MENSTRUAL HYGIENE AND BALANCED DIET IN ADOLESCENT GIRLS IN UTTAR PRADESH, INDIA - By Carlotta
Menstruation is a periodic and cyclical shedding of progestational endometrium accompanied by loss of blood (1) and characterized by rise and fall of hormones. It is a normal physiological process that begins during the phase of the adolescence between the age of 11 and 14 years old. Normal menstrual cycle occurs every 28-35 days (with a physiological variation of 2-3 days) with an average loss of 30mL-80mL of blood. However, it may be associated with various symptoms occurring before or during the menstrual flow (2). This leads to an abnormal menstrual cycle and to several diseases connected to it.
In India, the prevalence of menstrual diseases has been recorded as high as 85%-93% in total female population and it has been seen to be a disorder that mainly involves adolescents. In most cases, this affects the normal lifestyle of an adolescent, leading to a decrease of the quality of her life, to the loss of productivity and to innumerable psychological, physical and relational problems that may result to be debilitating. Before or during a period, girls often experience a general weakness and a deep sense of discomfort and feel so uneasy that they may not feel comfortable to go to school.
In general, health conditions, socioeconomic and nutritional factors play an important role in the duration and in the appearence of menstrual diseases. In this article we propose to take in consideration the role of a balanced diet in avoiding the main disases caused by menstrual flow.
A school-based descriptive study made on a population of 320 adolescent girls aged 14-17 years in Aligarh city (Uttar Pradesh) in the academic year 2017/2018 showed that main menstrual disorders prevailing in young girls are menstrual irregularities and pre-menstrual syndrome (PMS).
The prevalence of menstrual disorders was obtained through a menstrual questionnaire.
Menstrual irregularities are defined as missed, delayed or erratic periods or abnormal bleeding patterns. They include several diseases as infrequent menstrual periods which occur more than 35 days apart (oligomenorrhea); frequent menstrual periods which occur less than 21 days apart (polymenorrhea) and absent menstrual periods for 3 months continuously (amenorrhea).
In the population that was took in consideration by the first study, it was found that 12,8% of girls was affected by oligomenorrhoea, 22,2% of them was affected by polymenorrhoea and 21,3% of them by amenorrhoea.
In a more recent study, it has been recorded that almost 50% of adolescents in India have irregular menstrual cycle.
A persistent menstrual irregularity can increase the risk of incurring conditions such as iron deficiency anemia. Anemia develops when iron stores, which are needed for the production of proteins such as hemoglobin and for the proper functioning of red blood cells in distributing oxygen to tissues and in eliminating carbon dioxide, are reduced or absent. In a normal menstruation, about 3 mg to 30 mg of iron is lost.
As a result, these individuals are often weak, and they experience conditions such as headaches, prolonged migraines, fatigue and extreme exhaustion, hair loss, stress connected to a neurocognitive dysfunction and dizziness.
Premenstrual syndrome (PMS) is a heterogeneous set of physical and psychological changes, which are highly variable depending on the case. Premenstrual syndrome occurs 7-10 days before the arrival of the menstruation and improves or disappears completely a few hours after the onset of it.
The most common symptom is dysmenorrhea, that is defined as an acute and cramping pain which is manifested by spasms in the lower abdomen spreading to the back and thighs. The pain ranges from mild, to unpleasant, to severe and few adolescent girls require medical help (3).
Premenstrual syndrome affects the emotional sphere with mood swings, crying fits and hunger pangs accompanied by decreased concentration, confusion, depression and nervousness and the physical sphere with symptoms such as headache, breast pain and bloating.
Premenstrual discomfort is an important social consecuence that influences adolescent girls’ life in a major way and in numerous aspects, starting from a loss of school days due to a sensation of discomfort to a prolonged bed rest and a period of isolation, to a chronic sleep disturbance and decreased appetite.
Approximately, in 10%-40% of indian girls, this disorder has an impact on their school life and their lifestyle
(4).
Premenstrual dysphoric disorder (PMDD) is a severe form of premenstrual disease and it causes extreme mood shifts that can disrupt school life and daily life. Main symptoms include extrem depression and a marked anxiety in addition to PMS common symptoms such as bloatting and periods of crying.
As in PMS, the symptoms begin to interfere with girls’ usual social functioning.
In comparison to PMS, it's possible that the hormonal changes that trigger a menstrual period worsen the symptoms of mood disorders.
Previous indian studies have found a 20% prevalence of premenstrual syndrome in the general population and, among those with PMS, 8% had premenstrual dysphoric disorder associated with severe symptoms (5). Actually, in the menstrual questionnaire targeting a total 320 adolescent girls that we decided to take as a point of reference, the data revealed that premenstrual syndrome is the most common disorder with the majority of girls (71,3%) suffering from.
The causes of premenstrual syndrome are not fully known. Major contributing factors are thought to include low serotonin levels, a deficiency of magnesium and calcium, and hormonal fluctuations in estrogen and progesterone, in addition to alterations in response to these two hormones, which can cause transient water retention, that means an accumulation of fluids in the cavities of the body.
Calcium supplementation has a functional role in the relief of symptoms associated with PMS.
Impaired calcium metabolism leads to magnesium deficiency. Magnesium is a mineral and trace element essential for the maintenance of cellular homeostasis and it is important because it has an effective detensive action on the muscles of the uterus, improving spasm, with the consequence that it helps reduce symptoms related to dysmenorrhea. It also counteracts irritability typical of the premenstrual period and relieves water retention. An intake of magnesium is extremely helpful in the treatment of premenstrual syndrome. Its presence in foods is quite widespread, especially in vegetables.
Serotonin is a neurotransmitter found in the central nervous system and involved in the regulation of mood and behavior. In addition to acting as a mood stabilizer, serotonin allows one to live a balanced life by promoting a restorative sleep routine.
It is a substance responsible for the state of well-being, and its decrease in it in the body can affect women’ susceptibility, especially adolescents’ susceptibility, to PMS symptoms.
During a period, it is therefore recommended to consume foods that contain a generous amount of tryptophan, which is the aminoacid that contributes to the synthesis of serotonin, so as to counter mood disorders such as depression and anxiety.
Foods that keep serotonin levels high include eggs, fresh acid-set paneer, and salmon along with a serving of healthy carbohydrates such as basmati rice, oatmeal, and whole wheat chapati.
Therefore, there is a strict correlation between menstruation and a balanced diet. The more balanced and correct the diet is, the better are the chances of reducing the symptoms connected to the menstrual flow.
A balanced diet defeats fluid retention and, thus, it can alleviate or make the main symptoms of PMS disappear.
Diet is to be understood as a true lifestyle, that is, a set of healthy and correct habits, which put into practice on a daily basis, can exert a strong impact on the health both from a preventive and protective point of view (6).
As we mentioned, these elements (iron, calcium, and magnesium) play a key role in the management of symptoms related to PMS and irregular menstrual cycle, consequently they should be introduced in an appropriate amount by following a precise diet.
First of all, the water balance in the body must be rebalanced. In fact, hormonal fluctuations in estrogen and progesterone cause water retention in the lower abdomen, breasts and ankles, which causes a feeling of bloating, that can be aggravated by the other symptoms of PMS.
Since most PMS symptoms occur before menstruation, there are several ways to counteract fluid retention.
It is necessary to drink at least 2 liters of water daily (8 glasses of water a day) to ensure proper daily water intake and to expel salt and toxins from the body. Water is responsible for all the physiological processes that normally occur in the body, such as digestion, absorption of food, and the proper elimination of waste. However, water can also be introduced through other sources, such as fruits and vegetables. Fruits, vegetables, legumes and whole grains contain fiber, which are very important in maintaining bowel function and preventing constipation, which is one of the main consequences of water retention.
For instance, one can eat salad, fruit salad, one small cup of bhindi or kidney beans (rajma) and/or, as a beverage, natural tender coconut water.
Secondly, one needs to increase iron intake before or during a period to replace physiological iron loss during the menstrual flow. Iron is particularly bioavailable in certain foods, such as meat, fish, and legumes. In particular, fish is rich in iron, protein and omega-3 fat acids, so it is an excellent nourishment both to counteract a decrease in iron levels and to balance the ratio between omega-3 and omega-6 in the body.
The ratio of omega-3 to omega-6 in a healthy diet is 4:1, yet in India this ratio varies greatly between rural areas (6:1) and urban areas (38:1 to 50:1), a sign of a diet that is too unbalanced towards omega-6.
High circulating levels of omega-6 from a diet excessively rich in vegetable oils is another major cause of dysmenorrhea.
From a biological point of view, both omega-3 and omega-6 belong to the prostaglandin family; however, they have a antagonistic function, in fact omega-6 has a pro-inflammatory function while omega-3 has an anti-inflammatory function, so omega-3 counteract the action of omega-6 and are related to a reduction in inflammation levels and thus to a decrease in pelvic pain.
Increased omega-3 intake helps decrease menstrual pain and can balance mood and the feeling of sadness and nervousness typical of the days leading up to the arrival of a period.
It is recommended a diet that considers iron-rich foods, such as red meat or meatloaf dishes, as kofta, and fish curry.
Proper magnesium and calcium intake also has a defensive effect against PMS symptoms.
The introduction of calcium into the diet plays a key role in the relief of symptoms associated with premenstrual syndrome. Calcium is also important because it makes bones stay strong.
Among 99% of the human body's calcium is contained in the bones, where it is accumulated and stored. Nevertheless, small amounts of calcium are consistently removed from the bones, so they need to be refilled with calcium rich foods.
A research based on women taking 500 mg of calcium carbonate twice a day for 3 months found they had less fatigue, fewer changes in appetite and less depression than women with PMS who did not take the supplement (7). However, most of the times an appropriate diet is sufficient to promote adequate daily calcium intake in the body.
Most popular foods that provide calcium in the indian diet are dairy products, such as low-fat milk, cheese, paneer and in particular curd, which is one of the best probiotic, Mooli and Fresh fruit raita and Lauki ka raita, green leaf vegetables and sprouted moong beans.
Magnesium directly intervenes in the process of relaxing the smooth muscles of the uterus and reducing the levels of pro-inflammatory prostaglandins that usually stimulate uterine wall contractions and thus cause menstrual pain. It also contributes to the normal functioning of the nervous system, counteracting nervousness and depression, regulating mood and thus also increasing concentration.
Its presence and stability at the level of the body also makes it possible to regulate circadian rhythms, such as the sleep-wake rhythm, and to restore its balance.
The amount of magnesium that should be taken daily should be 240 mg up to 360 mg in an adolescent girl.
To maintain high and stable magnesium levels in the body, it is essential to have a healthy, balanced diet rich in grains, fiber, legumes and dark chocolate.
Magnesium intake during the menstrual cycle becomes most important when symptoms such as pain, headache, and migraine occur.
Serotonin is equally important and mainly affects mood swings. Some adolescent girls, in fact, as we have seen, may have such an intense hormonal imbalance that it can affect their daily lives and social relationships. Serotonin, also known as “the feel-good hormone”, is a neurotransmitter, levels of which can drop dramatically in the body as a result of hormonal changes in estrogen and progesterone that occur during or before the cycle.
Serotonin cannot be taken in through diet, but fortunately it is synthesized from tryptophan, which can be introduced through diet instead.
Serotonin mainly plays an active role in reducing mood disorders, and thus counteracting depression and anxiety, and promoting a restorative sleep routine.
The disappearance of sleep-related symptoms and adequate rest thus again promote increased levels of concentration in the girl.
Foods that are major sources of tryptophan are the yolks of eggs, dark green and leafy vegetables, pumpkin seeds and walnuts. In particular, it has been shown that the indian dish Besan Cheela helps converting food to energy and it helps in the serotonin synthesis which aids in reducing general fatigue.
One cup of tea or coffee per week are also recommended. In particular, coffee is one of the best and the most affordable boosters of serotonin (8). It is an ideal remedy to cure and reduce the feeling of unhappiness.
However, one must be very careful about the amount of coffee one drinks, in fact coffee increases one’s serotonin levels as long as one takes it, but once one stops drinking coffee, the effect will be exactly the opposite (9).
In the table below, we propose an ideal 7-days diet-chart that an adolescent girl with symptoms connected with menstrual irregularities and PMS should follow during and before a period.
Table 2: 7-days diet-chart sample for women suffering from PMS syndrome to follow during menstrual flow.
However, excessive and continuous caffeine intake can lead to overstimulation of the nervous system, resulting in increased mestrual pain, increased irritability and alterated mood, and, thus, having the opposite effect to that desired.
Caffeine is found in many beverages, such as coffee, tea, soft drinks and energy drinks. Therefore, one should decrease the intake of these drinks as much as possible during and before a period.
In general, one should reduce the intake of simple sugars and saturated fats from industrial foods that contain preservatives and have little nutritional quality because they are poor in micronutrients and macronutrients, including carbonated fizzy drinks, as well as snacks, chips, and ice cream.
Junk food, which has poor nutritional quality, can cause glycemic and energy imbalances, while salty foods, such as chips and snacks, worsen water retention, which is the accumulation of fluids in the extracellular environment within the body, resulting in menstrual pain.
In addition, socioeconomic conditions and urbanization may also contribute to the development of menstrual cycle issues, but not only that. A study conducted by Imperial College London (march, 2023) showed that adolescents growing in rural areas are showing a healthier growth trend (10) than those growing up in big cities, and especially, in city slums. This is cause of an improvement in sanitation, in nutrition and in healthcare in the rural areas, resulting in fewer nutrition defencies and malnourishment.
In contrast, in urban areas, the tendency to consume carbonated soft drinks and fast food in spite of fruits, vegetables, legumes, and healthy foods leads to a decrease in growth and an increase in obesity and menstrual cycle-related problems in children and in adolescent girls, respectively.
The risk is even greater if an individual, who previously lived in a rural area, decides to move to a densely populated city center.
Of course, this also varies greatly depending on the socio-economic conditions of a city. The degree of change in obesity and in pre-menstrual diseases, changes considerably between urban and rural areas if we consider middle-income countries rather than low-income countries.
For instance, the nutritional deficiencies of people living in a urban slum, an overcrowded residential area where unemployment rate is very high and equal to 60,61% in women and 21,02% in men (The Indian Express, november 2021), are highly prevalent especially in the children and iron deficiency is the most common among all (11). This is mainly due to the factor that the majority of adolescents living in slums are used to consume junk food and in particular hamburgers, that are in fact more affordable and cheaper than healthy food. As a consequence, it has been estimated that the prevalence of anemia in children aged 1–4 years (pre-schoolers), 5–9 years (school-aged children) and 10–19 years (adolescents) was 41%, 24% and 28%, respectively (12). The present study has established poor nutritional status and anemia to be often associated with common menstrual problems among adolescent girls from slum establishments (13).
In conclusion, we can say that menstruation is a physiological process common to all women, but that factors such as living and health conditions, as well as a nutrient deficiency and a poor and unbalanced diet, can affect its regularity and the occurrence of symptoms associated with menstrual pain.
Therefore, it becomes necessary to follow a diet that is varied in the intake of micronutrients and macronutrients, that aims to exclude carbonated beverages and junk food, and that adheres as closely as possible to that shown in Table 2, at least in the period immediately preceding the onset of menstruation, so as to restore the regularity of the menstrual cycle, to reduce anxiety and irritation, and to avoid abdominal cramps.
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