NUTRITION AND MENOPAUSE

NUTRITION AND MENOPAUSE Docteur Jean-Michel LECERF Service de Nutrition - Institut Pasteur de Lille Service de Médecine Interne – CHRU de Lille 1 Nut...
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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

Service de Nutrition – Institut Pasteur de Lille

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