Food and Nutrition for Disease Prevention
752-6102-00L
752-6102-00L
Fichier Détails
Cartes-fiches | 68 |
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Langue | English |
Catégorie | Biologie |
Niveau | Université |
Crée / Actualisé | 07.03.2021 / 11.06.2021 |
Lien de web |
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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
- how strong is the relationship?
- 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
- usually paper-based, otherwise PC-based
- 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
- age specific: accumulates over time up to age 40
- 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
- crucial for myelination in 3 TM as well as up to age 3 --> deficiencies irriversible long-term damage
- 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
- Nepal study: Fe & B9 during pregnancy until 12 months postpartum results in better cognitive outcomes and motorcontrol than placebo group
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
- oberservational studies of seafood intake: beneficial effect when consumed during pregnancy as well as childhood
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
- HALE: healthy life expectancy
- Global Burden of Disease study:
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
- about 1/3 of of illness-related expenses amount to healtcare in CH
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
- mental and musculoskeletal disorders have greatest impact --> chronic and very low mortality cause long absence
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?
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
- what is the importance of oral nutrition therapy in regards to malnutrition?
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
- prevalence of malnutrition increases during hospital stay (vgl Bild: nutritiona lstatus deteriorates...)
- 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
- Risk screening
- 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)
- access to stomach blocked
- 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
- bags/containers with different nutrients that can easily be mixed
- 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
- metabolic
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)
- nasogastric & nasojejunal
- 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
- protein requirements can differ between patient groups
- 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
- decreased newborn mortality --> protects against diarrheal and pneumonic infections
- 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
- protective against neurodevelopmental delays
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
- ensure food variety by feeding at least 5/8 food groups
- 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
- quality of foods important:
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
- little known on how breastfeeding and complementary feeding affect epigenetics and microbiota
- 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
- Anorexia nervosa (AN)
- 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
- mostly psychatric nature
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
- Character traits
- Socio-cultural factors
- beauty standards
- fashion standard
- overabundance of food
- unhealthy role models
- beauty standards
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
- gender differences:
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
- greater fracture risk
- 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
- mechanistic
- 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
- 2000 IU no effect on fall and fracture incidence
- link to muscle function
- 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
- meta-analysis across life-course shows different result depending on data used
- 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