NUTRITION AND MENOPAUSE JM LECERFmenopausesociety.be/upl_docs/en/nutrition-and-menopause.pdf ·...

Nutrition and MenopauseFévrier 2012 Service de Nutrition – Institut Pasteur de Lille

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NUTRITION AND MENOPAUSE

Docteur Jean-Michel LECERF Service de Nutrition - Institut Pasteur de LilleService de Médecine Interne – CHRU de Lille


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PHYSIOLOGICAL CHANGES WITH NUTRITIONAL IMPACT

Increase of bone loss

Reduction of lean mass

Resting energy expenditure

Change in adipose tissue distribution

Glucose tolerance

Changes in lipid metabolism

LDL TG HDL

No menstruation Decrease of iron requirements


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PSYCHOLOGICAL AND DIETARY CONTEXT

Psychological frailty Depressive mood

- Familial disturbance

- Loss of feminity and/or women status

- Disturbance of bodily image Restrictive regimen

Dietary adjustement

Disturbance of dietary behavious

Weight gain Cognitive restriction


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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


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FACTORS IMPLIED IN WEIGHT GAIN

LEAN MASS

PHYSICAL ACTIVITY

DIETARY INTAKE

HORMONAL FACTORS

GENETIC FACTORS

PSYCHOLOGICAL FACTORS

Physical activity expenditure

Resting energy expenditure Fat mass

Dietary intake in restreint subjects in case of stress

Adipose tissue distribution

Early obesity

Dietary adjustement for the mood


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BODY SHAPES AND OVERWEIGHT

MORPHOTYPE UPPER BODY OVERWEIGHT LOWER BODY OVERWEIGHT

ADIPOSE TISSUE ABDOMINAL AND VISCERAL FEMORAL

METABOLIC RISK ++++ -

CARDIOVASCULAR +++

CANCER ++ +

OSTEOPOROSIS +

APPLE PEAROR


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BODY CHANGES DURING PERIMENOPAUSAL PERIOD

543 WOMEN OF 42 – 52 YEARSFOLLOW UP DURING 6 YEARS7 MEASUREMENTS

/ year Total on 6 years

WEIGHT + 0,6 % (0,5 kg) + 3,4 % (+ 2,9 kg)

HEIGHT - 0,064 cm - 0,38 cm

BMI + 0,7 % + 4 % (+ 1,2 kg/m2)

Warst circumference + 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


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Int J Obes 2001, 25, 844-879


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Int J Obes 2001, 25, 874-879


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CHANGES IN ADIPOSE TISSUE DISTRIBUTION

MENOPAUSE ABDOMINAL ADIPOSE TISSUE

CARDIOVASCULAR RISK FACTORS

CORONARY HEART DISEASE RISKHormonal factorsNutritional factorsPhysical activitySocial stress

In primates- < menopause intra abdominal in dominates- > menopause intra abdominal in dominants

- Sub cutaneous- Perivisceral +++

Blood pressure Triglycerides HDL C Glycemia


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ENERGY BALANCE

PHYSICAL ACTIVITY

THERMOGENESIS

RESTING ENERGY EXPENDITURE

ENERGY EXPENDITURE

ALCOHOL

FAT

CARBOHYDRATES

PROTEINS

+++

NOT IMPLIED

++

BENEFICIAL EFFECT

5 to 40%

10 –15%

65 to 70%

30 to 40%

15 to 20%

40 to 55%

FIBRES


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ENERGY DENSITY

ENERGY / VOLUME

Chocolate 550 KcalCake 400 KcalSweetened bars 350 KcalBread 220 KcalVegetables 30 KcalFruits 50 Kcal

100 g

18 g25 g30 g40 g

300 g200 g

100 Kcal

Dietary intake controlSatiation


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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


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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


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INTERVENTION

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

WOMEN HEALTHY LIFESTYLE PROJECTCirculation 2001, 103, 32-37JACC 2004, 44, 579-85


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PHYSICAL ACTIVITY AND ENERGY EXPENDITURE AFTER MENOPAUSE

POEHLMAN Energy expenditureDirectIndirect : lean mass

Dietary intakes Physical activity during the day

MURIO Fat oxydation (nocturnal and diurnal)

ENDURANCE PHYSICAL ACTIVITY

PHYSICAL ACTIVITY (walking 3 x / week)

+ MODERATE RESTRICTION

Muscular fat

Improve glycemic and lipid metabolic parameters

ENERGY BALANCE =

EQUILIBRIUM

– 8 % WEIGHT (RYAN)


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SEVERE RESTRICTION INDUCE SARCOPENIA IN OBESE SUBJECTS

78 ♀ menopausal women50 – 70 yearsBMI 25 – 40 kg/m²Waist circumference > 88 cm- 400 Kcalories/EE

Regimen Regimen + mild physical activity

Regimen + intense physical

activity5 months Weight 11,5 kg

Fat mass 8,2 kgLean 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


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HORMONAL MODIFICATIONS INDUCING WEIGHT GAIN AND HUNGER SENSATION ARE MAINTENED AT 62 WEEKS

50 OBESE SUBJECTSVERY LOW CALORIE DIET8 WEEKS

If weight loss > 10% (moy 13,5 kg)

Stabilisation 2 weeks

Follow-up 62 weeks

Weight gain 5,5 kg

Weeks Hunger Leptin PYY CCK INS Amyline Ghrelin GIP PP

1062

NEJM 2011, 365, 1597-604


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VICIOUS CIRCLE OF COGNITIVE RESTRICTION

I don’t feel well

I want to do a regimen

I have to do a regimen

I STOP

Forbidden

foods

Frustration

Depression

Weight (re)gain

I eat more again

Guilt complex


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UPPER BODY OBESITYRISK FACTORS

MENOPAUSETESTOSTERONE DEFICIENCY

HIGH GLUCOCORTICOIDS

SECRETION

SOCIAL STRESS

THRIFTY GENOTYPE LOW BIRTH WEIGHT

ALCOHOL SMOKING

INACTIVITY

DIETARY FACTORS (excess)

MICROBIOTA

PSYCHOTIC DISEASES NEUROLEPTIC DRUGS


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METABOLIC SYNDROME

HIGH TRIGLYCERIDES

LOW HDL C

HIGH WAIST CIRCUMFERENCE

HIGH BLOOD PRESSURE

HIGH GLYCEMIA

LOW DENSITY LDLINSULINO RESISTANCE

LOW GRADE INFLAMMATIONPOST PRANDIAL HYPERLIPIDEMIA

OXYDATIVE STRESSHYPERINSULINEMIA

LDL OXYDATION

DIETARY FACTORS

YOYO SYNDROME

INACTIVITY

STRESS (GLUCOCORTICOIDS)

INTRA UTERINE RETARDATION

GENETIC FACTORS

OESTROGEN OR TESTOSTERONE

DEFICIENCY

MICROBIOTA


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CARDIOVASCULAR PREVENTION

NUTRITION

ABDOMINAL

ADIPOSITYHTA DIABETES DYSLIPIDEMIA OXIDATIVE

STRESSSMOKING

INACTIVITY – STRESS – GENETIC – HORMONAL DEFICIENCY - AGE


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WOMEN’S HEALTH INITIATIVE JAMA 2006, 295, 655-65648 835 W 62,3 years 2 groups – 8,1 years – BMI (mean) 29 kg/m²

PREVENTION GENERAL POPULATION

INTERVENTION CONTROLOBJECTIVE INITIAL REAL

Fat 20 % 37,8 % 28,8 % 37,8SFA 12,7 % 9,5 % 12,7TFA 2,8 % 1,6 % 2,8

PUFA 7,8 % 6,1 % 7,8MUFA 14,4 % 10,8 % 14,4

+ 5 fruits and vegetables/day6 grains /day

RESULTSINTERVENTION CONTROL HRCHD 0,63 % 0,65 % 0,97

Stroke 0,28 % 0,27 % 1,02CVD 0,86 % 0,88 % 0,98

MAJOR EVENTS RISK in women with previous cardiovascular disease (3,4 %) +26%


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WEIGHT CHANGE IN W H I


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CARDIOVASCULAR PREVENTIONReduction 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

Fatty fish

5 fruits and vegetables/day, half a plate

Fibers (bread and wholegrains - leguminous)

Decrease salt

Abdominal weight loss

Low glycemic index carbohydrates

Particularly omega 3


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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


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73 743 women 50 – 79 yearsW.H.I. Study5,9 years (follow-up)

VIGOROUS WALK IS ASSOCIATED WITH A LOWER CARDIOVASCULAR RISK EVEN FOR A SHORT DURATION

NEJM 2002, 347, 716-25


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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 breadPotatoes

Lentils LeguminousFruits

Whole breadWhole grainOats

FAT AND SWEETENED FOODSCakesLOW NUTRITIONAL DENSITY FOODSSweets

AVOID MODERATE FAVOUR FAVOUR


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SALT

ADDED NOT VISIBLE

COOKINGLow salt (at the beginning of cooking)

ON THE TABLEAvoid

BreadCheeseProcessed meatCanned foodsSoupsReady cooked dishes

POTASSIUMFruits

Vegetables


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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

Between 30 and 80 years

- 50% trabecular mass pool

- 30% bone mass pool

GeneticCalciumVit DPhysical activity

OsteoformationStable Resorption

Cellular ageingOestrogens resorption

Decrease of cutaneous vit D synthesisLow intake of Vit D

and calcium

PTH

Bone resorption


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SUN SHINE

VITAMINES D and K

PHYSICAL ACTIVITY AND GRAVITY

ALCALINIC FOODS

TEA

PROTEINS

VITAMINE AEXCESS OF

SALT

EXCESS OF ANIMAL

PROTEINS

CALCIUM

LOW BMI

SMOKING

STRESS

CORTISOL

ACIDIFIC FOODS

OSTEOPOROSIS

COFFEE

CALCIURIA

SILICE

VITAMINE C

SOFT DRINKS (SODAS)


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IS THERE A BONE BENEFIT OVERWEIGHT AFTER MENOPAUSE ?

PERIPHERAL ADIPOSE TISSUE

4A OESTRONE BMD

LESS PREVALENCE OF OSTEOPOROSIS FOR A BMI 25-28/LOWER BMI

AROMATASE

OSTEOPOROSIS

HIGH BMI HIGH

CALCIUM INTAKES

MUSCULAR STRENGHT

Low mineral bone density at menopause Mortality

= low oestrogenic impregnation ?

BUT FAT MASS PLAYS A LESSER ROLE THAN

MENOPAUSE


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WEIGHT LOSS IN PREMENOPAUSAL WOMEN HAS A FAVORABLE IMPACT ON CARDIOVASCULAR RISK BUT NOT

ON BONE MASS

WOMEN’S HEALTHY LIFESTYLE PROJECT373 ♀ 44 – 50 years2 groups - Control

- 1 with dietary changes + physical activity and weight lossControl Intervention

WeightBone mass

2,6 kg- 0,03 % / year

- 0,4 kg p < 0,01

- 0,20 % / year p < 0,01

NS after intervention (54 78 months)

J Clin Endocrinol Metab 2007, 92, 3809 - 3815

If HRTWEIGHT LOSS + 3%WEIGHT GAIN

Bone mass 0,25 % / an 0,02 % / an

54 months


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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)


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PREVENTION OF AGE RELATED MACULAR DEGENERATION

LUTEINZEAXANTHIN CAROTENOIDS INCREASE MACULAR

PIGMENTCABBAGELETTUCESPINACH

TURN OVER OF PHOTORECEPTOR DISKS

AGAINST OXIDATIVE STRESS

POISSONS GRAS

VEGETABLES, FRUITS, FISH, VEGETABLE OILS

EPADHA LONG CHAIN OMEGA 3 PUFA

ANTIOXIDANTS Vitamins E, CSelenium, zinc


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LIPIDSTRANS FA SATURATED

FAMONO

UNSATURATED FAPOLYUNSATURATED FA

OMEGA 6 OMEGA 3

Hard margarinesPastryBiscuitsCakes

ButterCheeseMeatProcessed meat

OliveRapeseedPeanutPorkPoultry

LINOLEIC ACIDSun flowerCornSoyPork Poultry

linolenic acidrapeseedwalnutsoybeanlinseedrabbitspinach pursle

EPAFish

DHAAvoid Moderate Moderate Moderate Favour


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OXIDATIVE STRESS

Iron

Mercury

UV – excess of sunshine

Tobacco

Excess of exercice

Grilled foods (Maillard reaction)

PRODUCTION OF FREE

RADICALS

Vitamin C

Vitamin E 8 isomers

Betacarotene

Carotenoids (600)

Polyphenols (4000)

Ferulic acid

FruitsVegetablesNutsCocoaTeaWineVirgin olive oilGrainsSoySpices

ANTIOXIDANT NUTRIENTS AND PHYTOCHEMICALS

in excess


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CANCER PREVENTIONIron

(moderate)Calcium

(sufficient)Physical activity

Weight Fat Fiber Alcohol

Omega 3

LUNG

COLORECTAL ENDOMETRIAL BREAST

ANTIOXIDANTS – POLYPHENOLS - CAROTENOIDS

FRUITS AND VEGETABLES

SMOKING


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PHYSICAL ACTIVITY

Energy expenditure for physical activity

Lean mass

Osteoporosis prevention

Total energy expenditure

Immune defenses

Cardiovascular and metabolic risk

factorsWeight control More

micronutrients


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BASIC PRINCIPLES OF PREVENTION NUTRITION

- WEIGHT GAINENERGY BALANCE FATS AND CARBOHYDRATE

- HYPERLIPIDEMIA

- GLUCOSE TOLERANCE

- OXIDATIVE STRESS

- HOMOCYSTEINEMIA

- PLATELET AGREGATION INFLAMMATION ARRYTHMIA

- HYPERTENSION

AVOID EXCESS OF SATURATED AND TRANS FATTY ACIDS

CHOICE OF CARBOHYDRATES HIGH IN FIBERS AND LOW GLYCEMIC INDEX

FAVOUR ANTIOXIDANT FOODS

VITAMIN B9

OMEGA 3 FATTY ACIDSOMEGA 6 / OMEGA 3 RATIO

REDUCE SALTAVOID ALCOHOL


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IN PRACTICE EMPTIED CALORIES

PORTION SIZE

HELP AGAIN TO A DISH

COOKING

FAT USE

BETWEEN THE MEALS

ALCOHOL

SOFT DRINKS ++

FOOD CHOICE


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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

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