NUTRITION AND MENOPAUSE
Docteur Jean-Michel LECERF Service de Nutrition - Institut Pasteur de Lille Service de Médecine Interne – CHRU de Lille 1 Nutrition and Menopause Février 2012
Service de Nutrition – Institut Pasteur de Lille
PHYSIOLOGICAL CHANGES WITH NUTRITIONAL IMPACT
Increase of bone loss
Reduction of lean mass
Change in adipose tissue distribution
Glucose tolerance
Changes in lipid metabolism LDL TG HDL No menstruation Decrease of iron requirements
Resting energy expenditure 2 Nutrition and Menopause Février 2012
Service de Nutrition – Institut Pasteur de Lille
PSYCHOLOGICAL AND DIETARY CONTEXT Psychological frailty
Depressive mood
- Familial disturbance
Dietary adjustement
- Loss of feminity and/or women status - Disturbance of bodily image
Restrictive regimen
Disturbance of dietary behavious
Weight gain
Cognitive restriction 3
Nutrition and Menopause Février 2012
Service de Nutrition – Institut Pasteur de Lille
DISEASES WITH A NUTRITIONAL COMPONENT Weight gain – Metabolic syndrome Metabolic diseases : diabetes – dyslipidémia Cardiovascular diseases (atherosclerosis) Degenerative disease : breast and endometrial cancer – colon cancer Osteoporosis Age related macular degeneration and age related cognitive decline 4
Nutrition and Menopause Février 2012
Service de Nutrition – Institut Pasteur de Lille
FACTORS IMPLIED IN WEIGHT GAIN LEAN MASS
Resting energy expenditure Fat mass
PHYSICAL ACTIVITY
Physical activity expenditure
DIETARY INTAKE
Dietary intake in restreint subjects in case of stress
HORMONAL FACTORS
Adipose tissue distribution
GENETIC FACTORS
Early obesity
PSYCHOLOGICAL FACTORS
Dietary adjustement for the mood 5
Nutrition and Menopause Février 2012
Service de Nutrition – Institut Pasteur de Lille
BODY SHAPES AND OVERWEIGHT APPLE
OR
MORPHOTYPE
UPPER BODY OVERWEIGHT
ADIPOSE TISSUE
ABDOMINAL AND VISCERAL
METABOLIC RISK CARDIOVASCULAR
PEAR
LOWER BODY OVERWEIGHT FEMORAL
++++
-
+++
CANCER
++
+
OSTEOPOROSIS
+
6
Nutrition and Menopause Février 2012
Service de Nutrition – Institut Pasteur de Lille
BODY CHANGES DURING PERIMENOPAUSAL PERIOD 543 WOMEN OF 42 – 52 YEARS FOLLOW UP DURING 6 YEARS 7 MEASUREMENTS
WEIGHT HEIGHT BMI Warst circumference
/ year
Total on 6 years
+ 0,6 % (0,5 kg)
+ 3,4 % (+ 2,9 kg)
- 0,064 cm
- 0,38 cm
+ 0,7 %
+ 4 % (+ 1,2 kg/m2)
+ 1%
+ 6,2 % (+ 5,7 cm)
Fat mass
+ 1,6 % (+ 0,57 kg)
+ 10,1 % (+ 3,4 kg)
Lean mass
– 0,18 %
1 1,08 % (- 0,23 kg)
Waist circumference increase is correlated to ovarian age J. Clin Endocrinol Metab 2007, 92, 895-901 7 Nutrition and Menopause Février 2012
Service de Nutrition – Institut Pasteur de Lille
8 Nutrition and Menopause Février 2012
Service de Nutrition – Institut Pasteur de Lille
Int J Obes 2001, 25, 844-879 9 Nutrition and Menopause Février 2012
Service de Nutrition – Institut Pasteur de Lille
Int J Obes 2001, 25, 874-879 10 Nutrition and Menopause Février 2012
Service de Nutrition – Institut Pasteur de Lille
CHANGES IN ADIPOSE TISSUE DISTRIBUTION MENOPAUSE ABDOMINAL ADIPOSE TISSUE - Sub cutaneous - Perivisceral +++
CARDIOVASCULAR RISK FACTORS
Blood pressure Triglycerides HDL C Glycemia
CORONARY HEART DISEASE RISK Hormonal factors Nutritional factors Physical activity Social stress In primates - < menopause intra abdominal in dominates - > menopause intra abdominal in dominants 11 Nutrition and Menopause Février 2012
Service de Nutrition – Institut Pasteur de Lille
ENERGY BALANCE PHYSICAL ACTIVITY
5 to 40%
THERMOGENESIS
10 – 15%
ALCOHOL
FAT
PROTEINS RESTING ENERGY EXPENDITURE
65 to 70%
30 to 40%
15 to 20% 40 to 55%
CARBOHYDRATES
FIBRES
+++
NOT IMPLIED ++
BENEFICIAL EFFECT
ENERGY EXPENDITURE
12 Nutrition and Menopause Février 2012
Service de Nutrition – Institut Pasteur de Lille
ENERGY DENSITY ENERGY / VOLUME
100 g
Chocolate Cake Sweetened bars Bread Vegetables Fruits
550 Kcal 400 Kcal 350 Kcal 220 Kcal 30 Kcal 50 Kcal
100 Kcal
18 g 25 g 30 g 40 g 300 g 200 g
Dietary intake control Satiation
13 Nutrition and Menopause Février 2012
Service de Nutrition – Institut Pasteur de Lille
DIETARY RECOMMENDATIONS Increase of physical activity Lean mass Energy expenditure
Reasonable decrease of energy intake carbohydrates and fats Progressive changes of dietary habits Daily protein intake Dietary balance Variety and regularity To change the food relation and to have a positive behaviour
14 Nutrition and Menopause Février 2012
Service de Nutrition – Institut Pasteur de Lille
WEIGHT AND MENOPAUSE ADIPOSE TIDDUE DISTRIBUTION Change in lifestyle (dietary habits, physical activity) Prevent
WEIGHT GAIN WAIST CIRCUMFERENCE INCREASE (Women’s Healthy Lifestyle Project)
Hormonal Replacement Treatment (HRT) increase visceral adipose tissue loss observed in case of weight loss 15 Nutrition and Menopause Février 2012
Service de Nutrition – Institut Pasteur de Lille
INTERVENTION WOMEN HEALTHY LIFESTYLE PROJECT Circulation 2001, 103, 32-37 JACC 2004, 44, 579-85
OBJECTIVE - PREVENT MENOPAUSAL WEIGHT GAIN - DECREASE WAIST CIRCUMFERENCE
METHODS DECREASE SATURATED FATTY ACIDS AND CHOLESTEROL EXERCICE
RESULTS WEIGHT AND WAIST CIRCUMFERENCE DECREASE / COMPARISON GROUP LESSER PROGRESSION OF ATHEROSCLEROSIS 16 Nutrition and Menopause Février 2012
Service de Nutrition – Institut Pasteur de Lille
PHYSICAL ACTIVITY AND ENERGY EXPENDITURE AFTER MENOPAUSE ENDURANCE PHYSICAL ACTIVITY POEHLMAN
Energy expenditure Direct Indirect : lean mass
ENERGY BALANCE = EQUILIBRIUM
Dietary intakes Physical activity during the day MURIO
Fat oxydation (nocturnal and diurnal)
PHYSICAL ACTIVITY (walking 3 x / week)
– 8 % WEIGHT (RYAN)
+ MODERATE RESTRICTION Muscular fat Improve glycemic and lipid metabolic parameters 17 Nutrition and Menopause Février 2012
Service de Nutrition – Institut Pasteur de Lille
SEVERE RESTRICTION INDUCE SARCOPENIA IN OBESE SUBJECTS 78 ♀ menopausal women 50 – 70 years BMI 25 – 40 kg/m² Waist circumference > 88 cm
Regimen
Regimen + mild physical activity
- 400 Kcalories/EE
Regimen + intense physical activity
5 months
Weight 11,5 kg Fat mass 8,2 kg Lean mass 3,6 kg
12 months
If weight gain 2 kg Fat mass gain + 26% Lean mass gain + 6%
- 1 kg fat = - 260g muscle + 1 kg fat = + 120g muscle
AJCN 2011, 94, 767-74 18
Nutrition and Menopause Février 2012
Service de Nutrition – Institut Pasteur de Lille
HORMONAL MODIFICATIONS INDUCING WEIGHT GAIN AND HUNGER SENSATION ARE MAINTENED AT 62 WEEKS 50 OBESE SUBJECTS VERY LOW CALORIE DIET 8 WEEKS If weight loss > 10% (moy 13,5 kg) Stabilisation 2 weeks Weeks
Hunger Leptin
PYY CCK INS Amyline Ghrelin GIP PP
Follow-up 62 weeks Weight gain 5,5 kg
10 62
NEJM 2011, 365, 1597-604 19 Nutrition and Menopause Février 2012
Service de Nutrition – Institut Pasteur de Lille
VICIOUS CIRCLE OF COGNITIVE RESTRICTION I don’t feel well
I want to do a regimen
Forbidden foods
Depression
Guilt complex I have to do a regimen Frustration
Weight (re)gain I eat more again
I STOP
20 Nutrition and Menopause Février 2012
Service de Nutrition – Institut Pasteur de Lille
UPPER BODY OBESITY RISK FACTORS MENOPAUSE TESTOSTERONE DEFICIENCY HIGH GLUCOCORTICOIDS SECRETION
MICROBIOTA
SOCIAL STRESS DIETARY FACTORS (excess)
THRIFTY GENOTYPE LOW BIRTH WEIGHT
INACTIVITY
Nutrition and Menopause Février 2012
ALCOHOL SMOKING
PSYCHOTIC DISEASES NEUROLEPTIC DRUGS
Service de Nutrition – Institut Pasteur de Lille
21
METABOLIC SYNDROME HIGH WAIST CIRCUMFERENCE
HIGH TRIGLYCERIDES
HIGH BLOOD PRESSURE
HIGH GLYCEMIA
LOW HDL C
DIETARY FACTORS
YOYO SYNDROME
LOW DENSITY LDL INSULINO RESISTANCE LOW GRADE INFLAMMATION POST PRANDIAL HYPERLIPIDEMIA OXYDATIVE STRESS HYPERINSULINEMIA LDL OXYDATION
STRESS (GLUCOCORTICOIDS) INTRA UTERINE RETARDATION
GENETIC FACTORS INACTIVITY
Nutrition and Menopause Février 2012
OESTROGEN OR TESTOSTERONE DEFICIENCY
MICROBIOTA 22 Service de Nutrition – Institut Pasteur de Lille
CARDIOVASCULAR PREVENTION NUTRITION
ABDOMINAL
HTA
DIABETES
DYSLIPIDEMIA
ADIPOSITY
OXIDATIVE
SMOKING
STRESS
INACTIVITY – STRESS – GENETIC – HORMONAL DEFICIENCY - AGE
23 Nutrition and Menopause Février 2012
Service de Nutrition – Institut Pasteur de Lille
PREVENTION GENERAL POPULATION WOMEN’S HEALTH INITIATIVE JAMA 2006, 295, 655-656 48 835 W 62,3 years 2 groups – 8,1 years – BMI (mean) 29 kg/m²
INTERVENTION OBJECTIVE INITIAL Fat
20 %
CONTROL
REAL
37,8 %
28,8 %
37,8
SFA
12,7 %
9,5 %
12,7
TFA
2,8 %
1,6 %
2,8
PUFA
7,8 %
6,1 %
7,8
MUFA
14,4 %
10,8 %
14,4 RESULTS
+ 5 fruits and vegetables/day 6 grains /day
INTERVENTION
MAJOR EVENTS RISK in women with previous cardiovascular disease (3,4 %) +26%
CONTROL
HR
CHD
0,63 %
0,65 %
0,97
Stroke
0,28 %
0,27 %
1,02
CVD
0,86 %
0,88 %
0,98 24
Nutrition and Menopause Février 2012
Service de Nutrition – Institut Pasteur de Lille
WEIGHT CHANGE IN W H I
25 Nutrition and Menopause Février 2012
Service de Nutrition – Institut Pasteur de Lille
CARDIOVASCULAR PREVENTION Reduction Saturated fats : butter, meat, cheese, processed meat and trans (fatty acids in pastry, hard margarines, cakes, biscuits…) Increase of polyunsaturated fatty acids
Rapeseed or walnut oils
Particularly omega 3
Fatty fish
5 fruits and vegetables/day, half a plate Fibers (bread and wholegrains - leguminous) Decrease salt Abdominal weight loss Low glycemic index carbohydrates 26 Nutrition and Menopause Février 2012
Service de Nutrition – Institut Pasteur de Lille
NUTRITIONAL ADVICES FOR METABOLIC SYNDROME MANAGEMENT WEIGHT LOSS (MODERATE) (5%) INCREASE PHYSICAL ACTIVITY DECREASE ENERGY INTAKE DECREASE CARBOHYDRATES > FATS (CHO 40-45% et F 35-40%) FATTY ACIDS CHOICE - SFA 12% - Dairy fat + - 6 not too much - 3 ++ (ALA – EPA – DHA) CARBOHYDRATE QUALITY : LOW GLYCEMIC – FEW FRUCTOSE GLOBAL NUTRITION +++ (F & V…) MEDITERRANEAN DIET 27 Nutrition and Menopause Février 2012
Service de Nutrition – Institut Pasteur de Lille
VIGOROUS WALK IS ASSOCIATED WITH A LOWER CARDIOVASCULAR RISK EVEN FOR A SHORT DURATION
73 743 women 50 – 79 years W.H.I. Study 5,9 years (follow-up)
NEJM 2002, 347, 716-25 28 Nutrition and Menopause Février 2012
Service de Nutrition – Institut Pasteur de Lille
CARBOHYDRATES FOODS FRUCTOSE
HIGH GLYCEMIC INDEX FOODS OR PURIFIED CARBOHYDRATES
LOW GLYCEMIC INDEX FOODS AND HIGH NUTRITIONAL DENSITY FOODS
RICH IN FIBERS
SWEETENED DRINKS
White bread Potatoes
Lentils Leguminous Fruits
Whole bread Whole grain Oats
FAT AND SWEETENED FOODS Cakes LOW NUTRITIONAL DENSITY FOODS Sweets AVOID
MODERATE
FAVOUR
FAVOUR
29 Nutrition and Menopause Février 2012
Service de Nutrition – Institut Pasteur de Lille
SALT
ADDED COOKING Low salt (at the beginning of cooking)
NOT VISIBLE
ON THE TABLE Avoid
Bread Cheese Processed meat Canned foods Soups Ready cooked dishes
POTASSIUM Fruits Vegetables
30 Nutrition and Menopause Février 2012
Service de Nutrition – Institut Pasteur de Lille
31 Nutrition and Menopause Février 2012
Service de Nutrition – Institut Pasteur de Lille
OSTEOPOROSIS – MECHANISMS WITH AGE
Bone mass peak MAX 20 – 30 years = higher bone mass Bone mass loss after 30-35 years - 0,2 à 1,3% /year - 2 à 3% /year > menopause
Osteoformation Stable Resorption
Genetic Calcium Vit D Physical activity
Cellular ageing Oestrogens resorption
Between 30 and 80 years - 50% trabecular mass pool - 30% bone mass pool
Decrease of cutaneous vit D synthesis Low intake of Vit D and calcium PTH
Nutrition and Menopause Février 2012
32 Bone resorption Service de Nutrition – Institut Pasteur de Lille
VITAMINE C SUN SHINE VITAMINES D and K
CALCIUM
SMOKING STRESS
SILICE
CORTISOL
SOFT DRINKS (SODAS)
TEA
PHYSICAL ACTIVITY AND GRAVITY
COFFEE
OSTEOPOROSIS
ALCALINIC FOODS
ACIDIFIC FOODS
PROTEINS VITAMINE A
LOW BMI
CALCIURIA
EXCESS OF ANIMAL PROTEINS
EXCESS OF SALT 33 Nutrition and Menopause Février 2012
Service de Nutrition – Institut Pasteur de Lille
IS THERE A BONE BENEFIT OVERWEIGHT AFTER MENOPAUSE ? LESS PREVALENCE OF OSTEOPOROSIS FOR A BMI 25-28/LOWER BMI PERIPHERAL ADIPOSE TISSUE
4A
AROMATASE
OESTRONE
BUT FAT MASS PLAYS A LESSER ROLE THAN MENOPAUSE
BMD OSTEOPOROSIS
Low mineral bone density at menopause Mortality = low oestrogenic impregnation ?
HIGH BMI
HIGH CALCIUM INTAKES
MUSCULAR STRENGHT
34 Nutrition and Menopause Février 2012
Service de Nutrition – Institut Pasteur de Lille
WEIGHT LOSS IN PREMENOPAUSAL WOMEN HAS A FAVORABLE IMPACT ON CARDIOVASCULAR RISK BUT NOT ON BONE MASS WOMEN’S HEALTHY LIFESTYLE PROJECT 373 ♀ 44 – 50 years 2 groups - Control - 1 with dietary changes + physical activity and weight loss 54 months
Control Weight
2,6 kg
Bone mass If HRT WEIGHT LOSS + 3% WEIGHT GAIN
Bone mass 0,25 % / an 0,02 % / an
Intervention - 0,4 kg
- 0,03 % / year - 0,20 % / year
p < 0,01 p < 0,01
NS after intervention (54 78 months)
J Clin Endocrinol Metab 2007, 92, 3809 - 3815 35 Nutrition and Menopause Février 2012
Service de Nutrition – Institut Pasteur de Lille
PREVENTION OSTEOPOROSIS (2) – 3 dairy products (1 cheese) Vitamin D (sun – fatty fish) Sufficient protein intake = one source of animal proteins Acide – base balance : fruits and vegetables Phytoestrogens
- Lignans (cereals) - Soy isoflavones very early in youth
Decrerase urinary calcium loss (less salt) Maintain moderate fat mass (BMI 25-28) 36 Nutrition and Menopause Février 2012
Service de Nutrition – Institut Pasteur de Lille
PREVENTION OF AGE RELATED MACULAR DEGENERATION LUTEIN ZEAXANTHIN
CAROTENOIDS
INCREASE MACULAR PIGMENT
CABBAGE LETTUCE SPINACH
EPA DHA
LONG CHAIN OMEGA 3 PUFA
TURN OVER OF PHOTORECEPTOR DISKS
POISSONS GRAS
ANTIOXIDANTS
Vitamins E, C Selenium, zinc
AGAINST OXIDATIVE STRESS
VEGETABLES, FRUITS, FISH, VEGETABLE OILS
37 Nutrition and Menopause Février 2012
Service de Nutrition – Institut Pasteur de Lille
LIPIDS TRANS FA
Hard margarines Pastry Biscuits Cakes
SATURATED FA
Butter Cheese Meat Processed meat
MONO UNSATURATED FA
Olive Rapeseed Peanut Pork Poultry
POLYUNSATURATED FA OMEGA 6
OMEGA 3
LINOLEIC ACID Sun flower Corn Soy Pork Poultry
linolenic acid rapeseed walnut soybean linseed rabbit spinach pursle
EPA Fish DHA Avoid
Moderate
Moderate
Moderate
Favour 38
Nutrition and Menopause Février 2012
Service de Nutrition – Institut Pasteur de Lille
OXIDATIVE STRESS Fruits Vegetables Iron
in excess
Mercury UV – excess of sunshine Tobacco
Vitamin C
Nuts
Vitamin E 8 isomers
Cocoa
Betacarotene Carotenoids (600)
Excess of exercice Grilled foods (Maillard reaction)
Polyphenols (4000) Ferulic acid
Tea Wine Virgin olive oil Grains Soy Spices
PRODUCTION OF FREE RADICALS
ANTIOXIDANT NUTRIENTS AND PHYTOCHEMICALS
39 Nutrition and Menopause Février 2012
Service de Nutrition – Institut Pasteur de Lille
CANCER PREVENTION Iron (moderate)
Calcium (sufficient)
Physical activity
Weight
COLORECTAL
Fat
Fiber
Alcohol
ENDOMETRIAL
Omega 3
BREAST
LUNG
SMOKING
ANTIOXIDANTS – POLYPHENOLS - CAROTENOIDS
FRUITS AND VEGETABLES 40 Nutrition and Menopause Février 2012
Service de Nutrition – Institut Pasteur de Lille
PHYSICAL ACTIVITY Energy expenditure for physical activity
Lean mass Osteoporosis prevention
Total energy expenditure
Immune defenses
Cardiovascular and metabolic risk factors Weight control
More micronutrients 41
Nutrition and Menopause Février 2012
Service de Nutrition – Institut Pasteur de Lille
BASIC PRINCIPLES OF PREVENTION NUTRITION - WEIGHT GAIN
ENERGY BALANCE FATS AND CARBOHYDRATE
- HYPERLIPIDEMIA
AVOID EXCESS OF SATURATED AND TRANS FATTY ACIDS
- GLUCOSE TOLERANCE
CHOICE OF CARBOHYDRATES HIGH IN FIBERS AND LOW GLYCEMIC INDEX
- OXIDATIVE STRESS
FAVOUR ANTIOXIDANT FOODS
- HOMOCYSTEINEMIA
VITAMIN B9
- PLATELET AGREGATION INFLAMMATION ARRYTHMIA
OMEGA 3 FATTY ACIDS OMEGA 6 / OMEGA 3 RATIO
- HYPERTENSION
REDUCE SALT AVOID ALCOHOL
Nutrition and Menopause Février 2012
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42
IN PRACTICE EMPTIED CALORIES PORTION SIZE HELP AGAIN TO A DISH COOKING FAT USE BETWEEN THE MEALS ALCOHOL SOFT DRINKS ++ FOOD CHOICE 43 Nutrition and Menopause Février 2012
Service de Nutrition – Institut Pasteur de Lille
DIETARY BEHAVIOURS COOKING HERSELF TIME SPENT FOR THE MEALS + WITHOUT WATCHING TV EAT WITH PLEASURE MANAGE THE EXCESS INTO THE REGIMENS LISTEN THE BODY AND THE SENSES – SATIATION + HUNGER CHANGE THE TASTE FOR SOME FOODS
44 Nutrition and Menopause Février 2012
Service de Nutrition – Institut Pasteur de Lille