estrogen levels in the blood.
25
Alcohol being a diuretic flushes nutrients out of the gastrointestinaI system (Grayson,
2002; Beckham, 2002). Besides, it also prevents bones from absorbing maximum
nutrients from the food. A woman should not exceed 14 glasses of alcohol in a week,
and should have a couple of alcohol free days. Taking high doses of thyroid
medication/steroids for asthmatic or arthritis (corticosteroids) encourage leaching of
calcium from bones which can cause bone thinning.
Heart diseases
Women have fewer heart attacks and heart diseases before the age of 50 than men
(Henkel, 2001). This trend has placed some laxity on the part of both the physicians and
women themselves on the issue of heart health. Physicians in the past had even pursued
less invasive procedures with female patients (Beckham, 2002). However research
reveal heart diseases to be fatal more often in women than in men (Beckham, 2002).
This is because women develop the disease when they are older than men do, and are
usually referred later and admitted to hospital later than men.
As women go through menopause and lose protective effect of cstrogen on their
circulatory system, they face the risk of cardiovascular diseases (Smith &Shimp, 2000;
Kermis, 1984). In women over 50 years, the first cause of death is cardiovascular
diseases (Henkel, 2001). Decreased levels of estrogen are associated with elevated levels
of plasma low-density lipoproteins (LDL) and triglycerides, presenting a higher risk to
cardiovascular diseases (Amoni &Aluko, 2005). Therefore, women need to be educated
about signs of early heart diseases and have their cholesterol levels checked regularly, at
least once a year.
26
Breast health
About 77% of women in their 50s are diagnosed with breast cancer each year in United
State of America alone (Henkel, 2001). Decreased estrogen levels have an effect on
breast tissues. Many women have sought refuge in Hormone replacement therapy
(HRT). Unfortunately, HRT has been associated with heart diseases and other health
complications especially if taken for more than 5 years (Beckham, 2002). Taking HRT
can calcificate artery in the heart and the extent of calcification can indicate underlying
diabetes or high blood pressure thus becoming a risk factor for heart attacks or stroke
(Chaubal & Vaishwanar, 2001). This condition increases with age and affects 10 per
cent of women in their late 40s to almost half of women in their mid-60s.
To prevent breast cancer, early detection is the best route for long-term survival. Women
should learn how to perform breast self-examination for detection of any suspicious
lumps in the breast. Mammography is recommended for women of 3S and above years
(Henkel, 2001; Ludington & Diehl, 2000). It is the most effective method of detecting
breast cancer. Clinical examination can also be used.
2.4 Psychological aspect of menopause
Underlying causes of menopausal symptoms are interwoven in a complex yarn in which
mind and body interrelate to consummate some of the problems experienced at
menopause.
27
2.4.1 Connection between body and mind during menopause
Menopause in itself is not a precipitator of major crisis or depression during menopause.
But physical changes that remind a woman that she is getting older can bring about
stress (Henkel, 2001). Body and mind interrelate, such that stress in the body affects
mind and emotions (Ludington & Diehl, 2000). Besides several biological changes
during menopause, there are sets of psychological changes too. Each can influence the
other. For instance, physical manifestations can bring about psychological symptoms
such as, mood swings, anxiety attacks, and/or mental confusion. These symptoms can be
translated to emotional responses such as sadness, regret and depression over getting
older (Ludington & Diehl, 2000). A woman's attitude and experiences as well as societal
views on specific aspects of menopause can further complicate emotions (Berger, 1999).
For example, menopause can be a relief to a woman who has had children but grieve for
one who is childless and would desire to have one.
According to researches, Negroid women living in America experienced severe
symptoms than their Caucasian counterparts (ALLBAH, 2000). However they view
menopause differently. Negroid women do not place the same emphasis on aging as
Caucasian women do. Negroid tends to view menopause more positively than their
Caucasian counterparts (ALLBAH, 2000).
Women encounter varied situations in their lives that are stressful. Type and working
conditions, family relationships are just a few examples. When stress accumulates in the
system, toxins build up causing sickness (Ludington & Diehl, 2000). Emotional stability
during perimenopausal period can be disturbed leading to disturbed sleep. These women
28
would report symptoms such as fatigue, headaches, nervousness, muscle and joint pains
(Chaubal & Vaishwanar, 2001).
The flip side of menopause is that women become busier, and if given an opportunity
that motivates them, they get a closer look at their stressful lives to emerge out more
emotionally healthier and productive (Henkel, 2001). Those who adjust well emerge in
healthier careers, family bonds and of general wellbeing.
To manage one's stress levels, a woman needs to identify the stresses, determine the
sources of stresses and see if they can be changed and lastly learns to become more
relaxed (Henkel, 2001). One of the methods of becoming relaxed is the use of support
groups. These are important, since they boost the general wellbeing influencing proper
functioning of the immune system. In menopause isolation, is the real enemy. If a
woman feels alone, that no one understands what she is going through, she is likely to
feel frightened and powerless. Support groups empower women. As one woman names
her reality, it becomes an empowerment for another. Turning to other ','{omen lightens
one's load, thus promoting a smooth transition. Recognition of a higher power brings
healing too. There is usually a strong and close relationship between mental, emotional
and spiritual components of human beings (Beckham, 2002; Ludington & DiehJ, 2000).'
2.4.2 Factors contributing to adverse psychological symptoms at menopause
During biological changes, declining estrogen hormone in the blood leads to changes in
body's hormone mix. This affects neurotransmitters in the brain. Endorphins, natural
29
opisids made in body are associated with estrogen. Once estrogen is replaced, opioid
activities are increased producing an anti -depressant effect.
New findings have shown psychological difficulties such as depression, irritability,
tearfulness and anger to be associated with lack of sleep (Beckharn, 2002). Hot flashes,
night sweats and interruption of Rapid Eye Movement (REM) accompany menopause.
REM sleep is necessary for deep rest and dreaming. Without it, the body mechanism is
set in a temporary unbalance, causing irritability, fatigue difficulty in thinking and
concentrating (Beckham, 2002; Henkel, 2001).
Society's view towards aging women can promote negative experiences of menopause,
or fear loss of control of their bodies (Henkel, 2001; Berger, 1999). Psychological
difficulties are not due to menopause, but are linked to getting older (Berger, 1999). The
real crisis for women is not hot flashes and all the other associated symptoms, but
coming to terms with the fact that they are no longer young (Henkel, 2001). Some study
refutes this line of thinking, as research stipulates that women's fear of growing old is
just a myth (Henkel, 2001). However, negative attitude is known to contribute to poor
mental health (R.G.Malkmus, 1995).
To some women, menopause is a disagreeable event and only the severe cases of
menopause seek medical help, as is evident from a study cited in Kimrnel, (1990). The
study also found that menopausal women rated symptoms less severely than either
nurses or physicians. Physicians regarded menopausal symptoms as pathological. Poor
counselling may result, triggering negative attitude towards menopause. At menopause
30
the disturbing issues that causes grief are having to face one's mortality, confronting the
realities of aging, facing end of reproductive years or childlessness and dealing with real
physical discomforts such as urinary incontinence, diabetes mellitus and joint or arthritis
pain (Henkel, 2001).
2.5 Socio-Cultural factors and menopause
Cultural beliefs play a major role in determining to which extent a woman will be
affected once she reaches menopause. Recent close examinations have revealed those
older women, above 45 years, depending on their cultural orientations, universally
welcome menopause (Swartz, Sherrnan, Harvey, Noell and Johnese, n.d; Berger, 1999;
Kimmel, 1990). For instance, the internal conflicts experienced especially by Caucasian
women, are usually linked to stereotypic mentality that aging is about loss of beauty and
respect (ABC Online News, 1999). In contrast Philippines women and African-
American women, view aging as a gain of status, are safe in their family circles and do
not regret loss of fertility (Swartz et al., n.d; Berger, 1999; Datan study as cited in
Kimmel (1990). Symptoms such as headaches, irritability, nervousness and depression
are found to be related to personality characteristics such as lower self confidence and
personal adjustment (Chaubal & Vaishwanar, 2001; Kimmel, 1990). A study on a
general urban population of 135 menopausal and post menopausal women found women
who reported greater number of symptoms tended to be less educated, less likely to be
working and reported poorer physical health than women with few or no symptoms
(Kimmel, 1990),
31
Moreover, there is a general lack of factual information about menopause, especially for
correcting the myth in cultures about menopause (Swartz, Sherman, Harvey, Noell and
Johnese, n.d). Studies have also neglected reports on how women in general population
feels about menopausal problems. The study will focus on Kenyan women's cultural
views of menopause in order to bridge this gap.
2.6 Dietary management of menopausal symptom
Researches show a small but significant increase in breast cancer, heart attacks, stroke
and blood clots with use ofHRT in treating menopausal symptoms. Many women are
looking for alternative solutions in dealing with the symptoms. Diet is seen as one of the
safe method in controlling or eliminating these symptoms.
2.6.1 Recommended foods for menopause
Phytoestrogens and menopause
Plant hormones; phytoestrogen present in soy, yams, sweet potatoes and peas, contain
isoflavones that have a gentle, safe and highly beneficial effects on the body (Beckham,
2002). Phytoestrogens have both estrogenic and anti-estrogenic actions in humans. They
increase levels of SHBG (Sex hormone binding globulin) and decrease the levels ofLH.
These help decrease free and active hormone levels by competitive blockage and hence
decrease hormone dependent tumors (Beckham, 2002).
Low levels of estrogen results to manifestation of varied menopausal symptoms. There
is also an increased loss of calcium from the bones, consequently leading to rapid
development of osteoporosis. Isoflavones mimics body's estrogen when the body's
32
natural secretions are depleted, thereby easing the symptoms of menopause as well as
enhancing calcium absorption by bones (parihar & Shar, 2001). Eating soy can increase
estrogen levels when they are low but will not boost them unnecessarily. Soybeans are
also high in vitamin E and lecithin. These are soy natural antioxidants that work to
prevent heart disease by controlling low - density lipoprotein (LDL) in the blood stream
(Omoni &AJuko,2005), without changing endometrial thickness (Hasler, 2001). During
menopause LDL usually tends to increase, putting women under the risk of cardiac
problems.
Successful studies on hot flashes and isoflavones have used isoflavones amounting from
40 to 80 mg/day, in approximately three months duration, to reduce incidences and or
severity of hot flashes (Grayson, 2002; Hasler, 2001; North American Menopausal
Society, 2000). There is a consensus statement that the safety of isoflavones at specific
amounts has not been established. Since these estrogens attach to the same receptors
that pharmaceutical hormones act on, possibility do exist that they too could affect the
same breast tissues and heart health (Beckham, 2002). To receive potential health
benefits, it is preferable to obtain isoflavones from whole foods (Hasler, 2001). For
instance, according to Hasler (2001), approximately 25 grams a day of soy protein in soy
foods provides approximately 50 mg/day of isoflavones (mg isoflavones =
approximately 2 times soy protein).
Isoflavones rich foods include tofu, soymilk, instant beverage soy powder, soy fiber, soy
flour and textured soy protein (Omoni & AJuko, 2005). Other isoflavones rich foods
include cowpeas, lentils mature seeds, peanuts and peas, yams and sweet potatoes. These
33
local foods were once African staple diets. However, with proliferation of the Western
culture in the community, these foods are no longer taken as regularly as they used to be
(K'Okul, 1991). According to Posner & Levine (1991), older women lack adequate
nutritional knowledge. The study addressed women's nutritional knowledge for
menopause and the influence on their choice of foods. Consumption of local isoflavones
rich foods and other nutrients were established in order to determine whether the levels
consumed were adequate to alleviated menopausal symptoms.
Lignans or resorcyclic lactones and coumestans are other classes of phytoestrogens that
help in active treatment of menopausal symptoms. Lignans are mycotoxins produced by
mold Fussarium roseem which infects poorly stored food grains (Beckbam, 2002). Its
major dietary source is seed oils, especially flaxseed oil (Smith & Shimp, 2000). Most
coumestrol are present in legumes sprouts and sunflower seeds (Beckham, 2002).
Complex Carbohydrates
These give energy, balance blood sugar, greatly reducing fatigue (Pamplona-Roger,
2000 b). They also help increase serotonin levels- a brain chemical that helps lift mood
and curb appetite (Ludington & Diehl, 2000). Unrefined complex carbohydrates are rich
in whole meal bread, brown rice and whole pasta, in beans and pulses.
Essential fatty acids (EFA)
These are also vital component in all cells. They increase calcium uptake in the intestine
and reduce the calcium excretion in the urine (Beckbam, 2002). They also insulate
nervous cells; keep skin and arteries supple and body warm. They boost metabolism.
34
EFA are found in nuts, grape seeds, linseed, eggs yolk, dairy products, oily fish and
soybeans.
Vitamin E
Vitamin E is required in exceptionally high amounts (up to 1200 IU daily) during
menopause (Kirschman " Kirschman, 1996). It is a significant biological antioxidant
whereby its supplements have been used to relieve night sweats, backaches,
nervousness, insomnia, dizziness, shortness of breath, drying of vaginal lining, certain
cancers and heart palpitations in many women (Kirschman & Kirschman, 1996; Suter,
1991;Woodruff & Birren, 1983). Foods rich in vitamin E include wheat germs, nuts and
!
peaches. Other foods are spinach, whole grain cereals, broccoli, dried pulses, avocados,
vegetable oils and seeds. Foods rich in zinc are also important for skin maintenance
(Kirschman & Kirschman, 1996).
Vitamin Cand bioflavonoid
These increase capillary strength (Kirschman & Kirschman, 1996). Vitamin C
strengthens bones, decreases water retention and hot flashes (Suter, 1991). Foods rich in
vitamin C include fruits such as oranges, lemons, passion fruits paw-paw and mangoes.
Vegetables rich in vitamin C include green leafy vegetables, cabbage.
B vitamins
Vitamins B especially pantothenic acid relieves nervousness, insomnia, and irritability
(Beckham, 2002). Food sources include meat and whole grain cereals, the common ones
in the community being millet, sorghum and maize.
35
Beta-carotene
These are advocated for their anti-oxidant effects. They decrease LDL in the blood.
Food sources include green, yellow, red-yellow, orange vegetables. Red palm oil is also
a rich source of beta carotene. Five or more servings of fruits and vegetables a day is
recommended (Grayson, 2002).
Boron
This is a trace element that boosts estrogen levels to that of replacement therapies
(Beckham, 2002; Kirschman & Kirschman, 1996). Foods rich in boron include fruits
such as grapes, dates, peaches, almonds, pears, tomatoes, oranges, raisin and apples.
Vegetables sources are soybeans, beets, cabbage, carrots, cucumbers, sweet potatoes,
wheat, onions, lettuce, cauliflower and turnips.
Calcium
Dietary calcium is needed for the protection against osteoporosis. Loss of endogenous
estrogen leads to decreased intestinal and renal homeostasis. Calcium intake should be
increased to maintain calcium balance (Beckham, 2002). It is suggested that life-long
dietary habits of three servings of calcium rich foods daily may be important than
estrogen treatment in maintaining bone structure (Kirschman & Kirschman, 1996;
Whitney and Rofles, 1993). A deficiency of calcium can cause nervousness, irritability,
insomnia, headaches and depression (Kirschman & Kirschman, 1996). Calcium rich
foods include milk and its products, green leafy vegetables, cooked dried beans,
soybeans and their products and whole grain cereals such as maize, millet and sorghum.
Vitamin D and magnesium are needed for proper calcium absorption. 2g calcium, 1000
36
IU vitamin D and 1 g magnesium daily have been effectively used in clinical setting
(Kirschman & Kirschman, 1996).
Dietary fiber
Natural fiber help reduce bloating and flatulence, lowering bad cholesterol - L.D.L,
modifies the levels of sex hormones by increasing gastrointestinal motility. Fiber alters
acid metabolism and interrupts enterohepatic circulation preventing estrogen uptake
causing increased estrogen excretion (Beckham, 2002) Over 150 studies show that
people who eat a large quantity of vegetables and fruits; rich sources of fiber, are up to
50% less likely to develop cancer than those eating small amount (Beckham, 2002).A
diet rich in protein and fiber will moderate amounts of fat, thus keeping blood sugar in
check. Soluble fiber found in oats, beans, rice and fiuits are recommended.
Fluids
Water is required for transportation of nutrients to the cells and other vital processes.
Women suffering from hot flashes should take lots of water to maintain body
temperature (Henkel, 2001). Women should take over six glasses of water a day
(Grandjean & Campbell, 2004; Ludington & Diehl, 2000).
2.2.6 Foods to be avoided during menopause
A glass of alcohol every other day can raise estrogen levels, prevent heart disease and
guard against osteoporosis in older women (Kirschman & Kirschman, 1996). However,
more than six drinks are harmful! Toxins in alcohol prevent bones from absorbing
maximum nutrients from food. Smoking reduces estrogen levels in the body. Caffeine in
37
foods should be avoided: they block receptors in nerve cells causing higher sensitivity to
pain, increasing anxiety with reduced protection against oxygen deficiency and hot
flashes (Kirschman & Kirschman, 1996). These substances are diuretics and with
carbonated drinks lower the amount of calcium the body takes from foods (Pamplona -
Roger, 2000 b).
Other foods to be avoided at menopause include highly spiced foods, hot fluids such as
tea, fatty foods, chocolates and refined processed foods (Kirschman & Kirschman,
1996). Refined carbohydrates cause fluctuation of blood sugar. When blood sugar levels
drop, stress hormone adrenaline is released and symptoms such as irritability, crying
spells, anxiety, excessive sweating, depression, tiredness, lack of concentration and
forgetfulness result (Beckham, 2002).
Highly refmed processed foods also contain saturated and hydrogenated oils that tax the
body in metabolism and at the same time drawing from the body valuable vitamins and
minerals.
"As mentioned earlier, fatty foods rich in cholesterol, can lead to plaque and
atherosclerosis. Animal fats are a rich source of saturated fats that are linked to heart
diseases (Ludington & Diehl, 2000). They are high in proteins too, which can lead to
leaching of calcium from the bones and causing kidney stones and gout (Pamplona-
Roger, 2000 b). Sugar should be limited as well. This is because too much of it causes
mood swings and fluctuating energy levels. It also causes teeth decay, decreases good
cholesterol thus increasing risks of heart diseases, as well as causing insulin resistance.
KENYATTA UNIVERSITY LIBRARY
38
Natural sugars such as fructose found in fruits and some vegetables and honey, are
regarded as being better (Pamplona-Roger, 2000 b).
2.7 Exercises during menopause
Diet therapy with regular exercises provides an additional preventive measure. Studies
show women with moderate exercises report improved immune function as compared to
sedentary women (Beckham, 2002). Walking for 30 minutes for four days a week over a
period of 12 weeks can significantly reduce blood pressure (Beckham, 2002). Regular
exercises improves joints and muscle flexibility, positively influence mood and anxiety
and improve bone density (Henkel, 2001). Any activity requiring exerted heavy effort is
all one need to be fit. Walking, step aerobics or any other enjoyable activity adjusted to
own requirement is adequate (Ludington & Diehl, 2000).
2.8 Herbal therapy
Herbal remedies are used to treat symptoms of menopause. Damiana Tumera diffusa
willd, sarsapavilla Smilax aspera 1., liquorice Glycyrrhiza glabra L., red clover avalerian
tea Valeriana officina/is L, alleviate hot flashes (Kirschman & Kirschman, 1996).
Ginseng Panax gingseng C.A.meyer and evening primrose Oenothera sativum L. herbs
\may be used to combat menopausal anxiety, depression, nervousness and insomnia
,
(Pamplona-Roger, 2000 a). Black Cohosh Cimmicifuga racemosa, products reduce LH
levels and improve vaginal tissue of menopausal women to same degree as
pharmaceutical estrogen (Beckham, 2002). Sage Salvia officinalis, contain small
quantities of phytoestrogen and thus, helpful in reducing hot flushes and night sweats in
menopausal women (Beckham, 2002).
39
Other herbs include Fenugreek Trigonella foenum - graecum L., dandelion Taraxacum
officinale web, hops Humulus lupus S L., Blind Nettle Lamium album L•.Hemp nettle
Galeopsis dubia leers and wild yams (Pamplona-Roger, 2000 a). Since the above herbs
are not indigenous, chances are that they are unavailable to the local Kenyan women.
Locally available herbs used in food preparation, such as garlic Allium sativum L,
rosemary Rosmarinus offcinalis L and onions Allium cepal L are useful in alleviating
specific menopausal symptoms (Kirschman & Kirschman, 1996).
2.9 Summary
Variability in perceptions of menopause calls for individualized treatment and
counselling for menopausal women. Generally, there exists a gap on reports of how
women in general population feels about menopausal symptoms. Also, there lacks
factual researched information about menopause especially among African women. At
the same time, the safety of isoflavones at specific amounts has not been fully
established and well-designed clinical trials on foods that alleviate menopausal
symptoms remain sketchy. Women may experience a crisis during menopause as a result
of varied interrelated factors but these can be overcome by nutritional knowledge and
management. Chapter three focuses on means and strategies that were used in the study
to select the sample size, collect and analyze the data.
40
CHAPTER 3
METHODOLOGY
3.0 Introduction
This chapter describes research design, population and sample, data collection
procedures, data analysis and measurements of variables.
3.1 Research design
The study adopted a cross-sectional descriptive survey design to establish women's
awareness, perceptions and attitudes of menopause as well as their dietary intakes and
the nutritional knowledge for menopause in regard to management of symptoms
associated with menopause. It was a cross-sectional study since the study was carried
out on menopausal women of between 40 and 59 years at the same time on a particular
measure.
3.2 The study area
The study was carried out in Maragua town; a local town in Maragua District (see
appendix 6.14). The town was created in 1997 as an autonomous local authority from
the greater Murang'a County Council (District water engineer Maragua, 2001). The
town was selected due to prevailing poverty levels (Republic of Kenya, n.d). Maragua
town council jurisdiction covers 75 squared km with the population of females being
12,013 (District water engineer Maragua, 2001). Rapid settlement of people by different
socio-economic ethnic backgrounds on Maragua vast plains since early 1970s during the
booming sisal and coffee farming is really the basis on which diversity of social life is
harnessed (District Water Engineer Maragua, 2001). A majority of the population is
41
living in absolute poverty, with 33.3% living below the poverty line (Republic of Kenya,
n.d). Consequently, a 40% to 45 % of the population consumes less than three meals per
day, while 50 to 55 % lack balanced diets (Republic of Kenya (n.d). In view of these,
economic constraints and cultural diversification in the town has resulted to altered
dietary habits.
3.3 Population
The target population comprised all menopausal women in Maragua Town while the
accessible population comprised of menopausal women of between 40 to 59 years living
and working in Maragua town. This age bracket took into account the existing
variability in menopausal age.
3.4 Sampling process
A multi-stage sampling technique was used to achieve a sample of 121 menopausal
women. Multi-stage sampling is a method, where sampling is done in two or more
stages or cycles (Mugenda & Mugenda, 1999). In this study, the stages included
selection of the town, selection of the town's council wards and women of between 40
and 59 years.
Purposive sampling technique was used to select Maragua town. The town was selected
due to its high poverty levels that contribute to poor eating habits and thus poor nutrition
status and likelihood of a high prevalence of menopausal symptoms among the
community (Republic of Kenya, n.d). Two town's wards were selected from the town's
four wards using simple random sampling technique. This was done by listing down the
42
wards in alphabetical order. Each ward was assigned a number. The numbers were
placed in a container and picked at random. Women of between 40 - 59 years living and
working in the wards corresponding to the numbers picked formed the sampling frame.
A total of 121 menopausal women of between 40 to 59 years were purposively selected
from their specific households and places of work within the sampling frame. This age
bracket (40 and 59 years) is inclusive of women likely to be in the menopause transition.
According to Henkel (2001), precise measurement of beginning and ending of
menopause is not useful during menopausal transition as body changes occur on a
continuum not a stop-start basis. This transition describes changes from decreased
fertility to cessation of menstruation and manifestation of estrogen deprivation. The
sample size was governed by the study design and data collection instruments, which do
not favour very large sample sizes.
Maragua District Hospital was purposively selected, since it is the only referral hospital
in the district, attending to the largest number of patients across the socio-economic
stratum in the district. Simple random sampling procedure was used to select four
clinical officers working in the Maragua District Hospital. They were chosen for the
study since they were the ones that mainly attend to the patients in Maragua District
Hospital on regular basis. The seven clinical officers working in the hospital were listed
down in alphabetical order. Each was assigned a number. The numbers were placed in a
container thoroughly shuffled and picked at random. The officers corresponding to the
numbers picked were selected for the study. The study included two regular nutritionists
posted at the hospital.
43
3.5 Research instruments
The study employed interview schedules, for the menopausal women (appendix 6.3),
nutritionists (appendix 6.4) and the clinical officers (appendix 6.5). Data were collected
by asking respective respondents questions to elicit self-reports and opinions in order to
meet the set objectives. Nutritionists and medical doctors provided information on the
number of women each attended suffering from menopausal symptoms or those
symptoms that coincide with menopause and treatments given for them.
Interview schedule guides for the menopausal women solicited [or women's
demographic data, their menopausal experiences, awareness, perceptions and attitudes of
menopause, dietary intakes and nutritional knowledge for menopause. Dietary intakes
were assessed by use of the dietary history, food frequency and a 24-hour recall tables in
the interview schedule for menopausal women (appendix 6.3). Likert scale (appendix
6.3) was used on women to measure their attitudes and satisfaction in the underlying
changes at menopause. Nutritional knowledge for menopause test formulated from the
literature review and an index set to measure women's nutritional knowledge for
menopause (appendix 63). The highest mark possible was 38 and the lowest O.
Women's nutritional knowledge for menopause was classified as low (0 - 12 scores),
average (13 - 24 scores) or high (25 - 38 scores). Focus Group Discussions (FGDs)
(appendix 6.6) were carried out with women of between 40 - 59 years belonging' to
varied socio-econornic backgrounds. F0CUS Group Discussions were to facilitate for in-
depth insight into women's menopausal experiences, their attitudes towards menopause,
cultural issues regarding menopause, information availability and accessibility as well as
strategies employed to cope with the menopausal symptoms.
44
3.6 Ethical considerations
Before conducting the research, perrmssion was obtained from the Ministry of
Education, Science and Technology and Maragua District Hospital Medical Officer of
Health (MOH), through the School of Pure and Applied Sciences, Kenyatta University.
Rapport was initiated between the researcher and respondents during which, essence of
the research and criterion used to select the respondent were carefully and patiently
communicated. Consent of the respondent was sought. Respondents were assured of
confidentiality, anonymity and absolute privacy prior to the interview.
3.7 Data collection procedures
Research assistants underwent two days training on the importance of the research, and
interviewing techniques; The researcher conducted the interviews with the research
assistants providing guidance around the town and introduction to the respondents.
3.7.1 Interview schedules for the clinical officers and nutritionists
The researcher explained the importance of the study and the role of the officer in the
study. This provided transparency that facilitated for total co-operation. Interviews were
conducted through appointments preceding their signed consent. The questionnaires
acted as interview guides during the interviews. Qualitative data were recorded verbatim
for further analysis.
45
3.7.2 Interview schedules for the women
Four research assistants, two for each sampled ward were adequately trained. They were
recruited to aid in the data collection procedure. They were women of authority in the
society and thus impacted confidence to women, quelling any fear or uncertainty that
might have existed on the credibility of the study or researcher. It was mandatory that
they belong to the menopausal age, so as to empathise with the women. Interviews were
mostly carried out in the afternoon, as women were busier with their daily activities in
the morning. Rapport ensured familiarity and women's confidence. The potential
candidates were requested to state their age in order to fulfill the sampling criterion.
Only women of between 40 and 59 years qualified for the interview. Each interview
schedule took an average of 45 minutes - 1 hour to administer, but the duration mainly
depended on the respondent's cooperation. Women's levels of satisfaction on their
financial status, sex life, physical appearance and physical and emotional health were
determined using a Likert scale.
Prior the research, assorted food portions were calibrated (see appendix 6.7) to the local
household measure to assess energy and nutrients obtained through the use of food
composition tables for Kenya (Sehmi, 1993) and computer software: Nutri-Survey. To
determine the volumes of food intake, household measures associated with known
household utensils were used. A 24-hour recall method was used to establish types of
food consumed, kilocalories, isoflavones and selected nutrients intakes and their
adequacy for health. The WHO, Geneva (1990) and the National Academy of Sciences
(1998), Recommended Dietary Allowances (RDAs) were used to determine adequacy of
selected nutrients. Dietary history method was used to establish women's meal patterns
46
and frequency intake of foods in a period of one week. Food frequency method was
used to establish the frequency of foods rich in isoflavones in the diets for a period of 3
months preceding the study and their adequacy in alleviating hot flushes. To measure the
women's nutritional knowledge for menopause, a test was structured from which a
measuring index was set for classification into levels of performances (appendix 6.3).
Women were classified as having low nutritional knowledge for menopause (0-12
scores), medium (13 - 24 scores) and high (25 - 38 scores).
3.7.3 Focus groups discussions
Two focus groups discussions, each comprising 6 to 7 menopausal women of between
40 - 59 years, some whom had participated in the interviews were held at a weeks'
interval. Convenient sampling method was employed. The result was a focus group
discussion comprising women of varied socio-economic status. Date, time and venue of
discussions were agreed upon with the women. A private environment allowed women
to be at ease to discuss their experiences. An interview guide was utilized to elicit
information. Responses were recorded verbatim.
3.8 Pre-testing
Pre-testing was done to ensure reliability of the research instruments and reduce
ambiguity. Convenience sampling was used to select the subjects. The instruments were
pre-tested on two menopausal women, one clinical officer and one nutritionist (field
officer) respectively, prior to the main study and the necessary corrections preceded the
main study. These subjects were not included in the main study to avoid sensitization
47
thatwould affect the reliability of the data. Two ambiguous questions were rephrased for
clarity.
3.9 Data analyses
3.9.1 Quantitative data
The instruments yielded both qualitative and quantitative forms of data. Food
consumption data were converted into nutrient data by the use of food composition
tables. Data from interview schedules were analyzed using the statistical Package for
Social Sciences (SPSS). Descriptive indices such as frequencies, percentages, standard
deviations, medians and means were used to describe, organize and summarize data on
women's demography, perceptions, awareness and attitudes of menopause as well as
dietary intakes and nutritional knowledge for menopause.
Pearson Product Moment Correlation (r) technique was used to determine the
relationships between amount of kilocalories, isoflavones and selected nutrients with
presence of symptoms associated with menopause and between scores of women's
nutritional knowledge for menopause test and amount of kilocalories, isoflavones and
selected nutrients in the diets at 0.05 level of confidence. Spearman's Rho correlation
was used to establish relationships between frequency of isoflavones rich foods in the
diet with presence of hot flushes as well as between women's levels of nutritional
knowledge for menopause and frequency intake of foods rich in isoflavones at 0.05 level
of confidence. Correlation Coefficient near 1.00 or -1.00 at 95 confidence levels showed
magnitude of the positive or negative relationships while near 0.00 indicated absence of
a relationship. Regression analysis was used to ascertain nutrients and nutrition
48
substances that were significant in predicting occurrences of menopausal symptoms.
Quantitative data were presented in tables, charts or graphs.
3.9.2 Qualitative data
All qualitative raw data from the interview schedules and focus groups were read
through thoroughly and relevant data organized for analysis. Transcripts were translated,
"cleaned up" and edited. Emerging themes and concepts were identified and grouped
according to similarities in order to develop categories. The relationships between these
categories were sought and coded. Qualitati ve data are reported in narrative form
accompanied by selected quotes from the respondents.
3.10 Operational definition of variables
3.10.1 Independent Variables
• Amount of isoflavones, kilocalories and selected nutrients in the diets: The total
amount of isoflavones, kilocalories and selected nutrients consumed as calculated
from the foods intakes.
• Adequacy of isoflavones, kilocalories and selected nutrients: Isoflavones,
kilocalories and selected nutrients were termed as adequacy in reference to the
WHO, Geneva (1990) and the National Academy of Sciences (1998) RDAs.
• Physical activities: Physical activities that a woman engaged in including aerobics
and gymnastics. For example, a brisk walk or just a job demanding heavy exertion. .
• Attitudes of menopause: Referred to women's way of thinking as regards
menopause and its manifestations.
IU:NYAi u\ ui j 'Lu\l111 LiBRA ~_
49
• Perceptions of menopause: Referred to women's understanding, as well as their
quality understanding of menopause and of symptoms associated with menopause.
• Awareness of menopause: Referred to having knowledge or being well informed
about menopause and the symptoms associated with menopause.
• Scores in the nutritional knowledge Cor menopause test: Referred to scores
awarded in the test on nutritional knowledge for menopause.
• Levels of nutritional knowledge for menopause: These referred to low, average or
high levels of nutritional knowledge for menopause.
3.10.2 Dependent Variables
Menopausal symptoms and those coinciding with menopause
• Night sweats: Incidences of profuse sweating during sleep.
• Mood swings: Sudden dips in moods that is unpredictable.
• Lack of libido: Loss of interest in sex.
• Insomnia: Lack of uninterrupted night sleep.
• Hot flashes: Instances of sudden sensation of heat throughout the body followed by
perspiration or chills.
• Headaches: Continuous dull pain in the head not pathologically oriented.
• Backaches: Pain or aches of the back not due to illness.
• Depression: Hopelessness, sadness, discouragement or Jack of enthusiasm in things
and issues that were once of interest.
• Anxiety: Fear of the unknown or being in constant uncertainties that consequently
caused troubled feelings,
50
• Crying spells: Unnecessary bouts of being weepy.
• Fatigue: Lethargy or excessive tiredness resulting from no hard labour, exercises or
illness.
The mentioned procedures facilitated the collection of data analysis which IS
presented and discussed in the next chapter.
51
CHAPTER 4
RESULTS AND DISCUSSION
4.0 Introduction
This chapter presents arid discusses the findings of the study under the following sub-
headings: Demographic information, women's reproductive health, menopausal
experiences, women's attitudes towards menopause and menopausal symptoms,
Women's dietary intakes, women's nutritional knowledge for menopause and
relationships between women's dietary intakes and menopausal symptoms.
4.1. Socio-economic data
Respondent's socio-economic characteristics were collected to describe the population
of the study. Table 4.1 presents women's ages, marital status, household sizes,
occupations, education levels and income levels. It can be observed from the table that
women's ages ranged between 40 and 59 years. Since expert opinion varies on the exact
age of menopause, this age range was selected to represent the menopause transition.
Studies show that menopause transition can come as early as in the 30s for some women
or late as 60 years in others (Beckham, 2002). However, below 40 years is regarded as a
premature onset into perimenopause (period immediately prior to menopause, and one
year after menopause) (Henkel, 2001). Therefore, menopause is a transition and not a
single time event.
52
Table 4.1: Socio-economic. characteristics of Maragua Town, menopausal women
Variable n 0/0
Age category( yrs)
40-49 70 57.9
50- 59 51 42.1
Marital status
Single 12 9.9
Widow 3 2.5
Divorced/separated 13 10.7
Married 93 76.9
Number of children
0 5 4.1
:9 16 13.2
4-6 44 36.4
7-9 39 32.2
~10 17 14.0
Occupation type
Professional/white collar jobs 37 30.6
Small scale farming 57 47.1
Small scale business 23 19.0
Casual labour 4 3.3
Education levels
~ College 12 15.7
Secondary level 22 18.2
Primary level 45 37.2
No formal education 35 28.9
Income levels (Ksh) per month
S5000 63 52.1
5001 - 10,000 41 33.9
10,001 - 15,000 14 11.6
~15,000 3 2.5
Women's marital status is established and categorized into 4 groups: married,
divorced/separated, widow or single. As shown in Table 4.1, majority of the women
were married (76.9%) compared with the single women (9.9 %), the widowed (2.5%)
and the divorced/separated Cl 0.7 %). These results indicate that more women often live a
married life and were thus likely to record higher fertility rates. Divorce or single-hood
is likely to lead to reduced fertility rates.
53
Women's household sizes were determined by asking respondents to state the number of
childrenone had born. As shown in table:4.1, 13.2 % of the women had born less than 4
childrencompared to 36.4 % of the women who had born between 4 and 6 children. The
average number of children per woman was 6.22 (sd=±2.827). Given that Kenyan urban
households' size records 3.5 persons on average (Central Bureau of Statistics, 2003);
theseresults show large households among the women.
Respondents' education levels were established by assessing the highest levels of
education achieved. It was found that majority (37.2%) had achieved primary level of
education, compared with only 18.2%who had attained secondary level of education.
However, 28.9 % of the women were illiterate (Table 4.1). These results indicate that
majority of the women were of low education levels. This fmding concurs with Central
Bureau of Statistics (CBS) Economic Survey (2004), report that majority of women
(89.4 %) of between 40 and 49 years in Kenya are illiterate in comparison with those
with above secondary education (19.8%).
Respondents' occupations were determined, to establish women's major sources of
livelihood. As indicated in Table 4.1, more women were engaged in subsistence farming
(47.1%) in comparison with those either in white collar jobs (30.6%), small-scale
businesses (19.0%) or casual labour (3.3%). The farms were either on rental basis at the
periphery of the town or were family owned. Small-scale businesses were mostly of
selling fruits and vegetables within the town. The major white collar jobs were teaching,
medicine, clerical works and banking.
54
These results show that subsistence farming was the major economic activity among the
women in Maragua town. The findings are consistent with the results of the Kenya
population and housing census (Republic of Kenya, 200l).Income levels were
determined by respondents stating their average gross income per month. It was found
that more than half (52.1 %) of the women's population reported an income of Ksh.5,
000.00 or less per month compared to a minority of2.5 % of the women with an income
of above Ksh 15, 000.00 per month. This indicates that majority of the women were
below or bordering on the absolute poverty line ofKsh.2, 648.00 per adult in urban areas
(Republic of Kenya, 2004). This finding agrees with similar findings in some studies
cited in Alford & Borgle (1982), that large numbers of elderly people have incomes
below the poverty line.
4.2 Women's reproductive factors
Women's neuro-endocrine factors that contribute to sexual maturity, nubility (the ability
to conceive) and menopause in later years were studied for the purposes of establishing
women's reproductive health. Table 4.2 shows women's menarche (age of first menses),
menstrual patterns, gynaecological problems and menopause phases women belonged to
at the time of the study.
Women's ages of menarche (first menstruation) were established to determine their
sexual maturity. As illustrated in Table 4.2, women's ages of menarche were between
12 and 19 years with a mean of 14.8 years (sd=±1.333). The findings show that women
reached sexual maturity earlier than what had been observed a century ago. According
55
to Aguilar & Galbes (2000) and R. Malkmus (1995) age of menarche in the tropics is
established as 11 years or less but was 16 years a century ago. The climate, lifestyles, the
physical conditions of the habitat and the different socio-cultural and ethnic factors have
an influence in female neuro-hormonal system, determining the age of menarche and of
the menopause (Aguilar & Galbes, 2000).
Table 4.2: Reproductive factors and menopausal status among menopausal women of
Maragua Town, Kenya
Variable n %
Age of first menses (menarche) (yrs)
12-15 87 7l.9
16-19 34 28.1
Age of first delivery
No delivery 5 4.1
~1l 1 0.8
12 -20 67 55.5
~ 21 48 39.6
Age of last delivery
No delivery 5 4.1
~30 22 18.2
31 -40 76 62.8
~41 18 14.9
Menses patterns prior pre-menopause
Regular 94 77.7
Irregular 27 22.3
Age irregularity of menses commenced
Not applicable (regular menses) 46 38.0
38-41 10 8.3
42-45 22 18.2
46-50 27 22.3
51-55 16 13.2
Menopausal status
Regular menses (1 -2 months) 48 3l.4
3 - 5 months (pre menopause) 14 16.5
6 -12 months (menopause) 7 18.2
~ 13 months (post menopause) 52 33.9
56
Women's first and last births were established to assess their fertility period. It was
found that first deliveries happened between 9 and 30 years among the women with a
median of 20 years and a mean of 19.72 years. Last child deliveries were reported by
women of between 21 and 47 years with a median age of 35 years and a mean of 33.7
years. A higher proportion of the women (55.5%) entered child bearing at earlier age
(between 12 and 20 years) than later - above 21 years (39.6%). In contrast, majority of
the women had born their last child at later years (31 - 40 years) (62.8%) than earlier
(18.2%). The findings show that the periods between starting and stopping child bearing
was long, thus a lengthened fertility period. According to Republic of Kenya (2004),
early child births translate to a lengthened fertility period. The results concur with the
Central Bureau of statistics (2003), report that median age for first births is 20 years with
more women (43.0%), giving birth in later years than younger (23.0%).
To establish a possible hormonal imbalance prior to perimenopause, women's menstrual
patterns were checked for any irregularity (Dysmenorrhea). It was established that
majority of the women (77.7 %) had had regular menses prior to perimenopause as
opposed to 22.3% who reported irregularity and painful menses (Table 4.2).
Dysmenorrhea may be triggered by certain lesions of the uterus, hormonal or
psychological cause (pamplona-Roger, 2004; Aguilar & Galbes, 2000). This finding
suggests that majority of the women had harmonised neuro-endocrine systems
throughout their reproductive years.
57
Decline in estrogen production was established by the respondents stating the ages
menstrual irregularity commenced for the purpose of determining onset of
perimenopause. It was found that the irregularity of menses that results to the ultimate
cessation of menses was noticed at between 38 and 55 years where majority of the
women(22.3%) experienced it between 46 and 50 years. However, 38.0% of the women
were still experiencing regular menses. These results suggest that women's estrogen
levelshad begun showing signs of diminishing as immediately after 30 years of age. As
a woman ages, the number of eggs available for release diminishes. According to
Henkel (2001), at 40 most women will experience at least some cycles that are
anovulatory (without the release of an egg), indicating a fluctuation of the oestrogen and
progesterone hormones that trigger menstrual change. Ovulatory cycles (with a release
of an egg) can occur during these years too (Henkel, 2001).
Women's menopausal status was established by respondents recalling the month menses
were last noticed and intervals between menses determined. As indicated in Table 4.2,
31.4 % of the women were still experiencing regular menses. Among women whose
menses were irregular, 16.5% experienced menstrual flow at intervals of between 2 and
5 months, 18.2%, between 6 and 12 months. Majority (33.9%) reported no menses in a
period of more than 13 months. The findings suggest that more women were in the
menopause transition. However, measurements of beginning and ending of menses are
not useful during menopause transition as body changes are occurring on a continuum
not a start - stop basis (Henkel, 2001).
58
Gynaecological conditions - hysterectomy (removal of both ovaries and uterus) and
oophorectomy (removal of ovaries) were established to determine women's
gynaecological health prior to menopause. As shown in Table 4.2, 0.8% of the women
hadboth their ovaries and uterus removed. The results indicate a population with fewer
gynaecologicalproblems which usually affect perimenopause entry period. Studies show
that hysterectomy or oophorectomy procedures interfere with natural onset of
menopause, due to its interferences with sex hormones (Parihar & Shar, 2001).
4.3 Symptoms associated with menopause among the Maragua menopausal women
Presence of hot flushes, night sweats and other symptoms happening eoincidently to
menopause were established in order to determine the types of menopausal symptoms
that were experienced by the women. Symptoms were systematically described to the
respondents, who then confirmed their presence. Table 4.3 shows the major menopausal
symptoms among women.
59
Table 4.3: Types of symptoms associated with menopause and their degree of severity
among menopausal women of Maragua Town-Kenya
Symptoms. Percentage of Frequencies of occurrences per week (%).
occurrence (%) 1-2 times 3-4 times > 5 times.
Fatigue 77.7 15.7 27.3 34.7
Backaches 71.1 19.0 15.7 36.4
Mood swings 67.8 19.8 18.2 28.9
Hot flushes 65.3 24.0 17.4 22.3
Insomnia 65.3 21.5 19.8 24.8
Depression 62.0 24.0 14.0 24.0
Anxiety 56.2 15.7 19.8 20.7
Night sweats 56.2 14.0 22.3 17.4
Headaches 53.7 24.0 11.6 19.0
Loss of libido 53.7 12.4 14.9 25.6
Crying spells 36.4 14.0 9.9 14.9
As presented in Table 4.5, hot flushes and night sweats were experienced by 65.3% and
56.2% of the women respectively; 22.3% and 17.4% of them showing severe forms
respectively. Other symptoms that may be due to menopause or happen coincidently
with menopause were fatigue (77.7%) and backaches (71.1%), where 34.7% and 36.4%
reported their severe forms respectively. Other common symptoms were mood swings
(67.8%), insomnia (65.3%), depression (62.0%), anxiety (56.2%), headaches (56.2%),
loss oflibido (53.7%) and crying SPells 3(6.4%). Higher percentage of women reported
severe forms of symptoms in all the reported symptoms.
60
The results show that menopausal symptoms were endemic among the women (above 50
%), majority exhibiting their severe forms. The specific symptoms to menopause were
established as hot flushes and night sweats. Other symptoms that may be due to
\
menopause or coincide with it included fatigue, backaches, mood swings, insomnia,
anxiety, depression, headaches, loss of libido and crying spells. According to Henkel
(200 I), common traditional signs of menopause are hot flushes, night sweats, changes in
the urinary tract and in the pH and vaginal lining. Others were headaches, heart
palpitations, tiredness, depression, forgetfulness, insomnia, restless legs, irritability,
tenseness, joint pains and dizziness (Henkel, 2001; Kimmel, 1990).
The fmdings concur with Alford and Bogie (1982) who reported that 50 % of the
women's populations experience menopausal symptoms with varying severities. To
some women, menopause is uneventful while others have no doubt as the symptoms
wake them at night and disrupt their routine during the day (Henkel, 2001). Severity of
symptoms therefore can be explained by individual variation of estrogen binding sites or
other factors to include nutrition, lifestyles and personality characteristics (R. Malkmus,
1995; Kimmel, 1990; Alford & BogIe, 1982).
4.4 Women's awareness of menopause
The local definition of menopause was sought to establish women's awareness of
menopause and their understanding of its implications. Menopause was described as
mambura ni mathirite metaphorically to mean 'child bearing' age has ceased: Entry into
old age. When menses stop, I knew I was in my aging years. A woman described her
interpretation of menopause. It was also found that women gladly welcomed cessation of
61
menses. No more bleeding (Personal communication, July 2003), was a unison response
from those already in menopause and post-menopause. Those still experiencing the
monthly now were anxiously waiting for its. cessation. Menopause is seen as a stage in
life free of restrictions and increased freedom. When will God take this burden off my
shoulder (Personal communication, June 28, 2003)? In addition menstruation was
associated with loss of body strength by others This blood loss makes us (womerV lose
strength (Personal communication, June 28, 2003).
The results mean that menopause was a locally recognized and a naturally expected
event in women's lives. It marked the end of youth and women did not seem to be afraid
of old age. Similar sentiments were observed in a study involving the Chinese,
Mexican-American and Puerto Rican women that menopause is a natural part of life.
(Swartz, Sherman, Harvey, Noell and Johnese, n.d). According to Berger (1999),
menopause is culturally welcomed by women as a positive and liberating event.
4.4.1 Women's awareness of menopausal symptoms
To assess the understanding women had of menopausal symptoms, the attributes they
associated with menopausal symptoms were stated. Varying factors which in women's
opinion contributed to menopausal problems were reported. Women's responses on
causes of menopausal symptoms are given in Table 4.4.
62
Table -1.4: Perceived attributes associated with menopause among menopausal women of
Maragua Town, Kenya
Causes n %
Don't know (Had no idea) 59 48.7
Age 15 12.4
Lack of knowledge 13 10.7
Stress 14 11.6
Hormonal changes 10 8.3
Chemical ill food/poor nutrition 19 15.7
Too much work 7 5.8
Menses stopping 5 4.1
Illness 3 2.5
Contraceptives and medicines 4 3.3
Poverty 5 4.1
Hysterectomy 1 0.8
Natural passage of aging
Table 4.4 indicates that women linked the symptoms to varied and diverse causes. In
24.8 % of the women the symptoms were due to old age, hormonal changes or cessation
of menses.
Ignorance
As indicated in Table 4.4, 48.7 % of the women had no idea of what caused the
menopausal symptoms. J think the blood stopped flowing in my body (personal
communication, July 2, 2003). Women seemed not to know the causes of the
menopausal symptoms they were experiencing. I don't know the cause. But I hope they
63
will pass away soon (pcrsonal Communication, June 28, 2003). Yet other women had
associated the symptoms with pregnancy. I don't know what has become of me. I often
find myself crying for no good reasons. It is very disturbing. I've not been like this. At
the beginning I even thought I was pregnant (personal communication, June 28, 2003).
Respondent elaborated that she used to experience similar bouts of sadness and constant
crying during her previous pregnancies.
Nutrition
Poor nutrition and presence of chemicals in food were linked to menopausal symptoms
(15.7%) (Table 4.4.). Where pesticides and herbicides have been used to increase food
production in the farms, foods were being looked upon with scepticism. Sukuma-wiki is
taking only two days to mature, whereas they used to take a whole week! Don't you think
they can affect our bodies? (Personal communication, July 2, 2003). Others blamed
preservatives and food additives commonly found in processed foods.
Stress
Stress due to problems encountered in families unions and extra burden of taking care of
the grandchildren left behind was linked to presence of menopausal symptoms by 11.6%
of the women. Stress to some was due to; many years o.fhard work (5.8 %) and poverty
(4.1 %) (Table 4.4).
-Illness
A small proportion of the women (2.5%) linked symptoms to diseases. I think my
headaches are due to malaria or typhoid (Personal communication, June 28, 2003).
64
Another thought she had a fatal disease like AIDS. She said, my periods resumed after
jive months of absence in a gush. 1 didn't know what was happening to me. 1 was
trembling, could not eat, sleep or go anywhere. I thought I had AIDS (personal
Communication, July 2, 2003). Menopause is not a disease, but when symptoms are
severe, a woman may think there is something terribly wrong with her (Henkel, 2001).
Contraceptives and medicine
Long-term use of contraceptives or medicine was associated with occurrence of
menopausal symptoms by 3.3 %of the women. These contraceptives that we keep on
using are really making us age faster (personal Communication, June 28, 2003).
These findings show that the symptoms were unexpected, puzzling, distressing,
discomforting and confusing. They were mostly linked to circumstances surrounding
women's lives and the advancing age. According to Berger (1999), psychological
difficulties that may aggravate the symptoms are linked to getting old. Other than
hormonal causes, low education, those having difficulties satisfying basic needs,
sedentary lifestyle, diets devoid of vegetables and fruits and smoking predispose women
to more menopausal symptoms (Kelliher, 2000; R. Malkmus, 1995 ).
4.4.2 Societal constriction in the information dissemination about menopause
Respondents were asked whether they shared their menopausal experiences and
preferably with whom. This information sought to establish the constrictions culture
may have in the dissemination of menopause information. Table 4.5 presents women's
preference for sharing menopausal experiences.
65
Table ./.5: Preference for sharing menopausal experiences among
menopausal women of Maragua Town, Kenya
Persons shared with n 0/0
Spouse 2 1.7
Friends 67 55.4
None 52 43.0
Total 121 100
It was found that more women (55.4 %) shared their menopausal experiences with close
friends as opposed to 1.7 % with their spouses. However, 43.0 % of the women hardly
opened up. Cultural issues surrounding menses were women's affairs and so was
menopause. It is strictly a woman's affair; men want nothing of it. Women revealed.
This implies that culture did not encourage dissemination of information about
menopause. This finding agrees with a studies done on women that issues of menses,
inclusive of menopause, were a taboo subject in other cultures as well, such as the
Chinese-Filipino, Native American and Puerto Rican (Swartz, Sherman, Harvey, Noell
and Johnese, n.d). However, it has been shown that support groups empower women.
When a woman feels she is alone and no one understands what she is going through, she
is likely to feel more frightened and more powerless (Henkel, 2001).
4.5 Women's perception of menopause
To establish women's opinions on menopause and its implication to quality of life,
women stated whether problems associated with menopause were a bother or strained
their relationships. Table 4.6 presents women's perceptions of the symptoms associated
with menopause.
66
Table 4.6: Perceptions of symptoms associated with menopause among
menopausal women in Maragua Town, Kenya
Perception Yes No
n 0/0 n 0/0
Symptoms a bother 92 76.0 29 24.0
Symptoms strained relationships, affected
work productivity and/or health. 64 52.9 57 47.1
It was found that majority of the women (76.0 %) perceived symptoms as bothersome as
opposed to 24.0 % who did not (Table 4.6). As menopause sets in, it was preceded by
menstrual irregularity that caught women off guard. This phase was shocking and most
stressing to some women. The menses just stopped; I wasn't using contraceptives and
when they came back after a few months the flow was so much, I couldn't leave the
security ofthe house (Personal communication, July 2,2003). Loss oflibido was cited as
stressing too. A respondent expressed it as thus: I didn't know what was happening to
me. I, couldn 'I tolerate my husband (in bed). I was cold. Consequently he (husband)
ignored me and later moved out of our home (Personal communication, July 28, 2003).
It was reported that some symptoms adversely affected women's work productivity. A
woman who was experiencing severe backaches commented. I no longer work in the
farm because of these backpains (Personal communication, July 2, 2003).
Majority of the women (52.9 %) were experiencing strained relationships with their
spouses, children, colleagues and friends due to the presence of symptoms in
comparison with 47.1 % who did not. These results mean that the unexpectedness of the
67
symptoms and their implications in women's lives was a nuisance. In a cross-section of
women, symptoms cause physiological and emotional distress (Beckham, 2002).
4.5.1 Coping with the symptoms
Among the women who took actions to control or alleviate the symptoms associated
with menopause, it was found that multiple actions for a particular symptom were
practised. Women's ways of controlling or alleviating menopausal symptoms are given
in appendix 6.9. Other than herbs used by some women, meals were hardly prepared
with the intention of alleviating menopausal symptoms (Appendix 6.9). Herbs used were
stinging nettle (thabai), black night shade (managu), tick berry (mikigi), Cape goose
berry (minathi) and Caesalpinia volkensii Harms (mibuthi). These herbs were used as
vegetables and were prepared with the foods or infused in water.
Hotflushes
Women coped with the problem of hot flushes by seeking divine interventions (7.4 %),
using anti-malaria medicines (1.7 %) taking frequent cold baths, resting and using
painkillers (0.8% respectively). Herbs and vegetables such as stinging nettle (thabal),
Caesalpinia volkensii Harms (mibuthi), cape gooseberry (minathi) and black nightshade
imanagu) were used to alleviate incidences of hot flushes too. Some women (2.5%)
sought medical help for hot flushes.
Night sweats
As shown in appendix 6.9 some women relieved themselves of night sweats by seeking
spiritual intervention (6.6 %), taking cold baths before going to bed (1.7 %) and visiting
68
hospitals (4.1 %). Other ways included using light clothing and bedding (0.8%) and
using herbs such as stinging nettle (thabai).
Fatigue
Use of divine interventions (5.0 %), taking breaks and rest when necessary (3.3 %) and
use of painkillers (2.5 %) were some of the ways women used to cope with fatigue.
Other means were visiting hospitals, exercising, and use of local herbs such as, stinging
nettle (thabai) and EM-l (0.8 % each). Women maintained that EM-l is multi vitamin
syrup. (The herb was readily available in agro - chemical shops within the town).
Headaches
Divine intervention and painkillers were used by 5.0 % and 5.7% of the women
respectively, to cope with headaches associated with menopause. A few (3.3 %) usually
visited hospitals, while others took anti-biotic and anti-malarial medicine (0.8 % each) in
the hope of alleviating the symptoms. Herbs such as herbal tea, stinging nettle, tick berry
(mikigi), and neem (muarobaini) were used by some women (0.8% each) to alleviate
headaches.
Backaches
Women resulted to use of painkiller medicines such as indocids, brufen, paracetamol
and analgesic (9.1 %), stinging nettle herb (thabai) (0.8 %) and medical consultations
(2.5 %) for backaches. Others coped with the problem through taking antibiotics,
exercising (walking) and neglecting duties whenever necessary (0.8 % each).
:KENYATTA UNIVERSITY LIBRARY
69
Insomnia
Women coped with loss of sleep through spending time praying (7.4 %) and using 'over
-the counter medicine' such as piriton to induce sleep (3.3 %). Reading in bed (mostly
the Bible), retiring to bed only when sleepy (1.7%) and visiting hospitals (2.5 %) were
other coping strategies applied. Anti-malarial medicines were taken by 1.7 % of the
women especially where lack of sleep was linked to illness.
Depression
Majority coped with depression through the use of prayers (8.3 %) to withstand things
otherwise unbearable and beyond their comprehension. A woman explained this as thus:
When I get into these moods and intense sadness, I usually offer myself to God A
sense of relieve washes over me then. Again I have come 10 accept these
problems: as long as I fight them involuntarily. I shall not be well.
Other coping strategies were singing (Christian songs) when in the depressed mood,
seeking medical interventions, withdrawing from other people, or avoiding being alone
and use of stinging nettle herb.
Loss of libido
As indicated in Appendix 6.9 women sought the solace in the power of prayers and
reading the Bible (2.5 %). Few (0.8%) sought medical expertise.
Mood swings
In case of mood swings, prayers (5.8 %) were used. Other coping means were medical
consultations, use of over the counter pain killers, withdrawal techniques, and use of
support groups (Appendix 6.9). Women drew strength from support groups by sharing
70
their problems with other women undergoing similar experiences. When I found that am
not alone in this, (Menopause phenomenon) I felt strengthened and can now withstand
them (symptoms) better (Personal communication, July 22, 2003).
Crying spells
Those experiencing crying spells sought for comfort and reassurance from God through
prayers (5.0 %). A few visited hospitals, sang Christian songs, used support groups and
anti-malarial medicine. In addition, some women strategised withdrawal mechanism to
avoid unnecessary outbursts that would otherwise ensue. It was noted that personal
testimonials were passed from one woman to another, especially in the use of local
herbs. Dosages were usually not specific or standardised.
These results indicate that changes that accompany menopause were dealt with mostly
by natural means, some falling under the 'unproven': for instance the use of local herbs.
According to ALLABH (2002), Negroid women prefer non-prescriptive remedies over
prescribed remedies. However, women should practise caution while approaching any
treatment (Henkel, 2001). To copy, women practised power of positive thinking as well
as trusting in a divine being. Studies have shown that prayers results to significant
improvement in self-esteem, anxiety and depression (Beckham, 2002).
The results also indicated a deficit of information about menopause and menopausal
symptoms. As a result, women more often than not used wrong remedies for the relief
of the symptoms. Research by Swartz, Sherman, Harvey, Noell and Johnese (n.d),
revealed that lack 0f factual information about menopause is a source of frustrations to
women.
J
71
4.5.2 Treatments of menopausal symptoms at the District Hospital
Medical consultations due to symptoms associated with menopause were established.
Women stated problems / symptoms that necessitated the hospital visits within a period
of3 months prior to the study. Table 4.7 highlights the ailments reported by women that
necessitated the hospital visits.
Women who had visited hospitals within 3 months prior to the study were 22.3%, of
which 9.9% of the women reported problems related to menopausal symptoms (Table
4.7). It was noted that these cases sought for medical interventions after all other
remedies had failed; an average of2 women per week.
Table 4.7: Complaints necessitating hospital visits among menopausal women of
Maragua Town, Kenya
Complaints n %
Other diseases 12 9.9
Symptoms associated with menopause such as hot 12 9.9
flushes, depression
Problems associated with muscoskeleton 2 1.7
Menstruation problems (PMS) 1 0.8
Total 27 22.3
This finding concurred with a study by Goodman, Grove and Gilbert cited in Kimmel
(1990), where a comparison was made between women not menstruating past 12 months
with those menstruating within 2 months and went to clinics for screening. It was found
that % of those in menopause did not report any of the symptoms associated with
72
menopause. These studies suggested that stereotypic symptoms of menopause may be
biased by the fact that women experiencing severe problems would be the ones to seek
physician's attention while majority of women may experience few or no symptoms and
view symptoms from a different perspective.
4.5.2.1 Clinical officers' recommendations
To establish treatments offered at the District Hospital, Clinical Officers were asked to
state menopausal complaints reported by menopausal women visiting the hospital and
the remedies they recommended. Table 4.8 shows the reported symptoms and treatments
offered at the Maragua District Hospital.
Table 4.8: Treatments given for symptoms associated with menopause at Maragua
District Ilospital
Problems Treatments
Mennorragia
Osteoarthrit is
Depression
Hot flushes
Insomnia
Vulva itch
Low backaches
General malaise
Headaches
Hormonal drugs
NSAID (Non-steroidal anti-inflammatory drugs)
Anti-depressant, counselling
Counselling, cold baths
Mild sedatives, Avoidance of stimulants drinks late at
night, valium low dose
Topical antihistamines
Mild analgesics
Multi-vitamins
Brufen or panadol
73
The frequently reported menopausal complaints were depression and menorragia (heavy
bleeding). Others included headaches, insomnia, hot flushes, low backaches, vulva itch,
general malaise and menstrual irregularity. According to the clinical officers who
attended to patients in the hospital, women associated these problems with diseases such
as malaria, age and gender. Doctors were in unison that the menopausal problems were
big challenge to women.
Doctors mostly prescribed medicines for most of the menopausal problems. From the
Focus group discussions, it was found that women regarded these prescriptions as not
very helpful in alleviating their problems, especially in cases of insomnia and headaches .
.. .After alf 1'If be given Piriton for lack of sleep (Personal communication, July 2,2003).
Piriton don't help me anymore and yet they are all I get (Personal communication, July
16. 2(03). I lowever, doctors noted that these menopausal problems are easily confused
with other medical gynecological manifestation or other ailments. Women may receive
wrong diagnosis due to this confusion.
The study also found that very little nutrition counselling was given to the women. This
counselling was done to referral cases only, which was one case per week at most. Only
necessary cases were booked for follow-up counselling. This individualized counselling
was helpful, as alleged by the concerned women. A woman narrated how depression had
weighed her down to the point of losing hope. I was so sick and with no money to buy
medicine any more. 1 could neither eat nor work. I lost weight, and became very weak.
In one of her hospital visit, she found a doctor who understood and diagnosed her
problem as due to menopause. She says, the doctor did not prescribe medicine, but
74
advised me 10 use the money available 10 purchase sorghum, millet and soya flours. She
was advised to take as much of the porridge mix as she could. In less than a week, the
woman had noticed positive results. She says, in a week's time my appetite had resumed
and gradually increased and I became strong enough to even work in the farm (Personal
communication, July 22, 2003) It was reported that outside hospital counselling was
rare.
4.5.2.2 Nutrition therapy at hospital
Foods recommended by nutritionists for alleviating the problems associated with
menopause were high protein diets or high calcium foods for backaches and joint pains,
and fruits and vegetables for loss of appetite. However, protein high foods and especially
animal protein must be moderated (Beckham, 2002). This is because high animal protein
encourages bone resorption (Smith & Shimp, 2000). Other than individualized
counselling in the Hospital, women hardly received any information about menopause.
It was noted that women craved [or information; it did not matter from where as long as
it shed light on their predicament. Who shall come to our predicament, except God
(Personal communication, June 28, 2003)?
The above fmding is similar to that of a study done on Native and African-Americans
that indicated that women tended not to go to doctors when encountered with
menopausal symptoms (Swartz, Sherman, Harvey, Noell and Johnese, n.d).This could be
due to the treatment given found as not being helpful. In another study, it was also found
that doctors tended to view menopausal problems as pathological as did the nurses than
75
the menopausal women themselves (Kimmel, 1990). This could have led to their
preference for medicine over nutrition or counselling.
4.6 Women's attitudes towards menopause
To establish women's attitudes towards changes at menopause, their feelings towards
them and the influence these had on their approach to managing them were collected.
Table 4.9 indicates the percentage of women who did not take any initiative to manage
symptoms associated with menopause and the reasons given for this complacent
behaviour.
Table 4.9: Reasons [or the insipid attitude towards managing symptoms
associated with menopause, among menopausal women of Maragua Town,
Kenya
Reasons n %
Growing old 3 2.5
I
Those things women have to live with 6 5.0
Normal for the age 15 12.4
Not a problem 20 16.5
Do not know what to do 24 19.8
Total 68 56.2
Despite menopausal symptoms being a bother and a nuisance among the majority of the
women (Table 4.6), 56.2% of the women hardly took any action to alleviate them.
Reasons for their inaction varied. It was found that some women (16.5 %) did not view
the symptoms as a problem; therefore no actions were warranted. In 12.4 % of the
women symptoms were viewed as normal phenomena for their age: therefore, no reason
76
to panic. These are some of the things a woman must endure in her old age (Personal
communication, July 16, 2003). Others viewed the menopausal symptoms as a natural
phenomenon. Isn't this normal for a woman my age? These problems don't forbid me
from doing my daily work. They are normal (personal communication, July 10, 2003).
However, majority of the women (19.8 %) did not know how to react to the menopausal
symptoms; the symptoms were both strange and embarrassing, prompting them to take a
passive stance with the hope the problems would disappear as mysteriously as they had
appeared. f have 110 idea what these are (the symptoms), unless you enlighten me
(Personal communication, July 2, 2003). This gushing heat and sweating could be due to
typhoid or malaria (personal communication, June 30, 2003). Statements such as these
are evident of'wornen's ignorance on the matter.
As indicated in Table 4.9, 5.0% of the women believed the symptoms were part and
parcel of a woman's life and one had to bear with the discomforts and stresses involved:
That-the symptoms are one of those things a woman has to learn to live with. Among
2.5 % of the women, approaching menopause or the onset of menopause was the
primary cause of the menopausal symptoms. Since 1 am growing old, what do you
expect? A woman asked rhetorically. There was no other alternative but to accept the
underlying changes. . .. after all, men don 't grow old, it's us (women) who do they
commented on the dwindling sexual desires and consequently sexual activities.
These results show that women had positive attitudes towards the experiences of aging.
Other studies show similar findings. For instance, though African-American women
often have more severe symptoms than Caucasian women, they tend to view menopause
77
more positively (ALLABH, 2002). According to Swartz, Sherman, Harvey, Noell and
Johnese, (n.d), Chinese, Mexican-American and Puerto Rican women, view menopause
positively too. How a culture view aging determines how menopause will be viewed
eventually (Kelliher, 2000). Other suggestions given for this finding is that most negroid
women experience problems such as racism, economic hardship, sexual discrimination
and menopause is therefore not a big problem (ALLABH,2002). However, problems
associated with menopause affect a woman physically, socially, mentally and
emotionally consequently affecting those around her; spouses, children and the whole
world (R. Malkmus, 1995).
4.6.1 Women's levels of satisfaction by various factors during the menopausal
transition
To establish women's attitudes during menopause, women were asked to rate their
present levels of satisfaction of different variables. These were their financial status, sex
life, physical appearance and health. Table 4.10 draws the comparison between women's
different levels of satisfaction of their financial wellbeing, sex life, physical and
emotional health as well as physical appearances.
78
Table 4.10: Measurement of attitudes at menopause (%) among menopausal women of
Maragua Town-Kenya
Levels of Financial Sex life Physical Physical Emotional
satisfaction wellbeing appearance health health
Dissatisfied 82 45 27 49 63
(67.8) (37.2) (22.3) (40.5) (52.1)
Neutral 20 37 44 32 20
(16.5) (30.6) (36.4) (26.4) (16.5)
Satisfied 19 29 50 40 38
(15.7) (24.0) (41.4) (33.1) (31.4)
N/A 0.0 10(8.3) 0.0 0.0 0.0
Financial wellbeing
As shown in table 4.10, majority of the women (67.8%) were dissatisfied with their
financial wellbeing compared with those satisfied (15.7%). As demonstrated in the
FGDs, financial constraints lead to stress and strained relationships. Misunderstanding
and domestic violence were therefore frequent. A case where a husband would suspect
his wife receiving money from their children secretly may result to violence as he
demands for the 'money'. My husband may result to violence demanding money on
assumption the children have left some money behind (with the mother), and that may
not be so. And if it were so why should I give him the money? Bitter sentiments like these
one were noted.
As effects of menopause negatively affected women's health, their productivity levels
were adversely affected too, consequently affecting the net income. Unpredicted
episodes of hot flushes, compounded by fatigue, backaches and headaches, were cited as
the major cause. A woman complained of frequent headaches that almost ruined her
marriage. J was constantly ill; J could not perform any duty, be it in the farm or at home.
79
My husband almost sent me awayfrom our matrimonial home (Personal communication,
June 28, 2003).
This suggests that economic wellbeing is very crucial in nurturing a positive attitude at
menopause. As demonstrated in Table 4.1, poverty was rife among the women and this
can be seen as one 0 f the reason for the high levels of dissatisfaction. Middle age and
specifically menopause creates a self-evaluating index from which women measure their
economic wellbeing. A survey on well-educated, successful men and women aged
between 40 and 60 years found that on the whole, people view themselves quite
positively and that a favourable self concept in middle years may not be true to people in
the lower socio-economic strata (Papalia and Olds, 1978).
Sex life
More women complained of being dissatisfied than satisfied with their sex life: the ratio
being 37.2 % to 24.0 %. The times when am tired and in no desire for sex are becoming
more frequent (Personal communication, July 22, 2003). Not having a partner decreases
the sexual activity even further. My husband is away with his friends and his ndogo
ndogo (mistress) most of the time anyway (Personal communication, July 22, 2003).
Data from the FGDs saw loss of libido being linked to several factors. These included
wife beating, irresponsible and uncaring partners, family problems and financial
constraints. Spouse negligence angered women who argued that their men had no right
then to demand sex with them. I would become uncooperative (in bed) (personal
communication, July 22, 2003). As a result, husbands literally sought company and
sexual gratification elsewhere, compounding the problem further. Others regarded
80
menopause as a gate to freedom from their husbands and their sexual demands. Since
issues on sex were not readily discussed between couples (See Table 4.5),
misunderstandings resulted.
These results indicate that, on average optimal sex life at menopause was not achieved.
A study on attitudes towards menopause among the caucasian women revealed that for
majority (65%) menopause had no effect on their sexual relations in comparison to 7%
whose sexual relations became more important (Kimmel, 1990). However, according to
La Haye (1998), menopause can create a problem to an already strained marital
situation; in a few cases it can overtax a healthy marriage. Sex problems may be related
to dysfunction on the part of either partner. Various psychological, physical, social and
hormonal factors affect sex function (Beckham, 2002).
Physical health during menopause
In comparison, 40.5% of the women were dissatisfied with their physical health in
relation to those satisfied (33.1%). From what was gathered in the focus group
discussions hypertensions, depression, headaches, gastritis, fatigue, heart palpitations
and heart burns were reported as the most disturbing health problems; depression ranking
the highest. Women linked the increased high blood pressure, headaches, fatigue and
heart palpitations to depression. Psychological stress leads to high blood pressure
(personal communication, July 22, 2003). Affected women claimed constant worrying,
anxiety coupled with economic hardship and deteriorating marriage unions exacerbate
the problem. This implies that women's physical health was not optimal. This is in
8\
contrast to Kimmel (1990), that menopause has no effect on women's physical and
emotional health as since 32% who had noted a negative change (Kimmel, 1990).
Physical appearance at menopause
The ratio between those dissatisfied and those satisfied with their physical appearance
was 22.3% to 41.4 %. Some women felt very insecure and unsure of themselves now
that they were no longer young, energetic and beautiful. When we were young and
beautiful things were better; we are now bound to feel jealous of the young and shapely.
They lamented. However, this to most women was not seen as a major setback in life.
The fmding suggests that aging was not a major setback in women's lives. Cultural
acceptance of menopause counterbalanced any negative feeling towards aging. The
fmding concurs with Dr David Archer, a Virginia (USA) gynecologist quoted in KeUiher
(2000, p.Z), that is not only how your culture views menopause, but also about how your
culture view aging.
Emotional health at menopause
The ratio between those dissatisfied with their emotional health with the satisfied ones
was reported as 52.1 % to 31.4 %. The state of being dissatisfied with ones' physical
health, dealing with emotional changes and other factors such as economic constraints
were seen to exacerbate an emotional and psychological turmoil among the women. This
means that women's psychological health was less fulfilling at menopause not because
of menopause per se but due to other socio- economic and health factors. These findings
are in line with a study cited in Henkel (2001) which revealed that "natural menopause
82
did not have negative mental health consequences for the majority of middle-aged
healthy women.
With the onset of perimenopause, menopausal symptoms encountered contributed to the
prevailing financial constraints, strained marriage unions and poor health in one way or
the other. The phase was coupled with various changes happening at once or
concurrently which in essence had negative impact on women's quality of lives.
Menopause by itself is therefore not a precipitator of major crisis or depression, but the
social, physical and health changes at menopause that may stress the body consequently
affecting the mind and quality of life (Beckham, 2003).
4.6.2 Women's attitudes towards changes experienced at menopause
To investigate women's attitudes towards changes experienced at menopause, women
described their feelings or opinions towards the changes experienced at menopause.
Women's attitudes on changes experienced at menopause are shown in Table 4.11.
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83
Table 4.11: Attitudes towards changes experienced at menopause
among menopausal women of Maragua Town, Kenya
Changes n 0/0
No change 67 55.4
Adjusted positively 24 19.8
Difficulty in adjusting 20 16.5
Overly sensitive and touchy 3 2.5
Impatient and rude 3 2.5
Inability to cope totally 2 1.7
Indifference 2 1.7
As noted in Table 4.11, 44.6% of the women noted changes of attitudes and
consequently their temperaments changed at menopause. Majority (25.0%) of these
women indicated negative attitudes towards changes experienced at menopause. They
complained of experiencing difficulties adjusting to changes at menopause (16.5%),
being impatient and rude more often than not (2.5%), irritable and touchy (2.5%) or
being in a state of indifference (1.7%). However, 19.8 % of the women showed a
positive attitude towards the changes. To this group, menopause allegedly had made
women more tolerant and accommodative. Presently I am a more optimistic person
unlike before (Personal communication, June 28, 2003). The findings suggest that
changes experienced at menopause may have an effect on women's behaviours.
According to Henkel (200]), menopause may signal a turning point in women's lives.
Personality changes as a result of experiences, relationships and self-evaluations that
occur during these years (Papalia and Olds, 1978).
KFNYATTA UNl ER(' TY UBRARY
84
4.7 Women's dietary intakes
4.7.1 Meals distributions
A dietary history method was used to assess meal distribution in a period of one week to
establish women's eating patterns. Women recalled their exact food intake during the
one week period prior to the study. Table 4.12 presents the usual women's meals
distribution.
Table 4./2: Meal distributions among menopausal women of Maragua Town-
Kenya
Meal patterns n %
Snack intake 41 34
Breakfast only 1 0.8
Lunch + supper 1 0.8
Lunch only 2 1.4
Breakfast + Lunch 5 4.1
Breakfast + Supper 27 22.3
Breakfast + Lunch + Supper 85 70.2
Table 4.12 shows that majority of the women 70.2% usually consumed three main meals
per day; breakfast, lunch and supper. Snacks were taken by 34.0% of the women. The
findings indicate that though one or two meal(s) were skipped in a day, snacks were not
taken to supplement the energy and nutrients. Given that women led active lifestyles
(Table 4.19), frequent and regular meal distributions were necessary as nutrient
distribution throughout the day is a requirement for good health. For adequate
consumption of nutrients and nutritional substances, meals and especially lunch and
breakfast should not be skipped (Grayson, 2002). Breakfast should be the most
important meal of the day, while supper should be light for adults except, the pregnant,
'.
85
the lactating mother and those performing heavy work (Pamplona-Roger, 2000 b).
Snacking is not recommended especially if breakfast meal is adequate. This is because
snacking between meals tires the digestive tract leading to digestive problems, reducing
appetite and weight increases (Pamplona-Roger, 2000b). However in line with women's
poor breakfast and active lifestyles (see Table 4.19), nutritive snacks between meals was
necessary to complement the diets for sufficient nutrient distributions throughout the
day.
Factors affecting women's meals distribution
Reasons for meals irregularity were determined. Table 4.13 presents the reasons for the
skipping of meals.
Table 4. /3: Reasons for skipping meals among menopausal women ofMaragua
Town, Kenya.
Reasons n %
Control of weight 2 1.7
No money to buy Iood away from home 3 2.5
A habit 4 3.3
Lack of time to cook the meal/eat 11 9.1
Working far from home 16 13.2
Lack of appetite 22 18.2
Total 58 47.9
Skipping of one or two meals was noted among 47.9% of the women. As shown in
Table 4.13, the largest proportion of the women skipped meals for lack of appetite (18.2
86
%). We leave velY early in the morning to work and have no appetite that early
(personal communication, July 22, 2003). This woman belonged to the category that
usually did not take breakfast. The long working hours neither allowed for lunch breaks
nor for time to cook and eat the meals. This was elaborated thus; When am working in
the farm, 1 don', see the need 10 stop for lunch; I would rather work continuously and
eat when have finished (personal communication, July 12, 2003). It was revealed. In
most cases, the working went on till late in the evening with only a tea break.
The results indicate that though majority normally took the three main meals per day,
meals were primarily skipped due to lack of appetite. In most cases when lunch was
skipped, a larger supper was preferred to compensate for the missed meal. This practice
encourages weight gain as much of the calories taken are burnt when fewest calories are
needed thus stored as fat (Pamplona-Roger, 2000 b). Small but frequent meals
throughout the day are recommended as more calories are burnt and metabolized when
meals are spread throughout the day (Grayson, 2002). Studies have shown that people
who eat small frequent meals throughout the day tend to consume fewer calories and fat
grams at the end of the day (Grayson, 2002).
4.7.2 Food portions
A dietary history method was used to assess women's specific classes of food intakes
and usual portion sizes in common household measures, in a period of one week. This
was done in order to assess women's diversification of foods in the recommended
portions. Table 4.14 illustrates women's food portions against the recommended portion
sizes based on a pyramid of a healthful diet.
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87
Table 4.14: Women's usual food portion sizes against the recommended portion sizes based
on pyramid of health diet
Food group Recommended Below the Above the Not taken
portions recommended recommended
portions portions
n % n 0/0 n % n %
Cereals 44 36.4 50 41.3 25 20.7 2 1.7
Vegetables 9 7.4 92 76.0 1 0.8 19 15.7
Fruits 5 4.1 4 3.3 1 0.8 111 91.7
Proteins foods I 0.8 97 80.2 - - 23' 19.0
Fats 11 9.1 101 83.5 2 1.7 7 5.8
Nuts - - - - - - 121 100
As shown in table 4.14, 36.4% of the women had consumed the recommended cereal
portion sizes, 7.4% of vegetables, 0.8% of proteins foods and 9.1% of fats. In both fruits
and nuts, foods portions were not only less than the recommended ones (3 portions and I
handful respectively), but also deficient in the majority's diets.
I
A balanced diet should be based on the pyramid of healthful diet. Foods taken in
abundance in the diet (group 1) should be cereals (4 portions), vegetables (3 portions)
and fresh fruits (3 portions). Foods to be eaten moderately (group 2) are protein foods (2
portions), and milk products (2 portions) and foods in group 3 such as olive oil or seed
oil (2/3 tsp ) and sweets should be eaten in very little amounts (Hasler, 2001; Pamplona-
Roger, 2000 b). It was, therefore, concluded that women's diets lacked variety and were
less than the recommended portion sizes in accordance to the Pyramid of a Healthful
Diet.
88
4.7.3 Food frequency
4.7.3.1 Frequency of consumption of different classes of foods in the diets
Dietary history method was used to obtain descriptions of foods and their frequency of
consumptions in a period of one week. Frequent intake of specific foods ensures
adequate supply of specific nutrients to the body. Table 4.15 presents the frequency of
specific foods consumed in a period of one week.
Table 4.15: Foods taken for lunch during a period of one week among the menopausal
Women ofMaragua Town, Kenya
Type of dish Frequency of dish taken in one week (%) Total intake
N/A 117 2/7 3/7 4/7 5/7 6/7 7/7 (%)
Githeri 9.9 10.7 19 17.4 25.6 12.4 3.3 11.7 90.1
Ugali 18.2 55.4 19.0 5.0 0.8 0.8 0.8 81.8
Tea 89.3 7.4 3.3 10.7
Rice 24.8 50.4 9.9 12.4 0.8 1.7 75.2
Pasta 99.2 0.8 0.8
Chapatis 69.4 28.9 1.7 30.6
Arrowroots 74.4 25.6 25.6
Sweet 81.0 18.2 0.8 19.0
potatoes
Cassava 97.5 2.5 2.5
Matoke 33.1 60.3 5.8 2.5 68.6
Yams 95.0 5.0 5.0
The study found githeri, a local dish made of a mixture of maize and pulses preferably
beans, as the most frequent dish in the week (Table 4.15). The largest proportion of the
women (90.1 %) included it in their meals where the highest proportion of the women
89
The study found githeri, a local dish made of a mixture of maize and pulses preferably
beans, as the most frequent dish in the week (Table 4.15). The largest proportion of the
women (90.1 %) included it in their meals where the highest proportion of the women
(25.6%) included it 4 times in a week. This dish was prepared as stew; where vegetables
such as potatoes, cabbages and I or carrots were added, fried, mashed with potatoes,
plantains and other green leafy vegetables to make mukimo or simply boiled. As shown
in Table 4.15, other staple foods frequently consumed were matoke (60.3%), Ugali
(55.4%) and rice (50.4%).
This indicates that majority of the women's diets usually lacked variety. This is
evidenced by diet being monotonously and repeatedly served over the days of the week.
Diets should be varied in their make-up to provide necessary energy, nutrients and
nutrition substances for the body use (Grayson, 2002; Pamplona-Roger, 2000 b).
4.7.3.2 Frequency of foods rich in isoflavones
Food frequency method was used to establish types and frequency of foods rich in
isoflavones in women's diets. Frequency of isoflavones rich foods in the diets are given
in Table 4.16. It was found that majority of the women had had no soya in their diets
(74.4 %) versus 2.5 % of the women who had consumed soya or its products daily
(Table 4.16). Soya was mainly taken as a beverage. A high percentage of the women
hardly consumed yams (54.5 %) and nuts (81.8 %). Foods frequently consumed (on a
daily basis) were vegetables (34.7 %) while the least frequent in women's diets were
yams (0.0%) and the nuts (2.5%). Dried pulses present in women's diets that are rich in
isoflavones included; lentils, green grams, cowpeas and pigeon peas. The vegetables
90
consumed by the women that are rich in isoflavones were cabbages, carrots, cucumbers,
onions and sweet potatoes. Fruits rich isoflavones found in women's diets included
-,
oranges, plums, tomatoes and pears which were mostly seasonal.
Table 4.16: Intakes of isoflavones rich foods in a period of 3 months among menopausal
women ofMaragua Town, Kenya
Never Occasionally Once a Twice Daily
week a week
• Soya products (soya beans, 74.4 19.0 1.7 2.5 2.5
soy flour, soya milk and
powered soya beverage)
• Yams 54.5 41.3 1.7 2.5 0.0
• Dried pulses (lentils, green 2.5 22.3 28.9 33.9 12.4
grams, cowpeas, pigeon peas)
• Nuts (peanuts/ground nuts) 81.8 12.4 0.8 2.5 2.5
• Vegetables (cabbage, carrots, 2.5 14.0 21.5 27.3 34.7
cucumbers, onions, sweet
potatoes)
• Fruits (oranges, plums, 9.1 62.8 10.7 8.3 9.1
tomatoes, pears)
These results indicate an infrequent consumption of isoflavones rich foods among the
women. Some of these foods, for instance, yams, sweet potatoes, peanuts and peas were
not readily available thus expensive for respondents to include them in their meals daily.
Some foods such as soya were regarded with skepticism. Isoflavones rich foods increase
estrogen levels when blood estrogen declines but will not boost them unnecessarily, thus
91
reducing hot flushes (Beckham, 2002). A regular intake of 40 and 80 gm/day of
isoflavones is beneficial for alleviating hot flushes (Hasler, 2001).
4.7.4 Foods commonly consumed by the women
A 24-hour recall method of dietary assessment was used to obtain data retrogressively
on women's food intake to include diet selection in each meal. This was done to
establish the types of foods consumed by the menopausal women. Table 4.17 lists the
foods women consumed in each meal while Figure 4.1 shows categorization of women's
breakfast.
Breakfast dishes
80~----------------------------------------~
60
40
20
Percent
o
Beverage only Beverage + left over
Beverage + bread, etc Not taken
Breakfast meals
Figure 4.1: Breakfast meal among menopausal women of Maragua Town, Kenya.
92
As shown in Figure 4.1 breakfast dishes were grouped into three categories; beverage
only, beverage with cereals, bread or tubers and beverage with 'left over' foods. A high
percentage of the women had beverage with no accompaniment (75.2%). Dishes taken
for breakfast were beverage with bread, mandazis or tubers (2.5%) and beverage with
'Left over' foods (19.8%). An ideal breakfast comprises of grains, soy or cow milk,
nuts, dried or fresh fruits and where necessary dietary complements such as wheat germ,
brewer's yeast or soy lecithin (Pamplona-Roger, 2000 b).
93
Table ./.17: Foods consumed by menopausal women of Maragua Town,
Kenya
Breakfast beverages n %
None 3 2.5
Tea 94 77.7
Nylon (Sweetened hot diluted milk) 14 11.6
Porridge 5 4.1
Soya 5 4.1
Snack consumed
None 80 66.0
Tea 28 23.2
Milk I 0.8
Chocolate I 0.8
Bread 5 4.2
Mandazi 2 1.7
Banana 3 2.5
Cake I 0.8
Lunch dishes/ Staple foods
Githeri 109 90.1
Rice 91 75.2
Ugali 99 81.8
Matoke 81 66.9
Chapatis 37 30.6
Arrowroots 31 25.6
Sweet potatoes 23 19.0
Tea 13 10.7
Cassava 3 2.5
Yams 6 5.0
Pasta I 0.8
Vegetables consumed
Sukuma-wiki (Kales) 42 34.8
Cabbages 45 37.2
Tomatoes 44 36.5
Irish potatoes 40 33.0
Carrots 19 15.8
Spinach 6 5.0
Coriander 2 1.7
Green peas 3 2.5
French beans 2 1.7
Green pepper 2 1.7
Pumpkins 2 1.7
Bitter gourd I 0.8
Pig weed (terere) I 0.8
Proteins foods/ group 2
Pulses 98 81.0
Meat 7 5.8
Eggs I 0.8
Bed time liquids
None 77 63.6
Tea 24 19.8
Plain water 12 9.9
Milk 6 5.0
Coffee 1 0.8
Porridge I 0.8
94
As indicated in Table 4.17, beverages among the women included tea (77.7%), nylon
(diluted milk without tea leaves) (11.6%), porridge (4.1%) and soya drinks (4.1%).
Hydrogenated bread spreads such as margarine, were used by a mere 3.3%. They were
regarded by the majority (96.7%) as luxuries, otherwise an unnecessary expense. J use
them only when money is available a respondent commented. Sugar was not preferred by
22.3% of the women. For those who included it in their beverages (77.7%), an average
of one teaspoon per 300 m1 China cup was taken. Sour porridge was preferred made
from single or flour mixtures; maize meal flour, sorghum, millet, and soya bean flours
was preferred.
These results indicate that though women's breakfast meals contained less animal
protein, it was also high in caffeine present in tea, less carbohydrates, vitamins, minerals
and dietary fiber. A standard breakfast may consist of grains and cereals, nuts, fruits,
milk or soy milk and dietary complements (Pamplona-Roger, 2000 b). Animal proteins
should be avoided at menopause as these foods are primarily the cause of osteoporosis,
increased risk of heart attacks, stroke and cancer (R. Malkmus, 1995.0steoporosis
highest rates are found in countries with highest calcium intake especially from daily
products (Beckham, 2002). All foods containing caffeine should be avoided. Sugar and
caffeine tend to increase incidences of hot flush (phelps, n.d).
Foods taken as snacks
As indicated in Table 4.17, snacks were not commonly taken by the women. The food
items taken as snacks included, tea (23.2%), milk (0.8%), bread (4.2%), mandazi (1.7%),
fruits (2.4%) and cakes (0.8%). These results show the possibility of ingesting
95
comparatively high caffeine as a result to the high intakes oftea and minimum intake of
fruits and vegetables. Tea is reported to have high caffeine which increases nutrients
loss, increases hot flushes and lowers calcium intake from foods (pamplona-Roger,
2004; Kirschman & Kirschman, 1996).
Foods take" for lunch
As presented in Table 4.17, lunch dishes were grouped into 3 major groups. Group 1:
Those to be taken abundantly such as fruits, cereals and vegetables. Group 2: Include
foods that should be taken moderately such as legumes, nuts, eggs, milk and its
derivatives. Group 3: Foods that should be taken in little amounts such as fats, sugar,
and sweets (Pamplona-Roger, 2000 b). It was found that dishes taken during lunch were
similar to those taken for supper. These included: Group 1; githeri (88.4%), rice
(85.9%), ugali (81.8%) and matoke (68.6%). Other foods taken for lunch by the women
were chapatis, arrow roots, sweet potatoes, tea, cassava, pasta and yams. Vegetables
consumed included cabbage (44.8%), tomatoes (36.5%), kales (34.8%), irish potatoes
(33.0%), and carrots (15.81%). Other vegetables were spinach (5.0%), coriander (4.1%),
green peas (2.5%), French beans (1.7%), pumpkins (1.6%), bitter guard (0.8%) and pig
weed (0.8%). Fruits were taken by 8.2% of the women.
Group 2 foods (those to be eaten moderately) were pulses (81.0), eggs (0.8%) and meat
(5.8%). Group 3 foods were hydrogenated vegetable fats (98.3%) and animal drippings
(1.7%) used in cooking. Farm produce from the locality were preferred as they were
easily accessible and cheaper. Any foods not grown locally tended to be expensive and
were not included ill women's diets. Women's diets were not different from the family
96
meals except in 5.0 % of the women who prepared their meals separately in order to
include herbs for the purpose of alleviating the menopausal symptoms. Additives were
hardly used as processed foods were not commonly available.
These findings show that, women's meals though of plant origin; rich in grains, legumes
and vegetables were devoid of fruits, These foods provide complex carbohydrates,
dietary fiber, variety of vitamins and minerals that help in the alleviation of menopausal
symptoms. Women's meals lacked variety as is evidently indicated by the high
proportions of women who took one particular dish (Githeri) continuously over a week
(Table 4.18). Foods rich in unrefrned complex carbohydrates sustain energy and balance
blood sugars greatly reducing symptoms associated with menopause (Beckham, 2002).
Fruits, cereals and vegetables when taken in abundance have been linked to fewer
problems that are associated with Pre-Menstrual Syndrome (PMS) and menopause
(Grayson, 2002; G.H. Malkmus, 1995). Vegetables offer many health benefits; fibre,
vitamins, minerals, phytoestrogen and are low in fats (Cataldo, De Bruyne and Whitney,
)995). Absence of animal products in the meals signifies a diet of less saturated fat and
cholesterol, which are linked to increased risks of heart problems, osteoporosis and
cancer (Parnplona-Roger, 2000 b; G. H. Malkmus, 1995).
Late flight dishes
Foods taken later than 10.00 pm usually after the evening meal were established to
determine the type and the quantity of foods that may have interfered with women's
sleep. Table 4.17 indicates that a high proportion of the women (19.8%) took tea as
opposed to milk (5.0%). These results show that snacks intake after the evening meal
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97
-was a rare practice and may have not interfered with sleep. A person sleeps better when
the stomach does not have to perform a heavy duty (Ludington & Diehl, 2000). For
people suffering from insomnia, a cup of malt beverage or of sedative plants with honey
is recommended with reduction or elimination of stimulant beverages such as tea, coffee
and chocolate (Pamplona-Roger, 2004). Stimulant beverages tend to increase anxiety
and interfere with sleep patterns (Kirschman & Kirschman, 1996).
4.7.5 Nutrients adequacy
The 24-hour recall method was used to collect women's food intakes from which the
mean levels 0 f nutrients intake of the group were estimated. This was done to establish
nutrients adequacy for the population in reference to the World Health Organization
(1990) and the National Academy of Sciences (1998). Detailed descriptions of all foods
and beverages consumed including the cooking methods were recorded. Quantities of
foods consumed were estimated in volumes associated with household utensils such as
cups; tablespoons, teaspoons and plates. Women's mean consumptions of kilocalories,
carbohydrates, dietary fiber, vitamins A and C, magnesium and calcium were
established to assess their adequacy in the diets. Amount of isoflavones in the diets were
determined from the consumptions of isoflavones rich foods such as soya, cow peas,
nuts, lentil, and beans. Table 4.18 presents the women's average consumptions of
kilocalories and selected nutritional substances and nutrients.
98
Table 4.18: Nutrient intake of kilocalories, isoflavones and selected nutrients among
menopausal women ofMaragua Town-Kenya
Nutrient Average Adequate (%) <RDA(%) RDA
nutrient (25-50 yrs)
Isoflavones 1.23 mg 0.0 100 40-80mg
2200kcal 1202.7 Kcal 19.0 81.0
Carbohydrates 225.4 g 47.1 52.9 275 -375 g
Fiber 9.5 g 14.9 85.1 25 g
Vitamin A 219.5 RE 4.1 95.9 800 RE
Vitamin C 232.1 mg 78.5 21.5 60mg
Magnesium 244.3 mg 52.1 47.9 280mg
Calcium 490.6 mg 22.3 77.7 1000 rng
Isoflavones
It was found that women's average consumption of isoflavones was 1.23 mg/day. As
shown in Table 4.18, all the women had consumed isoflavones below the recommended
intakes for the alleviation of hot flushes. Adequate isoflavones for a period of 12 weeks
I
has been proved to lessen incidences of hot flushes. In a study by Murkies and
colleagues as cited in Hasler (2001), incidences of hot flushes were reduced by 40% in
those consuming 45g soy flour for 12 weeks compared with 25% reduction in controls.
Kilocalories
As shown in Table 4.18, the average consumption of Kilocalories was 1202.7 Kcal/day;
with the majority of the women (81.0%) ranging below the RDA of 2200 KcaVday
(WHO 1990 as cited in Parnplona-Roger, 2000 b). This shows that women's diets were
inadequate of energy to fight fatigue.
99
Carbohydrates
Women's average consumption of carbohydrates was determined as 225.4 g/day (Table
4.18). Majority of the women (52.9%), had consumed inadequate intakes of
carbohydrates for health. According to WHO, Geneva (1990) as cited in Pamplona-
Roger (2000 b), carbohydrates Recommended Dietary Allowance should be between
275 - 375 g/day; meaning that women's consumptions of carbohydrates was inadequate.
Adequate carbohydrates give energy and help increase serotonin levels that help lift
mood swings, curb appetite, balance blood sugars and reduce menopausal symptoms
(Ludington & Dichl, 2000).
Dietary fiber
Women's mean consumption of dietary fiber was 9.5 g/day; a majority of the women
(85.1%) had levels below the RDA (Table 4.18). According to the Foods and Drug
Administration (FDA), Daily Reference Values (DRV) of dietary fiber is 25g. This is
an indication of an insufficient dietary fiber in the women's diets enough to reduce
menopausal symptoms. Dietary fiber is vital for energy release, removal of toxins and
harmful substances such as biliary acids; the precursors of cholesterol and modifies sex
hormones by increasing gastrointestinal motility (Beckharn, 2002).
Vitamin A
Women's average consumption of vitamin A was 219.5 RE; majority's (95.9%) intakes
being below the RDA. According to WHO, Geneva (1990) as cited in Pamplona-Roger
(2000 b), vitamin A RDA should be 800 RE. These fmdings indicate that the women's
consumptions of vitamin A were inadequate for health. Vitamin A is necessary for its
100
anti oxidative qualities, inorder to alleviating symptoms associated with menopause
(Parnplona-Roger, 2000 b).
Vitamin C
Women's average intake of vitamin C was 232.1 mg/day (Table 4.18). In reference to
the National Academy of Sciences (1998), as cited in Pamplona-Roger (2004), vitamin
C consumption was above the 60 mg/day for 78.5% of the women. This result indicates
that consumption of vitamin C was adequate among the women. Vitamin C is vital to
health at menopause due to its anti-oxidation properties and reduction of hot flushes
(Kirschman & Kirsclunan, 1996). According to Phelps (n.d), dietary vitamin C should
be modified to 1000 - 5000 mg in order to reduce excessive bleeding, increase iron
absorption and increase tissue strength of the perineal structures. However, vitamin C
being a volatile nutrient is lost easily to the atmospheric conditions for accurate
deductions to be made.
Magnesium
The average consumption of magnesium was found to be 244.3 mg/day; where more
women (52.1 %) had consumed adequate amounts (Table 4.18). Magnesium RDA
ranges between 280 - 350mg/day (Pamplona-Roger, 2004). Magnesium is needed for
proper absorption of calcium, prevents oesteoporosis, irritability, insomnia, headaches,
depression and lifts fatigue (Parnplona-Roger, 2000 b).
-,
10l
Calcium
As illustrated in Table 4.18, the average consumption of calcium was established as
490.6 mg/day, barely half the WHO's RDA of 800mglday (WHO (1990) as cited in
Pamplona-Roger (2000 b). Majority of the women (77.7%) had an inadequate
consumption of calcium. Some authors recommend calcium of between 1,000 to 1,500
mg/day from foods for menopausal women (Grayson (2002). Calcium plays a role in
bone formation, maintenance in cardiac rhythm and regulating the basic-acid balance of
blood, keeping it from becoming too acidic (Ludington & Diehl, 2000). Women at
menopause are susceptible to bone porosity and heart problems too and adequate
amounts of calcium should be taken to safeguard this (Henkel, 2001).
4.8 Vitamins and mineral supplementation
Women's use of vitamin and or mineral supplements was determined to establish their
intakes and use in managing menopausal symptoms. Women's vitamins and or mineral
supplementations consumed are presented in Figure 4.2.
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------------------,
Yes
No
88.4%
11.6%
Figure 4.2: Micronutrients supplementation among menopausal women of Maragua
Town, Kenya.
It was found that 11.6% of the women were on vitamins and or mineral supplements in
comparison with 88.4% who were not (Figure 4.2). Vitamins and mineral supplements
were, prescribed to correct nutritional disorders such as anemia and not for use in
managing symptoms associated with menopause. This finding indicates that the practice
of using nutrients supplements with regard to managing symptoms associated with
menopause was hardly used among the women.
4.9 Women's physical activities
4.9.1 Types of physical activities
Women's types of physical activities were established to determine their lifestyles.
Table 4.19 presents the physical activities women engaged in.
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Table 4. J 9: Physical activities and exercises among menopausal women
of Maragua Town, Kenya
Activities n %
House work and farm work
Farm work only
None
Forms of exercises
114
2
5
94.2
1.7
4.1
Walking
Aerobics
Gymnastics
None
114 94.2
2 1.7
2 1.7
3 2.5
2 1.7
6 5.0
10 8.3
33 27.3
70 57.9
Exercise Frequency
None
Once a week
Once every other day
Occasio nail y
Daily
Results presented in Table 4.19 show that 95.9 % of the women were involved in
activities requiring exertion of enormous energy such as farming and housework.
I
Among them, 98.3% of the women were involved in one or more forms of exercise,
walking being the most common (94.2%). Other exercises included aerobics (1.7%) and
gymnastics (1.7 %). The findings indicate that women led active lifestyles that are
linked to quality life. The activities they engaged in required enormous exertion of
energy. A healthy lifestyle can hold back the aging process, strengthen bones, lift
depression, relieves stress, insomnia and anxiety, increases energy and efficiency of life
processes among other benefits (Ludington and Diehl, 2000).
I
104
4.9.2 Women's levels of exercising
Women's levels of exercise (for instance walking) were determined to establish whether
they were recomrnendable. Women's frequency of exercising is presented in Table 4.
19. As indicated in Table 4.19, 57.9 % of the women walked everyday for not less than
30 minutes compared with 1.7% who did so for shorter periods. Women's daily chores
necessitated these high levels of walking. The results suggest that women's activities
levels were good for health. Natural activities of walking, jogging, running or swimming
are the best for older people as they maximize the rhythmic activity of large muscle
masses and minimize high activation of small muscle contraction (Woodruff & Birren,
1983). They increase supply of oxygen to the brain and cells thus increasing quality and
length of life (R. Malkmus, 1995).
4.10 Nutritional knowledge for menopause and its influence on food consumption
4.10.1 Women's nutritional knowledge for menopause
A test to measure Nutritional knowledge for menopause was developed to assess
women's mastery of nutrition for menopause. An index was formulated to classify
women to low, average and high levels of knowledge. Women with scores of between 0
and 12 were classified as of low nutritional knowledge on menopause, 12 and 24
average, 25 and 37 as having high nutritional knowledge for menopause. Women's
performances in the nutritional knowledge for menopause test are presented in Table
4.20.
105
Table 4.20: Performance in the nutritional knowledge for menopause test among
menopausal women in Maragua Town-Kenya
Performance n 0/0
Low 83 68.6
Medium 38 31.4
High 0 0.0
Total 121 100
Majority of the women (68.6 %) measured low in the nutritional knowledge for
menopause, in comparison with 31.4 % of the average knowledge. This finding implies
that. women had low nutritional knowledge about menopause. The finding is consistent
with studies in Posner and Levine (1991, pp. 424) on older population that, older
populations show limited nutritional knowledge concerning menopause.
4.10.2 Responses given to the nutritional knowledge for menopause test
Women's responses to the questions are given in Appendices 6.8. It was noted that those
who attempted the questions were fewer than those who chose not to attempt answering
I .
any; citing ignorance.
Lifestyles to avoid at menopause
On lifestyles to avoid during menopause, 16.5% of the women cited intake of poor diets.
Other [actors were long working hours, smoking, alcohol intake, contraceptives use,
sedentary lives, job insecurity and stress due to frustrations and poverty. Factors that
women should avoid during menopause include sedentary lifestyle, stress, smoking and
alcohol intake (R. Malkmus,1995).
106
Foods that alleviate ami control hot flushes
Foods that were regarded as effective in alleviating hot flushes, majority of the women
cited fluids intake (10.7%). Other answers included vitamins and mineral supplements,
consumption of vegetables, proteins and starchy foods. According to Hasler (2001),
foods that alleviate hot flushes are those rich in isoflavones; soya, pulses, vegetables
such as cabbage, sweet potatoes, and fruits such as oranges and pears (Hasler, 2001).
Recommended fats/oil for health
As indicated in , 95.9% of the women recommended hydrogenated shortenings such as
Kasuku while 4.1% recommended animal fat for cooking. The best oils for health are
vegetable oils such as olive oil, corn oil or sunflower oil. Hydrogenated fats should be
avoided. Their mechanism of action on plasma lipid profile, sabotage HDL's protective
effect on atherosclerosis by targeting HDL's major functional protein, by increasing
apoliprotein A-I 's (apoA-l) catabolism and clearance from the plasma. HDL's primary
protein constituent called apoliprotein A-I help clears cholesterol from the extra-hepatic
tissues and carry it back to the liver for breakdown and recycling.
Majority of the women (35.5%) did not regard fatty foods as healthy. Reasons for this
perception varied. According to the women, fatty diets were linked to; excess weight
gaining, heart problems, diarrhoea, and nausea. However, 3.3% of the women
recommended fatty foods. Fats should be taken in moderation so as to prevent
degenerative diseases such as heart diseases, cancer and diabetes (Ludington & Diehl,
2000).
107
Importance of vegetables andfruits in tile human body
Vegetables and fruits in the diets were associated with supple skin (3.3%) and reduction
of hot flushes (2.5%) O. A diet abundant of vegetables and fruits along with adequate
exercises and abundant oxygen are the key to good health and prolonged life (R.
Malkmus, 1995). Some vegetables and fruits are rich in isoflavones which when taken in
adequate amounts (40 and 80 mg/day) can alleviate hot flushes (Hasler, 2001).
Values of pulses in the body
According to the women, pulses provide warmth (1.7%), alleviating fatigue (2.5%) and
building body (3.3%). According to Grayson (2002), pulses are recommended for
menopause due to their high nutritive value and to alleviate symptoms associated with
menopause particularly hot flush.
Carbonated beverages and menopause
Carbonated beverages were seen to contribute to ill health (47.1%). Women attributed
general weakness, heartburns and ulcers, increased hot flushes and disturbances of sleep
(5.8%) to consuming them. Carbonated drinks contain extra sugar that creates blood
sugar surges, delay digestions and increase acid secretion that lead to more problems at
menopause (Ludington & Diehl, 2000).
Recommended beveragesfor menopause
The beverage women linked to good health was tea (5.8%). This response negated the
fact that caffeine found in tea and coffee aggravates hot flushes as well as encouraging
loss 0 f nutrients (Kirschman & Kirschman, 1996).
108
Most important meal
Lunch meal was regarded as the most important meal in a day (42.1 %) compared with
supper (33.9%) and breakfast (3.3%) respectively. Lunch was recommended for
provision of energy when most needed; when working, while supper was preferred since
for most women that was the only time meals could be taken calmly. According to them,
this prevented indigestion and promoted sound sleep. According to Ludington & Diehl
(2000), breakfast is the most important meal in a day to provide sufficient energy and
nutrients to last the day.
Foods for strong bones
A high percentage of the women recommended maize for strong bones (18.2%).
However, maize grains are rich in neither vitamin D nor calcium and phosphorous.
According to Pamplona-Roger (2004), foods rich in vitamin D, calcium, phosphorous,
magnesium and other trace elements such as boron and fluorine are necessary for proper
skeletal mineralisation. The foods should also prevent uric acid deposition in joints.
These foods include milk, soya, fruits and some green leafy vegetables, cabbage,
cauliflower, and broccoli which supply easily absorbed calcium (Pamplona-Roger,
2004).
Refined sugars and menopause
In 52.9% of the women, refined sugar was not regarded as good for health. Women
associated increased hot flushes, increased weight, diabetes and hypertension with high
intakes of sugar. Others allegedly fell sick upon its intake and thus avoided it.
109
According to Pamplona-Roger (2004), sweets and sugars exacerbate diabetes mellitus
while their excessive intakes promote colon, stomach and cervical cancers.
Weight gain and menopause
For 69.4% of the women increased, weight was not regarded as good for health.
According to the women, being obese interfered with working (19.0%), walking
(11.7%), increased health risks (33.9%), accelerates aging (0.8%) among others. A few
(0.8%) preferred being overweight, since being of slender body frame was associated
with a difficult and stressful lifestyle.
Exercises and menopause
Though 45.5 % of the women associated exercises with good health at menopause, 18.2
% viewed them as the source of their problems. Women regarded exercises as good in
management of weight, increasing appetite, a contribution to wellbeing through
alleviating stress, lifting moods, increasing libido and improving ones appearance. This
finding was in agreement with R. Malkmus (1995) that daily vigorous exercises enhance
clarity of mind, physical stamina, and give a sense of wellbeing.
4.10.3 Relationship between nutritional knowledge for menopause and
consumptions of foods rich in isoflavones
Spearman Rho correlations were used to correlate women's levels of nutritional
knowledge for menopause and frequency of foods rich in isoflavones. This was done to
establish whether the nutritional knowledge for menopause influenced consumptions of
various types of foods, especially those that alleviate hot flushes. Table 4.21 presents the
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110
relationships between women's levels of nutritional knowledge for menopause-and their
frequency in use of foods rich in isoflavones.
Table 4.21: Relationships between levels of nutritional knowledge for
menopause and frequency of intakes of foods rich in isoflavones among
menopausal women of Maragua Town-Kenya
Fruits
r value
r -.030
Sig.(2-tailed) .743
r -.185*
Sig.(2-tailed) .042
r -.001
Sig.(2-tailed) .995
r -.186*
Sig.(2-tailed) .041
r -.338*
Sig.(2-tailed) .000
r -.151
Sig.(2-tailed) .098
Foods rich ill isoflavones
Soya and its products
Yams
Dried pulses
Nuts
Vegetables
* & ** Significant at p<0:05
As shown in Table 4.2] inverse and weak relationships between women's levels of
nutritional knowledge for menopause and frequency of foods rich in isoflavones in the
diets were observed at 0.05 significant level. The significant relationships were however
between women's levels of nutritional knowledge for menopause and frequent of intake
of yams (r=-.185 p=.042), nuts (r=-.186 p=.041) and vegetables (r=-.338 p=.000) at 0.05
significant level. These results indicated that the frequent of consumption of foods rich
in isoflavones (Yams, nuts and vegetables) were accompanied by decreased levels of
.,rIIVATTA uumen ITV IIDQARV
111
nutritional knowledge for menopause. This fmding suggests that the higher the level of
nutritional knowledge for menopause the less frequently were the consumptions of foods
(yams, nuts and vegetables) rich in isoflavones. It was found that yams and nuts were
not common in women's diets as illustrated in Table 4.15 and Table 4.16. Vegetables
rich in ISO flavones such as cucumbers, turnips and sweet potatoes were also not common
in women's diets (see Table 4.16). Yams were no longer commonly cultivated locally.
Similarly, nuts were not produced locally.
Since foods produced locally tended to be readily available and cheaper yams and nuts
may not have been women's preference. This means that other factors such as scarcity of
the food, individual preference tastes and financial ability may have influenced
consumption of 100ds rich in isoflavones; nutritional knowledge for menopause
notwithstanding.
Relationships between the scores in nutritional knowledge for menopause test and
amounts of kilocalories and selected nutrients consumed by the women were determined
using Pearson Product-Moment correlation technique. This was done to determine
whether women's nutritional knowledge for menopause influenced their consumptions
of Kilocalories and the selected nutrients of the study. Table 4.22 illustrates the
relationships found between scores in the nutritional knowledge for menopause test and
the amounts of kilocalories and the selected nutrients consumed.
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112
Table 4.22: Relationships between scores ID nutritional knowledge for
menopause test and amount of kilocalories and selected nutrients among
menopausal women of Maragua Town, Kenya
Nutritional substances r Sig (2-taiied)
Kilocalories -.011 .905
Carbohydrates -.089 .334
Fibre .040 .667
Vitamin A -.132 .150
Vitamin C -.110 .230
Magnesium .124 .174
Calcium -.014 .877
As indicated in Table 4.22, there was no significant relationship between women's
scores in the nutritional knowledge for menopause test and consumption of kilocalories,
carbohydrates, dietary fiber, vitamins A and C, magnesium and calcium at 0.05
confidence level. With the exception of dietary fiber and magnesium (which were
positively correlated); inverse relationships were noted between symptoms associated
with menopause and kilocalories, carbohydrates, vitamin A and C and Calcium at 0.05
confidence level. The results indicate that the higher the scores in the test the less likely
were the consumptions of kilocalories and carbohydrates, vitamin A and C, and calcium.
These findings imply that women with higher scores in the nutritional knowledge for
menopause test tended not to consume foods that were rich in kilocalories,
carbohydrates, vitamin A and C, and calcium. Studies show that factors such as socio-
economic factors (reduced income, retirement or inflation, changes in family sizes,
institutionalization, changes in environment, and lack of storage or preparation
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113
facilities); psychological factors to include changes in dietary practices, depression,
confusion; and physiological factors compromises nutrition in the later years (Alford &
BogIe, 1982).
4.11 Relationships between dietary intakes and presence of symptoms associated
with menopause
4.11.1 Relationships between total amount of isoflavones in the diets and presence
of hot flushes
Pearson Product-Moment correlation technique was carried out to establish the
relationship between the total consumption of isoflavones and incidences of hot flushes.
It was found that there was an insignificant, inverse and weak relationship between
amounts of isotlavones consumed and incidences of hot flushes (r=-0.021, p=0.020) at
0.05 level of confidence.
This finding suggests that a decrease in isoflavones in the diet was being accompanied
by an increase in the incidences of hot flushes. This fmding concurs with research
reviewed in Hasler (2001), on soy and hot flushes that soy isoflavones were more
effective than control treatments in reducing the incidences and/or severity of hot
flushes. It has been found that a 40 - 80 mg/day of isoflavones in a period of not less
than 12 weeks help alleviate hot flushes (Hasler, 200 I).
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114
4.11.2 Relationship between consumption of kilocalories and selected nutrients with
the presence of symptoms associated with menopause
Pearson Product-Moment correlation was used to establish the relationships between
amounts of kilocalories and selected nutrients in the diet with the presence of
menopausal symptoms and those that coincide with menopause. Table 4.23 present the
relationships between total amounts of kilocalories and selected nutrients with the
presence of symptoms associated with menopause.
115
Table 4.23: Relationships between amount of kilocalories and selected nutrients consumed with
the presence of symptoms associated with menopause among menopausal women of Maragua
Town, Kenya
Variables Kcal eHO Fiber VitA VitC Mg Cat
Insomnia R -.055 -.018 -.I 71 .116 -.037 -.057 -.021
Sig. (2-tailed) .551 .848 .061 .204 .688 .532 .818
Anxiety R -.091 -.271 ** -.093 -.051 -.088 -.008 .051
Sig. (2-tailed) .321 .003 .310 .579 .335 .927 .576
Depression R -.125 -.178 -.211 * -.047 .015 -.139 -.101
Sig. (2-tailed) .171 .051 .020 .606 .874 .129 .273
Night sweats R -.076 -.011 -.076 -.037 .016 -.049 -.254**
Sig. (2-tailed) .405 .905 .408 .684 .865 .597 .005
Headaches R -.085 -.088 -.085 -.120 .032 -.047 -.043
Sig. (2-tailed) .354 .335 .352 .191 .731 .607 .640
Backaches R -.065 -.068 .014 .074 .081 .oI8 -.027
Sig. (2-tailed) .476 .455 .880 .421 .379 .844 .772
Loss of libido R -.153 -.179 -.110 .048 -.140 -.214* -.085
Sig. (2-tailed) .094 .050 .229 .599 .126 .018 .355
Mood swings R -.153 -.157 .006 .048 -.059 .019 -.017
Sig. (2-tailed) .095 .085 .945 .604 .522 .833 .851
Cryinr spells R -.040 -.148 .132 .013 .038 .027 .094
Sig. (2-tailed) .666 .106 .150 .887 .680 .772 .304
Fatigue. R -.303** -.360** -.149 -.068 -.211* -.190* -.224*
Sig. (2-tailed) .00) .000 .103 .457 .020 .037 .014
* & **= significant at pSO.05
The results in Table 4.23 shows that there was a significant, negative and weak
relationship between amounts of Kilocalories consumed and the presence of fatigue (r=-
.303 p=.OOl) at 0.05 level of confidence. Amounts of carbohydrates consumed by the
women were negatively related to anxiety (r=-.271 p=.003) and fatigue (r=-.360 p=.000)
116
at 0.05 level of confidence. These results suggest that women who had consumed low
amounts Of kilocalories and carbohydrates experienced incidences of fatigue and
anxiety. Symptoms such as irritability, crying spells, anxiety, excessive sweating,
depression, tiredness, forgetfulness and lack of concentration occurs when blood sugars
drop, releasing stress hormone, adrenaline (Beckham, 2002). Adequate consumption of
carbohydrates is associated with sustained energy and balanced sugars, greatly reducing
mood swings and fatigue (Ludington & Diehl, 2000).
Similarly, a significant, negative and weak relationship between dietary fiber and
anxiety (r=-.211 p=.022) at 0.05 level of confidence were observed. This indicates that
women who had low consumptions of dietary fibre were likely to experience anxiety.
Dietary fiber balances hormones more so at menopause controlling menopausal
symptoms (Parihar & Shar, 2001).
There:was a significant, negative and weak relationship between amounts of magnesium
with incidences of fatigue (r=-.190 p=.037) and loss of libido (r=-.214 p=.01O) at 0.05
level of confidence. This indicates that women who had consumed low amounts of
magnesium were more likely to suffer from fatigue and loss of libido. A diet with
adequate magnesium prevents fatigue and neurological alterations manifested m
menstrual cramps and heart palpitations among others (Pamplona-Roger, 2000 b).
Amounts or calcium consumed were negatively related to fatigue (r=-.224 p=.014) and
sweats (r=-.254 p=.005) at 0.05 level of confidence. These data show that consumption
of more calcium in the diet was accompanied by a decrease in fatigue and night sweats.
117
Inadequate consumption of calcium has been associated with increased irritability,
insomnia, headaches and depression (Kirschman & Kirschman, 1996).
4.11.3 Regression analysis
Regression analyses were used to ascertain the nutrients that were significant in
predicting occurrences of symptoms associated with menopause. In this study, variances
in incidences of symptoms associated with menopause were accounted for by
consumption of kilocalories and the other nutrients selected for the study. T test was
used to determine the significance of the regression analyses. Nutrients that were
significantly correlated with menopausal symptoms were regressed to predict the portion
of the total variance in which symptoms were accounted for by diet at 0.05 level of
confidence. Table 4.24 presents kilocalories and selected nutrients as the predictors of
symptoms associated with menopause.
As indicated in Table 4.24, 12.2 % variance in fatigue could be explained by inadequate
consumptions of carbohydrates. Variances in fatigue were also explained by 8.4%
inadequate consumptions of kilocalories, 3.7% inadequate consumptions of vitamin C,
2.8% inadequate consumptions of magnesium and 4.2% inadequate consumptions of
calcium. These data ascertain that incidences of fatigue at menopause could not only be
explained by inadequate consumptions kilocalories and the nutrients (vitamin C,
magnesium and calcium respectively) but also by other factors not looked into in this
study.
118
Table 4.24: Kilocalories and selected nutrients as predictors of menopausal symptoms among
menopausal women of Maragua Town, Kenya
Predictors R2 Std error of t value (Observed Significance
estimate vs. Critical) p
Fatigue predicted by Kilocalories 8.4 .400 10.855 .000
-.3.474 .001
Fatigue predicted by Carbohydrates 12.2 .392 14.048 .000
-4.206 .000
Fatigue predicted by Vitamin C 3.7 .410 17.983 .000
-2.357 .020
Fatigue predicted by Magnesium 2.8 .412 13.968 .000
-2.357 .020
fatigue predicted by Calcium 4.2 .409 13.273 .000
-2.506 .014
Anxiety predicted by Carbohydrates 6.6 .482 8.796 .000
-3.076 .003
Loss oflibido predicted by Magnesium 3.8 .491 9.046 .000
-2.389 .018
Depression predicted by dietary Fibre 3.7 .478 11.659 .000
-2.357 .018
Calcium predicted by sweats 5.7 .484 9.246 .000
I -2.866 .005
Carbohydrates explained 6.6% of the variance in anxiety while 3.8% of the variance in
loss of libido was explained by inadequate consumption of magnesium at 0.05 level of
confidence. A. significant predictor of depression among the women was dietary fibre.
As shown in Table 4.24 fibre accounted for 3.7% of depression and calcium for 5.7% of
night sweats. The error of estimates indicated that these predictions were dependable.
These results support findings reported in Grayson (2002) that adequacy of nutrients in
the diet can reduce menopausal symptoms.
/
119
r
CHAPTERS
SUMMARY, CONCLUSIONS AND RECOMMENDATIONS
5.1 Introduction
The study aimed at establishing women's menopausal symptoms, their awareness,
perceptions and attitudes of menopause, dietary intake as well as nutritional knowledge
for menopause in relation to managing menopausal symptoms. A cross-sectional
descriptive survey approach was used, where multi-stage sampling technique was used
to purposively sample 121 women aged between 40 and 59 years, living and working in
Maragua town while simple random sampling technique was used for four clinical
officers and two nutritionists. Data collection instruments were interview schedules,
likert scales and focus group discussions. Quantative data was analysed using Statistical
Package for Social Sciences (SPPS) while qualitative data were translated, transcribed,
coded, categorised into themes and presented in text form.
5.2 Summary of findings
5.2.1 Socio-economic results
Women of between 40 and 59 years were included in the study. This age bracket
encompasses women likely to be in the menopausal phase. Majority (76.9%) of the
women were married and were therefore more likely to have had a higher fertility rate.
More of the women belonged to the low social strata since majority had low 'education
levels (28.9 % and 37.2% of the women being illiterate or of primary education
respectively) and lived below poverty line (52.1 %). Farming at subsistence level was
their major occupation.
120
5.2.2 Women's reproductive factors
With the respondents' ages of menarche being established as between 12 and 19 years
women were found to have entered child bearing at a median age of 20 years and last
born child at a median age of 35 years. More women (55.5%) of between 12 and 20
years old had given birth by 20 years compared to 39.6% of the women between 21 and
30 years. Women's family sizes were 6 children per woman on average which is higher
than the ideal family size in urban settling (4.3 children). These women not only
exhibited fewer gynaecological problems but also experienced regular menses
throughout their reproductive years. Irregularity of menses among the women that
signals entry into perimenopause began as early as 38 years or later as 55 years
depending on individual women.
5.2.3 Menopausal experiences
The menopausal symptoms prevalent among the women were hot flushes (65.3%) and
night sweats (56.2%). Other symptoms that may happened due to menopause or
coincided with menopause were prevalent too. These were fatigue (77.7%), backaches
(71.1), mood swings (67.8%), insomnia (65.3%), depression (62.0), anxiety (56.2%),
headaches (53.7%), loss of libido (53.7%) and crying spells (36.4%). These symptoms
were established as severe among the women.
5.2.4 Women's awareness of menopause
Menopause was locally defmed as mabura ni mathirite to mean child bearing age has
ceased. Women gladly welcomed it as a natural and liberating rite of passage into old
121
age. When menses slopped, I knew I was in my aging year. A woman described her
understanding of menopause.
5.2.4.1 Women's awareness of menopausal symptoms
Uncertainty of the onset of symptoms was found as most confusing, puzzling,
embarrassing and distressing. Women linked menopausal symptoms either to biologic,
environmental, familial, economic, social, nutritional illness and long term uses of
contraceptives and medicine. However, a large proportion ofthe women (48.7%) neither
knew what was ailing them nor the cause.
5.2.4.2 Societal constrictions in the dissemination of information about menopause
Though symptoms were prevalent (above 50% in nearly all the symptoms) the society's
prevailing culture did not encourage for dissemination of information especially between
spouses (1.7%). Menopause was a woman's affair; men wanted nothing of it. Thus,
more women (55.4%) preferred sharing their menopausal experiences with fellow
women with similar experiences discreetly, while 43.0% did not divulge their
experiences. Consequently, menopause was surrounded by secrecy and mystery.
5.2.5 Women's perception of menopause
Majority of the women (76.0%) perceived menopausal symptoms as most bothersome
and distressing. Physical and psychological changes due to menopausal symptoms,
especially severe ones affected women's work productivity, strained marital unions and
relationships with other family members and members of the society .
• ~ ••.• -., •••. .".. •••••..••.• ., •.•• ,.-. ••. " •••••.•• a • .,.,., ••..•.••••.•.•••
122
5.2.5.1 Copying with the menopausal symptoms
Nearly half (43.8%) managed their menopausal symptoms. Multiple actions were
applied to manage a symptom. Among these, divine intervention, and hospital visits
featured most, especially after other strategies failed. Over the counter medicine such as
anti-malarial medicine and pain killers were used to treat hot flushes, headaches,
insomnia, moods wings and fatigue. Herbs such as stinging nettle, black night shade,
tick berry and neem were used to treat an assortment of symptoms which include hot
flushes, insomnia, headaches, fatigue and depression. Other strategies used were
antibiotics, neglecting work, withdrawal strategy in case of crying spells and depression,
use of cold baths to alleviate hot flushes and night sweats among others. At the hospital
level medicinal therapy was preferred over nutrition counselling. This counselling was
for referral cases only; an average of2 in a week.
5.2.6 Women's attitudes towards menopause and menopausal symptoms
Despite symptoms being prevalent among the women, some of them did not know how
to respond to the changes of menopause (39.7%), though 18.2% of the women preferred
the 'watch and see' attitude. These latter cases did not see the need to seek help since
they perceived symptoms as normal for their age; things that women must endure.
However, their levels of satisfactions in various factors during the menopausal years
were skewed more to the negative. Except for the physical appearance, majority of the
women were dissatisfied with their financial wellbeing, sex life, physical and emotional
health status during the menopausal ages. Consequently, nearly 20.0% of the women
adjusted positively while 25.0% recorded difficulties in adjusting to the changes due to
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123
menopause. More than 50% did not mention an attitude change and consequently no
behavioural changes were being experienced by this group during menopause.
5.2.7 Women's dietary intake
Most women (70.2%) observed three meals in a day. However, meals were skipped
mostly due to lack of appetite. Snacks between meals were observed by a minority, (34.0
%) of the women.
In accordance to the pyramid of healthful diets, it was found that majority of the women
had consumed less than the recommended portion sizes of various classes of foods. In
addition. women's choices of food per week were limited. Meals were therefore
monotonously repeated over several times in a day or a week. Isoflavones rich foods
were also not frequently consumed. In reference to the WHO (1990) and National
Academy of Sciences (1998) Recommended Dietary Allowances, diets registered
inadequate energy content, carbohydrates, dietary fiber, vitamin A, magnesium, calcium,
and 'isoflavones. Vitamin C consumption was above the RDA of 60 mg/day. However,
due to its volatile nature, its level was handled with caution.
5.2.8 Women's physical activities
Women involved in activities that required exertion of enormous energy such as farming
and housework were represented by 95.9% as opposed to 4.1% not active. More women
lead active lifestyles (98.3%) of which walking was the most common (94.2%). More
women (57.9%) walked for not less than 30 minutes daily as opposed to 1.7% of the
women who hardly walked. Other types of exercises were gymnastics and aerobics.
124
5.2.9 Women's Nutritional knowledge for menopause
Majority of women (68.6%) measured low nutritional knowledge for menopause
compared to 31.4 % of medium level.
5.2.9.1 Relationship between nutritional knowledge for menopause and
consumption of isoflavones rich foods
There were significant and negative relationships between women's levels of nutritional
knowledge for menopause and frequency of yams, nuts, and vegetables rich in
isoflavones in the diet. This meant that lower nutritional knowledge for menopause was
accompanied by increased intake of these foods. Foods rich in isoflavones were hardly
common in women's diets: Women's preference to cheaper substitutes for vegetables,
fruits and pulses rich in isoflavones with readily available ones which unfortunately
were not good sources ofthe isoflavones may have contributed to this fmding. Similarly,
no significant relationship was observed between the scores women got from the test and
consumption of kilocalories, carbohydrates, dietary fibre, vitamin A and C, The results
indicate a tendency )'Vherewomen with higher scores being less likely to consume
adequate kilocalories and nutrients.
5.2.10 Relationships between dietary intakes and incidences of menopausal
symptoms
Hot flush was negatively correlated with amounts of isoflavones in the diet and results
found insignificant at 0.05 level of confidence. This indicated that increased intake of
isoflavones in foods may have led to decreased incidences of hot flushes. Adequate
consumption of kilocalories was shown to be accompanied by decreased fatigue while
'.
125
carbohydrates consumed led to decreased anxiety and fatigue at 0.05 level of
confidence. Similarly, adequate consumption of dietary fibre showed a decrease in
anxiety while magnesium showed a decrease of fatigue and loss of libido. Adequate
calcium in the diets too was accompanied by decreased incidences of night sweats at
0.05 level of confidence.
As a result variance of fatigue was explained by inadequate amount of carbohydrates,
magnesium and calcium in the diet. Carbohydrates explained 6.6 % variance in anxiety
and 3.8 % loss of libido at 0.05 level of confidence. Dietary fiber accounted for 3.7 %
variance of depression and 5.7 % of night sweats.
5.3 Conclusions
Based on the results, the study's' conclusions were as follows; Women were ranked at
the lower social stratum. They sexually matured earlier than a century ago and entered
child bearing earlier than later. Consequently, their fertility periods were longer and this
could have contributed to the large households. Women's menses being regular prior to
pre-menopause and the fewer gynaecological cases, suggested that women's hormones
were generally harmonised.
Menopausal symptoms and those that happen eo incidently with menopause were
endemic among the women; the most common ones being fatigue, backaches, mood
swings, hot flushes, insomnia and depression. They were perceived to be associated to
not only the biological factors but also to psychological, socio-economic, cultural
lifestyle and nutrition. However, though culture recognized and welcomed menopause as
I
126
part of aging, it did not prepare the women for the implication cessation of menses had
on their lives and hence the prevailing confusion and secrecy.
It was also concluded that menopausal symptoms bothered and distressed women's
quality. Remedies chosen were as a result of lack of factual information and not
necessarily a preference to natural remedies. Women with severe symptoms were ones
that sought medical help in hospitals because they associated symptoms with other
illness. Nutrition counselling given at the hospital was inadequate and in some cases
inappropriate for good health during menopause. Medical practitioners preferred drug
therapy over counselling. Misdiagnosis could have led to wrong treatments as was
indicated by women mistrust towards convectional medicine in treating the symptoms.
Study concluded that women's attitudes towards menopausal symptoms were largely
influenced by individual perception of symptoms, cultural assimilation and ignorance.
Their positive attitudes somehow seemed to lessen the impacts of menopausal symptoms
in their lives. Therefore menopause signalled a turning point in women's lives that could
turn either turbulent or smooth.
In view of these results, it was concluded that though women's diets comprised mostly
foods of plant origin devoid of cholesterol and fatty acids concentrated in animal
products. However, they were monotonous and lacked variety along with a wide range
of nutrients namely; kilocalories, dietary fibre and selected nutrients (vitamin A,
carbohydrates, magnesium and calcium) and food substances such as isoflavones. The
isoflavones rich foods were less frequent in the diets. Women hardly used diets as a
mean 0f alleviating menopausal symptoms.
127
The study deduced that women lead active lifestyles, but had low nutritional knowledge
for menopause. However, when nutritional knowledge for menopause is treated in
isolation it does not influence food consumptions at menopause.
Diets rich in kilocalories, complex carbohydrates, dietary fibre, vitamins and minerals
are helpful in easing menopausal symptoms and can prevent their occurrences. This
means that food strategies can help manage menopausal symptoms thus allowing women
to pass through menopause more comfortably.
5.4 Recommendations
The following recommendations are given based on the fmdings of the study:
There should be increased counselling for women, especially on the effects of
menopause on health, relationships and work productivity. Men should be sensitized on
issues regarding menopause to reduce marital misunderstanding and participate more on
women's health to promote the wellbeing of the women and their families. Nutrition
education programme especially for menopause should be undertaken to bring about
specific food and nutrients increases in line with nutritional guidelines for good health at
menopause and post-menopause. Consequently, increased use ofisoflavones, vegetables
and fruits in managing symptoms associated with menopause should be encouraged.
Nutritionists should be in-serviced on nutrition for menopause. There should be up-to-
date publications about menopause that will be readily available to women and general
population. The government, through the Ministry of Education, should be sensitized on
the importance of incorporating nutritional knowledge for menopause into school's
curriculum as well as in the adult education programmes for better health at menopause.
128
Sustainable econorruc activities should be identified and encouraged to facilitate
women's economic independence.
5.5 Suggestions for further research
The study suggests the need for a clinical study on the effect of nutrients intake on
menopausal symptoms, with the aim of managing symptoms through nutrition. A study
on safety and significance of locally available herbs and traditional vegetables to
alleviate menopausal problems and a study on effect of exercises in the manage~ent of
symptoms associated with menopause should be conducted. A similar study may be
carried out in rural setting and well nourished women.
129
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Kermis, M.D. (1984).The Psychology of Human Aging: Theory, Research and Practice
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Kingsley, D. (2001, August 30). Early menopause is genetic. [On line] Retrieved on
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134
APPENDIX 6.1
Pop la ion of ain To 5;
Key: Number of
Inhabitants in
Main Towns
• Over 1 million
• 100 000 million
e 7 000-- 100 000
• 50 000 75 000
N
, MaralaJ
MiJlindi
Kilifi
INDIAN
OCEAN
c: 25 000--50 000
r, Below 25 000
135
APPENDIX 6.2
KEGEL EXERCISE
These can be made into daily routine. The correct muscle in the pelvic floor can be
achieved by simply squeezing to stop the urine stream from release every time the
woman is urinating. This is repeated several times a day to increase muscle control.
Regimens vary, but most agree that 10 repetitions two or three times a day are good.
Simply squeeze for a count of three seconds (count "one thousand one ... One thousand
two... One thousand three"). Then release. You can build up the repetitions, or squeeze
the muscle for longer periods of time. Health care practitioners agree that Kegel
exercises can be an important tool in preventing problems with urinary incontinence.
Source.: Janis Luft, R. N., M. S., Mt. Zion Faculty Practice, University of California at
San Francisco. In Henkel, 2001.
136
APPENDIX 6.3
INTERVIEW SCHEDULE FOR MENOPAUSAL WOMEN
(For Women of between 40-- 59 years)
Good day,
My name is Susan Wairegi, a post graduate student at Kenyatta University, Department
of Foods and Dietetics. I am undertaking a research entitled "Women's awareness,
perceptions and attitudes of menopause and their dietary intakes in managing symptoms
associated with menopause. A case of Maragua town, Kenya." I am interested in finding
out the symptoms associated with menopause, women's perception, awareness and
experience of menopause and dietary intakes in managing the symptoms associated with
menopause among Maragua town menopausal women.
You have been chosen as a respondent for this study, and Iwould be glad if you would
spare a few minutes and answer some few questions about yourself and dietary intake.
Your-responses will be treated with utmost confidentiality and will be for the sole
purpose of making recommendations on how nutrition counselling can be of used on
millions of women undergoing through menopause in order to make menopause a
comfortable transition.
Yours sincerely
SUSAN WAlREGl.
This part 10 be filled by the respondent.
I hereby consent to this interview. Signature _
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INTERVIEW SCHEDULE FOR MENOPAUSAL WOMEN
Respondent 110 _
Name of ward _
Age
SECTION A: Socio-economic and demographic information.
t. What is your marital status?
O. Single [I 1. Widow I] 2. Divorced 0 3. Married 0
2. How many children have you given birth to?
6. At what age did you conceive your first born?
7. At what age did you conceive your last born?
8. Have you ever had problems related to reproduction? 1. Yes 0 2. No 0
9. Ifthe answer to question 7 is yes, please name them. _
10. At what age did you notice your first menstruation period? _
11. Have your menstruation periods being regular? 1. Yes 0 2. No 0 3.N/ A 0
12. What is your education level? Tick the most appropriate answer.
1. No formal Education 0 2. Class 8/7 0
3.0 level/Form 4 [] 4. A level 0
5. College level 0 6. University level 0
13. Are you engaged in any occupation? O.No 0 l.Yes 0
14. If the answer to question 8 is yes, please specify which type. _
15. What is your income bracket? Tick the most appropriate answer.
16. If the answer tu question 12 is yes, please specify which type? _
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138
17. What is your income bracket? Tick the most appropriate answer.
1. Between 0 - Ksh5,000 0
2. Between Ksh 5,001 - Ksh 10,000 D·
3. Between Ksh 10,001 - Ksh 15,000 0
4. Above Ksh 15,001 - Ksh 20,000 0
5. Above 20,001. 0
18. In the past 12 months have you noticed any menstruation flow? 1. Yes 0 2. No 0
If your answer is no proceed to question 20.
19. Has your menstruation periods been regular? 1. Yes 0 2. No 0
20. At what age did you start noticing some irregularities in your menstruation?
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139
21. Approximately how long is it since you last noticed your menstruation period?
Answer yes or no 10 the following questions. If the answer is yes state how often in a
week.
Menopausal Symptoms Yes No How often in a week (1,2,3)
22. Do you experience sudden
sensations of heat throughout the body
followed by chills?
23. Do you lack sleep at night?
24. Do you have fear of the unknown or
uncertainties or troubled feelings?
26. Are you lacking enthusiasm In
things which were once of interest to
you?
27. Are you expenencing profuse
sweating through you clothes, especially
at night?
28. Are you expenencing continuous
dull pain in the head not pathologically
oriented?
29. Are you experiencing pain or aches
on the back?
30. Have you lost interest in sex?
28. Are you experiencing sudden and
frequent mood changes that are
unpredicted?
31. Are you experiencing tendencies to
crying triggered by insignificant issues
otherwise would not warrant the action?
140
Key;
1=1 -2 times in a week
3=5 and more times week
32. In your opuuon what factors do you associate these symptoms
2=3 -4 times in a week
with?------
33. Do these problems bother you? 1. Yes D 2. No D
34. If the answer to question 33 is yes, do you take any necessary measures to alleviate
or control these symptoms? 1. Yes D 2. NoD
35. If the answer to question 34 IS no, why not? Please give your
reasons. _
36. If the answer to question 34 is yes, what kind of action(s) do you take to alleviate
symptoms associated with menopause?
Name of the symptom(s) Ways of alleviating symptoms
r.
f
2.
3.
4.
37. Do these symptoms strain the relationships between you and your family members,
spouse, friends, your work output, etc? t. Yes D 2. No D
38. How? Please specify. _
39. Do you share your menopausal experiences with your spouse/friends?
1. Yes 0 2. No 0
40. Do you consult a medical doctor when these symptoms attack? 1. Yes D 2. No D
'.
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141
41~Within the last 3 months, have you consulted a medical doctor? 1. YesO. No 0
42. If your answer to question 40 is yes, what was your complaint? Please specify.
43. Do you engage in any activity at home or place of work, which results to exertion of
effort? 1. Yes 0 2. No 0
44. If the answer to question 32 is yes, what activity / activities is/are they?
45. Do you take brisk walks, or engage in any other forms or exercises? 1. YesO ~.No 0
46. If the answer to question 34 is yes, specify what type of exercise.
47. How often do you exercise?
1. Daily 0
2. Once every other day 0
3. Once in a week 0
I 4. Occasionally 0
5. Others. [J Specify. _
48. Has menopause changed your perceptions to life in any way? 1. Yes 0 2. No 0
49. If yes, in what ways? Please specify _
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142
50. Likert scale (To measure attitude of women towards menopause)
At this stage in you life cycle, attitudes and perceptions towards life in general
sometimes change. What can you say about the following in terms of how satisfying
they are in your life currently?
I. Financial status 1 2 3 4 5
2. Sex life I 23 45
3. Your physical appearance I 2345
4. Physical health 1 2 3 4 5
5. Emotional health I 2345
Key:
1=Extremely dissatisfied 3. Neutral 5. Extremely satisfied
2=Dissatisfied 4. Satisfied
'.
.,
It NVATT I
51. Food frequency table
From the food list below, state how often you take each of the following food items in
the last 3 months. (Tick where necessary). The following columns are represented as
follows. Number 1 = daily, 2 = twice a week, 3 = once a week, 4= occasionally,
5 = never,
Frequency taken
No Food item Amount 1 2 3 4 5 comments
1 Soy bean
Soy milk
Soy tlour
2 Yams
3 Dried pulses; Beans
Cowpeas
Peas
Lentil mature seeds .--
4 Nuts; Peanuts
Ground nuts
5 Vegetables
Cabbage
Carrots,
Sweet potatoes
Kale
Cucumber
Onions
5 Fruits; Pears
Tomatoes
Apples
Oranges
Plums
144
52. 24 -Hour recall table
Day of week recall Date _
(Respondents to recall the exact food intake and liquids during the previous 24 hour
period). Recall carefully the meals you have taken in the last 24- hours.
I. Name the meals you have taken in the last 24-hours? _
2. For each meal, in the last 24-hour.
1. What time did you take your meal?
2. What items did you take in your meal? - To include addition of herbs, sugar, salts
and other seasonings.
3. How much were they?
4. How were they prepared? Where were you when you were taking your
meal/snack
Offi . 1 nlCIa use 0 iy.
Time* Food Type and Items Amount Where Food Amount Code
items preparation added eaten code
*'" •••
I
Breakfast
Morning
Snack
Lunch
.-.---Afternoon
Snack
Supper
Evening
Snack
-
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145
• * Breakfast, tea snack, middy lunch, afternoon snack, supper,
everung snack.
• **Fried baked, toasted, whole wheat, fresh, frozen, canned,
creamed.
• * * * Ilome, restaurant carried lunch, school, semor center,
market, and childcare center.
53. Dietary history
1. Was the above intake unusual in any way? Yes. 0 2.No. 0
2. If yes, in what ways? _
5. for the other respective days of the week, what type of food / alternatives do you take
10r each of the following meals? _
1. Breakfast
2. Tea snack
3. Lunch
4. Afternoon snack
5. Supper
6. Evening snack.
Official use
Day of Food items Type and Items Amount Food Amount Code Comments
week preparation in it code
2 Breakfast
3
4
5
6
7 --------'----
'.
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146
Official use
Dayof Food Type and Items Amount Food Amount Code Comments
week items preparation in it code
2 Tea snack
3
4
5
6
7
Official use
Day of Food items Type and Items Amount Food Amount Code Comments
week preparation in it code
2 Lunch
3
4
5
6
7
Official use
Dayof Food items Type and Items Amount Food Amount Code Comments
week preparation in it code
2 Afternoon
snack
3
4
5
6
7
Official use
Dayof Food items Type and Items Amount Food Amount Code Comments
week. preparation in it code
2 Supper
3
4
5 --------
6
7
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147
Official use
Day of Food items Type and Items Amount Food Amount Code Comments
week. preparation in it code
2 Evening
snack
3
4
5
6
7
7. How many whole meals do you usually take per day?
1. One
2. Two
3. Three
4. Four and above.
8. If the above question is not 3 or 4, why do you skip the above meals?
9. Which specific foods do you take to alleviate or control the symptoms associated with
menopause that you have been experiencing?
I10. Do you take vitamins or mineral supplements? 1.Yes 0 2.No 0
11. If yes, how many per day? _
12. If yes, which kind (give brand name ifknown)
1. Multivitamin 0
2. Iron o
3. Ascorbic acid 0
4. Others o (List) _
13. Do you include herbs in your diet? 1. Yes 0 2. No. 0
14. If yes, name these herbs. _
148
16. Which herb do you use and for which symptom?
Name of the herb Symptom
1
2
3
4
149
54. Nutritional knowledge for menopause test
(For women of between 40 - 59years). Each correct answer carries 1 mark. Total marks
possible are 38.
Please answer the following questions to the best of your knowledge.
1. Name the lifestyles associated with health /nutrition that women in menopausal
transition in particular should avoid, in order to attain good health.
• Smocking, alcohol, sedentary life ..................................................... 3
• Two correct answer. ~ 2
• One of the above 1
• Don't know / any misleading answer. 0
2. Name the foods that can be used to control or reduce hot flashes and night sweats.
• Phytoestrogen rich foods such as soya, nuts, Pulses, grains, herbs 2
• One answer correct 1
• Don't know / any misleading answer. O
3. Which kinds of lipids are recommended for optimum health?
• Oils found in nuts, seeds, fish and vegetables .1
• Don't know / Don't know /incorrect answer O
4. Are high fat diets good for health?
• Yes 0
• No 1
5. Explain your answer.
• Avoid over weight, Avoid degenerative diseases 2
• One correct answer... 1
• Don't know/ any incorrect answer 0
150
6. Which health benefits do women acquire from consumption of fresh vege-tables and
fruits?
• Rich in fiber, vitamins, minerals, phytoestrogen and low in fat.. 3
Two correct answer. 2
One correct answer... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . 1
Don't know/ any incorrect answer. 0
•
•
•
7. What is the importance of pulses in the management of menopausal symptoms?
• Slows down digestion thus regulate hormones production, contribute to healthy
bones, low in fat thus control weight.. 2
• One of the above 1
• Don't know / any incorrect answer. 0
8. Do you think carbonated drinks and beverages containing caffeine have negative
effect on women's health and especially at menopause?
Yes 1 No O
9. Explain your answer.
• Encourage loss of nutrients, dehydration, lowers amount of calcium body can
take from foods 2
• One of the above 1
• Don't know / any incorrect answer. 0
10. What beverages should you take for good health?
• Fruit juices, water, vegetable juice to include soy milk and milk .3
• Coffee / tea 1
Don't know / any incorrect answer....... .. 0•
151
11. Which meal should be the largest in a day?
• Breakfast. 3
• Don't know / any incorrect answer 0
12. If question 11 is breakfast what are your reason for your choice.
• To provide ample nutrients for the day's activities 3
• Hungry more then 1
• Don't know / any incorrect answer. 0
13. Which foods are recommended for bone health?
• Low fat milk and its product, soy milk, green vegetables,
pulses 2
• Meat, bone soups 1
• Don't know / any incorrect answer 0
14. In your opinion, do high sugar foods have substantial benefits to the body especially
at menopause?
I yes O
15. If No, why.
• Cause hormone instability, increase weight, increase cholesterol level, and
No 1
contribute to dental caries, increase blood pressure 3
• Two answer correct. 2
• One answer COITCCt 1
• Don't know / any incorrect. 0
16. Is over weight recommended at menopause?
yes O No I
152
17. Explain your answer.
• Increase cholesterol, leads to heart and circulatory problems, Interfere with work
productivity; less work achieved 2
• One answer correct. 1
• Don't know / incorrect answer. O
18. Are exercises good for health at menopause?
yes J. No O
19. Explain your answer.
• Decrease cholesterol levels, decrease bone loss, improve stress management;
circulation and heart function, and improve nutrient
util ization 3
• Two answer correct. 2
• One answer correct. .1
• Don't know / incorrect answer 0
153
APPENDIX 6.4
NUTRITIONIST INTERVIEW SCHEDULE
Dear Nutritionist.
I am a postgraduate student at Kenyatta University, Department of Foods, Nutrition and
Dietetics. I am carrying out a research to find out Women's awareness, perceptions
and attitudes of menopause and dietary intakes in managing symptoms associated
with menopause. A case of Maragua town, Kenya. This interview guide aims at
finding out the average number of menopausal cases you attend in a day, the kind of
menopausal symptoms reported to you by menopausal women and the menopause
nutrition that you reconunend for these cases. The study will include menopausal
women, whose last birthdays lie between 40 and 59 years,
Assistance from you by granting me an interview at your convenient time will be greatly
appreciated. Information received will be treated in outmost confidence. Results of the
study will be shared on request.
Yours sincerely,
WAIREGI SUSAN.
This part to be filled by the respondent.
I consent to this interview.
Signature. _
'.
154
Nutritionist interview guide
Please fill in the following questionnaire.
1. Please indicate the years your have worked as a Nutritionist in this hospital?
1900 2000
2. For how long have you practiced Nutrition counselling? Years. 0 Months. 0
3. In your line of study in this hospital, do you come across women complaining of
menopausal symptoms? 1. Yes [] 2.No 0
4. If the answer to question 4 is yes please list the symptoms women complain o£
5. Do women come to you directly for nutrition counselling or does a Medical doctor
refer them? 1. Directly [J 2. Referred 0
6. What form of counselling do you carry out on menopausal cases?
1. Nutrition counselling only. 0
I 2. General counselling. 0
3. Both. 0
4 Others. 0 Specify _
7. What foods/herbs have you been recommending for women with menopausal
symptoms?
8. Do women come for follow-up counselling? 1. Yes 0 2. No. 0
9. What follow-ups actions do you usually recommend for these women?
'.
I
155
10. In your view women perceive nutrition counselling as
1 Not necessary 0
2 Not really making a differenceO
3 Beneficial 0
4 Others 0 Specify. _
'.
I
156
APPENDIX 6.5
PHYSICIAN (CLINICAL OFFICERS) INTERVIEW GUIDE
Dear Physician,
I am a postgraduate student at Kenyatta University, Department of Foods, Nutrition and
Dietetics. I am carrying out a research to fmd out Women's awareness, perceptions
and attitudes of menopause and their dietary intakes in managing symptoms
associated with menopause: A case of Maragua town. This interview guide aims at
finding out the average number of menopausal cases you attend in a day, the kind of
menopausal symptoms women complain of and the treatment given in the hospital. The
study will include menopausal women, whose last birthday lies between 40 and 59
years,
Assistance from you by giving me an interview will be fully appreciated. Information
received will be treated in outmost confidence. Results of the study will be shared on
request.
Yours sincerely,
WAIREGI SUSAN.
This part to be filled by the Clinical Officer.
I consent to this interview.
Signature _
I
157
Physician interview guide
Complete the following questionnaire.
1. Please indicate the year you were employed as a doctor in this hospital.
19 20---
2. For how long have you being a medical doctor? Years months. _
3. In your line of duty since the time you started working in this hospital, do you come
across women complaining of menopausal symptoms? 1Yes 0 2 No. 0
4. If the answer to question 3 is yes, please list these menopausal symptoms. _
5. What kind of therapy do you recommend for women expenencmg menopausal
symptoms?
6. Are there counselling services for women experiencing menopausal symptoms?
1.Yes 0 2. No 0
7. What complications related to menopause do these menopausal women experience?
8. On average how many menopausal women do you attend to m a day?
!
9. In your opinion what do women associate these problems with? (Tick the most
appropriate answer).
5. Disease 0
6. Stress from family, job, business etc 0
3. Contraceptives use in past years 04. Diet 0
5.0thers. 0 Specify. _
I
II AT r f\ j I 1, i•ur r, n j -r •. , .... _----
158
APPENDIX 6.6
FOCUS GROUPS DISCUSSION GUIDE
1. W11atis menopause?
2. What is the traditional definition of menopause?
3. How do you feel about it?
4. What kind of menopausal experiences do women suffer from?
5. What are the physical, social and emotional changes that occur during menopause?
6. How do women deal with the changes of menopause?
7. What kind of health problems do women at menopausal age suffer from?
8. What are the cultural perceptions of menopause?
9. Do women feel at ease discussing menopause and its' underlying symptoms?
10. Is information about menopause available and accessible?
159
APPENDIX 6.7
CALIBRATION TABLE
---Food item Enamel grams Spoon grams Others grams
cup (380
ml)
Bread - brown 4 slices 100
Bread - white 4 slices 100
Spaghetti 1 140
Macaroni 1/2 200
Maize meal 1 240
Finger millet I 240
Table sugar ltsp 10
Sorghum 1 tsp 6
Rice cooked (White) 1 350
Irish potato medium 1 medium 100
Beans, cooked ] 120
Bonavist I 120
Green grams 1 120
Peas, raw 1 120
Soya beans, raw I 320
Soya flour full fat 1 Tbs 12
Sweet potatoes 1 medium 310
I boiled
Proteins
Bacon slices 1 slice 10
Beefliver 5Tbs 100
Beefsteak 5Tbs 100
Eggs boiled 2 medium 100
Sausages 2 100
Milk and it product
Milk- whole milk 1 china cup 240
Yogurt 1 china cup 240
160
Food item Enamel grams Spoon grams Others grams
cup (380
ml)
Vegetables
Kale cooked I 260._-----
Tomato 1 medium 100
raw
Dhania 1/4 20 ITbs
Brinjals cooked J 320
Bitter gourd 1 medium
Carrot 1 medium 130 ITbs 20
grated 1 105-Cucumber 7 pc ' 28
Pumpkin peeled & 1 490
mashed
Cabbage boiled 1 140
Cassava leaves raw 1 260
Cowpeas leaves raw I 260
Managu I 260
Spinach leaves boiled 1 360
Sweet potatoes leaves 1 260
raw
Pumpkin leaves J 260
Green pepper Chopped 1 272
Fruits
Apple 1 small 80
Avocado 1/84" 25
diameter
Banana ripe 1 small 15
Banana raw 1 128
Lemon juice 1/2 200ml
Mangoes 1/2 small 70-Passion fruit 2 100
Orange juice 1/2 200
Paw paw 1/3 100
Plums 2 medium 100-------- .- ----Pineapples 'h cubed 160
Guavas 1
medium
Water melon J cup 350
Pears 1 medium 100
Tangerine 1 large 100-----_._._- _. --- .. -.-.----- --'-------
I
I(i I
Food item Enamel grams Spoon grams Others grams
cup (380
Illl)
Fats and oils
Cooking fat 1 tsp. 5
Margarine 1 tsp. 5
Salad oil 1 tsp. 5
Nuts
Ground nuts, dried & 6 small 12
salted
Beverages and drinks
Coffee infusion 1 china cup 240
Common soft drinks 1 small 300
ml
Chocolate instant 1 china cup 240
Tea black I china cup 240-Spices and condiments
Black pepper 1 tsp. 5
Red pepper Chili 1 tsp. 5
-.- ---- - ---Salt Itsp 5
Curry powder 1 tsp. 5
Garlic clove
Sugars
Honey ITbs 21
White sugar - ITbs 12
Grahulated
Others
Pancake 1 small 300
1 Plate chips I 250
Chapatis 1 6" 340
diameter
Green gram mix 1 china cup 240
Pigeon peas mix 1 china cup 240
Cowpeas mix I china cup 240
Irio 1 enamel 320
cup
Githeri 1 enamel 320
cup
Ugali cubed Ienamel 250
.-- - -- - ----- CLIP
'.
,
YATTA U , ERS T AR
162
API'ENDIX 6.8
Women's Responses to the Nutritional Test at Menopause
I. lifestyles to avoid N 0/0 Recommended
• Poor diets 20 16.5 Alcohol intake
• Frustrations due to stress and poverty 14 11.6 Smoking
• Over working 12 9.9 Sedentary lifestyles
• Sedentary lifestyles 3 2.5
• Change of jobs 2 1.7
• Alcohol intake, smoking, family 3 2.5
planning methods
2. Isoflavones rich foods
• fluids 13 10.7 Soya, nuts, pulses, grains
• Vitamins and minerals R 6.6 Herbs such as Valerian tea, Damiana
• Proteins 3 2.5
• Balanced diets, boiled foods, starchy @2 @ 1.7
foods
• Tea, green vegetables, cabbage 3 2.5
3. Recommended lipids.
• Vegetable fats such as Kasuku 116 95.9 Oils in nuts, seeds, fish, and
vegetables
• Animal fat 5 4.1
4. Fatty diets
• Good for health 18 14.9 Not good for health
• Not good for health 43 35.5
5. Reasons for or against fatty diets
• To avoid gaining excessive weight 36 29.8 Avoid over weight
• Avoid heart problems 13 10.7 Avoid degenerative diseases
• Nauseating 5 4.1
• Are good for health 4 3.3
• Causes diarrhoea 2 1.7
• Causes heartbums I 0.8
163
6. Importance of fresh vegetables and fruits N % Recommended
• improves skin 4 3.3 Supple skin
• Control symptoms 3 2.5 Fight diseases
• Build bones, for general health, @2 @ 1.7
facilitate proper digestion
7. Importance of pulses
• For body building 4 3.3 Slows down digestion
• Alleviate fatigue 3 2.5 Regulate hormones production
• For warmth and good health 2 1.7 Contribute to healthy bones
8. Carbonated drinks
• Recommended I 0.8 Not recommended in high amounts
• Not recommended 57 47.1
9. Reasons for Q 8
• Causes general weakness 13 10.7 Encourage loss of nutrients
• Increases hot flushes and other 15 12.4 Lead to dehydration
symptoms
• Causes ulcer, heartburns 7 5.8 Lowers calcium intake from foods
• Disrupt sleep pattern 7 5.8 Lead to weight gain '
• Affects liver 4 3.3
• Anti-diurectics 5 4.1
• Increase weight, disliked, addictive 3 2.5I
10. recommended beverage
• Tea 7 5.8 Fruit and vegetable juices
• Nylon, porridge 2 1.7 Water, soy milk, milk
11. Largest meal in a day
• Lunch 51 42.1 Breakfast
• Supper 41 33.9
• Breakfast 4 3.3
• Any 4 3.3
Y·-·~.... .. "".,,-r-o ..I .•. ..•.. . .. . - .~\J LI ARY
164
12. reasons N % Recommended -
• Lunch (Provide energy for work, 47 38.8 Provide nutrients for the day
prevent ulceration of stomach, be
active)
• Supper( To sleep well, taken calmly 36 29.6
to prevent indigestion, have time to
cook in evening, hungry in the
evening)
• Breakfast (To be active throughout 5 4.1
the day)
13. Foods for health bones N IX. Recommended
• Maize 22 18.2 Milk and its products,
• Fishl meat! bone soups 19 15.7 Green vegetables, pulses
• Milk 14 11.6
• Others such as githeri, pulses, salt, 19 15.8
14. High sugar foods
• Recommended I 0.8 Not recommended
• Not recommended 64 52.9
IS. Reasons for or against high sugar foods.
• Leads to hypertension 16 13.2 Cause hormone instability
• Leads to diabetes 14 11.6 Weight gain, > cholesterol levels,
I dental caries
• Increases hot flushes and other l4 l1.5 > blood pressure
diseases
16. Over weight / obesity at menopause
• Recommended I 0.8 Not recommended
• Not recommended 84 69.4
165
17. Reasons for or against N % Recommended -
• Interferes with working capability 23 19 > cholesterol levels,
• Interferes with walking! one tires 13 11.7 Heart & circulatory problems
quickly
• Increases symptoms e.g sweating 10 8.3 Interfere with work production
• Leads to health complications e.g 42 33.9
breathlessness, obesity
• Aging quickly 1 0.8
• Loss of weight may be 111 isconstrued I 0.8
as having problems
18. F,xcrciscs at mcnopa use.
• Recommended 55 18.2 recommended
• Not recommended 22 45.5
19. Reasons for or against
• Keep fit to remain healthy 22 23.2 < cholesterol levels,
• Reduce weight 4 3.3 < bone loss,
• AIlcviate stress, Iill moods, increase 10 8.3 Improve stress management,
libido, leads to self appreciation, improve circulation & heart
functions
• Increases appetite 2 1.7 Improve nutrient utilization
• Worsens symptoms 3 2.5
E T U y y
166
APPENDIX 6.9
Actions Taken to Relieve Symptoms Associated with Menopausal among Menopausal
Women of Maragua Town-Kenya
Symptom Action taken Action
N %
Hot flushes Prayers 9 7.4
Hospital visits 3 2.5
Anti-malaria drugs 2 1.7
Stinging nettle 2 1.7
Rest 1 0.8
Cold baths 1 0.8
Painkiller (Haraka) I 0.8
Black night shade (Managu) 1 0.8
Mibuthi 1 0.8
Total 32 18.2
Insomnia Prayers 9 7.4
Piriton 4 3.3
Hospital visits 3 2.5
Anti malaria drugs 2 1.7
Reading in bed 2 1.7
Total 20 16.5
Anxiety Prayers 11 9.1
Medicines 1 0.8
Hospital visits 1 0.8
Taking things easy 1 0.8
Stinging nettle I 0.8
Total 15 12.4
Depression Prayers 10 8.3
Hospital visits 3 2.5
Singing Christian songs 1 0.8
Withdrawing I 0.8
Avoid being with people 1 0.8
Stinging nettle I 0.8
Total 17 14.0
167
Symptom Action taken Action
N %
Night sweats Prayers 8 6.6
Hospital visits 5 4.1
Frequent baths 2 1.7
Stinging nettle I 0.8
Anti-malaria medicine I 0.8
Light clothing and bedding 1 0.8
Total 18 14.9
Headaches Prayers 6 5.0
Pain killers (Panados, 6 5.7
brufen, Haraka)
Hospital visits 4 3.3
Antibiotics I 0.8
Anti-malaria medicine I 0.8
Herbal tea 1 0.8
Stinging nettle 1 0.8
Muarobaini I 0.8
Mikigi I 0.8
Total 32 18.2
Backaches Pain killers 10 8.3
Prayers 6 5.0f
Hospital visits 3 2.5
Analgcsis 2 1.7
Antibiotics 1 0.8
Exercises 1 0.8
Avoid bendingloverworking I 0.8
Stinging nettle 1 0.8
Total 25 20.7
Loss of libido Prayers 5 4.1
Hospital visits 1 0.8
Total 6 5.0
168
Symptom Action taken Action
N 0/0
Mood swings Prayers 7 5.8
Hospital visits 2 1.7
Painkillers I 0.8
Withdrawing 1 0.8
Reading the Bible I 0.8
Support groups I 0.8
Total 13 10.7
Crying spells Prayers 6 5.0
Withdrawing I 0.8
Iluspital visits I 0.8
Singing Christian songs I 0.8
Support groups 1 0.8
Anti-malaria medicine 1 0.8
Total 11 9.1
Fatigue Prayers 6 5.0
Rest 4 3.3
Painkillers (Haraka) 3 2.5
Hospital visits 3 2.5
/
Taking a walk I 0.8
Stinging nettle I 0.8
EM-I I 0.8
Total 21 17.3
Y-_··. .~ . .~lTY L:BRARY
I
169
APPENDIX 6.10
IS OF LAVONES CONTENT IN FOODS
Source: Extracted from, USDA - Iowa state University Database on Isoflavones Content
of Foods, - 1999.
Units = mgll ~Og edible portion.
Description Nutr Desc Mean Max
9- grain bread Daidzein 0.01 0
Genistein 0.01
Total Isofl. 0.02
Beans, kidney, all Daidzein 0.02 0.02
types, mature seed, Genistein 0.04 0.06
raw Total Isofl. 0.06 0.08
Beans, red, mature Daidzein 0.00 0.00
seeds, raw Genistein 0.31 0.31
Total lso n. 0.31 0.31
Beans, small Daidzein 0.00 0.00
white, mature Genistein 0.74 0.74
seeds, raw Totallsofl. 0.74 0.74
Broad beans, fried Daidzein 0.00 0.00
Genistein 1.29 1.29
Total Isofl. 1.29 1.29
Chickpeas Daidzein 0.04 0.08
Genistein 0.06 0.12
Total Isofl. 0.1 0.2
Cowpeas, Daidzein 0.01 0.03
common, mature Genistein 0.02 0.03
seeds, raw Totallsofl. 0.03 0.06
Instant beverage, Daidzein 40.07 70.00
soy, powder, not
reconstituted Genistein 62.18 73.15
Glycitein 10.90 11.10
Totallsofl. 109.51 125.00
Lentils, mature Daidzein 0.00 0.01
seeds, raw Genistein 0.00 0.01
Total Isofl. 0.01 0.02
Peanuts, all types, Daidzein 0.03 0.05
raw Genistein 0.24 0.39
Totallsofl. 0.26 0.39
Peas, split, mature Daidzein 2.42 7.26
seeds. raw Genistein 0.00 0.01
Total Isofl. 2.42 7.26
170
Description Nutr Desc Mean Max
Pigeon peas(red Daidzein 0.02 0.02
gram), mature Genistein 0.54 0.54
seeds, raw Totallsoft. 0.56 0.56
Soy drink Daidzein 2.41 4.12
Genistein 4.60 7.10
Total Isoft. 0.1 11.22
Soy Daidzein 59.62 123.25
flour(textured) Genistein 78.90 144.02
Glycitein 20.19 28.28
Totallsoft. 148.61 295.55
Soy flour, full-fat, Daidzein 71.19 130.92
raw Genistein 96.83 145.23
Glycitein 16.18 24.83
Totallsofl. 177.89 264.84
Soy milk, fluid Daidzein 4.45 9.84
Genistein 6.06 11.28
Peanuts, all types, Glycitein 0.56 0.86
raw Totallsoft. 9.65 021.13
Soy protein isolate Daidzein 33.59 68.89
Genistein 59.62 105.10
Glycitein 9.47 26.40
Totallsoft. 97.43 199.25'
Soy sauce made Daidzein 0.10 0.10
from hydrolyzed
vegetable protein
I Genistein 0.00 0.00
Totallsoft. 0.10 0.10
Soy beans, mature, Daidzein 26.95 26,95
boiled, without Genistein 27,71 27.71
salt Totallsoft. 54.66 54.66
Soy beans, nature Daidan 46.64 91.30
seeds, raw(US, Genistein 73.76 134.10
food quality) Glycitein 10.88 16.70
Totallsoft. 128.35 220.90
Spices, fenugreek Daidzein 0.01 0.01
seed Genistein 0.01 0.01
Totallsofl. 0.02 0.02
Tea, green, Japan Daidzein 0.01 0.01
Genistein 0.04 0.04
Totallsofl. 0.05 0.05
171
Description Nutr Desc Mean Max
Tofu fried Daidzein 17.83 24.70
Genistein 28.00 35.10
Glycitein 3.37 5.30
Totallsofl. 48.35 65.10
Tofu, yogurt Daidzein 5.70 5.70
Gcnistein 9.40 9.40
Glycitein 1.20 1,20
Total Isofl. 16.30 16.30
Soy cheese, Daidzein 1.80 3.40
cheddar Genistein 2.25 4.00
Glycitein 3.10 3.50
Totallsofl. 7.15 10.90