Nutrition, Menopause, and Women’s Health at Midlife and Beyond with Annina Burns, PhD, RDN, FMCP

- Menopause is a major life transition for women that is associated with large changes in hormone levels and nutritional needs, as well as an increased risk of several chronic conditions. Many women are unaware of these critical changes until they begin to experience them for themselves. How can functional medicine clinicians help women understand their own unique nutritional needs following menopause and make appropriate lifestyle changes to prevent symptoms and mitigate the risk of chronic diseases? - Because nutrition counseling is largely an out of pocket, out-of-network service for most women, I thought, "How can I make it more accessible for people who cannot afford a one-on-one nutrition session?" And group coaching is the answer, because we can lower the cost, but also create community. - I am IFM Director of Medical Education, Dr. Kelechi Uduhiri. And on this episode of "Pathways to Well-Being," we welcome Nutritionist and Women's Health Expert, Annina Burns, to the show. And she will discuss how emphasizing gut health and food as medicine, instead of a focus on calorie intake and weight can help improve menopausal and midlife symptoms, and how the functional medicine collaborative care team model can help empower women to understand their unique nutritional needs and improve their health in midlife and beyond. Welcome to the show, Dr. Burns. - Thank you so much for having me. Absolutely. So thank you for joining us, and maybe we can begin by telling us a little bit about yourself and how you came to be a nutritionist, specializing in functional medicine, fertility, menopause, and women's health. - Thank you! I'm excited to be here. I got into nutrition as an Italian American who was always interested in food, having a grandmother who cooked all the time, having a mother that cooks all the time. And I was really interested in how food can be used to heal the body, in addition to being part of cultural tradition. And in terms of women's health, what I really noticed is there were these gaps in care for women. Before a woman wants to get pregnant, when she's looking at fertility, the pregnancy experience, postpartum, perimenopause. There's a lot of focus on like what we can do drug-wise or interventions, but there wasn't a lot of focus on how we could care for women and how women could best care for themselves to have the best possible outcome during these critical life course stages. - Yes, absolutely. So talk about what you learned along the way, because you are so correct. You know, as a physician myself, I remember in medical school, we got like maybe four hours of nutrition, and before that, there was so little in the education system about the impact on the health or food as medicine. So absolutely share a little bit more about what you discovered along the way. - Sure. So I had my own experience as a mother, as a woman trying to get pregnant, getting pregnant, trying to stay pregnant, have a healthy delivery, and a postpartum, and the difficulties in postpartum. And then, moving into perimenopause. And I felt like there's a lot of places for critical urgent care. - [Dr. Uduhiri] Mhm. - And a lot of the focus is very much on, certainly, survival as it should be. - [Dr. Uduhiri] Mhm. - But there's this whole other component of care, of how do we have optimum health? How do we prevent diseases later on? And we have these windows of opportunity that women have in the different life core stages that can really set the trajectory for later in life in those postmenopausal years. But there's not really a care model out there that's focused on women's overall health in those critical stages. And nutrition and food is critical in each life stage. Women have different nutrient needs depending on where they are in their life course and we need to address those needs. And then, they have their own genetic predispositions. There might be existing conditions, there's a whole host of factors that go into that really personalized precision care that women need to have the best possible outcome and also experience the best possible health wherever they are. - Absolutely. I love how you are sharing this, because for some reason, it is lost on the educational system. You know, how do we, as clinicians, as integrative or functional medicine providers, you know, we integrate food as medicine, but why do you think, even before we get to this specialty, that it's not even addressed? What is it in our society that is not focusing on food as medicine? What did you discover in your journey? - Well, I think we focus more on the diagnosis, right? So we're all about making a diagnosis and what you want to do is, long before there's a an actual disease state, there are conditions, and there are symptoms. And you wanna try to mitigate things before you actually have a diagnosis. But our system, and our reimbursement model, and everything else is focused on the diagnosis. And so, I think the whole system has shaped around that, versus focusing on the care course. And so, you know, what I do in women's health is, a lot of times, you know, before a woman gets to chronic UTIs, you can address that nutritionally. There's actually things that you can do, and then, you should still get a medical provider in on the picture. But you might not need to do a lifelong antibiotics in and out. You can actually do things nutritionally, and then, that will help you long term in terms of your course of your health, genitourinary urinary syndrome of menopause and other issues related in the postmenopausal space. And so, that's what I had really discovered. But I do think that we're, you know, providers are under intense pressure, and collaborative care is not often- - [Dr. Uduhiri] Mhm. - found in the true model and true form, the way it could be practiced, where you really get the best of all perspectives. - Absolutely. I think you hit the nail on the head when you said that we're focusing on the disease, right? So a model that focuses on disease is often not the same model that can also focus on wellness, correct? - Correct, that's right. And food is medicine truly means that day in and day out, you're actually taking care of your health. We're not using food at an end stage cancer diagnosis to try to troubleshoot. I mean, food is medicine in the best possible form. It's used in all forms, but it's really on that preventative side and that early symptom side to really mitigate other health issues that might develop further. - Right. And I also think that, you know, when a patient comes to a provider with a symptom, or a doctor, or their healthcare provider, right, because of, like you said earlier, there's such limited time, it's so much easier to just give them that pill, like a pill for the ill, versus focusing on, you know, the precursors, the nutritional aspects. So I think, you know, we should all be referring people to nutritionists, because it seems that if we're saying food is medicine, we need to teach people about that, correct? - Absolutely. And I think, often, there's, you know, a feeling that because we all eat, we're all experts on nutrition, and we're not, right? As you mentioned, you know, medical providers, you have a lot of training to do. It's not predominantly in nutrition. You might have four, six hours, a lot of that hasn't changed. But people, really, to unchanged dietary habits and fix food, a way that's best for your health, to understand the lab tests and the results that you have, and, you know, create a plan that's doable, and accessible for you, that's a multi-step process that you really need to work with someone on. - Wow. I feel like we can go on for days on this topic, because you're so right. You know, it's so multifactorial, and, you know, it seems like perhaps we're not set up in the conventional model to really manage this. And then, we get to menopause, and we're like wondering what happened, right? - Right. - But all the while, we have not really been taught how to nourish our bodies the right way, such that when it does change, we feel stuck and confused. So that brings me to that menopausal transition. That's a huge event in the life of a woman, but it seems like no one really talks about some of the big changes that occur for women nutritionally during this time. What are some of the main nutritional changes that happen for women during this time? You can start from midlife to menopause, that people are not aware of? - Sure. So let's capture first what the perimenopause and menopausal transition is. For many women, it starts in your late thirties, it's through your forties, and some women, in the early fifties. So the average age of menopause today in America is 51, and menopause is defined that you have 12 consecutive months without a menstrual cycle. So that's menopause. So the time before that in which you're starting to see metabolic changes is perimenopause. And that can last between four or 12 years, in some cases, longer. It's different for different women, it's different for different ethnicities. And so, and then, genetics plays a role in that too. I mean, how your mother, or your sisters, or your aunts experienced perimenopause can predict how you will experience it. So this menopausal transition period is, a period of metabolic changes. So when you asked, Kelechi, about nutritional changes, your nutrient needs change, because your metabolism changes. And for many women, they start to notice like, "Wow, I am now getting weight on my stomach, and I never had weight there before." I just had a picture last week from a client saying, "What is this little pouch?" And it's true- - Right, yeah. - that you get that weight in the abdominal area, because you actually have a decline in muscle mass. You have an increase in visceral fat. And visceral fat is more likely to show on the abdominal area. So even if you actually don't gain weight, a lot of times women notice that their weight, the way it is distributed in their body, it's more so on the abdominal area in the perimenopausal, postmenopausal timeframe. So this metabolism change occurs partly because it's muscle changes, which are related to hormones, but there's also glucose changes. So when you eat, your food breaks things down into glucose, and that is the energy that drives the body. Well, the glucose metabolism becomes altered. It doesn't work as efficiently. And we can talk about, you can change this, this is not an absolute trajectory, but hormones actually play a critical role in your metabolism. And as hormones decline, you actually see your metabolism declines and the efficiency of the body. And we have to work against this. But because that glucose metabolism changes, protein metabolism change also changes, ketone metabolism. And that means that you don't absorb and process foods the same way. And then, you know, Kelechi, you alluded to the microbiome in the gut, and we actually show that women's microbiome shifts in perimenopause, through post menopause. And it becomes less diverse. There are less bacteria, so your absorption of nutrients is altered. In short, what this means is women actually need more nutrients while their metabolic rate is declining, meaning you need to eat less, but more nutrient dense food. - Absolutely. And I feel like that could happen throughout all our life span, right? - Absolutely, yeah. - It's a great model, right? More nutrition dense, you know, our diet has been so calorie rich and nutrient poor from the time we were, you know, teenagers, or perhaps even- - That's right. - in early childhood. And so, I feel as if that pattern carries on through the different stages of life. And no one tells us that this is a problem before it's too late. So- - Right. And women notice it in perimenopause. - You notice it, yes! - Right. - So why do you think that so much of this information that you just shared with me right now is not more widely available? - I think there hasn't been a focus, historically, on perimenopause and menopause. It was considered something women just needed to go through and grin and bear it. And actually, it's a critical health stage and a life stage for women that can predict their later life years, their risk of chronic disease. You know, it is really important. And now, there's that realization that it's not just something that shifts, and there's nothing we can do. Actually, there's a lot we can do, and there's a lot we can push against in terms of natural actions that are happening, while also accepting them too. So what I'm saying is, I talk about what we can do actively, we can change our exercise, our food patterns, you know, our stress, our sleep, because all of those are going to be a little bit harder. Like, we're going to notice changes in our bodies. So we have to be more proactive in addressing, and we can't just, if we just sit back, we're gonna see more changes, mostly on the negative side, if we don't proactively act towards them. - Wow, that's really big, because, you know, what you just shared right now, I don't recall ever getting that training to share that with a patient, whether I was in family medicine, preventive medicine, not until I got to functional medicine, right? - Right. - So think of all that education, all the time we spent in school as clinicians and as dieticians. And you probably got it sooner, because that's the field you went into. You were inherently aware of the importance of food as medicine from a very early in your career. So it's so fascinating that we are in a model that sometimes misses that piece. - I think it is a missing piece for different providers. And I learned about food as medicine and nutrition, but I didn't learn about women's life course in a detail that I really approach it now, and I've done continuing education with, and developed an entire practice model on. And I think we could all be better versed in the life course stages and the basic nutrient needs that women and men also have in these different stages. - Absolutely. And you mentioned something that, you know, you learned about the nutrition, you learned about, you know, dietary changes and needs, but then, you didn't learn about the women's health piece. So at what point did you start to put two and two together and realize that those these two ones go together? - So as a woman, I struggled with getting pregnant, and I would go to an OBGYN.. And they said, "Well, try for six months. If not, go to IVF. Those are your two options." - [Dr. Uduhiri] Mhm. - But in fact, there are many reasons why women don't get pregnant. And it's important to look at all the different reasons. No one asked me what I was eating, no one asked me how I was sleeping, how my exercise was, sleep, and a host of other issues. There's genetics there, there's testing, our lab tests, what do my lab values look like, thyroid, adrenal testing, and so forth, nutrient testing. And so, I realized there's a space that is needed for women to really get answers for fertility, but also, for perimenopause. All of these contribute to your experience, and yet, we don't look at them, because the current model is just focused a little bit more on the diagnoses and is limited in what we can see. - Yes. And the reason that current model is so focused on diagnosis is because that is what we are taught to do. And so, when you're taught to do one thing, you do that thing, but like you said, the lifestyle piece is left out. And you know, that is, you know, so important to how a woman goes through these different life changes. So I'd love to hear more about, you know, how you've created that space for women, which I think is so critical. And I believe that if you're, no matter what type of provider you are, or doctor, or clinician, this is important information, because who's sick in healthcare the most? It's women, right? So tell us a little bit more about your collaborative care model that allows women to be seen and heard. - Sure. So I work in a pelvic health clinic. We have a physician, a pelvic floor physical therapist, and myself, and I'm the nutritionist. And what we've found is, what happens is women have issues. So they might have pain, vulvodynia, vestibulitis, they might have gut issues, abdominal issues, they might have a prolapse, they might not know what they have, right? And they can't seem to find a provider that knows the answer or has a diagnostic tool. But what we created was this pelvic health clinic so that you could see three clinicians at once in the same room, all providing their own diagnoses, but hearing what each other is discovering as well. And they walk away with three different steps of what to do for each. So I'll give you an example. You know, a patient will come in, the physician will do an ultrasound and kind of look and see what's available to see. So in some cases, we've seen C-section scars adhere to the bowel, and this is a woman in their 60s. These are 30-year-old scars that nobody picked up, had adhered to the bowel, and that's why they were having significant abdominal pain that was not picked up in a colonoscopy. The pelvic floor PT can do an exam, and also, you know, figure out what's happening in the pelvic area. How strong is the pelvic floor, can they do a contraction? What else is happening in the body? How is it impacting other muscles in the area, in the full body? And as a nutritionist, I can also help. So this particular patient had chronic constipation, and so, I could provide a diet for constipation, as well as focusing on low inflammation, like increasing fruits and vegetables, antioxidants, and addressing that. So they were gonna have a procedure to remove that scar, but also, that means that it's a postoperative nutritional plan. There's things that you can do to help you heal from surgery and prevent the growth of scar tissue unnecessarily. And so, they walked away with three different diagnoses and had a plan for each and a next step. They didn't need to wait six months to see your next provider who told them something different, and another year to see another provider. You see everybody in one place at one time. - Oh my goodness, that sounds amazing. Wow. - It's amazing to be part of. Because that satisfaction- - I mean, that's amazing. Right! - For the patients- - Yes! - Just to get an answer when they have been suffering for so long, in the case of this patient- - Right! - 30 years of pain, you know? Her kid was 30. - Wow! - And not having an answer, right? And suddenly, walking away in one hour, three clinicians and having an answer. - That is powerful. Thank you for what you do, Dr. Annina. Because, you know, it seems that is the right approach, that is the medicine that needs to happen, right? Truly seeing the patient and having a multidisciplinary team come together to look at it from a holistic perspective, not just, "You have pain? Here's a pill. Let us know how you do in six months." But, "You have pain? Let's do a deeper dive. Let's get to the root cause." That is what you are truly offering, so thank you for doing that work. That is amazing. - Oh, thank you. I'm so privileged to be able to do it. - Yeah, that is amazing. So what are some of the challenges that you have experienced with getting this kind of care covered for your patients? Because you know we live in this insurance model, you know, how do you navigate that system that is also disease focused? - Sure. So I think in a lot of cases, nutritional care is not covered for the most part. It is not required to be covered, unless someone already has cancer, already has heart disease, already has had a stroke, or diabetes, right? It's a very, nutrition at its best can help everybody in all different stages. But at its best, it can actually help you before you have a full blown diagnosis, a stage four cancer, and so forth. But it is not required to be covered. And so, it is a struggle. And that's why most dieticians and nutritionists work out of network. Unless they're in a clinical setting in a hospital, unless they're working under a physician in an outpatient care clinic, we work out of network. But what I try to do for my patients is I try to give them the best basic medicine, right? So with the least amount of cost. - [Dr. Uduhiri] Mhm. - So I look at, you know, what lab work they already have done in the last three months, what they have, you know, what medical paperwork we do have. We work from that. We figure out what lab tests they can get covered under insurance, you know, working through their physician or physicians that I work with and providers I work with, so that we're slowly, we're not just doing thousands of dollars of testing off the bat, but we're really thinking about what makes the most sense given their condition for the least amount of cost. And just being really cognizant of it. And so, that's how I work as best as I can in the model to provide the best possible care. - And would you agree that it truly has to be like this? You've seen great results from this approach. Share with us, what are some of the outcomes you've seen from this collaborative care model? - Sure. So I will say with the collaborative care model, I mean, being able to get lab tests ordered, having a, you know, physician's eyes look at it and say, "Okay, and also, I would add these things as well." And having a PT saying, "Actually, you know, based on my diagnosis, you know, I think there's a significant musculoskeletal issues that need to be addressed concurrently," right? One thing you don't wanna wait is six months for a diagnosis, right? Like, let's address what we can while we can. So as a nutritionist, a physical therapist, there's all things we could be doing. We don't need to always wait until the endgame to begin. And so, I would say that's a key thing on a collaborative care model. And the second is working truly collaboratively with your providers. So the providers I work with know me well, they know my expertise. They trust the judgment of, you know, what I have found and what I'm recommending in terms of tests being done. And then, we talk about it. But that is something that is not the standard of care, right? It's something that we do on our own time. A lot of times, that's not a reimbursed time, but it is better for patients, and it's better for outcomes, so we continue to do it. - I love it, I love it. And can you share more? So what I'm hearing is, you know, you have a team, right, of clinicians, who are looking at the patient. And they bring in all this different expertise, and then, you come together with a solution, a path to well-being for the patient. Share with us a little bit about who or what conditions fit the best to this kind of care. - Well, I think a lot of women's health conditions, because they're multidimensional, right? So I'll give you an example in terms of perimenopause and menopause, your body changes, but your bone health changes. - [Dr. Uduhiri] Mhm. - Your musculoskeletal health changes, your muscle tone changes, your strength changes. So physical therapists are really a key part in perimenopause, menopause. They're also a key part for fertility and postpartum with pelvic health and preventing prolapse and having a healthy childbirth. So you have to have their perspective. And then, you have the medical perspective in terms of, like I said, you can have an adhesion, like that patient did, you know, had a bowel adhesion, you know, from a C-section scar. I can't see that. The physical therapist can't see that, but the physician could see that with their ultrasound, and they can make that diagnosis. And so, we needed that diagnosis as well, so that we could all formulate our collaborative solution and prescription for health that we give the patient to leave with. And the same thing in perimenopause. So sometimes, you might have bone and joint damage, and you might actually need that addressed by a physician, but we can help support the system with good nutritional health and good physical health, along with that diagnosis and any medical treatment that patient needs. - This is so fascinating. I'm just loving what I'm hearing today, Annina. I mean, because it is so often missing in how we approach women's health issues, this collaborative, you know, multidisciplinary approach. How can we, as clinicians, or what can we, as clinicians, do to help patients access this type of care, despite the challenges or maybe the insurance barriers? Any quick tips or suggestions for us? - I mean, I think the key thing is, as providers, making sure that we're creating collaborative care models. I will say the model that we have set up for the pelvic health clinic, it took work, it took effort, it took time for us to meet, you know, and put it together. And then, we, you know, have a role, and we go on, and we also teach it to others too. And so, I think as providers, we need to remember that if we are doing something to share it, so it can be replicated in different settings, right? This is something that could be replicated in a hospital setting. This could be replicating in a long-term care setting. This could be replicated in a primary care setting. You know, it doesn't just need to be in a woman's health setting. And it's a great model. And I think being able to share it, so that other providers can do it and put it in place, and really being thoughtful on when we give our patients recommendations, that they can follow through. So that was that pain point for me and why we created this clinic is I hate being and saying, "You need to go to a physician and find a lab and get these lab tests done." And they said, "I don't have a primary care doctor, and all the wait lists, nobody's taking any patients. I can't get into one." It is my job as a provider to help my patient. I am not going to just leave them, waiting a year to try to get on someone's wait list. And I think we need to be really cognizant. We might not be able to fix system-wide problems, but it's like, what can I do in my immediate vicinity to help my patients get the care that they need without the length of time and not just send them out the door with a referral that never gets filled and diagnoses are not made. And the most important thing is often, people are in pain, or discomfort, or suffering unnecessarily, and a disease state can get worse during that time. - Wow, that's amazing. Thank you for sharing that. And I think that is so powerful, right? That, you know, owning the process, not letting patients, you know, struggle with the system, right? Helping them along the way and helping sure that the next step, that you are their advocate. So what I'm hearing is that not only are you a phenomenal clinician, but you're really an advocate for your patients as well. You help them move through the process and through the system, so that is awesome. I know that you've mentioned that you've recently shifted to doing more group coaching sessions with patients to make such services more accessible. Could you tell us a little bit more about how that works and the impact it's having on your patients? - Sure. So it's exactly what we were talking about, Kelechi. It's like, how can I take better care of my patients and make it more accessible? And because nutrition counseling is largely an out of pocket, out-of-network service for most women, I thought, "How can I make it more accessible for people who cannot afford a one-on-one nutrition session?" And group coaching is the answer, because we can lower the cost, but also create community, because many women are experiencing infertility. And there is a value in knowing that you're not alone. There is an intrinsic value, a community value, an individual value, but there's also a health value. And we've shown that. Isolation actually is a predictor for poor health, the feelings of isolation. And perimenopause and menopause is another area where I do group coaching in. And many women feel alone in the process, unheard, no one's talked to them about it. And so, they have that group, and it's at a lower price point that they can access. - Oh, I love that. And I know that, well, we know that you'll be a speaker at AIC 2026 in San Diego this May. Tell us more about what you'll be talking about there, and I hope you're gonna teach us about this collaborative care model. - Yeah, so I'm super excited to announce that the pelvic floor health clinic that I work with, the physician, the pelvic floor physical therapist, and myself, will be doing a panel on the collaborative care model, so that clinicians can learn exactly how our model works, how we actually provide billing for insurance reimbursement, how we do it in terms of time, how we fit it into our normal practice hours. because all of us practice separately. So you will have a chance to learn about it at AIC, and I'll also be talking about nutrition and menopause. - All right, folks, you heard it here first, Dr. Annina Burns will be at AIC 2026, bringing this amazing concept of group coaching and a collaborative care model to addressing nutrition, and midlife, and menopause. And I think it is just a must attend. So thank you for taking that time to, you know, bring your team to us in San Diego, and I cannot wait to meet you in person. So as we bring this episode to a close, I'm sad to say, what is the one big takeaway that you would like functional medicine clinicians to get from this episode, Dr. Annina? - That women's health is really important, depending on the life stage that they're in. Women are not just women. Women are where they are in the life course and their nutritional needs are different in each stage. - I love it. Thank you. Thank you so much for being here. Thank you for your time. Thank you for what you do. And thank you for making the world a better place for all women, Dr. Annina. - Thank you. - Thank you so much for having me. - Absolutely. And I'll see you at AIC! - Yep, I look forward to it! - All righty, take care. - All right, bye-bye! - [Dr. Uduhiri] Thank you for listening to "Pathways to Well-Being." Discover the latest research and clinical insights at IFMs Annual International Conference. Learn more at ifm.org/aic. The future is functional.