Nutrition for Bone and Muscle Health A Health Professionals‘ Guide www.prou.ie

NUTRITION FOR BONE AND MUSCLE HEALTH - A HEALTH PROFESSIONALS’ GUIDE

Why is nutrition important for bone and muscle health? Fact 1: 1 in 2 women (over 50) and 1 in 4 men (over 50) will develop a fracture from Osteoporosis during their lifetime (Irish Osteoporosis Society). Fact 2: A postmenopausal woman’s annual risk of fracture is greater than her combined risk of cardiovascular disease and breast cancer (Irish Osteoporosis Society). Fact 3: For the prevention of age related decline of muscle and bone health in postmenopausal women, The European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO, 2014) recommends optimal dietary protein with adequate Vitamin D and calcium intake alongside regular exercise combined with protein. Fact 4: Ireland has 0.5 million people over 65 (12% of population). This is to rise to 1.4m (22%) in the next 25 years (Central Statistics Office, 2013). Fact 5: During the 30’s onwards, muscle mass can decline by 1% per year, increasing to 1-2% per annum during the 50’s onwards. Muscle strength (Dynapenia) has been shown to decline by 1.5% between ages 50 and 60 and by 3% thereafter (Von Haehling, Morley, & Anker, 2010; Keller & Engelhardt, 2013). Fact 6: Sarcopenia is ‘a syndrome characterised by progressive and generalised loss of skeletal muscle mass and strength with a risk of adverse outcomes such as physical disability, poor quality of life and death (European Working Group on Sarcopenia in Older People, Cruz-Jentoft et al, 2010). Fact 7: Up to 33% of people aged over 50 suffer from sarcopenia, with higher prevalence in long-term and acute care settings (European Working Group on Sarcopenia in Older People, Cruz-Jentof el al, 2014). Fact 8: Due to the loss of skeletal muscle, metabolic rate drops by 2%-3% per decade after the age of 20, by 4% per decade after the age of 50 and overall by 30% between the ages of 20 and 70. This equates to approximately 150 kcal per day and combined with reduced physical activity can result in gradual weight gain during aging (Sakuma & Yamaguchi, 2013).

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NUTRITION FOR BONE AND MUSCLE HEALTH - A HEALTH PROFESSIONALS’ GUIDE

What can nutrition do to help your patients bone and muscle health? Three key nutrients for bone and muscle health It is well known that calcium is essential for bone health but this mineral also contributes to normal muscle function and neurotransmission (European Food Safety Authority, 2015). However, Vitamin D is also essential for bone health as without Vitamin D, only 10-15% of the calcium ingested is actually absorbed versus 30-40% of calcium when Vitamin D is available. In addition, Vitamin D contributes to the maintenance of normal muscle function (European Food Safety Authority, 2010; Rizzoli et al, 2014). A gradual, progressive loss of muscle mass and function is a common feature of aging. Sarcopenia, in the absence of a disease state or injury, results in a 3–8% reduction in muscle mass per decade. Like osteoporosis, the onset of physiologic and behavioural changes that precede sarcopenia can occur relatively early-during the fourth to fifth decade of life (Paddon-Jones et al, 2015). There is also increasing evidence that the presence of osteoporosis and sarcopenia or ‘osteosarcopenia’ frequently coexist and increases fracture risk (Drey et al, 2015, Levinger et al, 2016, Morley, 2016). Protein in food contributes to the growth and maintenance of muscle mass (European Food Safety Authority, 2012). The essential amino acids in protein foods stimulates the synthesis of muscle mass which in turn may lead to improved muscle mass, strength and function over time (Wolfe, 2012). Furthermore, bone mineral density has been shown to be positively related to protein intake and protein deficiency increases the risk of bone fragility and fracture (European Food Safety Authority, EFSA, 2012).

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How much calcium should people get from the foods they eat?

The Food Safety Authority of Ireland, (2014) advises that the daily reference intake for adults is 800mg of calcium a day for bone health. The guidelines recommend that adults eat three servings of dairy foods a day to help meet their calcium needs. Eating a varied diet including foods from each of the shelves on the food pyramid along with three servings of dairy foods a day will help meet dairy calcium needs. However, 9 out of 10 Irish women aged 18-64 and 8 out of 10 women aged over 64 do not currently meet the recommended guidelines of three servings of dairy foods a day (National Dairy Council, 2012, 2014).

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NUTRITION FOR BONE AND MUSCLE HEALTH - A HEALTH PROFESSIONALS’ GUIDE

Calcium Chart The table below shows examples of some foods that can contribute to calcium intake. Calcium rich foods can help to maintain a healthy skeleton. Dairy Sources Glass of low fat/full fat (200ml)

240mg

Pot of low fat yogurt (125g)

165mg

ProU yogurt (150g)

590mg

Cheddar cheese; gouda; edam (28g/1oz)

200mg

Mozzarella or Feta (28g/1oz)

100mg

Cottage cheese (28g/1oz)

35mg

Dairy Free Alternatives Glass of calcium enriched soya/rice milk (200ml)

260mg

Pot of soya yogurt 125g calcium enriched

150mg

Soya cheese fortified (25g)

100mg

Tofu fortified with calcium (100g)

400mg

Non-Dairy Sources Tinned salmon (106g)

280mg

1 tin sardines with bones (120g)

250mg

1 tablespoon of tahini (sesame seed paste)

130mg

2 slices bread (brown)

80mg

Small can baked beans (150g)

60mg

1 large orange (210g)

100mg

2 tablespoons raw spinach (100g)

170mg

How much Vitamin D should people get from the foods they eat? The daily requirements are based on whether there is adequate sun exposure to make enough Vitamin D. The daily reference intake for adults is 5μg from the diet. Irish research has found that women over the age of 51 take just over 3 µg per day and women have low Vitamin D levels between late winter and early spring (Hill et  

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NUTRITION FOR BONE AND MUSCLE HEALTH - A HEALTH PROFESSIONALS’ GUIDE

al, 2005). One of the main reasons women do not meet their needs is because few foods provide Vitamin D naturally. The Food Safety Authority of Ireland, (2011) recommends a daily Vitamin D supplement - 5µg per day for those aged 5-50 years and 10µg per day for those aged 51 years and over.

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What foods provide Vitamin D?

Food

Vitamin D (μg per day)

Fortified milks (200mls)

2-4 μg

ProU yogurt fortified with Vitamin D (150g) 1 tin tuna/sardines (100g)

ϳ͘5 μg 4-5.0 μg

Grilled salmon/trout (100g)

10 μg

2 x cooked eggs

2 μg

Pork, lamb and beef (100g)

0.7 μg

Source: These are approximate figures using Nutritics food analysis (nutritics.com) and may vary from product to product. Note: pregnant women need to limit fresh tuna to 150g per week or two 240g cans of tuna per week.

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How much protein should people get from the foods they eat?

There is a lot of emerging evidence that protein requirements are potentially higher for older people, however, a public health consensus on this has not yet been reached. For the general healthy population, adults should get at least the daily reference intake of 50g of protein a day (European Food Safety Authority, 2012). You can calculate individual daily protein needs by multiplying weight in kilograms by 0.83. For example, an 80kg adult requires 66g of protein a day (Philips, 2012). People who are very active and exercise may naturally eat more protein due to a higher intake of foods to meet the calorie/energy needs for their physical activity. The European Food Safety Authority, (2012) advises that an intake of twice the daily reference intake is safe. Recent research indicates that spreading high quality protein intake across three meals, with each meal containing 20-30g protein, may have the most benefit for muscles (Layman et al, 2015).

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NUTRITION FOR BONE AND MUSCLE HEALTH - A HEALTH PROFESSIONALS’ GUIDE

For example, a typical day that includes three servings of dairy foods (e.g. yogurts and milk) plus two servings of protein foods (e.g. lean meat, poultry, fish or beans) provides quality sources of protein to help reach an adults daily protein requirements. Also this spreading of protein foods across the day seems to help muscles. In addition, research indicates that eating high quality protein foods within a couple hours of physical activity may increase the effectiveness of building muscle (Bauer et al, 2013, Philips et al, 2016).

 How much protein in different foods? Fact is, not all protein foods are equal… Protein is made up of building blocks called amino acids. Some of these amino acids cannot be made by the body and are known as essential amino acids. Certain foods contain all of the essential amino acids and make the food a high quality protein, such foods include meats, chicken, fish, eggs, soy foods and dairy foods. Foods that do not contain all of the essential amino acids are called incomplete or low quality proteins. These include pulses (e.g. chickpeas, kidney beans), grains, nuts, seeds and vegetables. Adults need to eat a combination of high and low quality protein foods to get the full complement of essential amino acids. High Quality Protein Foods Food

Serving size

Grams of Protein

Milk

180mls

6

Yogurt

125g

6

ProU yogurt

150g

10

Eggs

50g

6

Meat cooked

25g

6

Fish

35g

6

Tofu

75g

6

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NUTRITION FOR BONE AND MUSCLE HEALTH - A HEALTH PROFESSIONALS’ GUIDE

Low Quality Protein Foods Food

Serving size

Grams of Protein

Baked beans

120g

6

Peas

100g

6

Nuts

25g

6

Wholemeal bread

30g

2-3

Breakfast cereals

25g

2-3

Pasta/Rice

25g

2-3

Exercise is important for bone and muscle health There is very strong evidence that physical activity improves muscular fitness. Research shows that physical activity can help build or maintain bone density and may reduce hip fractures. The recommended guideline for exercise is 30 minutes’ physical activity five days a week. Weight bearing activities are recommended two to three non- consecutive days a week to strengthen muscles and build endurance. A balanced diet including protein-rich foods such as yogurt can help to repair and build muscle after weight bearing exercise. The Irish physical activity guidelines and resources can be found on www.getactiveireland.ie.

Frequently asked questions  Can adults eat too much protein? The European Food Safety Authority, (2012) decided that an upper tolerable level could not be defined. Acute adverse events have occurred at protein levels >45% of calorie intake. The advised %energy from protein is 15% of calories but this can increase to 20% in those following active lifestyles which require more food intake overall. The European Food Safety Authority states that intakes of twice the reference intake for adults are safe.

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 NUTRITION FOR BONE AND MUSCLE HEALTH - A HEALTH PROFESSIONALS’ GUIDE

 Can adults take too much calcium or Vitamin D? The European Food Safety Authority, (2012) advises an upper tolerable level of 2500mg calcium per day and an upper tolerable level of 100µg (4000IU) Vitamin D per day for healthy adults. Calcium and Vitamin D supplements twice a day are often advised for patients with osteopenia/osteoporosis to provide approximately 1000mg calcium and 20µg (800IU) Vitamin D depending upon the brand used. Food is always the best way to get calcium and Vitamin D into the diet, fortified foods can also be beneficial, with supplements used to make up any deficits from food intake. The Food Safety Authority of Ireland, (2014) advises daily reference intakes of 800mg calcium and 5µg from packaged foods. The Food Safety Authority of Ireland, (2011) healthy eating guidelines advise calcium and Vitamin D intakes as follows:  Vitamin D (μg /day)

Calcium (mg/day)

Adults 19-50

Age

5 μg

1000mg

Adults 51 +

10 μg

1200mg

Useful websites www.indi.ie www.irishosteoporosis.ie www.efsa.europa.eu www.getirelandactive.ie

References Bauer J, Biolo G, Cederholm T, Cesari M, Cruz-Jentoft AJ, Morley JE, Phillips S, Sieber C, Stehle P, Teta D, Visvanathan R, Volpi E, Boirie Y (2013) Evidence-Based Recommendations for Optimal Dietary Protein Intake in Older People: A Position Paper From the PROT-AGE Study Group. Journal of the American Medical Directors Association, Volume 14, Issue 8, 542 – 559. Cruz-Jentoft, A. J., Baeyens, J. P., Bauer, J. M., Boirie, Y., Cederholm, T., Landi, F., … Zamboni, M. (2010). Sarcopenia: European consensus on definition and diagnosis: Report of the European Working Group on Sarcopenia in Older People. Age and Ageing, 39(4), 412–423.

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NUTRITION FOR BONE AND MUSCLE HEALTH - A HEALTH PROFESSIONALS’ GUIDE

Cruz-Jentoft, A. J., Landi, F., Schneider, S. M., Zúñiga, C., Arai, H., Boirie, Y., … Cederholm, T. (2014). Prevalence of and interventions for sarcopenia in ageing adults: a systematic review. Report of the International Sarcopenia Initiative (EWGSOP and IWGS). Age and Ageing, 43(6), 748–759. Drey M, Sieber CC, Bertsch T, Bauer JM, Schmidmaier R. FiAT intervention group. (2015) Osteosarcopenia is more than sarcopenia and osteopenia alone. Aging Clinical and Experimental Research. EFSA NDA Panel (EFSA Panel on Dietetic Products, Nutrition and Allergies), 2012. Scientific Opinion on Dietary Reference Values for protein. EFSA Journal 2012;10(2):2557, 66 pp. EFSA NDA Panel (EFSA Panel on Dietetic Products, Nutrition and Allergies), 2015. Scientific Opinion on Dietary Reference Values for calcium. EFSA Journal 2015;13(5):4101, 82pp. Hill TR, Collins A, O’Brien MM, Kiely M, Flynn A, Cashman KD. (2012) Vitamin D intake and status in Irish postmenopausal women. European Journal Clinical Nutrition. 59: 404-410. Keller, K., & Engelhardt, M. (2013). Strength and muscle mass loss with aging process. Age and strength loss. Muscles, Ligaments and Tendons Journal, 3(4), 346–350. Layman DK, TG Anthony TG, BB Rasmussen BB, SH Adams SH, CJ Lynch CJ, GD Brinkworth GD, and TA Davis TA (2015) Defining meal requirements for protein to optimize metabolic roles of amino acids. American Journal of Clinical Nutrition 101:1330S-1338S. Levinger I, Phu S, Duque G (2016) Sarcopenia and Osteoporotic Fractures. Clinic Reviews in Bone and Mineral Metabolism 14:38–44. Morley J (2016) Frailty and Sarcopenia: The New Geriatric Giants. Revista de Investigacion Clinica. 2016;68:59-67. National Dairy Council (2012) Report on the contribution of dairy foods to the nutritional quality of the Irish adult diet. Analysis conducted by Irish Universities Nutrition Alliance (IUNA), based on information from the National Adult Nutrition Survey (NANS).

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NUTRITION FOR BONE AND MUSCLE HEALTH - A HEALTH PROFESSIONALS’ GUIDE

National Dairy Council (2014) Report on the Contribution of Dairy Foods to the Nutritional Quality of the Diet in Older Irish Adults (Aged 65 years and older) Analysis conducted by Irish Universities Nutrition Alliance (IUNA), based on information from the National Adult Nutrition Survey (NANS). Paddon-Jones, D, Campbell, WW, Jacques, PF, Kritchevsky, SB., Moore, LL, Rodriguez, NR, and van Loon, LJ (2015) Protein and healthy aging. American Journal Clinical Nutrition 101(6): 1339S–1345S. Phillips SM (2012). Dietary protein requirements and adaptive advantages in athletes. British Journal of Nutrition, 108, pp S158-S167. Phillips SM, Chevalier S, Leidy HJ (2016) Protein "requirements" beyond the RDA: implications for optimizing health. Applied Physiology Nutrition Metabolism. 2016 May;41(5):565-72. Sakuma K & Yamaguchi A (2013). Sarcopenic Obesity and Endocrinal Adaptation with Age. International Journal of Endocrinology, 2013, 204164. Von Haehling, S, Morley, JE., & Anker SD (2010). An overview of sarcopenia: facts and numbers on prevalence and clinical impact. Journal of Cachexia, Sarcopenia and Muscle, 1(2), 129–133. Wolfe (2015) Update on protein intake: importance of milk proteins for health status of the elderly. Nutrition Reviews. 73 Suppl 1:41-7. Note people with specific conditions such coeliac disease, inflammatory bowel disease, osteopenia or osteoporosis will require higher calcium and Vitamin D intakes than an adult with no such condition. If you need a patient’s diet to be nutritionally assessed for bone and muscle health, contact a HSE Dietitian via your HSE hospital/community departments or a private Dietitian through www.indi.ie. Also people with osteopenia/osteoporosis may need to be assessed by a physiotherapist for an appropriate exercise prescription www.iscp.ie. This document is for healthcare professional use and not designed for distribution to patients or consumers. 

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NUTRITION FOR BONE AND MUSCLE HEALTH - A HEALTH PROFESSIONALS’ GUIDE

Notes

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Nutrition Information The contents of this publication reflect the opinions of the author Richelle Flanagan, NutritionWise, only. All nutritional information was compiled by NutritionWise and do not represent the opinions of ProU/M&J Nutrition.

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