ESPEN Congress Geneva 2014 DIETETIC SESSION: SPORT AND NUTRITION

Transcription

1 ESPEN Congress Geneva 2014 DIETETIC SESSION: SPORT AND NUTRITION Nutrition in the extreme environment: translating top physical experiences into clinical practice P. Bärtsch (DE)

2 Innere Medizin VII / Sportmedizin Nutrition in extreme environment: Translating top physical activity into clinical practice Peter Bärtsch

3 Ethical dilemmas Bioethical principles Application of bioethical principles to Nutrition at the end-of-life The decision-making process

4 Acute exposure (AMS) Chronic exposure: level altitude

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6 Aussicht CRM

7 Acute Mountain Sickness (AMS) headache loss of appetite nausea dizziness insomnia peripheral edeme severe headache vomiting

8 Characteristics of AMS Manifestation starting at m Delayed onset of 4-24 hours Maximum on day 2-3, usually most prominent after the first night at a new altitude Clinical course: - spontaneous recovery in 1-2 days - rarely progression to HACE Prevalence depending on: - altitude - susceptibility - rate of ascent - acclimatization - fitness Bärtsch P and Swenson E, NEJM 2013

9 Prevention of AMS by carbohydrate rich diet? Rationale: metabolization of glycogen greater CO 2 -production at a given O 2 -consumption Ventilation PaO 2 /SaO 2 Effect of 1 g sucrose/kg BW on SaO 2 : after 30 min at 12,8% O 2 ( 3500 m) 4% SaO2 (P. Golja, HAMB 2009) Effect on AMS questionable, largest study negative: - 68 % vs 45 % carbohydrates over 4 days - 8 hours at 10 % (FIO m), n= 19 - AMS score not different between groups -SaO 2 not different between gourps Swenson ER, Aviat Space Environ Med 1997

10 4559m 4559m 3611m 5h HA 1 HA 2 HA 3 4h 3320m 1,5h 1190m Day 1 Day 2 Day 3 Day 4 15:00 24:00 16:00 24:00 6:00 24:00 6:00

11 Ad libitum meal at 446 m and at 4559 m - hunger desire to eat - liking of fat and savory - liking of sweet = No association with plasma levels of: - glucagon - CCK - PYY - amylin (n=11) AMS score Correlation ns r = ns Aeberli I, Eur J Nutr 2012

12 Increased leptin with loss of appetite at 4559 m Viewpoint: Sierra-Johnson, JAP 2008 Role for Grehlin? Data controversial Tschöp M., Lancet 1998

13 Body weight with prolonged stay at m Increased demand - higher resting metabolic rate (Butterfield, JAP 1992) - possibly increased physical activity No malabsorption for - xylose 4800m: Chesner, Postgrad Med J fat 4800m: Chesner, Postgrad Med J protein 5000m: Kayser, JAP % of the ingested calories at 5000 m in feces (Kayser, JAP 1992) if appetite normal and food palatable: ± constant weight

14 Body weight with prolonged stay at m Pikes Peak 4300 m intake = (7 d) intake (14 d) g - 70 g per day Lobuche 5000 m study 92 study g - 96 g kg kg (50% fat) (mostly water?) Butterfield, JAP 1992 Kayser, JAP 1992 and IJSM 1993

15 Body weight at extreme altitude ( > 5000 m) Silverhut 1961, 5800 m On Makalu 7400 m Ward, Milledge and West: High Altitude Medicine Physiology, 1995

16 Views on diets (not only at altitude) are strongly held, often the strength of opinion being inversely related to the strength of scientific evidence. High Altitude Medicine and Physiology; Ward, Milledge, West (Chapman and Hall, 1994)

17 Weight Loss at 5800 m Base camp at 4500 m g/day West JB: High Altitude Medicine Physiology, Taylor & Francis 2013

18 Weight Loss with Operation Everest III (COMEX) 1 0 kg g/day -6 Richalet JP, High Alt Med Biol 2010

19 Weight loss at various altitudes Altitude Weight loss (g/d) (total kg) 14 d at 4300 m 70 g 1.3 kg Butterfield, JAP d at 5000 m 90 g 1.9 kg (50 % fat) Kayser, JAP days at 6542 m 233 g 4.9 kg (74 % fat) Westerterp, JAP 1994 AMREE - to 5400m (BC),(25 d) 76 g 1.9 kg (71 % fat) - above 5400m (47 d) 85 g 4.0 kg (27 % fat) Boyer, JAP 1984 OE II to 8848 in 40 d 185 g 7.4 kg (33 % fat) Rose, JAP 1988 OEIII to 8848 in 31 d 174 g 5.4 kg (75 % fat) Westerterp, JAP 2000 Everest BC in 37 d 86 g 3.2 kg Reynolds, J Nutr 1998 Everest climbers in 37 d 197 g 7.3 kg (mostly fat)

20 Energy deficit above 5000 m 24% in 6452 m (field study, n=10, little exercise) Average daily metabolic rate 2820 Kcal (Westerterp, JAP 1994) 45% in m (field study, n=5): Average daily metabolic rate 3250 Kcal, on Mt. Blanc 3500 Kcal (Westerterp, JAP 1992) 43% bei OE II (chamber study, n = 7): Average daily metabolic rate 3146Kcal (Rose, JAP 1988)

21 Possible causes for weight loss at extreme altitudes Increased energy requirements: resting metabolic rate, thermogenesis (cold environment), exercise Dehydration Acute mountain sickness Lack of palatable food Minor malabsorption possible: data inconsistent Reduction of appetite by severe hypoxia

22 Weight Loss with Operation Everest III (COMEX) 1 0 kg g/day -6 Richalet JP, High Alt Med Biol 2010

23 Energy intake and energy expenditure at each altitude Energiy deficit: m: 10% m: 21% m: 38% 43% m: 49% No influence of fluid balance Switch to nibbling pattern Influence of AMS at 7000 and 8000m Westerterp-Plantenga, JAP 1999

24 Hunger and satiety during Operation Everest III No studies that look into the mechanisms regulating appetite in acclimatized mountaineers above 5000m

25 Daily energy requirement of an Tour de France Cyclist F. Brouns, Ehrnährungsbedürfnisse von Sportlern, Springer 1993

26 S-N traverse of Anapurna over 6 days by N. Joos and E. Loretan, 1984

27 Steinbach-Tranutzer K, Reihe Bergabenteuer: Norbert Joos, AS Verlag Zürich, 2008, p 82 Energy intake in the 2 days crossing from the East peak to the main peak (± always 8000 m) + about 3 liters fluid 260 Kcal 260 Kcal

28 Reduction of VO 2max with altitude Per 100 m above 1500 m decrease of VO 2max by 1 % 8000 m: VO 2max is 65 % Fulco CS, Aviat Space Environ Med 1998

29 Recommendations for climbing 8000 m peaks Avoid AMS by adjusting ascent rate to individual altitude tolerance Eat what you like most, as often and as much as you can What works on long alpine tours also works on 8000 m peaks Logisitc aspects: weight and fuel consumption dehydrated food: water used for cooking drinkable

30 Nutrition in the mountains F. Brouns, 1993 Rheinwaldhorn 1983 Eat what you like and take your time - also at extreme altitudes

31 Rationale for treatment of obesity by hypoxia Mechanisms of loss of appetite not identified, significant effects above 4000 m, this altitude not suitable for obese individuals as at 4500 m: - PaO mmhg -SaO % - periodic breathing during sleep Hypoxia induces low grad inflammation, effect on adipose tissue? Modalities: - living in hypoxia? ( trekking) - sleeping in hypoxia (tents) - training in hypoxia (reduced intensity) No convincing studies