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Presentation 1

WEIGHTSTIGMA:Howdoesitaffectweightmanagement?

Dr.AngelaAlbergaAssistantProfessor,DepartmentofExerciseScience

DisclosureName:Dr.AngelaAlberga

Relationshipswithcommercialinterests:• Grants/ResearchSupport:Chercheur Boursier,Fonds de

Recherche deQuébec- Santé;AssistantProfessor,ConcordiaUniversity

• SpeakersBureau/Honoraria:DairyFarmersofCanada(forthispresentation)

• ConsultingFees:N/A• Other:N/A

Potentialforconflict(s)ofinterest:N/A

MarathonRunnerOrganizedKnitter

JunkFoodCanoeing

GoodLeaderSociallyAwkward

ErinCameron,PhD,MemorialUniversity

ImplicitAttitudesTest

Weightbias:Forms• Implicit(i.e.unconscious)• Explicit (i.e.overt)• Internalized (i.e.self-stigma,beliefthatthestigmaisdeserved)

• Canbesubtle,overt,verbal,physicalorrelationalforms:1. Verbalteasing(e.g.,namecalling,derogatoryremarks,being

madefunof)2. Physicalbullyingandaggression(e.g.,hitting,kicking,pushing,

shoving)3. Relationalvictimization(e.g.,socialexclusion,beingignoredor

avoided,thetargetofrumors).

Puhl &Brownell,2007.WeightbiasinHealthCareSettings.RuddCenterForFoodPolicy&Obesity

•NegativeattitudesandviewsaboutobesityandpeoplewithobesityWeightbias

•Labeling,stereotyping•Damagedidentities•DeeplyrootedinsocietyWeightstigma

•Verbal,physical,relational•Subtleandovertactions/expressionsWeight-based

discrimination

Bias

Stigma

Discrimination

XimenaRamos-Salas,MSc,UniversityofAlberta

Weightstigmastartsyoung…

Nophysicalhandicap

Crutches&alegbrace

Sittinginawheelchairwithablanket

coveringbothlegs

Lefthandmissing

Leftmouthfacial

disfigurementObesity

Richardsonetal.1961

UConnRuddCenterImageGallery

Health consequences of weight bias

Puhl etal.Clin Diabetes2016;34:44-50

Weightbias:Impactoneatingbehaviours

• Predictsbingeeating• >stigmaexperience>bingeeatingsymptoms

Ashmoreetal.2008;Friedmanetal.2005

• Wayofcopingwithweightstigma• Eatingmorefood,refusaltodiet

Puhl &Brownell,2006

Almeidaetal.,2010

Weightbias

Bingeeating

Weightmanagementdifficulties

Weightgain

Weightbias:Impactonphysicalactivity

Vartanian etal.2011

Weightbias:Impactonphysicalactivity

Pearletal.2015

⬆Stigmatizingexperiences

⬆Negativeemotions

⬇Motivation,self-efficacytomaintain

habits

Almeidaetal.,2010;Carels etal.,2009

Weightbias

AvoidPA,Bingeeating

Weightmanagem’tdifficulties

Weightgain

Weightbias:Impactonhealthcareutilization• Embarrassmentaboutbeingweighed

Puhl &Heuer,2009

• Inaccessibleequipment&facilitiesPuhl &Heuer,2009

• DoctorshoppingGudzune etal.,2013;Gudzune etal.2014,Puhl etal.2013

• AvoidanceordelayofhealthservicesDrury&Louis,2002;Puhl etal.2013

• LesstimespentwithpatientsMerrill&Grassley,2008

• Lowtrust&poorcommunicationBrownetal.,2006;Malterud andUlriksen,2010

Problemswithfocusingonweight

• Attributiontheory&weightcontrollability• Focusingonweightascontrollableà contributestoweightbias

• Internalizedweightbias(self-stigma)associatedwithgreaterbeliefinweightcontrollability&fatphobia

Pearletal.2015

⬆Weightcontrollability

beliefs

⬆Weightbias

⬇Healthybehaviours

Check-inwithyourself

§ Self-reflection,discuss&challengeweightstereotypes

§WeightImplicitAssociationTest(IAT)https://implicit.harvard.edu/implicit/

Challengeweightcontrollabilitybeliefs

http://www.shiftn.com/obesity/Full-Map.html

Societalfactors

Communityfactors

School&otherinstitutionalfactors

Peerinfluences

Peerinfluences

Familialinfluences

Individualcharacteristics

Bodyweight

ModifiedfromNeumark-Sztainer,2005

Questionassumptionsaboutweight

Thinkaboutworkenvironments

Criticalconsumersofmediaideals

MoststigmatizingFatMorbidlyobese

MostmotivatingUnhealthy weightOverweight

Puhl,Peterson,Luedicke,2013

Wordsweuse

Least stigmatizingWeightUnhealthyweightHighBMI

Least motivatingFatMorbidlyobeseChubby

Wordsweuse

• AskorPerson-first• E.g.personlivingwithobesity,childwithobesity,adultwithobesity

• Obeseperson,obeseteenager

Advocacy

Weightbias

AvoidPA,healthcare,disorderedeating

Weightmanagem’tdifficulties

Weightgain

Takehomemessage

TakehomemessageIssue Potential solutionWeightcontrollabilitybeliefscontributetoweightstigma

Seek outmoreinformationaboutfactorsthataffectweightoutsideofindividualcontrol

Weightstigmais abarriertoweightmanagement

Addressweightbiasinyourself,yourpractice&yourenvironment

Weightbiaspredictsbingeeating&exerciseavoidance

Challenge&discuss weightstereotypes

Weight biasispervasive&complex

Refer toresourcesonmentalhealth&copingwithstigma

Thankyou

Dr.AngelaAlbergaAssistantProfessorDepartmentofExerciseScience,ConcordiaUniversity

[email protected]

@DrAlberga

Presentation 2

Stéphanie Chevalier, PhD, RD

Research Institute of the McGill University Health CentreDepartment of Medicine, Faculty of MedicineSchool of Human NutritionMcGill University

Protein nutrition for optimal muscle health andfunction in older years

DFC Symposium 2017 - All rights reserved

Disclosures

Research Support: Dairy Farmers of Canada

Canadian Institutes of Health Research

Quebec Network for Research on Aging

Consultant: None

Discussion of Off-Label,

Investigational, or

Experimental Drug Use:

None


Sarcopenia

Definition: age-related loss of muscle mass and strength(European Working Group consensus definition; Cruz-Jentoft et al, Age & Ageing 2010)

Muscle massand strength

80 years

Sarcopenia threshold

mass ↓ ≅ 0.8% per yearstrength ↓ ≅ 2-4% per year

40-50

(Janssen I and Ross R, J Nutr Health Aging, 2005; Farsijani S et al. Am J Clin Nutr 2017)


Sarcopenia

Functionality, mobilityLoss of independence

Impact on health

Risk of disabilities, frailty

Disease outcomes (cancer, COPD, surgery…)

Morbidity, mortality

ICD-10-CM code (2016) Recognizes sarcopenia as a disease(Anker SD et al. J Cachexia Sarc Muscle 2016)


Prevalence of sarcopenia

community long-term care1-29% 14-33%

(Cruz-Jentoft AJ et al. Age & Ageing 2014)

80 years +5-20% ≥ 30%

(Dodds RM et al. J Clin Densito 2015)

70-79 years

*also differs by ethnicity

women men12-13% (2.3%) 5-6% (1.3%)

(Dam TT et al. J Gerontol 2014)

FNIH FNIHIWG IWG


Possible causes of sarcopenia

Sarcopenia

Neuro-degenerative:Motor neuron loss

Disuse:immobility

physical inactivity zero gravity

Primary causes:sex hormones

apoptosismitochondrial dysfunction

Inadequate nutrition (protein, vit.D)/

malabsorption

Endocrine:corticosteroids, GH, IGF-1,

abnormal thyroid function, insulin resistance

(Adapted from Cruz-Jentoft AJ et al., Age & Ageing 39, 2010)

Chronic diseasesinflammation


Factors related to reduced protein intake in the elderly

↓food intake↓protein intake

↓ total E expenditure

↓ muscle mass↑ % adipose mass

↓ resting E expenditure

↑inactivity

↓ activity-related E

diseasesmedications

anorexia

social & cognitive factors(food insecurity, solitude,

dementia, …)


How much protein should older adults consume?


Protein needs of older adults

Current Dietary Recommended Intakes (DRIs) in adults >51 y: 0.8 g/kg/d Cover minimal needs to avoid losses (based on N balance)

Consensus for revising upward: 1.0-1.2 g/kg/d

For optimal health and prevention of sarcopenia (Position paper: PROT-AGE study group, Bauer J et al. JAMDA 14: 542-59, 2013)


Evidence supporting greater protein DRIsSmall metabolic studies

EAR: 1.1 g/kg/d RDA: 1.15 g/kg/d n=8 women 80-87 y

EAR: 0.96 g/kg/d RDA: 1.29 g/kg/d n=12 women > 65 y

EAR: 0.94 g/kg/d RDA: 1.24 g/kg/d n=6 men >65 y

(Tang M et al, Am J Clin Nutr 99, 2014; Rafii M et al, J Nutr 2014, Rafii et al. J. Nutr 2016)

Indicator amino acid oxidation method(IAAO)Recent studies using stable isotope

methodology indicate greater protein requirements.


Evidence supporting greater protein DRIsLarge cohort studies


Risk of frailty per quintile of protein intake (%kcal) – Women’s Health Initiative Study

(Beasley JM et al., J Am Geriatr Soc 58, 2010)

Protein intakefrom FFQ

Regression from FFQ + participants characteristics

Odds ratios adjusted for age, ethnicity, BMI, income, education, smoking, alcohol, health status,comorbidities, hormone therapy , falls, lives alone, disabilities, depression, E intake

n= 24,417 women 65-79 y; OR of incident frailty at 3y follow-up

12% lower risk of frailtyfor each 20% increasein protein intake

= ≥ 1.2 g/kg/d


Change in lean mass (3 y) per quintile of protein intake* – Health ABC Study

(Houston DK et al., Am J Clin Nutr 87, 2008)

Appendicular lean mass

*Energy-adjusted total protein intakeModels adjusted for age, sex, race, study site, total E intake, baseline LM or aLM height, smoking, alcohol use, physical activity, oral steroid use, prevalent disease and interim hospitalizations

n= 2066 men & women 70-79 y

0.8 g/kg/d 1.2 g/kg/d


Lean mass changes related to protein intake only in weight losers and gainers

*Quintiles of energy-adjusted total protein intakeModels adjusted for age, sex, race, study site, total E intake, baseline LM or aLM height, smoking, alcohol use, physical activity, oral steroid use, prevalent disease and interim hospitalizations

Weight losers Weight stable Weight gainers

(Houston DK et al., Am J Clin Nutr 87, 2008)DFC Symposium 2017 - All rights reserved

Why do older adults need more protein?


S

synthesis

D

degradation

Normal Daily Regulation:Fasting: S<DPostprandial: S>DTotal (24h): S=D

Daily regulation of protein balance

Insulin ↑Amino acids ↑↑

Insulin ↓↓Amino acids ↓or →

Aging effect


Whole-body protein anabolism is correlated with insulin sensitivity

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

0 2 4 6 8 10 12 14 16

Glucose infusion rate during hyperinsulinemic clamp (mg/kg FFM.min)

Ch

ange

in n

et p

rote

in b

alan

ce(μ

mo

l/kg

FFM

.min

)

r= 0.519p<0.001(n=121) controlled for FFM


Insulin sensitivity

Pro

tein

anab

olis

m

Anabolic resistance: Summary of aging effects

In response to infused insulin: Lower protein balance (Chevalier S et al., 2006)

Lower muscle protein synthesis (Rasmussen B et al., 2006)

Normalization with:

supraphysiological hyperinsulinemia (Fujita et al., 2009)

hyperaminoacidemia (Chevalier S et al., 2011)

In response to oral low dose AA: Lesser muscle protein synthesis (Katsanos C et al. 2005, Cuthbertson D et al. 2005)

Normalization with higher dose (≈25-30 g protein) (Paddon-Jones D et al. 2004)


Model of anabolic threshold

(Boirie Y, J Am Med Dir Assoc 14, 2013)DFC Symposium 2017 - All rights reserved

Apart from quantity, does the quality of protein matter?


Protein quality = proportion of essential amino acids

Essential amino acids predominantly stimulate protein synthesis. (Volpi E & Wolfe RR, 2003)

The most potent, leucine, acts as an intracellular signal to stimulate mRNA translation and protein elongation through mTOR. (Kimball S et al, 2006)


Plant protein have less essential amino acids and some are limiting (Met and Lys): may need to ingest more to sustain muscle protein anabolism

Animal vs. plant protein


Proteing/100 g

Leucineg/100 g

Leucine g/portion

Lean beef, chicken, tuna 26 2.2 2.2 /100 g

Cheese (cheddar) 23 1.9 1.0 / 50 g

Milk 2% 3.3 0.3 0.8 / 250 mL

Soy beverage 3.3 0.2 0.5 / 250 mL

Soy beans (cooked) 12.4 0.9 1.0 / 125 g

Almonds 21.4 1.5 0.4 / 30 g

Pasta (cooked) 5.8 0.4 0.5 / 125 g

Leucine content of foods Relative Absolute

From the USDA Food Composition Database, https://ndb.nal.usda.gov/ndb/

Acute (postprandial) studies on the stimulation of muscle proteinsynthesis (MPS) by different protein sources (resting conditions)

In young men: whey > soy > casein (Tang JE et al. J Appl Physiol 2009)

In older adults: beef > soy; up to 40 g soy protein failed to induce MPS (Phillips SM. Meat Sci 2012)

In older men: casein > wheat; 60 g wheat protein = 35 g casein(Gorissen SH et al. J Nutr 2016)

AA and Leu content (relative and absolute) and digestibility are important to consider



Evidence from longitudinal cohort studies

Health ABC study: higher total and animal protein intake related to lesser loss in lean and muscle mass over 3 years (Houston DK et al., Am J Clin Nutr 87,

2008)

Framingham Offspring study: higher total and animal protein intakerelated to lesser loss in handgrip strength over 6 years (McLean RR et al. J Gerontol

2016)

But, consumption of plant protein is low (≅30-40%) in US and Canada: interpret with caution

In n=2726 Chinese older adults, highest vs. lowest quartile of plant protein intake lost less muscle mass over 4 years (Chan R et al. J Nutr Health Aging

2014)



Is there an ideal pattern of protein intake?


Protein distribution across meals

(Adapted from Paddon-Jones D & Rasmussen B, Curr Opin Clin Nutr Metab Care 12, 2009)

Proposed model based on minimal essential amino acids at each meal

Inadequate protein distribution

10 g

30 g

20 g

60g

30 g 30 g

breakfast lunch dinner breakfast lunch dinner

Maximalproteinsynthesis

Adequate protein distribution


Greater muscle protein synthesis with even protein distribution

(Mamerow MM et al., J Nutr 144, 2014)

7 d crossover design, 30 d washout, n=8 young adults

≈ 30-30-30 g ≈ 11-16-63 g

Muscle protein synthesis (24 h)

0

0.02

0.04

0.06

0.08

0.10

day 1 day 7 day 1 day 7

* *

24

h m

ixed

mu

scle

pro

tein

syn

thes

is

(FSR

, %/h

)


0

20

40

60

80

100

120

Uneven Even

1 RDA 2 RDA

Quantity (not distribution) affects protein balance and MPS

(Kim et al., Am J Physiol Endo Metab, 2015)

Change in whole bodyprotein balance (16h)

n=5/group older adults (52-75 y)4 d diet

FSR

(%

/h)

1 RDA2 RDA

0.8 g/kg/d1.5 g/kg/d

0

0.01

0.02

0.03

0.04

0.05

0.06

0.07

0.08

0.09

Uneven Even

**

Muscle protein synthesis (22h)

Uneven Even

*main effect of quantity, p<0.05

**


Protein distribution in a cohort study

Aim: to study mealtime distribution of protein intake in free-living older adults of the NuAge study and associations with:

lean mass loss over 2 years (Farsijani S et al. Am J Clin Nutr 104, 2016)

muscle strength and functional decline over 3 years (Farsijani S et al. Am J Clin Nutr, 2017)

Secondary analysis of NuAge (Quebec longitudinal study on nutrition as a determinant of successful aging)

1793 men and women, aged 67-84 y at entry

Well-functioning

Montreal, Sherbrooke, Laval


Dietary assessment

• 6x 24h food recalls by – Trained RD

– 5-step multiple pass

– Timing of meals

• Protein intake: Energy-adjusted protein intake

• Protein distribution:Coefficient of variation

Body composition (DXA)

• Lean mass (LM)

• Appendicular LM (aLM).

• Fat mass

Potential confounders

• Demographic • Age• Education• Smoking• Disease burden

• Physical activity (PASE) questionnaire

Methods


Total and distribution of usual protein intake across meals at baseline

0

10

20

30

40

50

60

Breakfast Lunch Dinner Snacks

Pro

tein

inta

ke (

g/

me

al)

Men (n= 351) Women (n= 361)

0

20

40

60

80

100

120

Total protein

Tota

l pro

tein

itak

e (

g/

d)

‡

‡

‡

**

**non-parametric test (Friedman test, P < 0.01) versus other meals within each sex; ‡Mann-Whitney U test, P < 0.0001 versus men.

(Farsijani S et al. Am J Clin Nutr 104, 2016)DFC Symposium 2017 - All rights reserved

Calculating protein distribution

Coefficient of variation of protein intake per day:

CV = SD/ mean g per meal

↑CV UNEVEN distribution

↓CV EVEN distribution

CV= 0 Total evenness of the protein intake over the dayB

L

D

B L D

UNEVEN EVEN


Protein intake per quartiles of protein distribution

0

10

20

30

40

50

Breakfast Lunch Dinner

Pro

tein

(g

per

mea

l)

Q1 Q2 Q3 Q4

**

**

**

**

**

0

10

20

30

40

50

60

Breakfast Lunch Dinner

Pro

tein

(g

pe

r m

eal)

Q1 Q2 Q3 Q4

**

**

**

0

20

40

60

80

100

Total protein

Tota

l pro

tein

(g

/ d

)

0

20

40

60

80

Total protein

Tota

l pro

tein

(g

/ d

)

*

A

B

Men

Q1 Q2 Q3 Q4

Women

Even Uneven


*

47

50

53

56

Q1 Q2 Q3 Q4

Lea

n m

ass

(k

g)

Protein distribution (CV)

Baseline 2-year Follow-up

34

36

38

40

Q1 Q2 Q3 Q4L

ea

n m

ass

(k

g)


Baseline 2-year Follow-upBA

Lean mass by quartile of protein distribution

Lean mass adjusted for physical activity, fat mass, smoking, protein intake, education and disease burden.Independent effect of protein distribution **p<0.01, *p<0.05 from mixed models.

Men Women

<0.38

Even

>0.67

Uneven

<0.38

Even

>0.67

Uneven

Time effect, P<0.05

**

(Farsijani S et al. Am J Clin Nutr 104, 2016)

** Lean mass is associated with protein distribution

2-year decline:

not associated with protein distribution


*

47

50

53

56

Q1 Q2 Q3 Q4

Lea

n m

ass

(k

g)


Baseline 2-year Follow-up

34

36

38

40

Q1 Q2 Q3 Q4L

ea

n m

ass

(k

g)


Baseline 2-year Follow-upBA

Lean mass adjusted for physical activity, fat mass, smoking, protein intake, education and disease burden.Independent effect of protein distribution **p<0.01, *p<0.05 from mixed models.

Men Women

<0.38

Even

>0.67

Uneven

<0.38

Even

>0.67

Uneven

(Farsijani S et al. Am J Clin Nutr 104, 2016)

Lean

mass

(k

g)

2-year decline:

not associated with protein intake

* Lean mass is associated with protein distribution

Lean mass by quartile of protein distribution

*


Muscle strength

• Handgrip strength– Vigorimeter (kPa)

• Arm & leg strength– Elbow flexors (kg)

– Knee extensor (kg)

– Max isometric

– Dynamometer Microfet2TM

• Strength composite score– 0 to 12

Mobility

• Timed Up & Go (TUG)

• Chair stand (5x)

• Walking speed– Normal

– Fast

• Mobility composite score– 0 to 16

Confounders

• Depression by GDS• Cognition (3MS)• Demographic

─ Age─ Education─ Smoking─ Disease burden─ Medications

• Physical activity (PASE)

• Mid-arm muscle area

• BMI

Muscle strength and mobility: Methods


6.0

6.5

7.0

7.5

8.0

T0 T1 T2 T3

Mu

scle

str

en

gth

sco

re

Measurement time (years)

Men Women

9.0

9.5

10.0

10.5

T0 T1 T2 T3

Mo

bili

ty s

core

Measurement time (years)

Men Women

**

*

**

3-year decline in strength and mobility

♂ = 20.0%♀ = 18.2%

♂ = 6.5%♀= 7.8%

(Farsijani S et al. Am J Clin Nutr, 106:113-24, 2017)DFC Symposium 2017 - All rights reserved

7.0

7.2

7.4

7.6

7.8

Q1 Q2 Q3 Q4

Mu

scle

str

en

gth

sco

re a

t T0

‡


Men Women

Even Uneven

‡ Adjusted for age, level of education, disease burden, total protein, BMI, depression, cognitive function, smoking, MAMA. Similar over 3-y follow-up using mixed model analysis; ** P <0.001; * P <0.05.

Strength is associated with protein distribution

* P♂ and ** P♀3-year decline:not associated with protein intake


No association between mobility (chair stand time) and protein distribution

7.0

8.0

9.0

10.0

11.0

12.0

Q1 Q2 Q3 Q4

Ch

air

stan

d (

sec)

at

T0‡


Men Women

Even Uneven

3-year decline:not associated with protein intake

‡ Adjusted for age, level of education, disease burden, total protein, BMI, depression, cognitive function, smoking, MAMA. Similar over 3-y follow-up using mixed model analysis.


1 meal/d

2+ meals/d

N= 1081 adults (50-85 yrs) from NHANES

(Loenneke et al, Clin Nutr 35, 2016)

Response as a difference from 0 meal/d, adjusted for relative protein intake, carbohydrate and fat intake, age, sex, ethnicity, blood pressure, smoking, participation in vigorous activity.

Strength (2+ meals)Lean mass (2+ meals)Strength (1 meal)Lean mass (1 meal)

Dose-response association between protein frequency and leg lean mass and strength

Lean

bo

dy

mas

s (g

ram

s)

Kn

ee e

xten

sor

stre

ngt

h (

N)

Threshold of dietary protein consumption (grams)


Summary Total protein intake: large body of evidence

Protein intakes of ≥1.2 g/kg/d are associated:

with higher lean mass and higher strength in most studies

preservation of lean mass during periods of weight loss and more muscle during weight gain

reduced risk of incident frailty

Protein quality: limited evidence More data needed from cohorts ingesting plant-based diets

Protein distribution: limited evidence Limited data from short-term studies:

even distribution increased muscle protein synthesis in young adults, but not in older ones.

From a longitudinal cohort study (NuAge): more even mealtime distribution of protein is associated with higher lean mass and muscle strength, but not decline over time.

Limitations: limited follow-up duration, well-functioning older cohort



years


Higher protein intakeMore even distribution

Even at the same decline, having higher muscle mass and strengthmay delay reaching a sarcopenic threshold…

Lower protein intakeUneven distribution



years


Higher protein intake More even distribution

Lower protein intakeUneven distribution

Exercise+

It is never too late !

↑ protein intake + resistance exercise = ↑ muscle mass and strength

(Cermak NM et al. Am J Clin Nutr 2015; Phillips SM. Adv Nutr 2015; Tieland M et al. JAMDA 2012)


Official protein recommendations should be revised and aimed at optimal muscle health

A large proportion of the elderly community may benefit from increasing their intake of good quality protein

Large controlled studies are required to clarify the role of protein sources and mealtime distribution on functional outcomes

Role of dairy product intake currently under investigation

Encourage exercise and physical activity

Conclusion



Take-home message

From the McGill University Health Centre homepage : https://muhc.caaccessed 05/09/2017

https://muhc.ca/

BiostatistitianRaman Agnihothram, PhD

CollaboratorsJosé A. Morais, MD

Errol B. Marliss, MD

Investigators of NuAge:

Hélène Payette

Pierrette Gaudreau

Katherine Gray-Donald

Bryna Shatenstein

Acknowledgements

Participants

Graduate StudentsSamaneh Farsijani, PhD

Anne-Julie Tessier, PhD Cand.


Presentation 3

NutritionandBoneHealthacrosstheLifespan

KelseyM.Mangano,PhD,RDAssistantProfessor,NutritionProgramDirectorDept ofBiomedicalandNutritionalSciences

CollegeofHealthSciencesUniversityofMassachusetts,Lowell

Disclosures

• Currentfundingsupport:– UniversityofMassachusettsLowell,InternalSeedGrant“Agingfrom

theinsideout”– UniversityofMassachusettsLowell,InternalSeedGrant“Linking

NutritionwithMuscleFunctionviaSignalingPathways”

• Relatedpreviousfundingsupport:– NIHNationalInstituteofAging(T32-AG023480)– AcademyofNutritionandDietetics,HealthyAgingDPGresearch

award– NIHR01-AR/AG41398– NHLBI’sFraminghamHeartStudy(N01-HC-25195)

• ThecontentissolelytheresponsibilityoftheauthorsanddoesnotnecessarilyrepresenttheofficialviewsoftheNationalInstitutesofHealth

Objectives

1. Definethecompositionandactivityofboneanddescribethepublichealthburdenofosteoporosisandfracture

2. Defineabonehealthydietandtheuniquecompositionofdairyfoods

3. Identifytheupdatedrolesofdairyproductsanddairynutrientsonbonemassinchildhood/adolescenceandonpreventionofosteoporosisandfracturesinolderadults

CompositionofBone

Mostboneshave~60–70% mineral/dryweight,andvarywithage,site,gender,diseaseandtreatment.

30%ofboneisorganicmatter,primarilycollagen,madeupofproteins

Theskeletonisanactiveorgan

Delaisse,2014

Osteoporosis:apediatricdiseasewithgeriatricconsequences

AmericanSocietyforBoneandMineralResearch,2003GoldenNH;2014

90%peakbonemassaccrued

40-60%

Menopauseisassociatedwithanaverageannualbonelossof3–5 %duringthefirstfewyearsandaround1 %thereafter

FactorsAffectingPeakBoneMass

• Non-modifiable– Gender– Race– Genetics(accountsfor70%ofthevarianceinbonemass)

• Modifiable– Hormonalfactors– Nutritionalstatus– Physicalactivity– Bodyweightandcomposition

Osteoporosis:lowbonemass

Whyshouldwecare?• Osteoporosisleadstobonefracture…..

– Ofthoseabletowalkbeforefractureonly50%walkafterahipfracture

– 10-20%excessmortalityafterhipfracture

• Worldwide,1in3womenoverage50willexperienceosteoporoticfractures,aswill1in5menagedover50

• InEurope,thedisabilityduetoosteoporosisisgreaterthanthatcausedbycancers(withtheexceptionoflungcancer)

Thewell-beingofagingadultsmustbeoptimizedtoimprovequalityoflifeandreducehealthcarecosts

NormalOsteoporosis

InternationalOsteoporosisFoundation

Osteoporosis:amajorpublichealthburdeninCanada

• EachyearinCanadathereare30,000hipfractures.

• TheoverallyearlycosttotheCanadianhealthcaresystemoftreatingosteoporosisandrelatedfractureswasover$2.3billionasof2010.

Website:OsteoporosisCanada

OsteoporosisFractureIncidencevs.IncidenceofHeartAttack,Stroke&BreastCancerinWomen

* Burge,etal.JBMR,2007§† AmericanHeartAssoc,HeartDisease&StrokeStatistics- 2007Update‡ AmericanCancerSociety,SurveillanceResearch,2005

1,456,000*

0

500,000

1,000,000

1,500,000

2,000,000

OsteoporoticFractures(allages)

345,000§

HeartAttack(age20+)

373,000†

Stroke(age20+)

269,730‡

BreastCancer(allages)

389,000vertebral

415,000othersites

327,000wrist

223,000hip

Annu

alincide

nce

103,000pelvic

Several Risk Factors for Osteoporotic Fracture

• Impaired vision despite correction• Low body weight• Currently smoking cigarettes• Amenorrhea-Estrogen deficiency • Dementia• Poor health/frailty• Recent falls• Low physical activity• Alcohol consumption >2 drinks per day• POOR DIET

DietandBone

• Nutrients• Protein• Calcium• VitaminD• VitaminC• Magnesium• Potassium• VitaminK• Carotenoids

• FoodGroups– Dairy– FruitsandVegetables– Legumes/beans

Whatisa“bonehealthy”diet?

• Optimaldietaryproteinintakeof1.0–1.2 g/kgbodyweight/dwithatleast20–25 gofhigh-qualityproteinateachmainmeal

• AdequatevitaminDintakeat800 IU/dtomaintainserum25-hydroxyvitaminDlevels>50 nmol/L

• Calciumintakeof1000 mg/d,alongsideregularphysicalactivity/exercise3–5times/weekcombinedwithproteinintakeincloseproximitytoexercise

AconsensusstatementfromtheEuropeanSocietyforClinicalandEconomicAspectsofOsteoporosisandOsteoarthritis (2014)

MostAmericans&Canadiansfallshortofdietarycalciumrecommendations

• 80%ofadolescentsaged8–18yfallshortofmeetingtheRecommendedDietaryAllowanceof1300mgCa/dwithameanintakeof1000mgCa/d(Bailey,2012)

Mangano,2011

• USadultsdonotmeetdietarycalciumrecommendationsacrossanyagegroup

• Dietarycalciumintakesdeclinewithage

• SimilarresultsobservedintheNutritionCanadaData(Vatanparast,2009)

Manydietaryrecommendationsincludetheconsumptionof3servingsofdairyproductsperday- anamountthatprovidesmostoftheDRIofcalciumforthegeneralpopulation

Bioavailabilityofcalciumfromfoods

ModernNutritioninHealthandDisease

Uniquecompositionofdairy

Dairyproductsprovidemoreprotein,calcium,magnesium,potassium,zinc,andphosphoruspercaloriethananyotherfood

Rizzoli,2014

IndividualNutrients,Interactions&BoneHealth

• Calcium• VitaminD• Protein

VitaminD:Recommendations

50-60 75-100

RDA =600 IU/d 700-800 IU/d

Optimum Threshold for Fx Prevention

Serum Vitamin D Levels (nmol/l)

Vitamin D Intake (IU/d)

AdaptedfromDawson-Hughesetal.Osteoporos Int ,2005,Bischoff-Ferrarietal.AmJMed2004

Age 19-70y Age >70y

VitaminD&HipFracture

Bischoff-Ferrarietal.ArchInternMed2009

>400 IU/d Vitamin D reduced hip Fx risk by 18%

FracturepreventionmaybemosteffectivewithvitaminDandcalciumcombined

• Previousmeta-analysesofRCTsdifferedaboutwhethervitaminDsupplementsreducetheriskoffalls orfractures incommunity-dwellingelderlyindividuals.

• Incontrast,amongpatientsdwellingininstitutions,800IUofvitaminDand1200mgofcalciumreducedtheriskofhipfractureandmortality

Cummings,2016

GapsintheLiterature

• SafetyandefficacyofhigherdailydosesofvitaminDinolderindividuals(megadosesofvitaminDmayincreaseriskoffalls)

• WhatistheoptimalcombinationofvitaminDandcalcium?

• Lackofdatainpre-menopausalwomen

CalciumandVitaminDSupplementationTrial:Women’sHealthInitiative

• Objective:Thecalcium/vitaminDstudytestedwhetherthesesupplementsreducetheriskofhipandotherbonefracturesinpostmenopausalwomen.

• Results:womenwhoconsistentlytookthefullsupplementdoseexperiencedasignificant29percentdecreaseinhipfracture.– Womenolderthan60hada

significant21percentreductioninhipfracture.

– Thesupplementshadnosignificanteffectonspineortotalfractures.

Jackson,2006

DietaryProtein&BoneHealthDietaryproteinhasbeenshowntoimprovebonemineral

density,lowerriskoffracture,resultinhighermusclemass&musclestrength

Adjusted 4-year Bone Loss (%) by Quartiles of Total Protein Intake

-5

-4.5

-4

-3.5

-3

-2.5

-2

-1.5

-1

-0.5

0femoralneck lumbarspine

% 4

-Yr

BM

D lo

ss

Quartiles of Total Protein Intake (g/d)

1234

**

**

*P<.05;**P<.01

*

Hannan,MTJBoneMinr Res2001

Protein & bone: more supporting evidence

Study StudySample Exposure Outcome

Kerstetter etal.2000NHANESIII

-n=1822-women-Age≥50y

Totalproteinintake BMD

Munger etal.1999IowaWomen’sHealthStudy

-n=41,837-women-Age=55-69y

TotalproteinintakeAnimalproteinintake

Hipfracture

Dawson-Hughesetal.2002Randomizedcontrolledtrial

-n=342-men&women-Age≥65y

Totalproteinintakeincalciumsupplementedgroup

BMD

Increased dietary protein

Improved bone density, strength, decrease risk of fracture

Improved synthesis of collagen &

non-collagen bone matrix

proteins

Improvedintestinal Caabsorption

Suppression of PTH

Suppression of bone resorption

Increasedgrowth

hormone

Increased IGF-1

Stimulation of bone

formation

Improved muscle mass,

strength

Increased anabolic stress

on bone, decreased falls

Dietaryproteinisbeneficialtobonewithadequatecalciumintake

©2003 by American Society for Nutrition Bess Dawson-Hughes J. Nutr. 2003

3y3y

500mgcalciumcitrate+700IU

vitaminD

PLACEBO

Total Protein Intake & Risk of Hip Fracture: dependent upon calcium intake

Total Calcium <800mg/d Total Calcium ≥ 800mg/d

1.412.02

Ref

0

1

2

3

4

5

6

T1 T2 T3Tertiles of total protein intake (g/d)

Haz

ard

ratio

0.66

Ref

0.30

0

0.5

1

1.5

2

2.5

T1 T2 T3Tertiles of total protein intake (g/d)

Haz

ard

ratio

P trend=0.12 P trend=0.09

Sahni,2010

Why should we consider dietary protein from a whole diet perspective?

Differentaminoacidprofilesoffoods

Interactionwithothernutrientswithinfoods

Dairyproteinispositively,significantlyassociatedwithBMDamongmenandwomen

fromtheCMOS

Langsetmo,2015

Clusteranalysisbyproteinintake:individualswiththegreatest%oftotalproteinfrommilkpresentwiththe

highestbonemineraldensity

Mangano,2016AdjustedmeanBMDacrossproteinfoodclustersfromtheFraminghamOsteoporosisStudy

Dairyimprovesbonemineralmassduringgrowthinadolescents

• Researchdemonstrates:– Inchildrenwhohadavoideddrinkingcowmilkforprolongedperiods,

fractureriskwas2.7-foldhigherthaninamatchedbirthcohort(Goulding,2004)

Rizzoli,2014

TheevidencefortherelationofcalciumandpeakbonemassreceivedagradeofA,andfordairyintake,a

gradeofBwasgiven.

Dairy&BoneHealth:Adults

• Studiesexaminingtotaldairyintakesandmilkintakeshaveshownamoreconsistentanddirectrelationshipwithbonehealthamongadults

• Dataonfractureriskislessconsistent,withmoststudiesreportingeitherbeneficialorneutralassociations

• Thereisapaucityofresearchexaminingtotaldairyandindividualdairyfoodswithfracturerisk

Review:Rozenberg,2016,Calcif TissueInt.

JournalofNutrition,2017

GreateryogurtintakeassociatedwithincreasedBMDandphysicalfunction

• Irishadults,averageage73years,~60%yogurtconsumersamongwomenand~50%amongmen– Highyogurtconsumer=>1s/d– Lowyogurtconsumer=<1s/wk/never

• Women:TotalhipandfemoralneckBMDwere3.1–3.9%higheramongthosewiththehighestyogurtintakescomparedtolowconsumers(P<0.005)

• Men:VertebralBMDwas4.1%higherinlowyogurtconsumerscomparedwithlowconsumers(P=0.028)

Laird,2017

Thegutmicrobiotaasaproposedregulatorofbonemass

GUTMICROBIOTA

Micronutrientmetabolism

Immunesystem Inflammation

DIET

ANTIBIOTICS

ENVIRONMENT

PRE/PROBIOTICS

Futuredirections• Exploretheimpactoftotaldairyandindividualdairyfoodsonbonehealthandriskoffractureinadults

• Examinepathwayslinkingalteredmicrobiomeprofilestobonehealth

• Determinewhetherdiet&dairyfoodscancauselongitudinalchangesinthemicrobiomeandsustaininfluenceonbonehealth

Acknowledgements

• ResearchTeam– UniversityofMassachusetts,Lowell

• KatherineTucker,PhD• SabrinaNoel,PhD

– InstituteforAgingResearch,HarvardMedicalSchool

• ShivaniSahni,PhD• MarianHannan,DSc,MPH• DouglasKiel,MD,MPH

Presentation 4

WomeninSport&Exercise

NutritionConsiderations

October2017 Bridging scienceintopractice www.peakperformance.ca

DisclosureofCommercialSupport

Currentbusinessrelationships:

• InBodyCanadaProfessionalEducation• PointTwo EquestrianAirVests• PolarHeartRateMonitors

Elizabeth(Beth)MansfieldPhD,RD,CSEP-CEP,CSSD

Overview

• Conceptsofrelativeenergydeficiencyandlowenergyavailability

• ReviewtheFemaleAthleteTriad

• Howtooptimizenutritionalstrategies

http://www.femaleathletetriad.org/athletes/what-is-the-triad/

Copyright©BMJPublishingGroupLtd&BritishAssociationofSportandExerciseMedicine.Allrightsreserved.

• MorewomenarerunningforexerciseandsportthroughoutCanada;

• OttawaRaceWeekend:– Womenrunnersnowmakeup

>50%ofparticipants(5,10,21,42kmraces)

– Pre-menopausalwomen(30-50yrs)arethekeydriversofparticipation;

• Runningfortoloseweight– Weightcontrolaswellashealth

andfitnessarekeymotivationstorun

TrendsinExerciseandSport

RelativeEnergyDeficiencySyndrome

SOURCE: Margo Mountjoy et al. Br J Sports Med 2014;48:491-497

Copyright © BMJ Publishing Group Ltd & British Association of Sport and Exercise Medicine. All rights reserved.

Certainsituationswhenenergyexpenditureexceedsenergyintake:

– Traininghardtoimprovefitnessandperformance;

– Trainingtocontrolbodyweight;– Trainingtocreateanenergydeficit

(trainLOW);

KEYDietaryConsiderationsOptimizeenergyintake

– Abilitytotrainwithoutunduefatigue?

– Fastrecoverybetweentrainingsessions?

– Maintenanceofbodycomposition?

– Optimalbiologicalfunctioning?

– Absenceofhealth&performanceissues?

SOURCE:Matzkin E,Paci GM:Thefemaleathletetriad,inMody E,Matzkin E,eds:MusculoskeletalHealthinWomen.London,UK,Springer-Verlag,2014,pp1-13.

OptimizingEnergyAvailabilityEA=Totaldietaryenergyintake– Energyusedindailyactivity/exercisetraining;– EnergyBalance=45kcal/kgFFM onceenergyexpenditureinphysicalactivity,exerciseandsporthasbeenaccountedfor;

– Minimumof30-35kcal/kgFFM+PAEEforweightloss;

– LowEA< 30-35kcal/kgFFMtherearesubstantialimpairmentsofmetabolicandhormonalfunctionwhichaffectperformance,growthandhealth;

Loucks, Anne B. Low Energy Availability in the Marathon and Other Endurance Sports. Sports Medicine, 2007, Vol. 37 Issue 4/5, p347-352

SpectraoftheFemaleAthleteTriad

Source: Nattiv A, Loucks AB, Manore MM; American College of Sports Medicine - Position Stand –The Female Athlete Triad, Med Sci Sports Exerc 2007;39[10]:1867=1882

LowEnergyAvailability• Compulsively

• TendencytosupplyneededenergyAFTERitisneeded– Exercisetoeatvs.eattoexercise

• prolongedexercisetraininginafastedstate(trainLOW)– todevelopgreaterenduranceortopromoteweight

loss;

• Intentionally• Bodyweightconcerns(aestheticorperformancerelated)

» Restrictiveeatingpatterns» Restrainedeatingpatterns» Disorderedeatingpatterns

• Inadvertently• poorbiologicaldrivetomatchenergyintaketoexerciseenergyexpenditure

• tightfoodbudget/poorshoppingorfoodpreparationskills

LEAF-QLowEnergyAvailabilityinFemalesQuestionnaire

• Self-reportedphysiologicalsymptomslinkedtopersistentenergydeficiencywith/withoutdisorderedeating/eatingdisorders;

• Variablesassociatedwithlowercurrentenergyavailability,menstrualdysfunctionandimpairedbonehealth:– Gastrointestinalsymptoms(lowenergyavailability)– Menstrualdysfunction– Injuries(lowbonemineraldensity)

SOURCE:Melin etal.,BrJSportsMed2014;48:540-545

CaseStudyofLEAASSESSMENT:• 46kgfemaleUniversityrunnerwith13.5%BF

Ø Verylowskeletalmass(<80%ofnormalforherheight)Ø BMI15.6UNDERWEIGHTØ 40kgFFM

• EstimatedDEIisrestrictedto1500-1800kcalØ Restrictiveeater“stomachinaknot”Ø Trains“LOW”

• CostofdailyPA+exercisetraining650kcal/dayØ 300-1200kcal/dayrange

• LEAF-QScore15(>8isatriskforFAT)– ManyGITsymptoms,bloating,gas,– Nomenstrualfunctionforlast6months(sincestoppingpill)

ISSUES:• LOWenergyavailableforphysiology:(1500-1800kcalDEI)– 650EE=850-1050kcal

– LOWEA=1050kcal/40kgFFM=21.25-26.25kcal/kgFFM

Casestudycont’d…

• MinimalEAneeds:40-45kcal/kgFFM;– 1600-1800kcal/daytosupportFFM– (+)200- 1200kcal/dinEEtobeaddedtoenergybudget

• HealthyphysiologicaladaptationtoEA– 1stGOAL:2200kcal/dayfornext3months

• MaintenanceofFFM• Kickstartmenstrualfunction

– 2nd GOAL:Structuredmealplan• TimingofnutrientintakestominimizedailyANDwithindayenergydeficits

• TrackGIsymptomswithconsistentfood/fluidintakes

ManagingEnergyAvailability

EnergyPhase

Optimizetheavailabilityofenergy(specificallycarbohydrate)andfluids:

ü Buildanenergybudgetincludingpre-workoutsnackstotopuphydrationandenergyavailability

• Carbohydraterichfoods3-4hrs priortoexerciseincreasesliverandmuscleglycogenstores

• Enhancesperformance

ü IncludecarbohydraterichfoodsforDURINGworkouts,whenneeded,tominimizeenergydeficitsthroughouttrainingsessions

• Minimizespotentialnegativeeffectsofcarbohydratedepletion

TimingisKEY

WithinDayTimelineEnergyAssessments

Large deficits lead to risks of LEA

Energy Deficits

ManagingEnergyAvailability

EnergyPhase

RecoveryPhase

RECOVERYPHASE

§ Enhancetissuerefueling:Ø Choosecarbohydraterichfoodsforsnacks

andmealspostworkout

§ Stimulateproteinsynthesis:Ø Leucineistheaminoacidthattriggers

muscleproteinsynthesispostworkout;

R5 ApproachtoOptimalRecovery

• Re-energizemuscleswithcarbohydraterichfoodsü Starches(breads,cereals,legumes,potatoes)andsugars

(fruits,milk,yogurt)andcombinationsofstarchy/nonstarchycarbohydrates(vegetables)

• within15-30minutesif2ormoretrainingsessionsthatday;• within2hoursiftrainingonceaday• within4-14hoursifnottrainingthenextday


• Re-buildbonesandmuscleswithessentialnutrientsfoundinproteinrichfoodsü Leucineistheaminoacidthattriggersmuscleproteinsynthesis

postworkout;• growing,injured&postmenopausalwomen• weightconsciouswomenexercisingforweightcontrol• Womentrainingforpower(e.g.Crossfit,bootcamp)• Womentrainingforendurance(e.g.runners,XCskiers,cyclists)


• Re-vitalizemuscleswithantioxidantvitaminsandmineralsfoundinbrightlycolouredvegetablesandfruits

• Re-oxygenatemuscleswithironfoundinmeats,leafygreenvegetables,fortifiedgrainsandcereals

• Re-hydratewithwater,otherfluids,andWETfoodsbefore,during,andafterphysicalactivity.

Foods vs. Supplements?

TimingisKeyforManagingEnergyAvailability

EnergyPhase

RecoveryPhase

BuildPhase

ü ENERGYPHASEBuildanenergybudgetincludingpre-workoutsnackstotopuphydrationandenergyavailabilityforDURING workouts

ü RECOVERYPHASEPromoterecoverypostworkoutwithfluidsandasnack/mealtopromoteenergyavailabilityforoptimalrecovery

ü BUILDPHASEIntegratefrequent,smallservingsofproteinrichfoodsatmosteatingoccasions:8-12gramsofproteinatsnacks12-24gramsproteinatmeals

0

2040

60

80

100120

140

Mus

cle

Ener

gy

Relative energy deficiency

Poor recoveryConsistently inconsistent performanceHealth issues

Sufficient energy availability in daily dietary pattern

EnergyRichDietEatingEnoughandattheRightTime!

Day 1 Day 2 Day 3 Day 4

Day 1 Training Session


Day 2Training Session

1

2

34


RoleoftheSportDietitianinManagingEnergyAvailability

§ Determinebodycompositionandenergyneedsü Bodycomposition,RMRü Energybudgetforexercise&body

composition§ Followthesport&nutritionscience

ü Fluidbalanceandenergyavailabilityü FoodsandfoodpatternsforhealthAND

performanceü Supplementationwhenneeded

§ Practicemakesperfectü Structuredmealplanning- helpsboost

confidenceofrestrictiveeatersü Trainingisthetimetotestwhatworksfor

performanceissues§ IndividualizationisKEY

KeyResourcesforYourSportNutritionToolbox

· pdf fileschool of human nutrition mcgill university ... research support: dairy farmers of...

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