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Cartes-fiches 68
Langue English
Catégorie Biologie
Niveau Université
Crée / Actualisé 07.03.2021 / 11.06.2021
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Nutrition and Brain, Baumgartner

Explain the role of macro and micronutrients in the brain

  • Give examples of some important micronutrients
  • Vulnerability to nutrient deficiency: what do studies need to consider?
  • how are microbiome and brain development related to one another?

Overall metabolism

  • brain highly metabolically active --> 60% of O2 consumption of child vs 20% adult
  • relies on many different nutrients for growth, repair, function
  • overall, brain's dry matter made up of
    • 60% fat
    • 20% CHO
    • 10% proteins

Vulnerability to nutrient deficiency

  • depends on timing and duration of deficiency --> short-term folate deficiency during conception much more dangerous than short-term folate deficiency postnatal
  • brains requirements, which change depending on developmental stage --> omega-3 FA necessary during breastfeeding period
  • study investigating the behavioral changes due to deficiencies must be designed properly:
    • what area is affected by the deficiency --> what function altered
    • when does the specific area develop --> when did deficiency occur or when is supplementation likely to show positive effects
      • eg: assing problem-solving skills in toddlers makes no sense, because area not fully developed at that time
    • dose/degree of deficiency --> may only cause harm at severe deficiencies --> pregnant mother can maintain normal TH despite mild iodine deficiencies, but severe deficiency causes cretinism

Folate

  • essential for proper formation of neural tube
  • important before and during conception, because neural tube formed at day 22

Iodine

  • Thyroid hormones important for neuronal migration, proliferation, and myelination --> fetus relies on maternal TH transfer up to 3rd TM
  • severe iodine deficiency results in cretinism --> important that fetus can stock up iodine

Omega-3 LCPUFA

  • make up largest part of fats found in brain (50-60%)
  • mostly DHA --> EPA can affect brain via peripheral mechanisms: modulation of sysntemic inflammation and vascular health
  • proportions and accrual of n-3 FA
    • switch in n-6/3 content in brain: up to 10y, ARA content > DHA --> stabilizes in adulthood
    • increase in DHA 35x from 30wk to 18 motnhs --> importance of mother's milk

Microbiome

  • development in offrping's microbiome coincides with brain development --> in line with brain-gut-axis-hypothesis
  • early life nutrition may affect microbiota and brain directly and indirectly due to the existing interactions between them

Nutrition and Brain, Baumgartner

  • fundamental questions & key concepts
    • which concepts need to be clear in regards to timing and the relation between nutrients & brain development?
    • what key concepts need to be considered: study design, timing of intervention, tools used...

Fundamental questions

  • Matching: does nutrient affect cognition/behavior beyond sheer brain development?
    • how strong is the relationship?
      • for nutrient(s) --> additive or interactive effects with other nutrients/environment?
      • for given timeframe, e.g. first trimester
  • Are the consequences of a deficiency long-term or short-term?
    • short-term: acute dysfunction
    • long-term: cognitive development delayed/hampered

Key concepts

  • Matching (see above)
  • proper tools
    • to assess deciciency per se as well as impact it has on cognitive domains
  • child age: early testing possible, but more reliable as child ages
  • study design
    • rct vs interventional
    • sample size

Nutrition and Brain, Baumgartner

  • What are the 3 types of tools used to study nutrition and brain development in children?
  • what are the strength and limitations?

Approaches to measuring cognition in humans

  • Cognition: involves many different factors, such as
    • language/psychomotor/perception/attention/memory/executive functions (vgl Bild)
  • Global measures: IQ,
    • usually paper-based, otherwise PC-based
      • motor and language based tests for infants
    • limitations
      • widley applied but limited sensitivity due to global assessment of cognitive function --> score difficult to relate to nutrient deficiency
      • timing
        • must be timed properly --> difficulty of test must be appropriate to child's developmental stage
        • may overlook long-term effects when short-term effects are not present
      • high intra and interindividual variability
        • child can be distracted in room or by assessor
  • Domain specific testing
    • test battery that assesses a given cognitive domain that is hypothesized to be affected by a nutrient deficiency at a given time point of development
    • must be sensitive enough for intervention duration
    • has replaced global testing because of higher specificity
    • cultural differences may turn questions more difficult to certain child group --> cultural fairness
    • requires validation
      • does the test depict cognitive domain of interest + does nutrient intervention affect domain of interest?
  • Neurophysiological tools
    • MRI and fMRI measure brain anatomy and function, repsectively
    • EEG: evoked potential of different stimuli can be assessed
    • NIRS, non-invasive and suitable for field
    • strengths & limitations
      • (-): expensive, not suitable for field, expertise required
      • (+): can be used during sleep, very sensitive thereby useful to clarify discrepant findings, potentially smaller sample sizes than with traditional assessment tools

Nutrition and Brain, Baumgartner

Iron

  • how distributed in brain?
  • what functions does it take on on brain?
    • what if deciciencies occur?
  • what evidence available?
    • hint: Nepal

Iron and brain development

  • Iron distribution in brain
    • age specific: accumulates over time up to age 40
      • highly present in areas undergoing myelinisation during development
    • area-, cell-specific: involved in neurotransmission of dopmainergic areas
  • Iron function in brain
    • oxygen transport to brain --> high O2 needs
    • energy production in cytochormes in mitochondria
    • NT synthesis: dopamine synthesis is Fe-dependent
    • myelinisation: Fe used as co-factor of enzymes reponsible for myelinisation as well as FAs
      • deficiency: myelin content and quality (via FA) affected --> transition speed affected in children
  • Iron deficiency
    • crucial for myelination in 3 TM as well as up to age 3 --> deficiencies irriversible long-term damage
      • slow speed of processing and synaptic efficiency
      • spatial memory and learning affected
      • poor school achievement, attention, memory, language development, motor skills and socioemotional development --> child prone to health and psychological chalenges in later life
        • on large scale, poor development results in poverty of a nation
  • Evidence
    • Nepal study: Fe & B9 during pregnancy until 12 months postpartum results in better cognitive outcomes and motorcontrol than placebo group
      • prolonging supplementation from 12 to 36 motnhs shows no additional benefit --> time-window pre/perinatal
    • deficiency as well as anemia can lead to short and long-term consequences on congitive, motor and socioemotional domains
      • short term: O2 supply to brain insufficient?
      • long term: neurological deficits due to hampered myelination
    • anemic school children benefit from supplementation --> example of short term negative consequence

Nutrition and Brain, Baumgartner

Omega-3

  • what effects do n-3 FA have on
    • brain development & structure
    • brain function
  • how do different LCPUFAs contribute to brian health?
  • what are known consequences of LCPUFAs deficiencies?
  • what is the evidence on LCPUFAs intake during pregnancy and childhood?

Omega-3 LCPUFA

  • make up largest part of fats found in brain (50-60%)
  • mostly DHA --> EPA can affect brain via peripheral mechanisms: modulation of sysntemic inflammation and vascular health
  • proportions and accrual of n-3 FA
    • switch in n-6/3 content in brain: up to 10y, ARA content > DHA --> stabilizes in adulthood
    • increase in DHA 35x from 30wk to 18 motnhs --> importance of mother's milk
  • affect brain function
    • via membrane fluidity --> receptor affinity in synapses increased
    • some n-3 FA used as fuel source --> brain requires lots of E
    • indirectly: attenuate inflammation and modulate IS via gene expression
  • LCPUFA deficiency
    • altered FA profile
    • processing speed of visual cues affected
    • during perinatal period, animal model
      • myelinisation, synaptogenesis and neural membran FA composition affected
    • reductions inf brain glucose uptake and metabolism
  • Evidence
    • oberservational studies of seafood intake: beneficial effect when consumed during pregnancy as well as childhood
      • cannot establish causal relation due to nature of study
    • intervention studies of omega-3 supplementation: no effects and inconclusive results

Intro lecture Baumgartner

Prevention and treatment

  • what factors are important to prioritize treatment and prevention?
  • wat are modifiable risk factors?
  • how is health captured, name two important factors reflecting health of a population

Prevention and treatmentent

  • Prioritizing of efforts necessary, but this requires knowledge about risk factors, stats and evidence
  • (modifiable) risk factors
    • smoking
    • phyical inactivity
    • alcohol abuse
    • unhelthy diet
  • statistics and evidence help to identifiy most important health problems as well as solutions to it
    • Global Burden of Disease study:
      • ongoing study in entire world since 1990
      • captures data on incidence, prevalence and mortality of different conditions causing premature death or disability
        • incidence: number of new cases
        • prevalence: number of existing cases at/during a given timepoint/period
      • mortality and morbidity can be extrapolated
      • published in the LANCET: continuous epidemiological data on development of many NCDs
    • population health summary measures --> not applicable to single individuals!
      • HALE: healthy life expectancy
        • compares healthspan with lifespan --> number of years to be lived in full health
        • increases if
          • risk factors are reduced
          • healtcare quality improves
        • decreases if (e.g. gap between HALE and lifespan increase)
          • with age --> usually #1 risk factor for NCDs
      • DALY: disability adjusted life years
        • sums life years lived with disability & non-fatal disease and compares to standard, normative mean of expecte life years --> basically how many years of theoretical maximum are cut short due to illness
        • time-based
        • uses factor to adjust for severity of different diseases experienced
          • not always clear where to draw line betwen healthy and unhealthy
          • death always more impactful on daly than disability/disease
        • metabolic factors make up large part of DALYs
      • DALY and HALEs allow to
        • assess burden of disease as well as efficacy of health system performance
        • target investments

 

 

Intro Baumgartner

NCDs

  • definition
  • trend worldwide
  • costs

Non-communicable diseases

  • global trend for NCDs is increasing while communicable, neonatal and maternal diseases decrease
    • injuries remain indifferent
  • affect men and women to same degree
  • costs: high because ncds are chronic diseases
    • usually remain for a lifetime or difficult to reverse (obesity, cancer)
    • expensive medication and treatment (antibiotics or other medication against communicable diseases less expensive)

Intro lecture Baumgartner

  • Explain epidemiological transition

Epidemiological shift

  • improvement in hygene, reduction in childhood mortality and healthcare improve --> mosrtality decreases --> demographics: more aged individuals --> higher NCD risk
  • shift from traditional foods to Westernized diet --> obesity and chronic diseases as well as chronic burden of malnutrition increase

Intro lecture Baumgartner

  • explain Fetal Origins of Adult Disease

  • discovery of increase prevalence of NCDs in men stemming from areas where childhood mortality was higher
  • low birth weight = proxy for poor prenatal nutrition --> associated with T2D, CVD & high bp
  • first 1000d as key timeperiod for health
    • high plasticity --> can backfire in case of maternal malnutrition due to (epigenetic) imprinting
    • evidence on humans almost impossible to obtain due to duration, but evidence from animals available

Costs of chronic diet-related diseases in Siwtzerland, Wieser

  • explain three main dimensions of disease cost
    • how do these dimensions look in CH, how have they changed and which ones are the most important ones
    • how are these dimensions assessed/established?

Direct medical costs

  • monetary value
  • ressources others have to invest in order to cure/take care of diseased person
    • can extend to family and non-professionals/non-medical persons
  • in CH: healthcare
    • about 1/3 of of illness-related expenses amount to healtcare in CH
      • 9730.- Fr/y per capita
      • in CH costs are high but when adjusted for purchasing power, expenses become 20% higher (and more realistic) as opposed to 50% difference in absolute means

Production losses

  • of the person affected
  • also measured in monetary fashion --> usually based on salary of individual x time
  • different types of production loss
    • partial loss: absenteeism (some weeks/months) or presneteeism (reduced workload/pensum)
    • total loss: permanent disability or death
    • potential loss: suboptimal development and cognitive weknesses, e.g. LMIC with stunting/nutrient deficiencies
  • how to measure production losses
    • questionnaires to capture how often/long employers absent/reduced workload
    • administrative data to assess partial or total disability
    • epidemiological data for premature mortality
      • additionally impared physical and cognitive development in LMIC
  • production losses in CH
    • mental and musculoskeletal disorders have greatest impact --> chronic and very low mortality cause long absence
      • more "deadly" NCDs have comparable low impact, but also because mortality higher

DALYs

  • disability and loss in quality of life measured in DALYs, not monetary
  • DALY two components: time and weight of disease
    • YLD: years lived with disability --> non lethal but disabling condition
    • YLL: years of life lost
  • severity reflect by DALY weight and must be defined --> worldwide questionnaires
    • chornic diseases realtively low weight
    • mental diseases and pain high weight
    • good correlation between different cultures shows agreement on severity of different conditions
  • In CH
    • neoplass responsible for large part of YLL
    • musculoskeletal diseases for YLD --> larger impact than YLL, typical for country with good healthcare system
    • DALY burden has  declined by about 30% in last 30 years --> big progress

Costs of chronic diet-related diseases in Siwtzerland, Wieser

Give an overview of the current knowledge on costs in CH

  • by what categories can the data be visualized?
    • what are the major causes of disease burden for these categories?
    • what costs are not included
    • how was GBD study used in this particular case?

Dimensions of healthcare costs in CH

  • by service
  • by type of service provider
  • by type of financing instance
  • by illness and disease
    • defined using the GBD study
      • costs for pregnancy, aesthetics and similar not included
      • co-morbidities separated

Enteral and Parenteral Nutrition Meier

  • Malnutrition
    • what is the importance of oral nutrition therapy in regards to malnutrition?
      • how's the situation in hospitals?
    • prevalence
      • WW & CH
      • who's most commonly affected?
    • procedures to identify malnutrition
      • what are signs

Malnutrition

  • Importance of oral nutritional therapy
    • prevalence of malnutrition increases during hospital stay (vgl Bild: nutritiona lstatus deteriorates...)
      • 55% of served food returned --> flight attendant experiment
    • affects therapy outcome and mortality
      • improving nutrition during hospital stay is economic
      • daily requirements of many nutrients not met, depending on which requirements chosen, 53-70% --> nutrition in hospital setting is highly insufficient
  • Reasons for malnutrition (kennste)
    • Clinical: Nausea, Cancer, infections, low BMI --> can affect hunger and appetite hormones
    • Non-clinical
      • mastication problems
      • monotonous food
      • food temperature & serving times
  • Identification of patients at risk of malnutritoin or suffering from malnutrition
    • high risk patients: low BMI, disease-related weight loss
    • geriatric and oncology most commonly affected
  • procedure of malnutritoin identification
    • Risk screening
      • using screening tools: NRS 2002
    • Diagnostic assessment
      • phenotypic: low FFM measured via DXA/BIA, unintentional weight-loss
      • etiologic: low food intake, disase-related difficulties eating
    • Diagnosis
      • at least one phenotypical and one etiological criterion
    • Severity Grading
      • moderate --> vgl Bild
      • severe --> BMI<18.5, NRS >= 3, >10% weight loss in past 6m, serum albumin < 30g/l
  • prevalence
    • worldwide about 25%, same for CH

Enteral and Parenteral Nutrition Meier

Parenteral Nutrition

Parenteral Nutrition

  • indications
    • access to stomach blocked
      • anatomical reasons: cancer
      • gut dysfunctional: perforation, obstruction...
    • tube feeding unsafe
      • excessive vomiting: pregnant women
    • patients who require bowel rest
      • acute gastroenteritis, radiation etheropathy, high output fistulas
    • major clinical indications
      • Acute and critically ill patients
      • Post acute patients (eg after surgery)
      • Pre operative malnutrition
      • Home parenteral nutrition (eg short bowel)
  • contraindications
    • gastrointestinal tract fully operational
    • no access to veins (vena subclavia most common)
  • Delivery systems
    • bags/containers with different nutrients that can easily be mixed
      • All in one options also available
    • Home parenteral nutrition
      • for chronic intestinal failure
      • short bowel syndrome or Crohn's
      • cancer patients with intestinal failure --> most common
  • must take present and future into account: assure safety and nutritional balance for existing benign condition (ex short bowel) + prevent future complications related to nutrition
  • will affect QoL and may become unsuited in an unpredictable time span due to laignant comorbidities
  • complications often occur in PN and can be reduced via monitoring
    • metabolic
      • Refeeding syndrome
      • Hyperglycaemia and hypoglycaemia
      • Hypertriglyceridaemia
      • Hepato biliary complications (HPN)
      • PN induced bone disease (HPN)
    • technical
      • early: pneumothorax, bleeding
      • late: vein thrombosis
    • infections --> local can develop to systemic
    • monitoring
      • anthropos: monitor weight, arm cicrumferences, BIA --> indicator for muscle mass
      • funtion: check hand grip strength
        • lab results of bioechical, haematological, microbiological values

Enteral and Parenteral Nutrition Meier

Enteral Nutrition

Nasogastric/enteral tube (enteral nutrition, EN)

  • main goal: treat malnutrition and improve outcome
  • performed if foods intake in coming 7 days anticipated to be insufficient or if malnutrition diagnosed
    • ethical consideration: EN must improve QoL --> if it prolongs suffering of a dying patient, it is unethical
    • prior to insertion of tube, expected benefit must be considered
  • contraindications
    • gastrointestinal issues: obstruction of intestines + others (vgl Bild)
    • circulatory: schock, cardiac insufficiency
    • metabolic: coma, ketoacidosis (diabetes)
  • Different accesses types for different durations
    • nasogastric & nasojejunal
      • short term less than 30d --> longer periods via parenteral or special types of enteral
    •  percutaneous endoscopic gastrostomy: PEG, PEG-J, D-PEG
      • access to stomach via inserted tube --> food injected into stomach with seringe (Dave having lunch)
  • Complications
    • reflux
    • infections
    • malpositioning of tube in brain or lung
    • refeeding syndrome: reintroduction of food results in ATP generation, yet micronutrient deficiencies limit many biochemical processed so that organism is overtaxed putting the individual in a life threatening situation

Enteral and Parenteral Nutrition Meier

ONS

  • Evidence: top or flop?
  • what types exist and when are they do be used?

Oral Nutritional Supplements

  • first line adjuvant nutritional therapy
  • different types
    • polymeric: entire foods, commercially available --> usually better tolerated and used most often
    • oligomeric: broken down macros --> peptides & micro's
    • disease specific: diabetes, CKD...
    • isolated macros
  • Forticifaction of foods first step of malnutrition treatment, further step taken with sip feeds if fotification insufficient
  • concinving evidence for the effectiveness of ONS in the clinical setting (multiple meta-analyses)

Enteral and Parenteral Nutrition Meier

Oral Nutrition Hospital

Oral Nutrition Hospital

  • special types of criteria to adapt nutrition to patient
    • protein requirements can differ between patient groups
      • restricted: e.g. renal insufficiency
      • elevated: e.g. dialysis patients
    • Energy
      • elevated: malnutrition
      • restricted: obesity
    • medical indications
      • gastroenterogical: gluten free, lactose free...
      • speicial conditions: frc free, germ reduced, phenyl-alanine free
  • Protected Mealtime Policy
    • assistance for people who need help (paralysis, e.g.)
    • give patients enough time to consume meal -->no doctors or nurses present
    • in between snacks to increase kcal intake
  • Monitoring of food intake via supervisisoin of tray collection

Infant and young child feeding, Baumgartner

Breastfeeing practices

  • what is the rationale for breastfeeding
  • what are short and long-term effects on breastfeeding
    • on child --> name 3 main domains, then exemplify
    • on mother
  • possible mechanisms mediating the above effects

Breastfeeding practices

  • Timing
    • within one hour of birth
    • until up to age 2 or even beyond, on-demand
  • exclusive breastfeeding for first 6 months
    • HIC: introduction of complemetary foods as of fifth month recommended
  • rationale
    • no adverse outcomes on growth & natural (mother’s milk much more complex and rich in diverse nutrients/bioactives than formulas)
    • short-term (infancy)
      • decreased newborn mortality --> protects against diarrheal and pneumonic infections
        • sudden-infant-death syndrome (SIDS)--> two months reduce risk by 50%, longer breastfeeding further reduces risk of SIDS
        • compared to non/partially breastfed children: not breastfeeding increases infection-realted mortality 2x
      • beneficial effect on gut health --> necrotisation of enterocolitis prevented in pre-term infants
    • long-term (later life)
      • protective against neurodevelopmental delays
        • potential enhancement of motor development
      • protective against metabolic diseases (hypertension, diabetes, obesity)
      • protective against immune-related diseases (allergies, coeliac, IBS)
        • WHO meta-analysis: non or sporadically breastfed children prone to develop obesity whereas breastfeeding for at least 6 months protects children
      • Protective effect possibly mediated but gut microbiome modulation during first 1000d
        • Microbiota of breastfed infants differs from formula fed à more commensal, less pathogenic strains
      • Protective effects also for mother à diabetes, obesity, breast/ovarian cancer

Infant and young child feeding, Baumgartner

Complementary feeding practices

  • what importance of complementary feeding, what is the goal?
    • what if complementary feeding fails?
  • what foods shoould be consumed
    • amounts
    • rythm
    • type
    • foods to avoid
  • how many children get appropriate complementary feeding worldwide?
  • important aspects of compl. feeding during illness
  • explain:
    • responsive feeding
    • early protein hypothesis

Complementary feeding practices

  • necessary to cover increased needs as of 6 motnhs that cannot be covered by mother's milk anymore
    • sub-oprtimal complementary feeding à stunting
  • complementary foods (= first foods)
    • semi-solid and soft
    • complement mother's milk --> closes the gap between requirements covered by milk and requirements milk cannot cover but that the growing infant has
    • from month 6 to 23 --> some children ready earlier, around 4 months
    • 70% children WW are introduced to first foods, but only 20% with minimum diversity and frequency à breastfeeding from 12-23 months persists in 65% of cases WW
  • weaning: stopping breastfeeding and switching over to semi-solid foods
  • complemenary feeding practices & recommendations
    • quality of foods important:
      • ensure food variety by feeding at least 5/8 food groups
        • animal foods incl. mother’s milk
        • fruits & veggies
      • avoid empty calories --> high nutrient density foods important
      • Portion sizes: start with small portions, soft and little variety and 2-3 meals per day
      • Variety increase variety, volume and frequency of feeding
    • other important aspects & special situations
      • hygiene & proper food handling
      • use fortified foods if necessary
      • in case of illness --> increase drinking volume and offer favorite foods to ensure proper food intake
    • responsive feeding: watch out for and respect child’s reaction to feeding à foundation of (good) eating habits
    • early protein hypothesis: protein intake > protein requirements primes metabolism to become obese

Infant and young child feeding, Baumgartner

DOHaD

  • explain framework --> draw!
  • hints
    • environment
    • early nutrition
    • adult health & disease

DOHaD Framework

  • environmental stressors prime organism à organism becomes prone to diseases if environment changes / is not-well prepared to environment
    • genetic
    • epigenetics
      • DNA
      • Histone
      • Chromatin structure
      • miRNA
  • trajectories in early life more modulable/plastic, relatively low effort and pronounced impact on later life
    • little known on how breastfeeding and complementary feeding affect epigenetics and microbiota
      • obesity incidence more strongly correlated with microbiome at 3 months than at 12 months
    • partial breastfeeding with additional formula à microbiota more similar to formula-fed infants
    • breastfeeding/mother’s milk has epigenetic effects
  • epigenome and microbiome interact with phenotype and early nutrition à 1000d for microbiota modulation

Eating disorders, Milos

Definitions

  • General characteristics of eating diorders
  • three types of eating disorders
    • prevalence
  • common co-morbidities
    • mortality

 

Risks and complications of eating disorders

  • Types
    • Anorexia nervosa (AN)
      • typical symptoms: worry about body shape, self-esteem linked to weight/appearance, fear of gaining weight
      • 1.2% women
      • weight 15% below expectation
      • BMI < 17.5 kg/m2
      • weight loss caused by active or non-active measures
        • active: vomiting, laxatives
        • non-active. eating-restriction
      • always a behavioral and psychologic features
    • Bulimia nervosa (BN)
      • typical symptoms (same as AN): worry about body shape, self-esteem linked to weight/appearance, fear of gaining weight
      • normal weight, but preoccupation with weight --> self-esteem related to weight
      • high food intake due to food attacks --> 1/week
      • vomiting to compensate for food attacks
    • Binge eating
      • food intake >>> during at least 3 months
      • characteristic behavior: fast and abnormally bulky food intake despite absence of hunger followed by disgust and guilt
  • Characteristics
    • often slowly and gradually developing bnormal eating behavior with tendency of becoming chronic
    • eating disorder is hidden from family/friends and third parties
    • profound impact on life: physical, psychological, professional, and social
  • Co-morbidities
    • mostly psychatric nature
      • high rates of suicidal tendencies amongst eating disorders
      • difficulties to assess own and other's emotions
      • difficulties to see big picture, obsessive with details
    • mortality in anorexic people ~6%
    • hormonal foundation: leptin-like effect observed in AN
      • increased activation of HPA and HPG (gonads) axes --> reduced BMD, increased physical activity but also reduced reproductive activity
    • organ specific --> vgl Bild
      • gastric emptying
      • osteoporosis --> 40% of patients have low BMD
      • amenorrhea --> fertility affected
      • cortical brain atrophy

Eating disorders, Milos

Etiology & Therapy

  • name three main areas of etiology and exemplify each
  • give an overview of therapy
    • who is involved?
    • who is targeted?
    • what are the main goals of therapy?

Multifactorial etiology

  • Biological and genetic factors
    • genome-wide association found 8 loci involved in AN
    • pre- and perinatal factors:
      • infections during pregnancy
      • SGA
      • birth complications
      • feeding disorders in infant
      • childhood: obsessive, perfectionistic behavior
    • Neuro
      • alteratino in the dopaminergic system leads to self-starvation becoming a trigger of motivation --> viscous cicle
  • Personality and individual experiences
    • Character traits
      • low self-esteem
      • obsessiveness
      • anxiety
      • emotional inhibition
    • trauma
      • sexual abuse or other trauma
      • strict diets in family
      • critical experiences towards appearance/weight/eating
  • Socio-cultural factors
    • beauty standards
      • fashion standard
    • overabundance of food
    • unhealthy role models

Therapy

  • interdisciplinary --> communication is key!
    • medical entities (family physician, specialists, gynecologists, dentists, internal medicine)
    • employer
    • social services
    • psychiatry
  • target patients as well as patient's surrounding
    • get insight and enhance trust, and motivate change
    • family, relationship
    • work
  • major goals
    • reach at least BMI = 18.5 or stabilize weight if normal BMI
    • normalize eating habits --> 3 meals/d with 2-3 snacks
    • treat comorbidities (somatic/psychiatric)

Musculoskeletal diseases and nutrition, Andersson

Bone basics

  • bone homeostasis
    • renewal duration
    • BMD pattern throughout life --> draw
      • same for all?

 

 

Bone homeostasis

  • Bone basics
    • trabecular: 15.25% calcified
    • cortical bone: 80-90% calcified,
    • cells
      • osteoblasts & osteoclasts: build/resorb bone
      • osteocytes: derive form osteoblasts and represent mature cell, 80-90% of bone
  • renewal every 10 years
  • peak bone mass between age 30 and 40
    • gender differences:
      • women have lower BMD to begin with --> 60-80% genetically inherited, rest modulated by environment
      • menopause-caused fall in estrogen results in greater bone resorbtion and therefore lower BMD in females

Musculoskeletal diseases and nutrition, Andersson

  • Osteoporosis
    • prevalence --> how many falls
    • burden of fractures
    • risk of fracture depending on first/seonc fracture and gender
    • how measured/proxy
    • reatment and preventive strategies

 

Osteoporosis

  • loss of bone mass (quantity) and deterioration of bone archtecture (quality)
  • consequences
    • greater fracture risk
      • most commonly spine, hip or wrist fractured
      • 5-6% of falls actually result in fracture
    • collapsed vertebra --> tooped posture
  • prevalence
    • gender differences --> 20% females, but also 5% males affected
    • worldwide variance in prevalence assumed to have genetic reason, not nutritional
    • 75% of osteoporotic fractures in >70 year-olds
    • risk for first fracture differs between gender (50% or more for females vs 20% males), but not for second fracture: 20% both gender
      • risk for second fracture highest in the year following the first fracture
  • cost & disease burden
    • 13'000€/hospitalization --> greater than cancer, heart, and stroke combined due to greater prevalence of osteoporosis fractures than other
  • link to sarkopenia
    • fear of falling reduces mobility and thereby muscle mass --> ultimately increases fall risks
    • muscle strength correlates with BMD

Musculoskeletal diseases and nutrition, Andersson

Sarkopenia

  • prevalence
  • consequences
  • etiology
  • risk factors

Sarcopenia

  • prevalence: 20-75%, depending on population and source of information
  • consequences
    • poor hospital outcomes, risk of falls, loss of independence
  • definition and diagnosis not always clear --> muscle mass measurements, handgrip strength
  • muscle strength via handgrip
    • peak in early adulthood
    • bi-phasic decline --> gradual as of age 40, substantial as of age 50
  • etiology
    • systemic inflammation
    • ageing-associated processes
      • reduced autophagy
      • loss of mitochondria with additional decline in mitochondrial function
      • impared stem cell regeneration
    • los protein intake and negative protein turnover --> decrease in MyoPS and MitoPS
  • Risk factors
    • sarcopenic obesity
    • extreme weight loss
    • drugs & pharmacological therapy --> ACE inhibitors
    • smoking & alcohol
    • sedentariness
    • genetic/intrsinsic factors: gender, sex hormone deficiency, comorbidities
  • Prevention
    • sarcopenia considered to be a nutritional disorder
    • lifestyle interventions effective
      • exercise: less conclusive evidence
      • nutrition: evidence more equivocal and in favor of greater protein intakes
    • pharmacological treatments use hormone replacement --> testo / SARMs

Musculoskeletal diseases and nutrition, Andersson

Osteoporosis

  • Risk factors
    • what clinical RF exist?
  • Screening
    • typical tool used
    • cut-off values
    • how do informatics play a role in risk assessment? Exemplify!
  • What typical areas of body fractured?

 

Risk assessment

  • Risk factors
    • clinical --> vgl Bild
    • BMT-D score --> assessed using DXA
      • < -1 SD: osteopenia
      • <= -2.5 SD: osteoporosis
      • <= -3 SD: severe osteoporosis
    • BMD is integrated into the FRAX algorithm  (fracture risk assessment tool) with clinical risk factors to predict 10-y risk for certain fractures
    • sometimes no BMD assessemtn available (e.g. men or subsequent to typical fracture) --> recommended treatment if:
      • FRAX risk > treshold (country specific)
      • fracture of hip, vertebrae, proximal humerus, pelvis, distal arm
  • who to screen
    • essentially, screening is recommended to postmenopausal women, especially >65y 
    • men >70 recommended to screen depending on Consensus/Foundation

Musculoskeletal diseases and nutrition, Andersson

Calcium

  • requirements increase slightly after 50y from 800 to 1000 mg/d
  • recommendations
    • 800-1200 mg/d
    • foods preferred source
    • addition of vitamin D in institutionalized individuals
  • calcium rich foods: mostly dairy and animal-based, although present in many fruits and vegetables too
    • average intake in Western 700-900 mg/d
    • dairy product effective in preventing the decline of BMD, but not in its restauration
      • under debate: evidence for persisting bone loss in postmenopausal women despite intakes of Ca of 300 - 2000 mg/d
  • supplements
    • supplements sometimes necessary to meet recommendations --> 30-50% of older women in western countries prescribed supplements
    • uptake kinetics between dairy and supplemental Ca differs
      • supplements peak vs dairy plateaus --> potential mechanism for vascular complications, but not yet clearly identified
  • Evidence
    • may increase risk of vascular diseases
    • inconsistent results on fracture reduction (meta-analysis)
      • reduction total fractures and vertebral fractures but not forearm or hip
      • often supplementes combined with vitamin D --> no additional effect
      • overall: no convincing evidence and, if any beneficial effects of Ca on BMD, then only minor
    • increased BMD by 1% after 1y --> not cost-effective

Musculoskeletal diseases and nutrition, Andersson

Vitamin D & risk of fractures and falls

  • what is the recommended dosing
  • deficiency
    • what is special about cut-off values?
    • compare different regions: Northern EU vs rest of EU vs middle east
  • evidence
    • inconsitsent findings: why?
    • what is still recommended
    • who is liekly to benefit?

Vitamin D

  • deficiency
    • serum 25(OH)-D best marker for Vit D status
    • disagreement regarding cut-off values but unanimity that <25 nmol/l severe deficiency
    • values <50 nmol/l increase from Northern Europe to Western/Southern/Eastern Eruope and up to 80% of individuals deficient in Middle East --> more sun not necessarily more Vit D
  • Evidence
    • link to muscle function
      • mechanistic
        • muscle has vit-D-receptor (VDR) and converts it to 25OH-D --> supplementation increases VDR expression
        • deficiency affects mostly type 2 fibers
      • lower strength & functional decline in vit D deficient individuals observed in observational studies
      • supplementation shows reduced fall incidence
    • Lancet meta-analysis suggests no benefit of vit D supplementation to decrease fall incidence
      • negligable effect on vit D vs control as well as high vs low dose
      • small effect on selected populations (es = 0.83)
      • critiqued by mani experts in the field
        • biased study selection: no studies of vit D an calcium --> 40% of high quality data not included in meta-analysis
        • deffectiveness of daily dose of 800-1000 IU well established
    • Dosing
      • 2000 IU no effect on fall and fracture incidence
        • DO-HEALTH
        • doses of 20'000 IU/d for prolonged period may increase risk of falls
      • 800 IU usual recommendation to at-risk population (elderly and little exposure to sunlight)
      • >4000 IU not recommended, unless malabsorbtion
  • Supplementation & approach
    • in case of deficiency, supplementation is required and likely to reduce risk of falls
    • replete individuals are unlikely to benefit from supplementation

Musculoskeletal diseases and nutrition, Andersson

Protein

  • intake recommendations
  • evidence on protein intakes and bone health (not muscle!)
    • how do types differ?
    • what are the advantages and disadvantages of greater protein intakes?

Protein

  • 1.2-1.5 g/kg/d to overcome anabolic resistance --> often unfeasible due to lack of appetite, too much food, mastication problems...
    • 25-30g protein per meal required
  • Evidence for protein & bone health
    • moderate evidence: protein with Ca and vit D might improve BMD and
    • amount: higher protein intakes are generally better than low in terms of bone health --> no effects on bone biomarkers
      • meta-analysis across life-course shows different result depending on data used
        • non-adjusted: greater protein intake associated with better bone health
        • covariate adjusted: no association between amount or type of protein and fractures
    • higher protein intakes have at least no deleterious effects
    • type: soy and animal-based protein seem indifferent in terms of how they affect bone health