ESPEN Congress Cannes Education and Clinical Practice Programme

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1 ESPEN Congress Cannes 2003 Organised by the Israel Society for Clinical Nutrition Education and Clinical Practice Programme Session: Dietitian Symposium: Nutrition throughout the woman life cycle Prevention in Osteoporosis: a Pediatric Approach Doctor Geila Rozen Haifa, Israel rgeila@rambam.health.gov.il Q&A voting panels Is Osteoporosis a women's health issue? 1. Yes 2. No Number the following diseases as death cause among women, from the most prevalent, to the least: 1. Breast cancer 2. Ovarian cancer 3. Arthrosclerosis and MI 4. Osteoporosis 2 What is the best age to prevent osteoporosis? ESPEN For personal use only. 1

$fragility and susceptibility to fracture Consensus Development Conference 3$

2 Osteoporosis - definition a systemic skeletal disease characterized by low bone mass and microstructure deterioration with a consequent increase in bone fragility and susceptibility to fracture Consensus Development Conference 3 Osteoporosis Int 1997;7:1-6 Osteoporosis micro structure 4 ESPEN For personal use only. 2

$fractures Colle s$ Fracture 6 ESPEN

3 Osteoporosis of vertebra Healthy bone Osteoporotic bone 5 Typical osteoporotic fractures Colle s Fracture 6 ESPEN For personal use only. 3

$Typical osteoporotic fractures Femur neck$ One out of 3 women over 50 One out of 7 men

4 Typical osteoporotic fractures Femur neck fracture 7 Who suffers from Osteoporosis? One out of 3 women over 50 One out of 7 men overo ESPEN For personal use only. 4

5 Bone mass by age & gender 9 Mundy, Nature 1994 Factors effecting PBM Genetics Environmental Nutrition Exercise Smoking PBM General Health & Drug use 10 Gonadal effect ESPEN For personal use only. 5

6 Genetic polymorphism factors As of now, five known factors: Type 1 collagen Vitamin D receptor (VDR) Osteocalcin gene promoter Estrogen receptor gene (ER) Androgen receptor All have potential relationship with BMD 11 Factors effecting PBM Genetics Environmental Nutrition Exercise Smoking PBM General Health & Drug use Gonadal effect 12 ESPEN For personal use only. 6

Can we improve BMD / BMC? For a decade, randomized, double blind, placebo controlled trials have consistently shown that calcium supplementation can increase bone density by 2-7% a year.

7 Can we improve BMD / BMC? For a decade, randomized, double blind, placebo controlled trials have consistently shown that calcium supplementation can increase bone density by 2-7% a year. Lloyd et al, 1993 Lee et al 1995 Chan et al 1995 Cadogen et al 1997 Bonjour et al 2001 Rozen et al Effect of calcium enriched diet on BMD in girls aged ± ± ± ±43 14 Bonjour et al, J. Clin. Invest. 99, 6, 1997, ESPEN For personal use only. 7

8 Effect of 1 year calcium enriched diet on bone mass, 3 y after intervention 15 Bonjour et al, Lancet Oct 13;358(9289): % BMD Effect of 1 year calcium Supplementation in girls aged 14.5 on BMD, 4.5 y after intervention Study A Placebo Active Treatment Calcium Study B Placebo Calcium D1 yr D4.5 yr 16 P=0.03 P=0.05 Dodiuk-Gad, Rozen, Ish-shalom, submitted AJCN 2003 ESPEN For personal use only. 8

9 Focus on calcium When daily calcium requirements are not met from diet, necessary calcium for maintaining physiological functions is mobilized from bones by increasing resorption 17 DRI s vs RDA for Calcium (females) Ca mg / day DRI RDA ESPEN For personal use only. 9

10 Ca mg / day Ca intake survey by Age & Sex Compared to Recommendations Israel DRI 1200 Daily calcium intake of boys 6-8 year old 61.3% below Daily calcium intake of girls 6-8 year old % below 800 Boys DRI 800 Girls Girls Only one of the 9-12 year olds consume Boys more calcium than is recommended ± ± 260± 221± Lack of calcium by caloric intake 100 Calcium intake < 800 Mg/day % 50.2% < > % Rozen G.S., et al, JAm Coll. Nutr ESPEN For personal use only. 10

11 Lack of calcium as an indicator of other deficiencies % 85% 91% 100% 89% <800 > % % 16% 0 21 Phosphate Magnesium Iron Zinc Rozen G.S., et al, J Am Coll. Nutr Pediatric risk factors for osteoporosis Endocrine Cushing syndrome Glucocorticoid therapy Diabetes mellitus Hyperthyroidism Hyperparathyroidism Hypogonadism Turner s syndrome Gastrointestinal Inflammatory bowel disease Cystic fibrosis Celiac disease Biliary atresia Hepatitis Malabsorption Inborn errors of metabolism Glycogen storage disease, type 1 22 ESPEN For personal use only. 11

12 Other issues related to calcium intake & more dairy products in the diet that we could / should / won t talk about Calcium intake and blood pressure Calcium intake and body composition 23 Mean change by research group Height Weight Control Milk LBM % body fat Percent change 24 Cadogen BMJ 1997 ESPEN For personal use only. 12

13 Conjugated Linoleic Acid - CLA Mainly derived from dairy products Strong anti tumor activity (local and systematic) Growth factor of lean body mass (protect against catabolism induced by endotoxin) Increase lipolysis in adipose tissue in animal models Prevention of atherosclerosis in animal models 25 Park Lipids 1997, Lin J Dairy Sci 1995 Food : What a surprise! Milk is a food designed by nature to support tissue growth, and thus it adds far more than calcium to the diet. Heaney Am J Clin Nutr ESPEN For personal use only. 13

$Osteoporosis prevention the pediatric approach Aim at achieving highest possible PBM It is estimated that adding 10% to PBM reduces risk of osteoporosis fractures by 50% 27 Q&A voting panels Is$

14 Osteoporosis prevention the pediatric approach Aim at achieving highest possible PBM It is estimated that adding 10% to PBM reduces risk of osteoporosis fractures by 50% 27 Q&A voting panels Is Osteoporosis a women's health issue? 1. Yes 2. No Number the following diseases as death cause among women, from the most prevalent, to the least: 1. Breast cancer 2. Ovarian cancer 3. Arthrosclerosis and MI 4. Osteoporosis 28 What is the best age to prevent osteoporosis? ESPEN For personal use only. 14

15 Thank you Research team: Dr. Sophia Ish-Shalom MD Dr. Gad Rennert MD Dr. Ronnie Dodiuk-Gad MD Prof. Edi Karnieli MD Batia Raz M Sc Hedy Rennert M Sc 29 ESPEN For personal use only. 15

Case Finding and Risk Assessment for Osteoporosis

Case Finding and Risk Assessment for Osteoporosis Patient may present as a fragility fracture or risk fracture Fragility fracture age 50 Clinical risk factors aged 50 Very strong clinical risk factors