exam 1 Women's Health

Health Consequences of Primary Amenorrhea

(Absence of periods by age 16) •Increased risk of scoliosis •Failure to reach peak bone mass •Increased risk of osteoporosis

Fetal origin of disease (FOAD) is based on the concept that in-utero malnutrition may result in the baby being born with which of the following?

-an increased ability to deposit fat -increased risk of future adult disease -increased insulin resistance Correct! all of the above

What characteristic(s) need to be present in the DSM-V for a classification of Anorexia Nervosa?

-body shape disturbances -significantly low body weight in context of age, sex, and development trajectory -intense fear of getting fat Correct! all of the above

MyPlate for Older Adults proposed by Tufts Human Nutrition Research Center included which new graphic icons?

-canned and frozen foods -examples of liquids -range of colors of fruits and vegetables Correct! all of the above

Based on scientific evolving knowledge: Recognition diet-related chronic diseases are very prevalent. These guidelines focus on dietary patterns and also take a lifespan approach. Be familiar with the 4 major guidelines

1. Follow a healthy dietary pattern at every life stage. 2. Customize and enjoy nutrient-dense food and beverage choices to reflect personal preferences, cultural traditions, and budgetary considerations. 3. Focus on meeting food group needs with nutrient-dense foods and beverage and stay within calorie limits. 4. Limit food and beverages higher in added sugars, saturated fat, and sodium and limit alcoholic beverages. Note: Initially the recommendation of the USDA Dietary Guideline Committee was to reduce Men's Alcohol Limit by Half-- to one drink a day - from the DGC previous recommendation. However, the final 2020 - 2025 report backed down and allows for two drinks a day for men.

Protein Needs

1.2 - 2.0 g/kg/d for metabolic adaptation, repair, remodeling and protein turnover May need higher for short intensified training; guidelines for competition 0.3 g/kg body weight after key exercise sessions and every 3 - 5 hours over multiple meals Consumption of energy, especially adequate CHO to match energy expenditure Muscle adaptation maximized by ingesting protein 0.3 g/kg body weight after key exercise session & every 3-5 hr over multiple meals Up-regulation of muscle protein synthesis (MPS) for at least 24 hours following exercise MPS - incorporation of multiple protein feeding after exercise and throughout the day contributes to improvements in skeletal muscle protein accretion Well-times protein intake even if not trying to increase muscle mass with training Use of high biological value protein optimized MPS in the early recovery phase (0 to 2 hours after exercise)

PMS and Complementary & Alternative Medicine (CAM) 2

2009 systematically review of evidence from randomized controlled trials (RCT) Meta analysis supports use of: Calcium Chasteberry Vitamin B6 may be effective Some preliminary evidence for ginkgo, magnesium pyrrolidone, saffron, St. John's Wort, soy and vitamin E None from evening primrose oil or magnesium oxide Chasteberry Authors from College of Pharmacy in Nova Scotia Scientific evidence searchers were up to April 2008 from variety of methods: PubMed, Cochrane library, Medline 62 herbs, vitamins and minerals were identified for which claims of benefit for PMS were made BUT: RCT evidence found for only 10 Performed a meta-analysis Calcium: surprised............2009 article showed that 500 mg of calcium carbonate twice daily for 3 months reduced early fatigue, changes in appetite and depression in women with PMS Evening primrose oil: has been used for eczema (dry skin); more recently for inflammation (rheumatoid arthritis); extract from seeds of evening primrose. NIH: Has the National Center for Complimentary and Alternative Medicine (CAM)

2016 Position Nutrition & Athletic Performance

2016 Position Academy of Nutrition and Dietetics, Dietitians of Canada, and American College of Sports Medicine Evidence Analysis Library (EAL) March 2006-2014 11 energy and body composition + training ?s Nutrition Themes: Nutrition goals are not static; plans need to be personalized; competition nutrition focus on adequate substrate to meet fuel demands; energy availability important; achieve optimal body composition; training and nutrition interact; some nutrients should use kg/body weight; tightrope between maximal training and avoiding injury; brain sensing of carbohydrates in oral cavity can enhance; pragmatic approach to use of supplements and sport foods The position paper identified a range of themes Overall topic listed above Paper identified the EAL Question and the conclusion and evidence grade. Publications from 2006 to 2014 were reviewed and assessed. Major energy, body composition and training questions were the focus

The 2008 Physical Activity Guidelines for Adolescents included all of the following EXCEPT:

30 minutes of physical activity daily

The folate requirement during periconceptions is:

400 ug/day

What is the folate requirement during preconception?

400 ug/day

Effects of menopausal transition on dietary intake and appetite

5 year observational, longitudinal study Average age 50 y, BMI 23 Assessed body composition by DEXA, appetite by visual analogue scale, energy and macronutrient intake Compared to women in menopausal transition, women 5 years later decreased significantly total energy and carbohydrate consumption But desire to eat & hunger increased during the menopausal transition and remained higher in postmenopausal years Fasting fullness decreased also across menopausal transition Objective of the study was to determine changes in dietary intake and appetite during menopausal transition Although they showed a decrease in energy intake in postmenopausal women (about 254 kcals/day), the mean body weight changed minimally Likely a reduction in energy expenditure with a shift to a more sedentary lifestyle This is the first study of appetite related variables during menopausal transition; showed desired to eat and hunger increased during menopause years, which could place the women at higher risk for weight grain Other authors have reported that ghrelin levels are higher during the menopausal transition compared with both pre and post menopausal women.

Basic Ovarian Activity

500,000 follicles in two ovaries - most are primordial follicles and in a resting state Follicles leaves primordial state: Ovulate Atretic Follicles that have left the resting state are referred to as the "proliferating pool" At birth, females have nearly 500,000 follicles in two ovaries - most are in the primordial resting state Primoridial: Can remain "primordial" for as long as 50+ years What makes the primordial follicles move to the proliferating pool is unknown Once a follicle begins to develop beyond the primordial state, it is committed to progress to ovulation or be atretic Atretic: The degeneration and resorption of one or more ovarian follicles before a state of maturity has been reached withering away.......... The process continues until functional follicles are depleted from the ovaries around 50 years of age🡪 MENOPAUSE

Mini-Nutritional Assessment Tool

A validated nutrition screening and assessment tool 65 and + who are malnourished or at risk for malnutrition Quick Sponsored by Nestle

Which of the following is NOT true:

A women's life expectancy in Bangladesh is equal to a man's.

Previous 2009 Nutrition and Athletic Performance:Academy Position Key Recommendations

Adequate energy Menstrual dysfunction, loss of bone Body weight and composition should not be sole criterion for sports Daily weigh-ins discouraged DRI equations for adult women + physical activity factor The previous - Academy Position paper: published end of 2009 - DiMarco one of authors who is a full Professor of Nutrition on the TWU Denton Campus 2009 Energy: needs increase during high intensity and long duration to: maintain body weight and prevent loss of muscle Satisfaction of Energy Needs - High priority Low intakes of females <1,800 to 2,000 kcals is a Major concern DRI - predictive equation shown here for adults + physical activity factors Body Weight and composition: Optimal body fat levels depend on age, sex, and may be sport specific These can be much higher for sports: Weigh-in: wrestling and rowing; dance, gymnastics, figure skating and diving Weight loss/fat loss - preferable to take place during off season Recommend Sport Dietitian work with athletes

Physiological/Nutritional Aspects Female Athletes

Aerobic power and muscular strength of females naturally lower than males Well trained athletic females can perform superior to poorly trained males Female hormonal variations over menstrual cycle can influence energy metabolism during exercise Females have gender-based metabolic difference during prolonged exercise Greater capacity for lipid oxidation Allows females to maintain normoglycemia and preserve muscle glucose during very long events Of note: females were excluded from participating in the Olympics marathons until 1984 Several studied demonstrated that female could actually perform better than males in ultra-endurance events - especially when the distance exceeded 90 km.

Menopause

After menopause, weaker estrogens contribute Primary estrogen is estrone (much weaker estrogen than estradiol) Two major consequences of estradiol withdrawal Bone loss Cardiovascular disease Two major consequences of estradiol withdrawal: Cells remodeling of bone - rapid demineralization associated with increased fractures Loss of cardioprotective benefits

Population by Age & Sex: 2000 and 2010

Age pyramid - comparing males to female populations US Census bureaus population estimates - there are more recent Tables from the Census but this Figure illustrates best the population by age and sex Baby boom Generation: the largest cohort of people - born 1946 to 1964 According to US Census Bureau: Age and Sex Composition: 2010, the median age of Americans is now 37.2, with seven states recording a median age of 40 or older. The Census brief also shows the male population grew 9.9 percent between 2000 and 2010, while the female population grew 9.5 percent. Of the total 2010 Census population, 157.0 million people were female (50.8 percent) and 151.8 million were male (49.2 percent). 2000 Census report: - From age 40 on, women were in the majority. Among people in their 90s. The ratio of men to women was 38 to 100.

Malnutrition: A Viscous Cycle

Age-induced anorexia may then have diseases causing further reduction of food intake May be difficult to recover usual food intake Can set up a downward spiral Between age 20 & 80 yrs, the decrease in food intake is approximately 1200 kcals/d for men & approximately 800 kcals/d for women Reduced caloric intake associated with natural aging does not seem to change weight Usually stable weight until starts to decrease in people >70yr

Mayo Clin Proc 2013: 88: 996-1009

Algorithm includes assessment of disordered eating, bone mineral density loss and menstrual dysfunction. Bone Mineral Density (BMD) testing: measurement of BMD by DXA remains widely used for skeletal health assessment because relatively easy to use. BMD should be repeated in 6 to 12 months to determine trends BMD : When history of hypoestrogenism, disordered eating or eating disorders for cumulative total of 6 months or more History of stress fractures or fractures from minimal trauma Note: wide variability in BMD athletes with amenorrhea because of genetic influences and the sport played (e.g. gymnasts higher BMD due to impact loading) Sites assessed: posteroanterior aspect of spine and hip for premenopausal female athlete over 20 years , and posteroanterior aspect of spine and whole body (not head) for < 20 years BMD Z scores: between -1 and -2 managed initially with increased energy and periodic assessments; Z scor

Metabolic Response After Exercise

Although females mobilize lipids during exercise, they lose LESS fat mass than males during physical training Three hours after stopping exercise, male subjects have higher rates of blood glucose appearance and disappearance, higher metabolic clearance, and lower glycaemia No differences were found in females Results suggest females have a greater ability to maintain glycaemia during recovery Overall: Females mobilize lipids to a greater extent during exercise Lipid stores are greater Show greater propensity to spare glycogen Have a greater ability than males to maintain constant energy substrate stores during exercise and during recovery

Female Athlete Triad

American College of Sports Medicine (ACSM): Low energy availability Menstrual dysfunction Altered bone mineral density (BMD) Most athletes diagnosed actually manifest all three components to the same degree simultaneously Continuum Etiology: begins with low energy availability Energy Availability: Dietary energy within the body after exercise training is completed Athlete may fail to keep up with her energy requirements secondary to daily rigorous routine and/or poor nutritional habits Athletes maybe at increased risk of developing disordered eating Ways that energy intake maybe decreased can involve: purging, fasting, diet pills, laxative, and diuretics Prevalence of disordered eating may span 1% to 62% of female athletes

Causes of Malnutrition

Anorexia associated with aging due to impairment of a number of factors: Taste & smell capability Poor dental health Ill fitting dentures Digestive disorders; chew/swallow Taste and smell sensitivity: may contribute to decreased enjoyment of food Loss of taste of sweet and salt - may contribute stronger Sour and Bitter taste of foods Usually digestive functions are maintained with aging but ORAL problem - tooth loss and lack of saliva play a role in reduced food intake Many nutritional deficiencies are manifested in the oral cavity Oral exam should be included in an assessment of nutritional status - Non invasive -- should check for: No. and looseness of teeth Caries or plaque Dentures - how well do they fit? Condition of the lips and skin Condition of the bums

Antioxidants: Vitamin A, C & E

Antioxidants prevent free radical production Vitamin A: Vitamin A - form of β carotene - may reduce risk of some reproductive cancers Vitamin C High intake may reduce cancers: oral, esophageal & stomach Does not prevent or reduce heart disease Vitamin E - Not shown benefit for CVD Vitamin A: Pre-formed in animal products Provitamin A: carotenoids in fruits & vegetables Vitamin A - form of β carotene - may reduce risk of some reproductive cancers Vitamin C High intake may reduce cancers: oral, esophageal & stomach Does not appear to prevent or reduce heart disease Vitamin E Supplementation trials have not shown benefit for CVD The antioxidant network showing the interaction among vitamin E, vitamin C and thiol redox cycles

Evaluation

Appropriate screen in at-risk athletes should take place during pre-participation exams or annual checkups Thorough evaluation of medical, dietary, sport injuries, etc. Trainers, coaches, parents - often first to notice abnormal psychological behavioral characteristic Anxiety, unnecessary dieting, compulsiveness regarding exercise, social withdrawal, binge eating, substance abuse, increased agitation Evaluation should include: medical history, energy intake history, dietary practices, weight fluctuations, eating habits Menstrual history: onset of menarche and current menstrual status Sport-specific: number of training hours per day, number of sports played, prior history of stress fracture/injury ACSM recommends a baseline DEXA test in an athlete with evidence of greater than 6 months of amenorrhea, oligomenorrhea, and/or disordered eating

Physiological & Metabolic Factors Altering Nutrient Needs of Elderly

Atrophic gastritis ↑ folate, calcium, vit K, vit B12, iron Reduced skin synthesis; impaired renal activation & gut response ↑ vitamin D & calcium Retention of vitamin A - hepatic altered ↓ vitamin A Age related ↑ homocysteine Possible ↑ folate & vit B12 Menopause, cessation of menstruation ↓ iron for women Poor fluid balance regulation Could ↓ or ↑ fluid needs Decreased total energy expenditure ↓ calories Decrease immunocompetence Possible ↑ for iron, zinc, other nutrients Note the ones where needs decrease Vitamin A Iron Calories

B Vitamins & Folic Acid: Benefit on CVD Risk in Women

B vitamins: May help maintain normal homocysteine levels & potentially reduce CVD risk Meta analysis - 25% lower homocysteine associated with 32% lower risk of CHD of men Folic acid: Women's Antioxidant & Folic Acid Cardiovascular Disease Study (WAFACS) Homocysteine levels have been directly associated with CVD risk in observational studies Daily supplementation with folic acid , vitamin B6, Vitamin B12 or a combination have been shown to reduce homocysteine level in various intervention studies Women's Antioxidant & Folic Acid Cardiovascular Disease Study (WAFACS) Tested combination of folic acid, vitamin B12, & vitamin B6 vs. placebo B vitamins did not reduce total CVD events 5442 Women health professionals aged 42 or older with either history of CVD or 3 or more Coronary risk factors were enrolled in Randomized Controlled Trial treated for 7.3 years - April 1998 until July 2005 2.5 mg folic acid, 50 mg of vitamin B6, and 1 mg of Vitamin B12 (these are all rather high levels that were tested) Conversion of homocysteine to methionine involved tetra-hydrofolic acid

Premenstrual Syndrome (PMS)

Behavioral and physical symptoms usually 7 - 10 days prior to the onset of menstruation PMS syndrome symptoms: Headaches and depression Irritability Insomnia and mood swing Water retention based symptoms (breast tenderness, bloating) Changes in appetite and food cravings PMS: Relieved at or shortly after menstrual flow begins Pharmacological treatments are available

Review of Botanical Dietary Supplements for Menopause

Black cohosh does not improve menopausal symptoms Soy and Isoflavones extract mixed results Single clinical trials - do not support dong quai, ginseng or evening primrose seed oil Black cohosh has received more scientific attention than other botanicals on relieving menopausal symptoms National Center for Complementary and Alternative Medicine (NCCAM) and national Institute on Aging (2005) concluded that black cohosh did not relieve hot flashes and night sweats; also no effect on gynecological problems such as vaginal dryness or abnormal bleeding. Isoflavones extract clinical studies (6) showed mixed results Wide range of dose of soy made conclusions difficult Generally consider safe Single clinical trials do not support the use of dong quai, ginseng or evening primrose seed oil for improving menopausal symptoms

Bone Mineral Density

Bone strength measured with dual-energy X-ray absorptiometry (DEXA), specifically looks at bone strength component - BMD. Other important components of bone: quality, bone mineral content Female athlete's BMD is a single snapshot of cumulative bone health - BMD of athlete should be charted over time to pick up trends Possible for premenopausal women who become amenorrheic, oligomenorrheic, or postmenopausal to lose approximately 2% of BMD per year !! Figure above: average BMD in collegiate athletes across a number of sports found that runners had the lowest BMD of all sports Stress fractures diagnosed with low BMD and menstrual dysfunction may approach 17% Females demonstrate accelerated bone resorption due to the lack of suppressive effect of estrogen on osteoclast (cells breaking down bone) activity

Breast Cancer Risk & HRT

Breast Cancer incidence in postmenopausal women is approximately 30 cases per 10,000 women per year Figure: Risk of Breast Cancer of hormone-related indicators Relative risk: The ratio of the likelihood of an event in a treated or exposed groups compared with a control group Other risk factors during this age range include: alcohol consumption obesity nulliparity (no children) no breast feeding Higher risks are associated with family history of breast cancer Early menarche Delayed Menopause

Potential Shortfall Nutrients for Individuals 70yr & Older

Calcium Vitamin D Vitamin E, Vitamin K, & Potassium Fiber This is a classic paper from the Tufts USDA Research Center on aging summarizing elderly nutrient needs - the research center is located in Boston Vitamin and mineral deficiencies more frequent in this age group Calcium Found in dairy products High rates of lactose intolerance (increases with age) Vitamin D - Inadequate vitamin D and calcium - well documented in Elderly Vitamin E, Vitamin K, & Potassium Vegetables & fruits good sources of vit K & potassium Vegetable oils - soybean & canola - sources of vit E Fiber Note: this reference citation is a good review on nutrition and the elderly

Cardiovascular Adaptations in Pregnancy

Cardiac output 150%Heart rate 130%Stroke volume 135%Plasma volume 150%Systemic vascular resistance 60%

Beginning and End of Menstrual Cycles: Menarche and Menopause

Childhood period of sexual immaturity Women who are usually 50 years of age or older go through menopause Very low estradiol levels - low or absent ovarian follicle growth Menarche: the first menstrual period Menopause: lack of periods Two periods during which normal, health individuals exhibit little or no ovarian activity: Low circulating estradiol no reproductive potential

Not All Seniors Underweight: Overweight & Obesity

Common problem in the elderly Prevalence of overweight & obesity decrease in extreme old age Reduced function & decreased quality of life Increase heart disease & Type 2 diabetes risk Factors with aging predispose to increased fat: Decreased physical activity Decreased energy expenditure Reduction in muscle mass (sarcopenic obesity)

Academy of Nutrition and Dietetics Resources on Botanicals & Dietary Supplements

Currently a newer edition to this guide is not available as of 2017; however, now there is an online version.

Sarcopenia

Defined as loss of muscle mass & function associated with aging Value below mean of -2 SD of the distribution in healthy young of similar weight Present in twice as many patients > 80yrs than < 80yrs 29% men & 16% women > 80yr have sarcopenia Sacropenia is responsible for most of the age-associated loss in lean mass It is aggravated when stress - surgery, sepsis, inflammation , or cancer - occur

Nutrition & Cognitive Decline

Dementia/Alzheimer's Disease Weight loss frequent & occurs in ~ 40% of patients Depression may be associated with deficiencies of vit B6, magnesium, & niacin We will spend an entire module on Alzheimer's

Luteal Phase of Menstrual Cycle

During 96 hours following LH surge, progesterone and estradiol production rises Corpus luteum: progesterone-secreting mass of cells forms from the follicle after the release of a mature egg (oocyte) Luteal Phase: Once ovulation occurs, corpus luteum forms This is a mass of cells that secretes progesterone Corpus luteum functions for about 15 days then it regresses With regression of the corpus luteum 🡪 reduction to basal levels of: Estradiol, Progesterone This signals the end of the Ovarian Cycle.................menstruation then occurs

Exercise Recommendations for Elderly

Endurance or aerobic exercises (i.e., walking, swimming, dancing, & climbing stairs) increase the heart rate & build stamina, while reducing the risk of diseases like type 2 diabetes Strengthening exercises (i.e., lifting weights) builds muscle & increases an older adult's ability to do activities of daily living (ADL) like get out of chairs & walk without assistance Balance exercises (i.e., standing on one foot) are important to build strength in the lower extremities & to increase coordination, a major cause of falls in older adults Flexibility exercises (i.e., stretching) helps older adults to become more limber, also important in reducing falls These recommendations from an older publication - put point out important recommendations specific for Elderly. Endurance or aerobic exercises (i.e., walking, swimming, dancing, & climbing stairs) increase the heart rate & build stamina, while reducing the risk of diseases like type 2 diabetes Strengthening exercises (i.e., lifting weights) builds muscle & increases an older adult's ability to do activities of daily living (ADL) like get out of chairs & walk without assistance Balance exercises (i.e., standing on one foot) are important to build strength in the lower extremities & to increase coordination, a major cause of falls in older adults Flexibility exercises (i.e., stretching) helps older adults to become more limber, also important in reducing falls

Energy Requirements with Aging

Energy needs decrease Total Energy Expenditure (TEE) declines about 7 & 10 kcals/yr for women & men, respectively NHANES III: between 20s & 80s, mean energy intakes ↓ 1200 kcal in men & about 600 kcal in women Energy needs decrease because of: reduction of metabolic rate loss of muscle/lean mass reduced physical activity There is an average decline of ENERGY needs of about 1 to 2 percent per decade in men and women who maintain constant weight Total Energy Expenditure (TEE) declines about 7 & 10 kcals/yr for women & men, respectively More rapid decline around 40 yr men; 50 yr women

2016 Nutrition and Athletic Performance:Academy Position Key Recommendations

Energy requirements can be derived from weighted/measured food records (3-7 days), multi-pass 24-hr recall, and food frequency questionnaires Energy balance when total energy intake (EI) = total energy expenditure (TEE) TEE = BMR + TEF + TEA TEA = planned exercise expenditure + spontaneous physical activity + non-exercise activity thermogenesis Energy estimates with Harris-Benedict with appropriate activity factors BMR = Basal Metabolic Rate Harris-Benedict Equation for females: For women, B.E.E. = 655.1 + (9.563 x kg) + (1.850 x cm) - (4.676 x age) Athlete's energy requirements depend on periodized training and competition cycle. Vary from day to day throughout the year training. Factors increasing energy needs above normal: exposure to cold or heat, stress, high altitude, specific drugs or medications (eg. caffeine and nicotine), increased lean body mass, and possibly luteal phase of menstrual cycle

Theory and evidence in support of the "Barker Hypothesis" include all of the following EXCEPT:

Epigenetic programming alters the DNA sequencing and not the gene expression.

Menstrual Dysfunction

Eumenorrhea: cycle occurring at intervals near mean for adult women (~ 28 ±7 days) Within general females, menstrual dysfunction averages 2% to 5% 6% to 79% of female athletes experience menstrual dysfunction Amenorrhea: absence of cycle lasting longer than 3 months Anovulation: cycle without ovulation Oligomenorrhea: cycles longer than 35 days Oligomenorrhea in female athletes higher in athletes, occurring in about 21% to 40% in sports-specific domains Threshold at which menstrual dysfunction likely to occur when total caloric intake is about 30 kcal/kg lean body mass per day

Fat Requirements with Aging

Fat major fuel source Saturated, monounsaturated & cholesterol are not required Adequate Intake (AI) recommendations for polyunsaturated fatty acids: α-linolenic: Men 1.6g/day, Women 1.1g/day Linoleic: Men 17g/day, Women 12g/day Total GI transit time & fat absorption unchanged No age-related changes in fat intake recommendations Fat intake declines 60yr & reaches lowest in the oldest age groups Recommended 20 - 35% calories from fat Fat fuel source and Aids in absorption of fat-soluble vitamins Saturated, monounsaturated & cholesterol are not required Adequate Intake (AI) recommendations for polyunsaturated fatty acids: α-linolenic: Men 1.6g/day, Women 1.1g/day Linoleic: Men 17g/day, Women 12g/day Total GI transit time & fat absorption are unchanged with aging No age-related changes in fat intake recommendations Fat declines with age after 60yr & reaches lowest in the oldest age groups Recommended 20 - 35% calories from fat PUFA: Linolenic (omega 3) Linoleic (Omega 6) Body cannot make them. Lack of either will result in EFA deficiency - scaly skin, dermatitis, Rare in the US

Do you recognize anyone like this?

Female athletes participating in intense training are at risk of developing menstrual dys- functions, that can lead to stress fractures, infertility, decreased immune function, decreased bone mineral density, and increased risk of premature osteoporosis Don't let this happen to you or anyone you know! It doesn't have to happen!

Evaporation and Hydration

Females differ from males in exogenous heat storage and heat production Mainly attributed to lower body mass to surface area ratio, greater fat-mass, and lower exercise capacity Greater fat layer in females increase distance between active, heat-producing tissues (skeletal muscle) and the skin Reduces rate of non-evaporative heat loss Hormonal variations of menstrual cycle modify thermoregulatory responses to exercise May fluctuate more than 0.6 °C at rest and during menstruation Rise in progesterone during luteal phase triggers rise in body and skin temperatures 🡪 delays perspiration Females sweat less while maintaining the same body temperature Females have great efficiency of sweat evaporation Recommendations for post-exercise rehydration are similar in males and females Aim to compensate for water and electrolyte losses

Healthy Eating Patterns in Midlife 2

Fiber DRI for women 51-70 yr is 21g/d Weight loss possible benefit May improve vasomotor symptoms related to menopause Soy isoflavones & soy protein for CHD FDA (1999) approved health claim for soy protein at 25g/d for reducing cholesterol AHA (2006) reported only a modest benefit on cholesterol (~ 3%), & AHA has requested FDA revoke its claim in 2008 As of 2016, the claim has not been revoked by FDA AHA concludes that the evidence over the past 10 years has not been confirmed by many studies Majority of research suggests a very large amount of SOY protein - more than half the daily protein intake - may lower LDL cholesterol by a Few Percentage points When it replaces Dairy Protein or a mixture of animal proteins Also: no evidence of benefits of soy protein on HDL, TG, lipoprotein (a), or blood pressure Direct benefit of soy protein or isoflavone supplements is minimal at best AHA asked the FDA to revoke the health claim in Feb 2008

Fiber Intake Recommendation

Fiber is important in older adults DRI: Men >50yr = 30g/day Women >50yr = 21g/day Fiber supplements often used Adequate fluids Average daily dose is ~ 20g/d Fiber is important in older adults Provides bulk & promotes peristalsis Fiber intake often inadequate DRI: Men >50yr = 30g/day; Women >50yr = 21g/day due to decreased food consumption Dietary fiber supplements often used for peristalsis & bowel regulation Adequate fluids should be consumed Average daily dose is ~ 20g/d

Common Causes of Death ≥ 65 yrs

Five of the eight most common causes of death of adults aged 65 years and older in US have known nutritional influences Almost 80% of older adults have one chronic condition

Skin: Forehead & Sternum

Fluid Recommendations: 1 ml/kcal intake OR 30 mL/kg body weight with a 1500 mL/d minimum Pinching the skin on the back of hand or on the sternum may be a good physical indicator of hydration status Well-hydrated tissue will resume normal position immediately on release of the skin pinch Keep in mind: use of skin turgor to assess fluid status lack precision and more in-depth evaluation of fluid balance may be needed

Overweight & Obesity

Focus of treatment should be: Reduction of intra-abdominal fat Preservation of muscle mass & strength Effectiveness of exercise interventions in the elderly Knowledge about treatment of obesity in older adults is limited - because clinical trials tend to exclude older persons Surgery (bariatric) is not a reasonable option Physical Activity: older adults can benefit from strength training regular exercise stimulates protein turnover, maintains muscle mass and burns more calories

Treatment

Focus on energy availability "energy positive" diet by increasing intake, reducing energy expenditure, or combination Increased energy leads to increased BMD and restoration of menstrual function Increases in BMD of 5% per year have correlated with increases in body weight in amenorrheic athletes Use of food records and bone-building supplements such as calcium + vitamin D should be given Appropriately treat disordered eating Pharmacological therapy may be helpful Antidepressants may be used with abnormal eating behaviors Hormone replacement therapy (HRT) and Oral Contraceptive do NOT address the underlying pathological mechanism of bone formation and health e.g.. provision of estrogen will not serve to restore age-appropriate BMD Bisphosphonates, approved for postmenopausal osteoporosis, also are not recommended for the female athlete have not been proven to be efficacious in this population 12 screening items for all female athletes are recommended by the Female Athlete Triad Coalition Almost 90% of universities surveyed do not use standardized pre-participation evaluation (PPE) 8 pertain to disordered eating, 3 to menstrual dysfunction and 1 to risk of fractures of the AAP/ASF{/ASCM PPE form Incorporation of screening for the triad has been suggested because athletes may not self-identify due to secrecy or denial If an athlete appears to be at risk for the female athlete triad on basis of positive answers to any screening questions, further evaluation must be performed Several dietary, exercise-related, and psycho-social behaviors are associated with increased risk of the triad When athlete found to be at risk for disordered eating, more detailed assessment of eating habits and exploration of risk factors for disordered eating and poor self-image should be undertaken. There are standardized eating disorder questionnaires such as the Eating Disorder Examination interview (the "gold standard"), and Eating disorders inventory or Eating Attitudes Test Also there is an eating disorder questionnaire specific to the athlete population - Female Athlete Screening Tool - looks at atypical exercise and eating behaviors on a 4-point Likert scare which correlated well with the Eating Disorder Examination interview Athletes at risk: should meet with RD, food and exercise assessment should be performed, and menstrual history and history of musculoskeletal injuries assessed; physical exam by physician

Potentially Over-consumed Nutrients for Individuals 70yr & Older

Folate Fortification of foods & beverages Mask a vitamin B12 deficiency Intakes 1000μg/d vs. upper level (UL) of 1000μg/d Sodium High sodium intakes Sodium sensitivity increases & renal function decreases, which limits ability of kidney to excrete sodium Folate: Widespread & relatively unregulated fortification of foods & beverages May mask a vitamin B12 deficiency Intakes approaching 1000μg/d compared to the upper level (UL) of 1000μg/d (these are possible) Sodium: High sodium intakes are a population-wide problem Sodium sensitivity increases & renal function decreases, which limits ability of kidney to excrete sodium

Folate Absorption

Folate: water-soluble B vitamin found in dark green leafy vegetables - Folic acid: synthetic folate in supplements & fortified foods - Natural folates: polyglutamates (these forms serve to keep the folates within cells)- Small intestine enzymes in the lumen convert the polyglutamate form to the monoglutamate for absorption

current intakes ages 60 and older

From the 2020-2025 Dietary Guidelines - the displays is the average intakes of the food groups compared to the range of recommended intakes at the calorie levels most relevant to males and females in this age group. It is obvious than many older adults are not achieving the recommended intake of vegetables, fruits, and dairy food groups.

Functional Impairment with Sarcopenia

Functional impairment greater than expected muscle mass change ~ 30% mass decrease corresponds to a 50% function loss Sarcopenia - loss of autonomy Strength decline is estimated to be 1% per year Influenced by physical activity (resistance exercise) Functional impairment in the Elderly affects ability to perform activities related to food or nutrition: Shopping Meal preparation Self-feeding A commonly used measure of independence is the ability to perform functional tasks necessary of activities of daily living (ADLs) Instrumental tools to assess elderly can be used

The Female Athlete Triad Coalition

Go to website for additional information: http://www.femaleathletetriad.org/category/faces-of-the-triad/# An international consortium Website has a link to find a Sports and Cardiovascular Nutrition (SCAN) dietary practice group dietitian Several organizations - AAP, ACSM, American Academy of Family Physicians, Orthopedic Society for Sports Medicine and International Olympic Committee have drafted guidelines This website has information for professionals and some interesting case studies

Endocrine Regulation of the Menstrual Cycle: Hypothalamo-Pituitary Axis 3

Gonadotopins drive: Ovarian secretion of inhibin Steroid hormones estradiol and progesterone Sex hormones support: Female appearance Regulate changes in cell structure of the uterine lining or endometrium Inhibin: One of two hormones (designated inhibin-A and inhibin-B) secreted by the gonads (by granulosa cells in the female) that inhibit the production of follicle-stimulating hormone (FSH) by the pituitary gland. FSH stimulated 🡪 Inhibin secretion in ovaries 🡪 which ↓ FSH (negative feedback)

CHD Prevention Studies

HRT is not indicated for primary or secondary prevention of CHD Estrogens may delay or ameliorate atherosclerotic plaque development Estrogens may increase the risk of acute events when at risk plaque is present HRT does not increase the risk of nonfatal or fatal myocardial infarction (MI) used for symptoms perimenopausal HRT should be protective against atherosclerosis if initiated early but potentially harmful if administered to women with mature at-risk plaque Older women may benefit from standard therapies for primary & secondary prevention Cardiovascular disease is leading cause of death in postmenopausal women CHD rates are lower in premenopausal women than in men incidence rises after menopause The Women's Health Initiate : Relative Hazard by age and HRT Plots primary prevention of continuous combined E/PT actually increased CHD risk despite a significant 12.7% reduction in LDL cholesterol and a 7.3% increase in HDL Most of the excess CHD risk was in nonfatal MI events In the unopposed (no progesterone) - Estrogen did not cause a significant increase in CHD risk The risk was LOWER when HT was started within 10 years compared to more than 10 years after menopause Prevention strategies therefore should rely on maintaining fitness, eating healthy diet, and keeping body weight in health range Used to treat symptoms in peri-menopausal women HRT does not increase the risk of nonfatal or fatal myocardial infarction (MI) MI is rare within 10 years of menopause Older women may benefit from standard therapies for primary & secondary prevention aspirin antihypertensive drugs statins when appropriate

USDA Healthy Eating Index

Healthy Eating Index (HEI) tool developed by the USDA to assess overall quality of a person's diet 10 component system: 5 food groups 4 nutrients Variety Reports the HEI scores for adults 60 & older The 2020-2025 Dietary Guidelines report that the HEI of adults 60 years and older is 63 - next slide illustrate that on average, older adults have higher HEI scores compared with other age groups

Midlife Transition

Hormonal and physiological changes Menopause: mens = monthly [ Greek]; pause = stop Cessation of menstruation & termination of fertility Perimenopausal period may be 10 - 15 years Postmenopausal are years following last menstrual cycle (could be ~ 1/3 of woman's life) The World Health Organization definition: permanent cessation of menstruation resulting from loss of ovarian follicular activity. Menopause is identified retrospectively following 12 months of amenorrhea not due to other factors such as pregnancy or lactation - with the Final Menstrual Period (FMP). Staging of reproductive aging in 2011 - characterized into 7 stages: Reproductive life - 3 stages: early, peak and late Menopausal transition years - 2 stages - early and late Postmenopausal years - 2 stages - early and late that follow FMP

Menopause & Hormone Therapy

Hormone Replacement Therapy (HRT) Generally effective reducing or eliminating most symptoms Many symptoms can be alleviated or lessened Three major classes of estrogens available Premarin - conjugated estrogen Premarin combined with low dose of progesterone to prevent endometrial hyperplasia (intact uterus) Natural estrogens & synthetic estrogen Premarin: obtained from urine of pregnant horses first approved for use in 1962, by 1990 it was the 4th most prescribed drug in the US The Two Broad categories are: Estrogen Alone Estrogen plus progesterone Standard treatment applied to all menopausal women will not necessarily meet the needs of many individual women Need to consider the relative balance between the Benefits and the Risks

All of the following are strategic goals to be addressed by the 2020-2030 NIH Strategic Plan for Nutrition Research EXCEPT:

How do nutrient needs of females differ from males?

Endocrine Regulation of the Menstrual Cycle: Hypothalamo-Pituitary Axis

Hypothalamo-pituitary axis No direct neural connection Secrete a peptide - Gonadotropic hormone-releasing hormone (GnRH) GnRH binds receptors that produce: Luteinizing hormone (LH) Follicle stimulating hormone (FSH) The menstrual cycle is regulated by the Hypothalamo-pituitary axis Neural tissue located at the base of the brain Direct vascular connection to anterior pituitary gland No direct neural connection between the brain and anterior pituitary gland (base of the hypothalamus) Specific neurons in the hypothalamus secrete a peptide - Gonadotropic hormone-releasing hormone (GnRH) GnRH binds to specific receptors on gonadotropes in the anterior pituitary produce: Luteinizing hormone (LH) Follicle stimulating hormone (FSH)

Initiated Pregnancy

If sexual intercourse occurs around ovulation time, the corpus luteum changes Fertilized ovum begins to undergo cell division while traveling down the oviduct toward the uterine cavity Upon arrival in the uterus about 5 days after ovulation, implantation can occur into the uterine wall

Functional Impairments: Elderly Malnutrition

Impaired immunity Loss of muscle mass Functional impairment with loss of strength Decreased cognitive function Impaired immunity Declines with aging naturally Further impaired by fasting & caloric restrictions that may accompany disease Loss of muscle mass Loss is directly responsible for functional impairment with loss of strength Increased likelihood of falls Loss of autonomy Decreased cognitive function Weight changes may accompany Alzheimer's disease

Carbohydrate Intake during Recovery

Improved glycogen repletion when carbohydrates (or CHO + protein) are consumed immediately after exercise vs. later No differences between males and females When carbohydrate intake is proportional to body mass, no significant differences appear between males and females in ability to replenish glycogen stores

Cessation of Menstrual Cycles: Menopause

In most women, menopause occurs at 50 yr (48-52 yr) Loss of ovarian follicles capable of responding to FSH & LH Primary source of estradiol during reproductive years in ovarian follicles is 16β-estradiol Later menopause: Longer menstrual cycles, higher parity (no. children), oral contraceptives, improved nutritional status, increased average body size Earlier menopause: smoking The low estrogenic state may affect estrogen target tissues adversely: Brain, Skeleton, Skin, Cardiovascular, Genitourinary system Concentrations and functions of hormone receptors vary in the organs and systems Sequence: ~ 8 - 10 year prior to cessation, circulating FSH begins to increase without a concomitant increase in level of luteinizing hormone (LH). Circulating estrogen levels decline - probability of anovulatory cycles increases When ovulating ceases & absence of corpus luteum, progesterone secretion ceases FSH begin to rise slowly approximately 6-8 years before the FMP; rise increases 2 years before the FMP

Premenopausal Nutrition Concerns

Iron deficiency - women need to replace menstrual and other iron losses Folic acid to prevent Neural Tube Defects (NTD) in pregnancy 400 ug/d Iron: Many women world wide to not get enough iron to replace iron lost during menstruation or during pregnancy Microcytic anemia Reminder: about 10 to 15% of iron in the diet is absorbed heme form of iron is more bioavailable - found in hemoglobin and myoglobin in animal products nonheme iron: in plants - beans, spinach, oats fortified foods and supplements Vitamin C helps to increase absorption: helps reduce iron from the Ferric (+3) form to Ferrous (+2) for iron transfer and storage involving transferrin and ferritin Folic Acid: discusses previously during the adolescent section

Guidelines for Carbohydrate (CHO) Intake by Athletes

Light Low intensity or skill-based activities 3 - 6 g/kg of athlete's body weight/d Moderate Moderate exercise program (about 1h/d) 5 - 7 g/kg/d High Endurance program (1 - 3 h/d to high-intensity exercise) 6 - 10 g/kg/d Very high Extremely commitment (> 4-5 h/d moderate to high-intensity exercise) 8 - 12 g/kg/d Carbohydrates - note recommendations are in g/kg/d: Factors: size of body CHO stores relatively limited and can be manipulated on daily basis by dietary intake or even a single session of exercise Carbohydrate provides a key fuel for the brain and central nervous system Evidence supports that performance of prolonged sustained or intermittent high- intensity exercise is enhanced by strategies that maintain high carbohydrate availability; depletion of these stores is associated with fatigue (reduced work, skill, concentration and increased perception of effort. Glycogen play important direct and indirect roles in regulaing muscle's adaptation to trining.

Multivitamin Use & Risk of Cancer & Cardiovascular Disease (2009)

Long term multivitamins - no impact on risk of common cancers, cardiovascular disease or mortality in postmenopausal women 162,000 women in the Women's Health Initiative (WHI) Followed for ~ 8 years 42% of participants reported using multivitamins on regular basis Many postmenopausal women use multi-vitamins many believe supplements prevent chronic diseases Data are consistent that diets high in Fruits and Vegetables are associated with lower Cancer and CHD risk low serum concentrations of B vitamins, carotenoids, and tocopherols have been associated with and increased risk of colorectal cancer and CVD Data collected on multivitamin use at baseline and disease end points collected until 2005 Looked at documented cancers and CVDs

Endocrine Regulation of the Menstrual Cycle: Hypothalamo-Pituitary Axis cont

Luteinizing hormone (LH): "LH surge" - triggers ovulation LH on the maturing follicle produces ↑estradiol Follicle-stimulating hormone (FSH) FSH initiates follicular growth Regulates development, growth, pubertal maturation, and reproductive processes Luteinizing hormone (LH): An acute rise of LH - the "LH surge" - triggers ovulation LH is a glycoprotein LH receptors are also expressed on the maturing follicle that produces an increasing amount of estradiol Follicle-stimulating hormone (FSH) FSH initiates follicular growth, specifically affecting granulosa cells FSH regulates the development, growth, pubertal maturation, and reproductive processes of the human body

Lipid Intake

Many female athletes limit lipid intake to 10 -15% of total calories Believe that lipids compromise performance and increase body fat mass Low fat diets reduce intra-muscular triglycerides that are crucial for supplying free fatty acids to muscles during recovery Importance of FAT is especially true for Endurance sports - sports of long duration or when training multiple times per day Long events : fat intake must be ~ 30% If not enough, depletion of intramuscular triglycerides can still occur 2 days later

Premenopausal and Athletic Performance

Many of the potential effects of nutrition on current health and future health of women are covered later in the course. Therefore, we will be focusing on a review of hormonal changes that occur during the monthly cycles of the adult female. In addition, we will be reviewing the key concepts discussed in the Academy of Nutrition and Dietetics (AND) Position paper on Nutrition and Athletic performance published in 2016. Dr. Nancy DiMarco, Professor in our TWU Nutrition Department was a key author of the previous AND position paper in 2009. For some, the section on athletics and performance will be a review.

Healthy Eating Patterns in Midlife

Many women gain weight - especially after menopause Evidence suggests total amount of fat is less important than the type of fat 2015 Dietary Guidelines: < 10% saturated fat 2022 Dietary Guidelines < 10% saturated fat Midlife is when many women gain weight - especially after menopause Reducing amount of dietary fat intake may decrease risk of breast cancer & heart disease Evidence suggests total amount of fat is less important than the type of fat 2015 Dietary Guidelines gave more specific recommendations on fat: Consume <10% of calories from saturated fat, & keep trans fatty acid consumption as low as possible. Consuming 2 servings of seafood per week (4 oz cooked) provides 250 mg/day of omega-3 fatty acids from marine sources docosahexaenoic acid (DHA) eicosapentaenoic acid (EPA)

Menopausal Quality of Life: Yoga, Exercise and Omega-3 Supplements (continued)

Mean baseline vasomotor symptoms average 7.6 per day with MENQOL score of 3.8 (range 1-8 from better to worse) Yoga, relative to usual activity, slightly improved MENQOL scores at 12 weeks and reduce the extent to which hot flashed interfered with women daily functions Exercise and omega-3 supplements had no effect on MENQOL and vasomotor

Dr. Cynthia Bulik discussed the major findings of the GWAS research in the posted video. She highlighted all of the following a major findings EXCEPT:

Men were found to have the same genes that increased risk of anorexia nervosa.

Presentation of Dehydration in Elderly

Mucosal xerosis Swollen tongue Sunken eyeballs Elevated body temperature Decreased urine output Constipation Nausea & vomiting Decreased blood pressure Mental confusion Electrolyte disturbances Acute renal failure

Clinical Improvement Outcomes of Intentional Weight Loss

Metabolic syndrome Insulin resistance & type 2 diabetes mellitus Dyslipidemia Hypertension Pulmonary disease Inflammation Cardiovascular disease Intentional weight loss can improve or prevent many of obesity related risk factors Moreover, metabolic benefits are often found after only modest weight loss ≈ 5% of initial weight Metabolic syndrome: wt loss can improve all features Insulin Resistance: improves rapidly after energy deficit diet before much weight loss and continues to improve with continued weight loss Lipids: Weight loss decreases LDL-cholesterol on TG, and often increases HDL Hypertension: Wt loss decreases both systolic and diastolic blood pressure - dose response fashion Pulmonary: excess abdominal fat mass mechanically interferes with lunch function; Obstructive sleep apnea Inflammation: obesity associated with increased inflammatory markers - C Reactive Protein (CRP) CVD: Although weight loss modified CVD risk factors, not know whether wt reduction decreases CVD events or CVD mortality in Obese person Nevertheless, data large population studies reveal obesity assoc. with increased CVD mortality

Nutrition & Midlife - Aging

Midlife includes the transition from active reproductive capacity to reproductive senescence.

Exercise and Pharmacological Therapy

Modification of exercise Inclusion of higher loads may stimulate bone formation Antidepressants when appropriate Optimizing calcium and vitamin D intake Hormone replacement therapy (oral contraceptives) has not had consistent efficacy in reversing low BMD Bisphosphonates - (Fosmax) are not currently approved treatment of premenopausal women with amenorrhea associated with exercise

Effect of Fat Intake on Blood Lipids

Monounsaturated Lowers LDL, raises HDL Polyunsaturated Fat (2:1 n-6 to n-3) Lowers LDL, raises HDL N-3 Lowers triglycerides N-6 High n-6 has negative effect Saturated Raises both LDL & HDL Trans Raises LDL Choose the low saturated fats - American Heart Association (AHA) recommendation is 7% of calories N-3: omega fats such as oily fish, flaxseed oil - have beneficial effect of lowering TG and possibly CVD Fish: AHA recommends twice a week N-6: animal fats include linoleic acid found in vegetable oils (corn oil, safflower oil) and beef, milk Ratio in American Diet are closer to 10 - 20: 1 of n-6 to n-3

Weight for Height

Most indicators of appropriate body weight require individual's height Accurate measurements of stature often difficult Body Weight: Absolute weight may stay constant, but composition may change Published height & weight reference tables Height measurement issues: Some can not stand erect chronic diseases, - arthritis, osteoporosis, Parkinson's May have compression of the vertebral disc space Body Weight: Absolute weight may stay constant, but composition may change Published height & weight reference tables Limited data on average or reference weights for persons age 74yr Height and Wt. table: Metropolitan Life Insurance Company, national Center for health Statistics,

my plate for older adults

MyPlate for Older Adults which corresponds with MyPlate - the federal government's new food group symbol. Developed by Tufts - USDA Human Nutrition Research Center Provides examples of foods that contain high levels of vitamins and minerals per serving that are consistent with the 2010 Dietary Guidelines Drawing features forms of vegetables and fruits that are convenient, affordable and readily available ½: Fruits and Vegetable icons - in range of colors they also include icons representing frozen, pre-peeled fresh, dried and certain low-sodium low sugar canned options Includes: whole, enriched and fortified grains - because high in fiber Emphasis on limiting sodium to less than 1,500 mg of Na per day Inclusion of several examples of liquids (water, tea, coffee, soup) 🡪 common age-related decline in thirst 🡪 dehydration Promotion of regular physical activity (daily errands, household chores)

protein needs athletes

NOTE: on page 34 protein intake needs are 1.2-1.4 g/kg/d based on Sports Med article. However, the 2016 Academy position paper uses are broader protein intake range of 1.2 - 2.0 g/kg body weight per day which is what we will use for this course.

Comparison of Diet Health

Nevertheless, diets of many older adults could be improved.

Female Carbohydrate Utilization

Numerous studies have shown that estrogen (in part) is responsible for the decreased reliance upon hepatic glycogen stores Result is an increased availability and oxidation of fatty acids Decreased amino acid breakdown during exercise 17ß-estradiol decreases hepatic glucose rate of appearance and disappearance and total oxidation Results in a relative sparing of hepatic glycogen stores during exercise Estrogen promotes free fatty acid availability and oxidation during exercise Intramuscular stores of triglycerides are generally much larger in females than in males

Elderly Women

Physiological changes with aging Nutritional requirements of elderly Malnutrition Over nutrition Eating patterns Now moving on to Elderly women Topics to consider Life Expectancy: Persons living to age 65 years have an average life expectancy of 18.8 more years Men and women who reach age 85, can expect to live more than 5.7 and 6.8 additional years, respectively

Nutrition Assessment Tools

Nutrition Screening Nutrition Screening Initiative (NSI) developed three tools Subjective Global Assessment (SGA) Mini-Nutrition Assessment (MNA) Nutrition Screening Reliably identifies the existence of risk factors of malnutrition Contributes to avoidance & reversal of malnutrition Developed by the American Academy of Family Physicians + Academy of Nutrition and Dietetics + National Council on Aging Nutrition Screening Initiative (NSI) developed three tools A screening checklist & two assessment levels Subjective Global Assessment (SGA) Mini-Nutrition Assessment (MNA) (Nestle) Reliable, defined threshold, minimal training, free of rater bias, inexpensive

Type 2 Diabetes & Elderly

Obesity & non-insulin dependent diabetes mellitus 80% type 2 diabetes middle aged are obese 18% of people > 65yr have type 2 diabetes ~ 50% are not diagnosed Prevalence of diagnosed diabetes in elderly is expected to increase 44% in next 20 years Obesity - risk factor for vascular dementia & Alzheimer's disease Obesity & non-insulin dependent diabetes mellitus (NIDDM) strongly associated 80% of middle aged people with type 2 diabetes are obese 18% of people > 65yr have type 2 diabetes ~ 50% are not diagnosed Prevalence of diagnosed diabetes in elderly is expected to increase 44% in next 20 years Obesity also a well-know risk factor for vascular dementia & Alzheimer's disease

Obesity in Older Adults

Obesity is associated with disability Can impact quality of life issues: Independence Limitation of activities of daily living Mobility Weight generally increases until about in Women until about 50, then levels off for 15 - 20 years, and then then starts to decline Ideal BMI 18.7 - 25 may be overly restrictive in elderly

Osteoporosis & HRT

Osteoporosis cause 1.5 million fractures per year in the US Hip fracture is the most severe consequence of osteoporosis - we will have an entire section on this topic RCT involving outcomes measure of Bone Mineral Density uniformly indicate that HT maintains or improves: Bone mineral density in Spine, femur and radius

Premenopausal Health Concerns

Overweight and obesity Cancer Mental & emotional Chronic Pain Menopause Will be discussed over the next few weeks. In addition - health concerns include maintaining bone mass for the prevention of Osteoporosis.......as well as prevention of heart disease

Continuum of Menstrual Disturbances in Athletes

Ovulatory Luteal Phase Defect Anovulation Oligomenorrhea Amenorrhea This slide shows the continuum of menstrual disturbances known to occur among athletic women and range from a normal ovulating woman all the way to Amenorrhea - complete follicular and luteal suppression - most severe disturbance experienced by athletes and ranges from 1 - 44% among athletic women As mentioned earlier, luteal phase defects affects up to 79% of exercising women - the ovarian system functions well enough to ovulate but would be inadequate to sustain implantation of an embryo.These women would have a shortened luteal phase and a prolonged follicular phase. Luteal phase defects occur in athletes at a much greater prevalence than nonexercising women. These most often go undiagnosed and often are not apparent to the woman because her cycle length is unchanged. Those with these abnormalities, however, may be much more susceptible to developing the female athlete triad

Amenorrhea to Oligomenorrhea

Part of a continuum of normal to abnormal menstrual cycles ranging from oligomenorrhea to amenorrhea -Could be primary: absence of periods by age 16 -Could be secondary: absence of 3 or more consecutive periods after they are established -Could be luteal phase deficiency: total cycle length is unchanged but luteal phase is shortened -Could be anovulation/oligomenorrhea: absence of ovulation (release of an egg) combined with abnormal cycle lengths

Factors Influencing Quality of Life and the Aging Process

Position of the Academy of Nutrition and Dietetics: Food and Nutrition for Older Adults - published in 2012 "Older Adult" - is an individual who is aged 60 years older Figure illustrates the factors that influence health-related quality of life and the aging process enjoyment of food other environmental factors

IOM Recommended Weight Gain during Pregnancy

Preconceptional BMI BMI Classification IOM Recommended total Gestational Weight Gain (kg) < 18.5 Underweight 12.5 - 1818.5 - 24.9 Normal Weight 11.5 - 1625.0 - 29.9 Overweight 7 - 11.5> 30.0 Obese 7

Food Intake Through Menstrual Cycle

Premenstrual phase can be consider time when women are especially vulnerable to overconsumption, food craving and depression Carbohydrate (CHO) cravings reported Soy Rich diets: can have a possible intake on the length of the menstruation and the length of the cycle (study findings vary) intakes of isoflavones (found in soy) ranging from 32 to 200 mg per day usually resulted: in increased length of the cycle (more time between cycles) e.g.. longer than typical 28 days reduction in the level of sex steroid hormones Therefore, periods are more spread out, less likely to get pregnant? 🡪 author concludes small effects

Where do We Find Malnutrition?

Prevalence of malnutrition depends on where the elderly person lives: 5% or < of people living at home 10% to 38% when at home with disease 28% to 65% when hospitalized Prevalence varies with the criteria used for diagnosis of malnutrition

Follicular Development

Primordial: Structure of follicles in the resting stage Ovum with nucleus surrounded by single layer of flattened epithelial cells - Follicles can remain in this stage indefinitely Preantral: First phase of active growth of follicles after recruitment from resting stage Differentiation of cells: this stage can take 5 - 8 weeks Early Antral: Follicle at beginning of rapid growth phase Under the stimulus of FSH - rapid proliferation of granulosa cells Gradual increase in size of the antrum Antrum: A general term for cavity or chamber Preovulatory Follicle: very large size Ovum ↑ receptors LH, FSH + large antrum Stages C and D - occur only during the menstrual cycle and are generally completed within 14 days The duration of stage D is usually 2 - 3 days and culminates in ovulation

Neurovascular Symptoms

Principal symptom of early menopause is vasomotor flush 50% to 85% of postmenopausal Sleep disturbances caused by nocturnal hot flashes & sweating 🡪 lethargy & depressed mood Vasomotor symptoms more common & severe after surgical menopause The frequency of hot flushes decreases with time Only a small percentage of women continue to suffer from vasomotor flushes 10 years after menopause 15 years afterwards, approximately 3% report very frequent hot flushes and 12% report moderate to severe hot flushes HRT (hormone replacement therapy) - is the most effective treatment for hot flushes and also decreased sleep disturbances reported reductions of about 75%

Visceral Type (A) and Subcutaneous Type (B) Fat Distribution

Prior discussion: women, much fat storage is subcutaneous fat in gluteal & thigh regions ("protective") Women with aging increase % fat mass Shows two types of distribution In this study: At baseline and final visits, a CT (computed tomography) scan for visceral fat measurements was performed using a single cut at L4 Women's visceral fat increases with aging

Health Benefits Associated with Regular Physical Activity for Older Adults

Progressive resistance training and aerobic exercises can have numerous benefits on nutritional status including improved energy and nutrient intake Exercise also recognized to counteract some of the effects of pharmacotherapy that is common in older adults such as corticosteroid treatment, depression, alterations in gastrointestinal function and anorexia Central in prevention and treatment of functional decline and frailty Resistance exercise results in decreased nitrogen excretion, and lowering protein needs

Fat Needs

Proportion of energy from saturated fats should be limited to < 10% should include sources of essential fatty acids (EFAs) Exercise induced adaptation appears to not maximize fat oxidation Some athletes may restrict fat intake to lose body fat or improve body composition Fat intakes below 20% of energy intake likely to reduce nutrients such as EFAs and fat-soluble vitamins

Multivitamin Use and Risk of Mortality and Cancer Incidence

Prospective examination of 182,099 participants enrolled Multiethnic Cohort Study in Hawaii and California between 1998 and 1996 During 11 years of follow-up, models controlling for tobacco use and other potential confounders found: No association between multivitamin use and mortality from all causes, cardiovascular diseases or cancer 1993-1996, the Multiethnic Cohort Study enrolled more than 215,000 adults aged 45-75 years living in Hawaii and California Participants completed a 26-page mailed questionnaire on diet, medical history, and lifestyle when they entered the cohort The baseline questionnaire included questions about the use of multivitamins (with and without minerals). Asked to indicated whether they had used any of the supplements at least weekly during the previous years. In follow-up questionnaires, participants were asked the same questions on multivitamin use. During an average 11 years of follow-up, 28,851 deaths identified Cox proportional hazard models used and concluded no clear decrease or increase in mortality or morbidity with multivitamin use.

Protein Intake

Protein intake needs higher (1.2-1.4 g/kg) Female athletes specializing in strength sports, recommendations can reach 1.4-1.8 g/kg body weight (NOTE: AND Position Paper range was 1.2 - 2.0 g/kg; for course we will use this range) Especially considering muscle damage that can occur Muscle damage is associated with increased inflammatory response 17 ß-estrdiol has protective effects upon muscle damage

Carbohydrate Requirements

RDA for carbohydrate is 130g/d for all ages Energy for the brain Median intake of carbohydrate ranges from approximately 220-330g/d for men & 180-230g/d for women Intakes of CHO decrease with age 45 - 65% calories from carbohydrates 2020-2025 Dietary Guidelines: Limit added sugars to less than 10% of calories per day for age 2 and older RDA for carbohydrate is 130g/d for all ages Source of energy for the brain Carbohydrate emphasis should be on Whole grains and complex carbohydrate dietary sources, fresh fruits and vegetables Common to find older adults have intolerances to some vegetables such as cabbage, broccoli, (gaseous)

Menopausal Quality of Life: Yoga, Exercise and Omega-3 Supplements

Recent study looked at efficacy of 3 non-hormonal therapies for improvement of menopause-related quality of life in women with vasomotor symptoms (hot flashes) Compared in 355 peri and postmenopausal women age 40-62 years over 12 weeks: Yoga Exercise Usual activity Double-blinded omega-3 or placebo Used Menopausal Quality of Life Questionnaire (MENQOL) Yoga intervention: 12 weeks of 90 minute classes with daily home practice of 20 minute per day Exercise intervention: 12 weeks of 3 individual cardiovascular conditioning training sessions at a local fitness facility; women exercised 40-60 minutes per session Usual activity: instructed to follow usual physical activity behavior Omega-3 or placebo: daily omega-3 capsule contain 425 mg eicospentaenoic acid, 100 mg of docosahexaenoic acid and 90 mg of other omega-3s. Placebo and the omega 3 capsule contain natural lemon oil, rosemary extract and vitamin E

Health Risk Changes with Menopause

Reduced energy needs Heart disease Osteoporosis Metabolic Syndrome Reduced energy needs: Menopause is a physiological change & not a medical condition Loss of lean body mass (reduced metabolic rate) & reduced physical activity contribute to reduced energy needs Heart disease: Estrogen provides CVD benefits of decreasing LDL & increasing HDL Menopause increases vulnerability to heart disease similar to men Osteoporosis: Aging & decline of estrogen increase risk of osteoporosis Metabolic syndrome: Increased risk with menopause

Hormone Replacement Therapy (HRT) is indicated for women in which situation?

Treating women with perimenopausal symptoms.

PMS and Complementary & Alternative Medicine (CAM)

Review of randomized controlled trials investigating CAM in women Studies on B6 supplementation suggested that 9 found improved PMS symptoms One study no significant effects with vitamin E Three showed calcium supplementation had positive effect on symptoms Dysmenorrhea (menstrual pain) Oily fish in eicosapentaenoic acid (DPA) and docosahexaenoic acid (DHA) may help to modulate prostaglandin production Many women with premenstrual syndrome (PMS) seek relief from Natural products This article summarizes some of the more previous trials Review was a MEDLINE 1985-2002 and some additional files Actually in Europe, B6 supplementation is accepted treatment Dosages of B6 range from 50 - 600 mg per day RDA for B6 is 1.5 mg/d .............so Pharmacological levels

Vegetarian Athletes

Risk for low intakes of: Energy Ca, vitamin D, riboflavin Zinc and vitamin B12 Protein Iron Females - for lean body composition in some sports Energy: high fiber diets tend to be less energy dense fiber may reduce energy availability Calcium, D and riboflavin - major sources are dairy products which may be avoided True vegan avoid dairy; lacto-ovo is most common with dairy & eggs included in the diet Zn and B12 - meat and other animals sources are good sources Protein: may be lower protein quality from plant sources (more limiting amino acids) Academy suggests an increased intake of 10% protein 1.3-1.8 g/kg/d in 2009 Iron: Female vegetarian athletes may be at higher risk for iron deficiency heme iron has higher bioavailability Female Athlete Triad: vegetarian diets may be a clue of eating disorders Shown here is April Ross - sliver in the London Olympics in 2012 cut out meat in 2015 - and she doesn't miss the meat and has never felt stronger. In Rio she won the Bronze metal.

Factors Influencing Elderly Hydration Status

Sedatives impair desire to drink Fear of incontinence - may avoid drinking fluids Decreased kidney size, loss of smooth muscle tone, decrease blood flow to kidneys, difficulty emptying bladder- prone to urinary tract infections (UTIs) Maximal capacity to concentrate urine reduced Some other factors: Laxative or diuretic abuse Confusion and depression Over-hydration is less of a nutritional problem Assessment of actual fluid needs is often difficult: Intake and output records may be inaccurate or difficult to collect

Menstrual Cycle Phases

Several studies attempted to look at estrogen/progesterone changes and response to exercise Significant alterations in carbohydrate, free fatty acids and protein metabolism in early follicular phase (low estrogen/low progesterone) vs. mid-luteal phase (high E/high P) Increase protein catabolism during exercise observed during luteal phase vs. follicular phase

Menstrual Cycle

Single event in a sequence of the uterine lining (endometrium) by cyclic secretions of the ovary Usually 28 days (24 - 33 days normal range) Follicular, or proliferative phase (lasts ~ 12 days) "Day one" of cycle Preiovulatory phase (48 hr) Luteal, or secretory phase (lasts ~ 14 days) Menstrual cycles - are a single event in a sequences of changes of the uterine lining - endometrium caused by cyclic secretions of the ovary Menstrual cycles: periodic sloughing of the endometrial lining of the uterus (menstruation) Note: period menstruation associated with ovarian cycles is NOT common in nature Primarily in Humans and nonHuman Primates The Elevation in serum FSH concentration at the beginning of the menstrual cycle initiates the FSH-Dependent follicle growth that occurs in the early antral stage start of menstruation.......day ONE FSH: Acts as the Primary growth hormone to support follicular development

Soy & Isoflavones Menopausal Symptoms

Soy contains isofalvones: genistein, daidzein, & glycitein Isoflavones are phytoestrogens - similarities to human estrogen (17-β estradiol) Agency for Healthcare Research and Quality (AHRQ) 21 trials soy &/or isoflavones - decreases hot flashes in both treatment groups & control Isoflavones are phytoestrogens & have structural & functional similarities to human estrogen (17-β estradiol) Mimic estrogen but much weaker Women use soy for treatment of menopausal symptoms & aging changes Agency for Healthcare Research and Quality (AHRQ) 21 trials examine soy &/or isoflavones on hot flashes & night sweats - inconsistent Decreases hot flashes in both treatment groups & control AHRQ MissionTo improve the quality, safety, efficiency, and effectiveness of health care for all Americans. As 1 of 12 agencies within the Department of Health and Human Services (HHS), the Agency supports health services research initiatives that seek to improve the quality of healthcare in America

In comparison to men, women are more likely to develop depression and anxiety.

True

WHI Multivitamin Findings

Strengths: Large postmenopausal Dietary supplement data Outcomes - physician reviewed Limitations: Manufacturers change formulations & ingredients Multivitamins - women who engage in preventive health measures already Postmenopausal - can not generalize to all women WHI = Women's Health Initiative Strengths: WHI one of largest postmenopausal women's studies More dietary supplement use data (dose, frequency, duration of supplements) Outcomes were physician reviewed to minimize misclassifications Limitations: Manufacturers change formulations & ingredients may not reflect content Persons taking multivitamins frequently engage in other preventive health behaviors WHI was postmenopausal; results not generalizable The authors of the study did attempt to control for other health behaviors

Disorders May be More Frequent with Hormone Treatment

Stroke Risk for healthy postmenopausal women is 2/1000 per year Inconsistent results HRT increases risk Venous thromboembolism (VTE) is uncommon but a risk for women receiving HRT Stroke Risk for healthy postmenopausal women is 2/1000 per year Claims to show that HRT increases stroke risk have shown inconsistent results Some suggest that HRT effect on stroke may be dose dependent (↑ HRT dose, ↑ risk) Subgroup analysis has suggested that ↑ risk may be in older age groups Venous thromboembolism (VTE) is uncommon but a risk for women receiving HRT Risk of VTE increases ~ two fold Thromboembolism: Formation in a blood vessel of a clot (thrombus) that breaks loose and is carried by the blood stream to plug another vessel. The clot may plug a vessel in the lungs (pulmonary embolism), brain (stroke), gastrointestinal tract, kidneys, or leg. Treatment may involve anticoagulants, aspirin, or vasodilators.

Nonpharmacological Therapy and Nutrition Therapy

Strongest success achieved by increasing energy intake Weight gain of 1 to 2 kg or 10% reduction in exercise can restore menstruation and increases BMD up to 5% per year ACSM: recommended sedentary women is 1800 - 2000 kcal/d and additional 500 to 1000 kcals/day for active women RD can personalize to the individual Psychological therapy for eating disorders

Additional Side Effects of Menopause

Temperature regulation Pelvic floor muscles - prolapse & incontinence Dryness of vagina & genital tract Skin Depression Inappropriate temperature regulatory activity (hot flashes) Weakening of pelvic floor muscles leading to uterine prolapse/incontinence Dryness of vagina & genital tract Loss of hydration & elasticity in skin Normally women are already at increased risk for depression compared to men. Odds of high depressive symptoms significantly greater as women progressed through menopausal transition.

Ten Steps to Successful Breastfeeding

The Ten Steps to Successful Breastfeeding are:1. Have a written breastfeeding policy that is routinely communicated to all health care staff.2. Train all health care staff in the skills necessary to implement this policy.3. Inform all pregnant women about the benefits and management of breastfeeding.4. Help mothers initiate breastfeeding within one hour of birth.5. Show mothers how to breastfeed and how to maintain lactation, even if they are separated from their infants.6. Give infants no food or drink other than breast-milk, unless medically indicated.7. Practice rooming in - allow mothers and infants to remain together 24 hours a day.8. Encourage breastfeeding on demand.9. Give no pacifiers or artificial nipples to breastfeeding infants.10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or birth center.

Which fatty acid is important in fetal vision, development, and learning ability?

docosahexaenoic acid (DHA)

Corpus Luteum and Released

The corpus luteum develops from an ovarian follicle during the luteal phase of the menstrual cycle Following the release of a secondary oocyte (Mature Egg) from the follicle during ovulation, the follicle forms corpus luteum. The term corpus luteum simply refers to the visible collection of blood left after rupture of the follicle and has no functional significance the oocyte (later the zygote) traverses the Fallopian tube into the uterus ( the corpus luteum remains in the ovary )

Ovarian Cycle

The diagram show the changes the follicle undergoes through ovulation Shaded: Ovulation Follicular phase (left) and Luteal phase (right) Note: changes of the endometrium

Jean Mayer USDA Human Nutrition Research Center on Aging (HNRCA)

The mission of HNRCA is to explore the relationship between nutrition, aging, & health by: determining the nutrient requirements that are necessary to promote health & well-being for older adults examining the degenerative conditions associated with aging http://www.hnrc.tufts.edu/ The public health impact of the HNRCA's research accomplishments has been enormous. For example, its findings have provided a substantial underpinning for the Dietary Guidelines for Americans, and the Recommended Dietary Reference Intakes. HNRCA scientists contribute to national and international boards that create nutrition policy to ensure healthier and productive societies

Intakes Age 60 and Older

This Figure from the 2020-2025 Dietary Guidelines which shows the percent of older adults exceeding the recommended limits for added sugars, saturated fat, and sodium , along with average intakes of these components. Many older adults are exceeding added sugars, saturated fat , and especially sodium.

Research Trials with HRT

Three major Randomized controlled trial Three major observational studies

Menstrual Cycle: Hormone Patterns & Uterine Cytology

Top: Changes in FSH and LH secretion in serum throughout menstrual cycle Small inserts in panel show diagrams of expected patterns of detail profiles of LH Note the slowing of LH pulse frequency during the luteal phase arrows(10 hrs pulses vs. every 4 in follicular) Center: profiles estradiol and progesterone during a 28 day menstrual cycle ' Lower: changes in the uterine cytology that would be expected at each phase of the menstrual cycle Menstruation: follicle starting to develop Proliferative: follicle continuing to mature Secretory: endrometrium thickens Know and understand this slide

Protein Requirements with Aging

Total protein intake steadily declines with age Most cases, intake is sufficient to meet needs Dietary Reference Intake (DRI) is 0.8 g/kg body wt/day regardless of age Some elderly continue to lose muscle mass May need 1.0 -1.2 g/kg/d Sick elderly are higher: 1.2-1.5 g/kg/d Increasing protein intake may improve immune status, wound healing, blood pressure, & bone health Extra protein may be needed if Older adult Intakes of 1.5 g protein/kg/day or about 15 - 20% of total calorie intake is a reasonable target to optimize protein in terms of health and function Common concerns with higher protein intakes: High protein diet increasing calcium loss - recent studies indicate that high protein diets do not adversely affect calcium retention Increased satiety - advantage to many but for an elder malnourished could be a potential problem Challenge: dietary protein source are frequently omitted difficulty chewing, expense of foods, trying to lower cholesterol

Typical human menstrual cycle:

Typical human menstrual cycle: 1. Pituitary secretes FSH during first part of month - this causes follicles of ovaries to begin growing 2.GnRH causes the release of the gonadotropins, luteinizing hormone (LH) and follicle-stimulating hormone (FSH), which in turn act upon the gonads to stimulate their maturation, and to cause synthesis of sex steroid hormones, estrogen, progesterone and testosterone. 3.GnRH from hypo then causes Pit to begin to also secrete LH - acts synergistically with FSH causing follicles of ovary to grow rapidly and secrete more and more estrogen which feeds back positively on hypothalamic—pit system to enhance the output of LH and cause further growth of follicles resulting in ovulation of one of them 4.3. Under influence of LH, follicular cells are transformed into corpus luteum that begins to secrete estrogen and progesterone that together exert a negative feedback on hypothalamus-pit and cause FSH and LH to decrease. Corpus luteum secretes estrogen and progesterone for 14 days reaching peak outputs by day 22 of cycle 5.4. From 23rd to 27th day of cycle, corpus luteum involutes, probably because of decreased output of LH. Estrogen and progesterone secretion have decreased which allows the pit to begin producing FSH in large quantities followed by LH 6.Increase in FSH and LH then stimulate new follicles and new cycle begins

Weight Loss & Malnutrition

Typically for elderly refers to energy & protein Micronutrients Weight status BMI < 18.5 (undernutrition) Weight loss of 10% Severe weight loss >15% or >10% in one month Weight status BMI < 18.5 (undernutrition) Weight loss of 10% Within 6 months OR 5% weight loss in one month Malnutrition severe when weight loss >15% OR >10% in one month

Protein Utilization

Urinary nitrogen (as indicator of protein utilization) rises in males within 24 hours after endurance exercise compared to controls No significant difference observed in females Proportionally greater amounts of amino acids are oxidized by males during exercise than females. Evidence suggests that intramuscular oxidation of branched-chain amino (BCAA) acids does NOT differ between males and females Females use leucine as an energy substrate to a lesser extent than males Differences in leucine utilization likely sparing of glycogen in liver The difference in utilization of leucine as an energy substrate were studied during a 90- minute pedaling exercise at 65% VO2 max before and after a 31 day endurance training program

Cancer Risk with HRT

Use of ET and E/PT has been associated with a reduced risk of Colon Cancer 40% reduction of risk from RCT one possible biological explanation would be decrease in concentrations of secondary bile acids which are potentially tumor-promoting Estrogen and progesterone increase cholesterol in the bile increased bile increases secondary bile acids associated with increased colon cancer risk

Elderly at Increased Risk for Hydration Disorders

Water reserve in elderly is lower than in younger adults ↓ LBM and TBW Thirst thresholds Young adults - 294 mOsm/L Elderly threshold - 297 to 300 mOsm/L Water is most abundant component of the body 45% to 70% of body weight (depends on the amount of body fat) Water reserve in elderly is lower than in younger adults Lean mass decreases with age; total body water reserves decrease Young adults thirst threshold is 294 mOsm/L vs. healthy elderly threshold is 297 to 300 mOsm/L Amount of fluid to quench thirst in elderly is lower Mild dehydration: elderly less able to compensate Therefore, elder less likely to detect dehydration

Comparison of Body Composition Compartments: 25yr vs. 70yr Man

Weight and body composition have been shown to change with age - and these changes have implications regarding nutritional needs Weight tends to increase until the early 40s in men and the early 50s in women Weight then tends to hold steady for the next 15 or 20 years, and to decrease thereafter Decrease in lean body mass is characteristic of aging , regardless of energy intake Loss of protein mass and increase adipose tissue

The efficacy of dietary supplementation for the prevention of hip and other fractures in women was studied in which prospective trial:

Women's Health Initiative (WHI)

Linda is an adolescent attending middle school in Houston. She is very active this Spring semester in sports (lacrosse three times a week, daily cross-country long distance running) and is on the Highest Honor Roll. Linda went on a "healthy and low calorie diet" because she felt fat a few months ago. She lost 30 pounds over the past 2 months. She is 5'7" and now weights 104 pounds. What DSM-V eating disorder diagnosis most closely matches Linda's current situation?

anorexia nervosa

Prevention and Treatment

approach Multidisciplinary team approach Education originating within school system on triad-specific components is critical to establish awareness of Female Athlete Triad Should the athlete continue to train and participate? Female Athlete Triad Treatment Team Athletic Trainer Primary Care Sports Medicine Physician Sports Psychologist Nutritionist Family Coaches Team - each can impact the treatment plan : health care providers, mental-health practitioners, dietitians, coaches parents, athletic trainers, exercise physiologists Athletes must comply and be closely monitored by physician; they must place the importance of treatment over training Steps likely will need to be taken to modify training (intensity, duration, type) If athlete chooses not to accept treatment, breaks contract, or does not show steady progression in weight gain 🡪 athlete must be removed from competition

The strongest evidence for successful treatment of the female athlete triad to restore mensuration and to improve bone mineral density includes all of the following EXCEPT:

bisphosphonate therapy (e.g. alendronate - Fosamax)

Body mass index can be used to classify body weight into health categories. Which of the following statements related to body mass index is NOT correct?

body mass index (BMI) = body weight in pounds/height in meters squared

The newest Physical Activity Guidelines for Adolescents recommend 1 hour of physical activity each day of all of the following types of physical activity EXCEPT:

bone strengthening

Purging type of eating disorder can be characterized by all of the following EXCEPT:

excessive exercise

Amenorrhea is characterized by a progesterone deficiency.

false

Breastfeeding woman should avoid all fish due to the high methyl mercury content.

false

Daily weigh-ins used for sports such as gymnastics and wrestling are recommended by health care and sport professionals.

false

Females peak gains in weight occur 12-18 months later than gains in height.

false

Gender refers to the biological and physiological characteristics of males and females.

false

Gender refers to the biological and physiological characteristics that define men and women.

false

Intermittent high intensity exercise of athletes can be enhanced by providing 3 - 6 grams of carbohydrate per kilogram of body weight per day.

false

Luteinizing hormone (LH) begins to rise about 6 years before the final menstrual cycle.

false

Multiviatmin use of females in the Women's Health Initiative (WHI) trial demonstrated a reduction of the risk of cardiovascular disease

false

Sarcopenia in elderly women is caused by an inadequate intake of protein primarily.

false

The American Heart Association supports the health claim regarding the benefits of soy protein on increasing HDL and decreasing triglycerides, lipoprotein (a), and blood pressure.

false

The average age of menopause is 45 years.

false

Total Energy Expenditure (TEE) typically begins to decline rapidly in women around 40 years of age.

false

Typical symptoms of a women having a heart attack include chest pain that radiates down the left arm, both arms or back, along with shortness of breath.

false

Females have a greater capacity to oxidize which macronutrient during exercise than males?

fat

Hydration status of elderly is impacted by all of the following EXECPT:

fear of incontinence sedatives kidney function Correct! all are important factors

Which of the following sports has been reported to increases the risk development of the female athlete triad?

figure skating

Excessive intake of which nutrient can mask a vitamin B12 deficiency?

folate

Which of the following is a potentially over consumed nutrient for individuals 70 years of age and older?

folate

The leading cause of death for females in the United States is:

heart disease

The fetal origin of disease/Barker Hypothesis is a theory suggesting that factors early during fetal life may have long term consequences. Which of the following factors does NOT contribute to the development of obesity in later adulthood according to the fetal origin of disease theory?

high birth weight

Female athletes should be referred for a bone mineral density screening under what conditions?

history of stress fractures disordered eating history of low estrogen levels Correct! all of the above

All of the following occur during the maternal catabolic phase (20+ weeks) EXCEPT:

increased glycogen stores

A vegetarian athlete may be a risk for low intake and/or reduced absorption of:

iron

In comparison to men, women are more protected against:

language loss with left hemisphere stroke

Ovulation is triggered by a rise in which hormone?

luteinizing hormone

An inadequate intake of iron during adolescence may result all of the following EXCEPT:

megaloblastic anemia

Which of the following is an outcome of folate deficiency in pregnancy?

megaloblastic anemia neural tube defects orofacial clefts Correct! All of the above

Extreme laxative abuse with an eating disorder is often associated with:

metabolic acidosis

An inadequate intake of iron in female adults may result in:

microcytic anemia

Sarcopenia is characterized by all of the following EXCEPT:

no effect on activities of daily living

An elderly patient was admitted to the hospital with a serum osmolarity of 308 mOsm/L. Which of the following can be ruled out as an explanation for why this occurred?

over-hydration

Which of the following is a risk factor for iron deficiency anemia in teenagers?

participation in endurance sports

Females differ from males regarding heat production and heat loss compared for all of the following reasons EXCEPT:

post-exercise rehydration requirements are very different

The corpus luteum functions to secrete which hormone during the menstrual cycle?

progesterone

Preconception Maternal Diet

• Excessive intake of nutrients- Vitamin A: craiofacial malformation- Vitamin A: abnormalities of central nervous system, thymus, & heart• Well balanced diet according to Choose My Plate guidelines• Health and Nutrition Information for Pregnant and Breast Feeding Women:• http://www.choosemyplate.gov/mypyramidmoms/• Supplement should not > RDA unless need determined

What period of life is a women more likely to be risk for developing an eating disorder?

puberty

Individuals 70 years and older often do not get enough of which of the following nutrients EXCEPT:

sodium

The 2020-2025 Dietary Guidelines encourage the limitation of foods high in which of the following:

sodium

Estrogen and progesterone increase cholesterol in bile which may increase the incidence of inflammatory bowel disease and colon cancer in women.

true

Isoflavones are phytoestrogens & have structural/functional similarities to human estrogen.

true

Pregnancy increases the risk of cardiovascular disease but it protects against ovarian cancer.

true

The 2020-2025 US Dietary Guidelines for Americans recommends that adults limit their intake of sodium to 2,300 milligrams per day.

true

The Academy of Nutrition and Dietetics 2016 position paper on nutrition and athletic performance recommends that athletes participating in sports should maintain protein intakes of 1.2 - 2.0 gram of protein per kilogram per day.

true

The Dietary Reference Intake for calcium (1,000 mg/d) for a pregnant women is the same as a women who is not pregnant due to an increased absorption of calcium during pregnancy.

true

The Estimated Average Requirement (EAR) is used to assess nutritional status of large populations.

true

The corpus luteum that forms after ovulation has no functional significance.

true

The risk of developing an eating disorder is increased by all of the following factors EXCEPT:

twin sister with normal eating habits

Typical clues of an abusive relationship include which of the following factors EXCEPT?

unexplained injuries unkempt appearance explanations that do not make sense Correct! All are typical factors

What nutrient is a greatest risk of inadequate intake during adolescence based on the highest percentage of males and females with dietary intakes below the estimated average requirements (EARs)?

vit E

When is the AI used to assess nutrition needs?

when there is not sufficient enough information to establish a level for individuals

The AI is used to assess nutrition needs:

when there is not sufficient enough information to establish a level for the RDA/EAR

How Long Should You Wait?

• 18 months between pregnancies- Healthy baby and healthy pregnancy- Increases premature birth before 36 month- Body needs time to recover• Use effective birth control until you are ready• If you are older than 35 or miscarriage/or still birth

Vitamin and Mineral Needs during Lactation

• Estimated by determining total amount of a nutrient secreted into milk (milk volume X nutrient concentrations) multiplied by a bioavailability correction factor- Estimate then added to the needs of nonpregnant, nonlactating women• Folate and B12 are secreted into human milk which increases mother's requirements- Folate content of milk is tightly regulated and remains stable during lactation even if mother's own blood folate levels decline- RDA for folate during lactation is 500 ug/day of DFE

Pregnancy Dietary Intakes on Infant Birth Weight

• 2015 Comprehensive review on dietary and supplemental intakes of omega-3 fatty acids, zinc, folate, iron, calcium, vitamin D, dietary patterns on infant birth weight:- Not enough evidence to support omega-3s reduce risk of low birth weight (LBW)- Iron supplementation appears to increase birth weight; especially in third trimester- Limited evidence that folic acid supplements reduce risk for LBW• Consumption of whole foods such as fruit, vegetables, low-fat dairy and lean meat throughout pregnancy appear beneficial for appropriate birth weight

2009 March of Dimes: Women's Folic Acid Awareness

• 84% of women ages 18-45 reported having heard of folic acid• 39% of women ages 18-45 reported taking a vitamin containing folic acid daily in the United States• 20% of women aware of folic acid mentioned that folic acid prevents birth defects• 11% of women aware of folic acid mentioned that folic acid should be taken before pregnancy

Preconception: Iron

• Adequate preconceptional iron reserves may reduce risk of iron deficiency & anemia- Women often have to increase dietary iron to offset menstruation losses- Prevalence in US women childbearing age is ~ 12% in general• 19%-22% among minority groups- Decreased dietary iron absorption in first trimester of pregnancy & increased iron needs in later pregnancy

Obesity and Fat Distribution

• An average of 3.5 to 4 kg of maternal fat tissue is accumulated during pregnancy• Strong age-related effects for obesity and fat distribution• Relatively small long-term changes in obesity and fat distribution may be attributed independently to pregnancy

Assessment of IOM Weight Gain Recommendations

• Association between Institute of Medicine (IOM) recommendations and adverse infant outcome by BMI studied- 570,672 women 18-40 yr using birth certificates• Outcomes: large-for-gestational age (LGA) and small-for-gestational age (SGA)• 41.6% women began pregnancy as overweight and obese• 51.2% gained weight excessively during pregnancy based on IOM recommendations

Changes in Body Composition during Pregnancy

• Average of 3.7 kg of fat• Increase of 927 gm of protein- = 40,000 kcals or 180 kcals/d throughout pregnancy• First trimester: 8 kcals/week ....recommend ↑ during 2nd and 3rd • Second trimester: 340 kcal/day• Third trimester: 425 kcals/day

Fish Intake and Breastfeeding

• Breastfeeding mother should not eat shark, swordfish, king mackerel, or tilefish due to possible mercury• Mothers can eat up to 12 ounces per week (2 average servings) of fish and shellfish that have lower concentrations of mercury- Shrimp, canned light tuna, salmon, pollock, catfish- Albacore (white) tuna has more mercury than canned light tuna - limit to 6 oz. per week• Local advisories should be checked about safety

Calcium & Lactation

• Calcium for the mineralization of the infant comes from the mother in utero and through breast milk- Breast milk Ca averages ~ 200 mg/d• Bone resporption of mother and dietary source used to provide calcium- Loss of bone of breastfeeding mother is replaced once breastfeeding stops and menstruation begins again - No evidence of association between lactation history and long-term bone mineral density or fracture risk• Therefore, no evidence Calcium Intake should be increased above nonlactating women- The RDA for lactating women is 1,000 mg/d

Chronic Disease associated with Fetal Origins of Adult Disease (FOAD)

• Diabetes• Obesity• Dyslipidemia• Hypertension• Coronary artery disease• Stroke• Kidney failure• Liver failure• Lung abnormalities• Immune dysfunction• Reduced bone mass• Alzheimer's disease• Depression, anxiety, bipolar disorder, schizophrenia• Cancer

Pregnancy: Stages

• Embryonic period- First 14 weeks of gestation- Development of fetal anatomical features- Placenta formation- Prior to implantation (6-12 days postconception) embryo nourished by oviductal & uterine secretions• Fetal period- Next 26 weeks are fetal growth and development- Maternal-fetal circulatory exchange established full at about 8 weeks gestation

Nutrient Needs during Pregnancy: Energy and Protein

• Energy: deposition of maternal & fetal tissue- Added metabolism of uterus & fetus• Increased work of maternal heart & lungs• Basal energy expenditure (BEE) increase of 106-180 kcals/d• Total energy cost of tissue is ~ 180/kcals/d- Small amount during first trimester; 340-452 kcals/d more than non-pregnant during second & third trimesters• Protein:- Amount deposited sum of protein components• Small amount during first trimester• RDA 25/g above protein needs of non-pregnant females during second and third trimesters (0.8 + 0.27 or 1.1g/kg/day)

Global Outreach

• Enhancing professional education and research. - Partners in other countries to improve education of health care providers in the fields of perinatal health, including medical genetics. • Expanding capacity for community action. - Encourages the development of parent, community and other local groups in support of babies and children with birth defects. • Increasing public awareness. - Expanding awareness of the human and economic costs of birth defects.

Epigenetics

• Epigenetics: stable alteration in gene expression that occurs without changes in DNA sequencing• Possible mechanism:- Methylation of cytosine residues of DNA and post translation modifications of histone proteins associated with the DNA strand- DNA methylation patterns largely set in utero• Folate, Vitamin B12, choline, zinc, and methionine contribute to the methyl pool of the body- Formation of s-adenosylmethionine (SAM)

Nutrient Needs during Pregnancy: Fat

• Essential Fatty Acids (EFA)- Linoleic acid arachidonic- α Linolenic docosahexaenoic (DHA) & eicosapentaenoic (EPA)• Long chain fatty acids involved with:- Fetal brain- Retina• No clear consensus on n-3 (ω-3) fatty acids effects - Modest effect on increasing gestational duration/birth weight- Possible enhancement of neuro-development- DHA found to be important in fetal vision, development and learning ability

Vitamin and Mineral Needs During Pregnancy: Vitamin A

• Essential for vision, gene expression & immune function- Placental transfer of vitamin A- Poor maternal vitamin A associated with increased infection with HIV & maternal mortality/night blindness• Risk of toxicity highest during first trimester- Craniofacial malformation and abnormalities of CNS- Β carote

Maternal Effects of Pregnancy: Lipids and Diabetes

• Women who have been pregnant have lower HDL levels than those who have never been pregnant- Multiparity - if 5 or more pregnancies• Women who had gestational diabetes are at increased risk of Type 2 diabetes

Normal Physiology

• First Half = Maternal Anabolic- Build capacity of mother's body to deliver relatively large quantities of blood, oxygen, nutrients to fetus in 2nd half• Second Half = Maternal Catabolic- Heightened capacity to deliver stored energy & nutrients to the fetus predominates• ~10% fetal growth occurs in first half; 90% in second half

Folate Requirements

• Folate required for synthesis of DNA, cell proliferation, & protein synthesis- Deficiency anemia (megaloblastic)- Neural tube defects- Fetal malformations: Orofacial clefts and congenital heart defects• Folate RDA is 400μg Dietary Folate Equivalents (DFE) for adolescents 14-18yr & females +19yr• Periconceptional use: 400 μg Folic Acid supplement - March of Dimes Gallup survey - 40% US women of childbearing age take daily vitamin with folic acid

Vitamin and Mineral Needs During Pregnancy: Folate & Iron

• Folate: during pregnancy increase to 600μg/day dietary folate equivalents (DFE)- Low intakes associated with low birth weight, placenta abrupta, spontaneous abortions• Iron: requirements increase slowly from first trimester to third trimester to 27mg/d- Supplementation usually required to prevent iron deficiency- Positive: iron supplements may also increase birth weight & decrease preterm delivery- Negative: may increase gestational diabetes & oxidative stress

Classification of Hypertensive Disorders of Pregnancy

• Gestational hypertension- Onset of hypertension without proteinuria after 20 weeks of gestation - Blood pressure levels return to normal postpartum (12 weeks)• Preeclampsia- Hypertension plus proteinuria• New onset of blood pressure of ≥ 140/90 (two readings four hours apart)• Diastolic >110mmHg once or >90mmHg x2 four hours apart• ≥ 0.3gm of protein in 24 hrs or ≥ 1+ on urine analysis

Overall Summary

• Gestational weight gain influenced the risk of LGA and SGA in opposite directions• Minimal weight gain or weight loss lowered risk for LGA among obese• The 2009 recommendation included weight gain ranges that are associated with lower risk of LGA and higher risk of SGA

Baby Friendly Hospital Initiative

• Global program launched by World Health Organization (WHO) and Unite Nations Children's Fund (UNICEF) in 1991• Recognizes facilities implement the Ten Steps to Successful Breastfeeding and International Code of Marketing of Breast-milk Substitutes

Support of Breastfeeding 2

• Help mother with breastfeeding and teach parents how to recognize and respond to their baby's feeding cues• Avoid separations of healthy mothers and babies• Do not give pacifiers to breastfeeding newborns, or any other supplements, formula, water or glucose water to healthy babies• Do not give mothers discharge gift bags with formula samples or formula discount coupons

Epidemiology of Preeclampsia

• Incidence in US: 5 - 7% first pregnancies- Risk of recurrence: 20 - 25%• Major cause of maternal and neonatal morbidity and mortality worldwide- 5-fold risk of neonatal mortality• Major contributor to premature birth and intrauterine growth restriction

Vitamin and Mineral Needs During Pregnancy: Calcium

• Increased efficiency of absorption early in pregnancy• Bone resporption becomes elevated- No detectable change in bone mineral content between conception and parturition• Very little additional calcium needed during pregnancy- So DRI for calcium is the same at 1,000 mg/d

Benefits of Breastfeeding

• Infants' immune system not fully mature until about 2 years; human milk contains white blood cells transferred to the child, acting to fight infections• Human milk contains factors that enhance immune response to polio, tetanus, diphtheria, and influenza• Reduces the incidence and/or severity of: respiratory tract infections, ear infections, bacterial meningitis, pneumonia, urinary tract infections, and infant diarrhea• Breastfed infants are at lower risk for sudden infant death syndrome (SIDS)

March of Dimes Folic Acid

• KEY POINTS• Taking folic acid before and during early pregnancy can help prevent neural tube defects in your baby. • Before pregnancy, take a vitamin supplement that has 400 micrograms of folic acid in it every day.• During pregnancy, take a prenatal vitamin that has 600 micrograms of folic acid in it every day.• Take a vitamin supplement with folic acid every day, even if you're not trying to get pregnant.• You can get folic acid from food, too. Look for fortified foods to make sure you're getting enough.

Assessment of Obese Women Wt Gains during Pregnancy

• LGA were higher among obese women and increased with higher wt gain- Compared with IOM recommended weight gain, an ORs (odds ratio) for LGA were Lower with less than recommended wt gain- When wt gain was < than IOM recommended, the a ORs for LGA were lower • SGA was less prevalent among obese women- Gains < IOM wt recommendations increased odds of SGA

Maternal Anabolic and Catabolic Phases of Pregnancy

• Maternal Anabolic Phase 0-20 weeks- blood volume expansion, increased cardiac output- buildup of fat, nutrient, liver glycogen stores- growth some maternal organs- increased appetite, food intake- decreased exercise tolerance- increased levels anabolic hormones• Maternal Catabolic Phase 20+ weeks- mobilization of fat and nutrients- increased production and blood levels glucose, triglycerides, fatty acids; decrease glycogen stores- accelerated fasting metabolism- increased appetite and food intake declines near term- increased catabolic hormones

General Observations on Pregnancy Weight Gain

• Newborns of mothers with inadequate weight gain are more likely to be premature or small-for-gestational age- May increase risk of future obesity & diabetes• Many overweight women exceed target weight ranges- More large-for-gestational age & caesarean sections • Medically advised weight gains are strongly associated with actual weight gains• Excessive weight gain pregnancy predicts weight retention

Prepregnancy Weight

• Obesity prepregnancy is a risk factor for gestational diabetes, preeclampsia, cesarean delivery, stillbirth, macrosomia, and increased use of medical care.• Underweight prepregnancy is risk factor for low birth weight, prematurity, and intra-uterine growth retardation• Obese and underweight pre-preganancy BMI with excessive gestational weight gain is associated with increased risk of gestational diabetes, cesarean delivery, preterm birth, macrosomia, LGA, and post-partum weight retention

Optimizing Maternal Nutrition

• Pregnancy & lactation increase energy & nutrient needs- All phases of preconception, pregnancy, & lactation are impacted• Suboptimal nutrition typically associated with:- Inadequate intake, avoidance of animal products- Excess caloric intake• Micronutrients: folate, iron, iodine, vitamin D, vitamin A & zinc

Maternal Health Effects of Pregnancy:Cardiovascular Disease

• Pregnancy increases the risk of cardiovascular disease but it protects against ovarian cancer• Large case-controlled or cross-sectional studies show a modest increased risk of heart disease among women with more and/or earlier reproductive events

Vitamin and Mineral Needs During Pregnancy: Vitamin D

• Primary function to maintain serum calcium levels to optimize bone health- 1,25(OH)D3 increases in pregnancy and 25(OH)D levels tend to decrease• 2010 the IOM revised RDA of 15 μg (600 IU); not different during pregnancy• Vitamin D insufficiency during pregnancy appears to factor increasing risk of Type 1 diabetes and autoimmune diseases (MS, rheumatoid arthritis, etc)• IOM increased vitamin D recommendations (200 IU 600 IU)- Above 37 degrees no synthesis during winter- Supplementation needed

Support of Breastfeeding

• Provide mother with comprehensive, accurate, and culturally appropriate breastfeeding education and counseling• Encourage skin-to-skin contact for at least 30 minutes between mother and baby within 1 hour of an uncomplicated vaginal birth or within 2 hours for an uncomplicated cesarean birth• Give mother opportunity to breastfeed within 1 hour of uncomplicated vaginal birth; 2 hours uncomplicated C-section• Encourage newborns to receive breast milk as their first feeding after both vaginal and cesarean births

Iron and Zinc during Lactation

• RDA for iron during lactation is 9 mg/day during lactation (assuming no menstrual losses)- Compared to RDA for iron of 18 mg/d when not pregnant or lactating. Why? Usually no period.- But if menses restarts, RDA of 9 may be too low• Zinc levels in breast milk decline rapidly from 2 to 12 weeks- Average zinc needs during lactation increase 4 mg/d above the nonpregnant, nonlactating women to a RDA for Zinc of 12 mg/d

Vitamin D & Lactation

• RDA for vitamin D updated in 2010: - 15 ug/d (600 IU) for pregnancy and lactation• IOM 2010 report notes that increased maternal vitamin D intakes increase maternal serum 25OHD levels, with no effect on neonatal serum 25OHD levels of breast-fed infants unless maternal intake of vitamin D is very high - i.e. 4,000 - 6,000 IU/d• No evidence that lactating adolescents require any more vitamin D or higher serum 25OHD levels than non-lactating adolescents- Therefore, the RDA is 600 IU/d for each group

Lactation

• Recommendation to exclusively breast fed first 6 month- Complementary foods until at least end of fist year• Advantages include decreased incidence of:- GI illness (diarrhea)- Reduced respiratory infections- Otitis media (ear infections)• Energy needs increase 500 kcal/day- Based on mean milk production of 780 mL/day, energy density of milk of 0.67 kcal/g- After 6 months, milk production typically is reduced to 600 ml/d and recommended energy intake for partially breastfeed is 400 kcals/d- RDA for energy is about 330 kcals/d more than nonpregnant, nonlactating women• Recommendations for energy intake for lactation are based on a slow weight loss of about 5 kg during the first 6 months

Maternal Effects of Pregnancy: Long-Term Hypertension

• Reports on a relationship and subsequent hypertension are not consistent• A large well controlled study by Ness, using NHANES II data used regression models to adjust for confounding variables- Increasing parity association with increasing systolic & diastolic blood pressure- Blood pressure changes may be different at younger ages

Preconceptual Maternal Obesity

• Risk of early miscarriage in obese compared to normal weight• Increase NTD- Especially spina bifida, omphalocele, & heart defects• Increased risk of preclampsia & gestational diabetes• Increased unexplained fetal death

Classification of Preeclampsia

• Severe preeclampsia- BP 160/110, 5gm of proteinuria in 24 hrs- Oliguria or <500mL in 24 hrs- Cerebral visual disturbances- Pulmonary edema or cyanosis- Fetal growth restriction- Thrombocytopenia- Impaired liver function• Eclampsia- Presence of new-onset grand mal seizures in women with preeclampsia

Maternity Care Practice

• The World Health Organization has identified the following intra-partum mother-friendly childbirth practices as supportive of breastfeeding: - Minimizing routine procedures that are not supported by scientific evidence- Minimizing invasive procedures and medications- Providing emotional and physical support in labor- Freedom of movement and choice of position during labor and birth- Staff trained in non-drug methods of pain relief and who do not promote the use of analgesics- No unnecessary induction or augmentation of labor, instrumental delivery, and cesarean section

Epigenetic Programming

• Theory that chronic adult diseases may be impacted by early fetal life- "Barker Hypothesis"- Epidemiological evidence of low birth weight associated with: • CVD, stroke, Type 2 diabetes, and hypertension- Susceptibility results from adaptations made by the fetus in an environment limited in its supply of nutrients ("thrifty phenotype").

Vitamin B12 & Lactation

• Vitamin B12 levels in breast milk reflect maternal B12 status- Therefore, vegetarians and vegans may be higher risk- Vegans should take a vitamin B12 supplement or consume foods fortified with vitamin B12 (breakfast cereal)• Insufficient B12 can lead to anemia (megalobastic) and neurological damage to mother and breastfed infant

Vitamin and Mineral Needs During Pregnancy: Zinc & Iodine

• Zinc: needed during periods of rapid growth & tissue differentiation- Globally, mild-to-moderate zinc deficiency relatively common- Mild zinc deficiency associated with low birth weight, intrauterine growth retardation & preterm delivery- Ratio of iron to zinc: 15mg of zinc when more than 30mg of iron per day taken (IOM)• Iodine: thyroid hormones (T3 & T4)- Severe iodine deficiency in perinatal period can lead to irreversible mental retardation - Cretinism- RDA of 220μg/day

Extent of menstrual cycle dysfunction

•Depends on a number of factors: -Degree of energy restriction -Body's reserves of energy -Initial hormonal status before energy restriction

Some Observed Nutritional Disturbances

•Elevated retinol and retinyl esters - maybe delayed chylomicron clearance •Hypercaroteinemia; skin turns yellow • •Changes of tocopherol - maybe related to lipoprotein (carrier) changes • •Calcium - may have increased bone resportion to maintain blood calcium with ↑ urinary excretion of calcium •Increase risk of osteoporosis and fractures • •Zinc - lost in catabolic states such as in anorexia nervosa Decreased calcium may have long term consequences Ballet dancers may be almost crippled by mid life

Resolving the problem

•If you are struggling with balancing food intake, stress, exercise, seek counseling - physician, dietitian, counselor •Exercise 5 to 15% less and increasing caloric intake and weight, sometimes less than 5 pounds

Nutritional Therapy for Weight Regain

•Initially start at 1000 - 1300 kcals per day •Increase weight goal of ½ to 1 pound per week by increasing calories 100 - 200 every few days •Gradually increase the "forbidden foods" •Fat may need to remain relatively low due to the "fat phobia" •Too rapid advancement may lead to "refeeding syndrome" -Fluid retention, congestive heart failure, phosphosphatemia BMI , <85th percentile: Criteria for automatic Hospitalization at Texas Children's Hospital Other admission criteria: significant irregular heart beats and/or low blood pressure Treatment: 4-6 snacks or meals no more than 4 hours between avoid foods that increase the desire to purge avoid foods that are triggers reduce caffeine (reduces appetite) reduce use of calorie-free foods and drinks Re-feeding Syndrome: re-introduction of carbohydrates too quickly increases the need for ATP CHO increase insulin Causes a shift in phosphorous, potassium, magnesium intra cellularly Therefore, get a fluid imbalance and heart changes

Who is more likely to develop amenorrhea?

•Lose weight quickly •Have a low body weight •Have low percent body fat •Exercise very hard •Have had irregular menstrual periods even before training hard •Emotionally stressed •Practice restrictive eating behaviors

Health Consequences of Secondary Amenorrhea

•May afflict as many as 66% of female athletes - depends on sport and criteria to define amenorrhea •Infertility problems •Decreased bone mineral density •Increased risk of stress fractures (3X higher incidence - 24% in athletes with no periods or irregular periods compared with 9% of athletes with regular periods) •Increased risk of premature osteoporosis

Health Consequences of Anovulation/Oligomenorrhea

•May be a precursor to secondary amenorrhea •Infertility problems •Decreased bone mineral density •Increased risk of stress fractures and musculoskeletal injuries •Increased risk of premature osteoporosis

Long term damage?

•May restore some but not all of bone mineral density lost during amenorrhea •Depends on extent of amenorrhea

What is cause of amenorrhea?

•Most accepted theory is "energy availability" theory •Definitions: •Energy availability = dietary intake minus exercise energy expenditure •Exercise stress = everything associated with exercise except its energy cost •Bottom line - if not taking in enough calories to support reproductive system and exercising excessively, body will shut down reproductive system to provide calories to more important body functions

Health Consequences of Luteal Phase Deficiency

•Possible precursor to secondary amenorrhea •Infertility problems •Decreased bone mineral density •Increased risk of stress fractures and other musculoskeletal problems •Increased risk of premature osteoporosis

Strategies to improve

•Throw away the bathroom scale •Don't crash diet if you need to lose weight - cut back on calories by ~20% •Eat adequate, high quality protein - yogurt, fish, chicken, beans, tofu, nuts •40 - 60+ grams of fat each day are essential - nuts, peanut butter, salmon, olive oil •Eat red meat 2 - 3 times per week (vegetarians are 5X more likely to have menstrual problems!) •Maintain calcium rich diet - 3 - 4 servings each day

Treatment of Eating Disorders

•Weight restoration is the cornerstone of treatment of anorexia nervosa • •Psycho-social treatment is effective in treatment of anorexia nervosa, bulimia nervosa, & binge eating disorder -Behavior therapy -Interpersonal therapy -Family therapy Address : Core beliefs and Self Image issues Successful Treatment takes a team approach - medical, nutrition, and psychological support

Amenorrhea or AMEN .... I have no periods!

•What is amenorrhea? -A symptom, not a disease -Lack of menstrual periods, characterized by estrogen deficiency, similar to menopause •How common is it? -Among female athletes - ~20% stop having regular menstrual periods -Sports with highest prevalence include 19 - 44% of ballet dancers and 24 - 26% of competitive runners

Daily Recommendations of Fiber, Sodium, & Potassium for Females

Fiber recommendations are based on 1800 calories/day with goal of 14 g/1000 kcals Recommendations were adapted from the 2020-2025 Dietary Guideline Advisory Committee Total Fiber: Goal of 14 gm/1000 kcals Less than 3% of adolescent females have fiber intakes that exceed 26 gm/day

Average Ages of Puberty

Among US girls evaluated at 3 -12 years: •Average ages of onset of pubic hair developments were: -8.8 years African American -10.5 years White •Average ages of menarche were: -12.2 years for African Americans -12.9 years for Whites •Menarche usually occurs just after the adolescent growth spurt -Growth during childhood occurs at rate ~ 5-6 cm (2.5 in) per year -Growth increases in females to rate 8 cm/year until peaks around 11.5 years Appearance of breast buds is the first sign of physical development in females note: African Americans have earlier maturation Menarche - start of menstruation periods Number in the US breast buds appear at an average age of: 9.5 years in African Americans 9.8 years in Mexican American females 10.3 in non-Hispanic white females Linear Growth during adolescence is a final 15 to 20% gain of Adult Height

Hormonal Changes Through Life

Both men and women experience significant changes in serum testosterone and estrogen throughout life cycle Women's susceptibility to specific disease may be increased at distinct stages of the life cycle in which marked changes in circulating estrogen occur Dotted line represents changes in circulating estrogen in females falls in estrogen associated with osteoporosis, osteoarthritis, mental changes Solid line represents changes in circulating testosterone in males throughout the life cycle Pregnancy: is a time in which specific states such as rheumatoid arthritis and periodontal disease may remit (go away for awhile) or worsen.

Sex-Based Differences in Diseases & Nutrition

Cardiovascular disease (CVD), osteoporosis, depression, and rheumatoid arthritis can be favorably impacted by nutrition •CVD - Low fat, high fiber, n-3 fatty acids, vegetables and fruits •Bone health - calcium, magnesium, vitamin D •Mental health - possibly vitamin supplements such as folic acid, omega-3 fatty acids, and vitamin D •Rheumatoid arthritis - symptoms may be improved with fish oil supplementation

changes in Serum Hormone Concentrations and Tissues Deposition during Pregnancy

Changes 10 Weeks 20 Weeks 30 Weeks 40 WeeksSerum placental hormonesHuman chorionic gonadotropin(104 U/L)1.3 4.0 3.0 2.5Human placental lactogen (nmole/L)23 139 255 394Estradiol (pmol/L) 5 22 55 66Products of conceptionFetus (g) 5 300 1500 3400Placenta (g) 20 170 430 650Amniotic fluid (g) 30 250 750 800Maternal tissue gainUterus (g) 140 320 600 970Mammary gland (g) 45 180 360 405Plasma volume (mL) 50 800 1200 1500

Trends in Obesity Prevalence among Children and Adolescents 2-19 years

Childhood and adolescent obesity have reached epidemic levels in the United States. Currently, about 17% of US children are presenting with obesity per this publication. The latest data from the National Health and Nutrition Examination Survey show that the prevalence of obesity among US children and adolescents was 18.5% in 2015-2016. Overall, the prevalence of obesity among adolescents (12-19 years; 20.6%) and school-aged children (6-11 years; 18.4%) was higher than among preschool-aged children (2-5 years; 13.9%). Adolescent girls (20.9%) had a higher prevalence of obesity than preschool-aged girls (13.5%). Moreover, the rates of obesity have been steadily rising from 1999-2000 through 2015-2016 (Figure above). 80% of adolescents aged 10 to 14 years, 25% of children younger than the age of 5 years, and 50% of children aged 6 to 9 years with obesity are at risk of remaining adults with obesity.

Estimated Energy Requirements (EER) for Female Adolescents

Female Adolescent (9 - 18 years): EER= 135.3 - 30.8 X Age (years) + PA X [10.0 X Weight (kg) X Height (m) ] + 25 (kcal/day for energy deposition) Physical Activity Coefficient (PA): •Sedentary = 1.00, less than 30 min a day of moderate physical activity in addition to daily activities •Low active = 1.16, at least 30 min and up to 60 min of daily moderate physical activity in addition to daily activities •Active = 1.31, at least 60 min of daily moderate physical activity in addition to daily activities •Very Active = 1.56 Note: you do not need to memorize the EER equation ! Reminder about the Dietary Reference Intakes (DRIs): DRI used indirect calorimeter and double labeled water techniques with stable isotopes of oxygen and hydrogen. These were used to develop the predictive equations There is NO RDA for energy PA = Ratio of Total Energy Expenditure (TEE) / Basal Energy Expenditure (BEE) BEE = basal metabolic rate (measures) extrapolated over 24 hours (kcals/24 hrs)

Mortality-Morbidity Paradox

Females have more severe chronic, but not life-threatening, illnesses than men The number one reason for female disability- particularly later in life at age ≥ 45 is arthritis women have higher rates of arthritis through midlife and later women are more prone to severe arthritis too Disparities for a number of other chronic conditions such as: hearing loss - men have more vision loss: women are diagnosed more often with - cataracts, macular degeneration, diabetic retinopathy

Highlights to be familiar with:

Food, Drug, and Cosmetic Act (1938, 1962) Legalization of contraceptives for women Women's Health Equity Act of 1990 and establishment of NIH Office for Research on Women's Health (ORWH) Women's Health Initiative Institute of Medicine - Exploring the Biological Contributions to Human Health: Does Sex Matter? 21st Challenges: Racial/ethnic gaps, aging, globilization Genomics

Brain Physiological Differences

Functional magnetic resonance imaging shows that females rely on both sides of the brain for certain aspects of language, whereas males predominantly rely on the left hemisphere. Differences may explain why women who have left-sided stroke are more protected from language loss

Life Expectancy at Birth By Race and Sex - United States , 1970 - 2013*

Life expectancy for white males has increased or remained the same for nearly every year since 1975. In contrast, life expectancy for black males declined every year from 1985 through 1989, then resumed the long-term trend of increase for most years from 1990 through 2013. For white females, life expectancy increased in most years from 1975 through 1998. In 1999, life expectancy for white females briefly fell slightly below 1998's then record high but began to increase again in 2001. Life expectancy figures for Hispanics have been available starting in 2006. Since that year, life expectancy for Hispanic population has increased by 1.3 years. In 2013, life expectancy for Hispanic females was 83.8 years and males was 79.1.

IOM: Reference Heights &Weights for Female Adolescents

IOM - Institute of Medicine Trend is towards increasing weight for height with growth BMI = wt in kg/ height in meters squared BMI ranges (KNOW THESE) for Adults: 18.5 - 24.9 - normal 25 - 29.9 - over weight > 30 - obese Gender Age years Median Body Mass Index Reference Height (in) Reference Weight (lbs) Female 9 - 13 18.3 58 88 Female 14 - 18 21.3 64 125

Trends in Energy & Macronutrients Adolescents 1999-2000 through 2009-2010 (no more recent reports)

NHANES data was analyzed to assess trends in the intake of energy and macronutrients in children and adolescents from 1999-2000 through 2009-2010 Average intake (Figure 1) for all boys and all girls aged 2-19 decreased over this 12 year period Boys average intake decreased from 2,258 kcals in 1999-2000 to approximately 2,100 kcals in 2009-2010. The average energy intake for girls decreased from 1,831 kcals in 1999-2000 to 1,755 kcals in 2009-2010. Were there any changes in Macronutrients intakes expressed as a percentage of the total daily kcals intake for children and adolescents? Figure 2 The percentage of kcals from protein increased from 13.5% to 14.7% for boys and from 13.4% to 14.3% for girls aged 2-19 years. Percentage of kcals from Carbohydrates decreased 55.0% to 54.3%; for girls from 55.8% to 54.5% No trend changes in % of calories from total fat or sat fat for boys or girls

Estimated Calorie Needs per Day by Age, Sex, and Physical Activity Level

New 2020-2025 Dietary Guidelines have in the appendix recommendations now expressed for age and activity level. Note these now include even young children. There also are estimated calorie needs per day for Ages 12 - 23 months. Table A2-2 (Appendix)

What Causes the Sex Difference in Longevity?

Question: Is this difference in longevity due to one or a few major diseases? Or: is it general phenomenon across a whole series of diseases? We all know about differences in the development of heart disease between men and women. This slide takes the 6 causes of death and compares them as a function of age. - Expresses the Log Ratio of Male to Female Death Rates: For virtually all these causes of death - including accidents (solid circles) , cancer (open circles) heart disease (solid triangles), flu and pneumonia (open triangles), cerebrovascular accident (stroke) (solid squares) and chronic obstructive pulmonary disease (open squares) Virtually every age, males die at a higher rate (Basically log ratios above zero)

Recommendations of the Committee on Understanding the Biology of Sex and Gender Differences

Report of the committee on understanding biology of Sex and Gender differences resulted in clear recommendations IOM developed a framework for studying how sex modulates susceptibility to specific disease and overall health

Iron Requirements during Adolescence 2

Risk Factors for Iron Deficiency Anemia in Teenagers: •Low intake of meat, fish, poultry or iron fortified foods •Frequent dieting or restricted eating •Vegan or vegetarian eating styles •Meal skipping •Chronic or significant weight loss •Heavy menstrual periods •Rapid growth •Participation in endurance sports •Intensive physical training

Sexual Maturation Rating (SMR) Stages

SMR 1: pre-pubertal development SMR 2: beginning of pubertal development SMR 3 or 4: ongoing development -Pubertal growth spurt begins shortly after appearance of pubic hair -Gain in height and weight -Female reproductive organs continue to mature SMR 5: secondary sexual characteristics Slide summarizes the sexual maturation changes during the puberty period of growth.

2020 - 2030 NIH Strategic Plan for Nutrition Research

Strategic Goal 1. Spur discovery and innovation through foundational research -- What do we eat and how does it affect us? Strategic Goal 2. Investigate the role of dietary patterns and behaviors for optimal health -- What and when should we eat? Strategic Goal 3: Define the role of nutrition across the lifespan - How does what we eat promote health across our lifespan? Strategic Goal 4: Reduce the burden of disease in clinical settings - How can we improve the use of food as medicine? Health of WomenNutrition plays an important role in many diseases and conditions that primarily affect women or that affectwomen differently than men. Inherent within this Plan and its implementation are research approaches and activities that address the roles of sex and gender in health and disease; promoting participation of women in clinical nutrition research; and integrating sex as a biological variable in basic, preclinical, and translational nutrition research. Another vitally important area of emphasis isthe role of nutrition in pregnancy and lactation.

Dietary Guidelines 2020-2021:Recommended Servings for People age 2 and Older

Table A3-2 (Appendix of the Report) The 2020-2015 Dietary Guidelines gives recommendations on amount from food groups, subgroups and components based on caloric level that is recommended for age 2 and older. Footnotes in the report give descriptions of the food groups and subgroups. Note that the protein foods are listed into three subcategories.

Life Expectancy in Sweden

The Historical pattern: women have lived longer than men in virtually every place and at every time we can identify Sweden keeps excellent demographics - from the middle of the 1700's life expectance then was in the high 30s Now the life expectancy in Sweden is 80 yr In 1900 - in US it was about 48 years: 46.5 for Men and 49.0 years for women

Classifications of Eating Disorders - DSM V

The May 2013 American Psychiatric Association released the categories form the Diagnostic Criteria from DSM-V. Binge Eating was created as a separate category. The residual group is now called "Other Specified Eating Disorder."

tanner scale

The Tanner Staging also known as Sexual Maturation Rating (SMR) is an objective classification system that providers use to document and track pre-pubertal through puberty stages.

Newest PA Guidelines 2018 - 2nd Edition

This 2nd edition of the Physical Activity Guidelines for Americans has the potential to change physical activity of Americans. It is grounded in the most current scientific evidence and informed by the recommendations of the 2018 Physical Activity Guidelines Advisory Committee. This Federal advisory committee, which was composed of prestigious researchers in the fields of physical activity, health, and medicine, conducted a multifaceted, robust analysis of the available scientific literature. Their work culminated in the 2018 Physical Activity Guidelines Advisory Committee Scientific Report, which provided recommendations to the Federal Government on physical activity, sedentary behavior, and health. Informed by this Scientific Report and by public and Federal agency comments. The new edition provides guidance on the amounts and types of physical activity necessary to maintain or improve overall health and reduce the risk of, or even prevent, chronic disease.

% Females and Males 14-18 yr with Dietary Intake < EAR

The percentage of the population having intakes of a nutrient below the EAR can be taken to represent the prevalence of inadequacy for that nutrient Clearly: Again -- Vitamin E for both males (dark bars) and females (lighter bars) A Higher percentage of females in older age group have inadequate intakes: magnesium phosphorus vitamin A Zinc , Folate and Iron Data suggests that nutritional status of Females is poor relative to Males

% Females and Males 9-13 yr with Dietary Intake < EAR

The percentage of the population having intakes of a nutrient below the EAR can be taken to represent the prevalence of inadequacy for that nutrient Females (age 9 - 13 yr) are represented by the lighter horizontal bars Clearly: Vitamin E for both males (dark bars) - 97% and females (lighter bars - 95% ) is the nutrient most at risk for inadequate intake (about 95-97% are NOT meeting the Estimated Average Requirement) Others for females: magnesium - 44%, phosphorus - 42% , vitamin A - 34%

Prevalence of Eating Disorders - Annual and Lifetime by Age

This figure is from a recent publication on prevalence of eating disorders. The highest estimated mean annual prevalence of ED overall occurred at approximately age 21 years for both male (7.4%; 95% UI, 3.5%-11.5%) and female (10.3%; 95% UI, 7.0%-14.2%) individuals, with mean lifetime prevalence increasing to approximately 1 in 7 (14.3%; 95% UI, 9.7%-19.0%) for male individuals and approximately 1 in 5 (19.7%; 95% UI, 15.8%-23.9%) for female individuals by age 40 years (Figure 1). The solid lines are means; dashed lines are medians. Shade areas are the 95% confidence intervals.

Women Are More "Robust"

This figure shows the Sex Difference in the probability of dying when expressed on a logarithmic scale Men: Solid circles with a mean life expectancy of 74.1 Women: Open circles with a mean life expectancy of 79.8 Birth - is a time of relatively high mortality drops down to the peak of low death around 10 years of age After that - it is all down hill !! Notice the jump in probability of dying in late teens and early 20s which is more pronounced in males Similar jump in female deaths but it is not quite as dramatic Important point: Looking at the slope of the increase of death, it is virtually identical for males and females - Robust definition: "Full of health and strength; vigorous" Women have a lower probability of dying: they are "Robust".

Body Mass Index for Age Percentiles for Age: 2 to 20 Females

This is the CDC chart that is used to track changes in BMI for age by percentiles.

Impact of Nutrition and Health Access on Longevity

Today in the US, Western Europe, and basically all the technologically developed countries, women live longer than men Most people do not realize how widespread this difference in longevity is across countries of the world During the time period that the United Nations has been keeping records, there have been just 5 countries where men were noted to live longer than women: Bangladesh India Nepal Iran and Maldives Islands Bias for men is their access to nutrition and health care - this Figure illustrates the life Expectancy by year with Females to Males Seeing more recently in India, Iran and Maldives - women are now living longer than men

Stature for Age: Girls 2 to 20

Using the CDC statue-for-age and weight for age graph: Lower graph is weight showing the weight of a 11 year old female - 85 pounds showing the wt. of same female at 16 years - 120 Gain of weight is an increase of 35 lbs/85 lbs X 100 = 41% increase Note: Although hard to see, the girl is moving along the line with growth that corresponds to the 25th percentile. The darker line corresponds to the 50th percentile for weight.

Prevalence of Eating Disorders

bulimia 1-2% anorexia 0.5-1 binge eating 1-2% • Over 90% are female & white • More than ¾ are adolescents when first develop disorder • Prevalence among adolescent females 0.5 - 5% • Most from middle to upper SES families • Increasing - bulimia nervosa - awareness of minority & males •As many as 10% of college age women report some symptoms of eating disorders Not hard fast categories About 40% of patients with anorexia have bulimic phases Certain groups like athletes, dancers are at increased risk

Leading Causes of Female Death United States

heart disease 21.8 cancer 20.7 chronic lower respiratory disease 6.2 stroke 6.2 alzheimer disease 6.1 list is specific for Females (but men are similar) Percentage represent total deaths due to cause indicated. Listing is the most recent available from the CDC website.

Need to Optimize Women's Health

• Review some of the recent research on biological and physiological differences among men and women.• How do these differences translate into varying disease trends?- What are the common major diseases or conditions that specifically affect the health of women?- What is the role of nutrition in disease risk reduction and management?• Consider nutritional needs which vary during life cycle: adolescence, pregnancy & lactation, pre-menopause, menopause, mid-life, and elderly •Sex-based nutrition is a relatively new area of research • •Known that men and women have biological and physiological differences throughout the life cycle •in general, differences have not been studied to explain susceptibility to disease or metabolic responses of women compared to men

Pregnancy Alterations

• Steroid hormones: estrogen, androgen, & progesterone• Peptide hormones: cortisol, insulin• Structural: vascular, placentation• Immunological hCG - human chorionic gonadotropin (HCG)nPL - human placental lactogen

Adolescence

•Adolescence: major biological, social, physiological and cognitive changes occur • •Special nutritional needs: -Rapid growth -Maturation changes - •Many adolescents do not meet dietary recommendations for their age group •Adolescence has special nutritional needs: -Rapid growth: lean body mass, fat mass, bone mineralization -Maturation changes: onset of puberty - A healthful diet during this period can help to reduce the risk of iron deficiency anemia maturation delays weight issues poor bone mineralization poor school performance Period of time when eating behaviors are established that often influence eating behaviors during adulthood Nutritional surveys show many adolescents do not meet dietary recommendations for their age group

Peak Weight Velocity &Peak Bone Accrual

•Adolescents gain 50% of their ideal adult body weight •Bone mineral density increases through puberty -Calcium requirement highest: RDA for calcium age 9 - 18 years is 1300 mg/day Weight: - Adolescents gain 50% of their ideal adult body weight -Females peak gains in weight of 8.3 lb per year occur 3-6 months later than peak gains in height -So they shoot up in height first and then increase weight -Females add about 1.14 kg fat mass per year during adolescence -Equivalent to about 2.5 pounds per year -Bone: Calcium requirements are considerably higher for adolescents than for children or adults -DRI (RDA) for calcium age 9 - 18 years is 1300 mg/day

Nutrition Related Characteristics

•Anorexia: -Monotonous, low-calorie, low-fat foods & beverages -Lots of forbidden foods -Vegetarian often to limit fat & calories à eating "healthy" -Breakfast, snacks, & desserts are avoided -Increased cooking and watching others eat •Bulimia: -Binge eating triggered by emotions -Especially addictive -Self-deprecation relieved by purging that may evolve into vicious cycle -Tremendous shame

Calcium Requirements during Adolescence

•Approximately 99% of total body calcium in skeleton • •Growth spurt - increased skeletal length and mass • •Calcium RDA is 1300 mg/d for age 9 - 18 yr •< 10% of adolescent females have calcium intake > RDA • •Factors impacting calcium metabolism -Protein, vitamin D, phosphorus, and magnesium •Growth spurt - increased skeletal length and mass -Skeletal growth 45% of adult skeletal mass -During peak the average calcium retention is 300 mg/d - Note: beginning at about 12 ½ years, females accumulate 40 - 45% of their life time bone mass over a 3 to 4 year periods Adequate calcium intake during this time may reduce Fracture risk •Factors impacting calcium metabolism -Protein, vitamin D, phosphorus, and magnesium

Sex Affects Behavior & Perception

•Basic genetic and physiological differences - in combination with environmental factors - result in behavioral and cognitive differences between males and females -Brain differences -Sex-types behavior and gender identity -Cognitive ability - •Hormones play a role in behavior and cognition

Medical Complications of Anorexia Nervosa

•Semi-starvation affects most organ systems -Constipation -Cold intolerance -Bradycardia -Abdominal distress -Hypotension -Fine body hair •Anorexia can lead to: -Anemia -Renal dysfunction -Cardiovascular problems -Osteoporosis -Dental Problems

Sex-Specific Biology of the Female Gastrointestinal Tract 2

•Bile composition differs -Estrogen and progesterone increase cholesterol content •Breakdown products of bile may contribute the higher incidence of inflammatory bowel disease and colon cancer -Men have higher pancreatic cancer rates -Sex differences in gut innervation may be associated with higher incidence of functional bowel disease in women •Men have higher microsomal oxidative enzymes and females have more microsomal reductive enzymes (in utero) -Differences in drug metabolism -Cytochromes P450 are oxidative enzymes that metabolize drugs -Alcohol metabolized less efficiently Transplants: another interesting point made related to liver transplantations the greater success seen with female to female transplantations and the male to male transplantations versus female-male or vice versa

Diseases More Common Among Women

•Breast cancer •Pelvic organ infection •Incontinence •Osteoporosis •Connective tissue diseases •Depression/anxiety/eating disorders •Dementia Note: men do get breast cancer and men do have eating disorders (often "muscle dysmorphia" )

Differences in Gender Disease Incidence & Risk between Women and Men

•CVD more in men •Depression 2x w •Migraines 2x w •IBD w •Cancer varies •Osteoporosis w •Rheum Arthritis 3x w •Lupus 9x w •Fibromyalgia 9x w IBD - irritable bowel syndrome Men and women differ in their life span - women have longer lives than men Although women have lower mortality rates, they have: • More severe chronic diseases •More disability days - especially arthritis •More physician visits •Longer hospitalizations

Diseases & Health Conditions Unique to Women

•Cancer of the ovary, cervix, and uterus •Dysmenorrhea •Endometriosis •Uterine fibroids •Pregnancy Unique disease are related to sex organs of females

Bulimia Medical Complications

•Complications associated with self-induced vomiting -Permanent loss of dental enamel -Salivary gland hypertrophy -Electrolyte disturbances -Cardiac & skeletal myopathies -Hypothermia -Russell's sign (calluses over knuckles due to inducing vomiting ) •Laxative abuse associated with: -Metabolic acidosis -Permanent disruption of normal bowel functioning - •Binge Eating can cause (rarely): -Gastric rupture -Esophageal tears

Course & Outcome of Eating Disorders

•Course and outcome of anorexia is variable; mortality among those with chronic course is as high as 10% -Recovery rates suggest ≈ 46% recover, 33% improve, & 20% remain ill • •Less is known about course & outcome of bulimia -Intermittent & chronic course is common -Recovery rates suggest 50% of patients recover, 30% improve & after 10 years only 10 % will continue to meet the full criteria of the disorder Anorexia: many have multiple hospitalizations or out patient therapy programs before achieving recovery Anorexia has the highest mortality rate of any psychiatric disorder this is a MENTAL ILLNESS

Women's Health Initiative 2021

•Current website: https://www.whi.org/ -WHI strives to improve health through research on risk factors, prevention, and early detection of serious health conditions, so postmenopausal women thrive. •Now offering in 2021: -They are pleased to offer you a webinar every month starting in February. Learn more about WHI research, meet researchers, and hear perspectives and experiences from other women like you! -Join in real-time by computer or phone. -Questions? Call us at (800) 218-8415 or e-mail [email protected]. The Women's Health Initiative (WHI) is a long-term national health study funded by the National Heart, Lung, and Blood Institute, or NHLBI. The original WHI study began in the early 1990s and concluded in 2005. Since 2005, the WHI has continued as Extension Studies, which are annual collections of health updates and outcomes in active participants. The second Extension Study enrolled 93,500 women in 2010 and follow-up of these women continues through another extension that will conclude in 2020. NHLBI intends to fund the next Extension Study for the follow-up of WHI participants through 2027. As with the original WHI study, the main areas of research are cardiovascular disease, cancers, and osteoporotic fractures. While WHI continues to focus on strategies to prevent the major causes of death, disability, and frailty in older women, the breadth and richness of the WHI data allow for the exploration and investigation of many more research questions on women's health and aging. To learn more about the original WHI study that began in the early 1990's, including specific details about the three clinical trials and the observational study, visit the WHI program page on the NHLBI website.

Binge Eating Disorder Con't

•DSM-V Diagnostic Criteria (continued) for Binge Eating: -Marked distress regarding binge episodes is present -Binge eating occurs, on average, at least once a week for 3 months -The binge eating is not associated with the regular use of inappropriate compensatory behavior as in bulimia nervosa and does not occur exclusively during the course of bulimia nervosa or anorexia nervosa The prior DSM-IV required the frequency of at least twice a week for 6 months for a diagnosis of binge eating. The DSM V reduced the incidence to at least once a week and for a period of 3 months.

Other Specified Eating Disorder Con't

•DSM-V Diagnostic Criteria (continued): -Bulimia nervosa (of low frequency and/or limited duration): All of the criteria for bulimia nervosa are met, except that the binge eating and inappropriate compensatory behaviors occur, on average, less than once a week and/or for less than 3 months -Binge-eating disorder (of low frequency and/or limited duration): All of the criteria for binge-eating disorder are met, except that the binge eating occurs, on average, less than once a week and/or for less than 3 months. •DSM-V Diagnostic Criteria (continued): -Purging disorder: Recurrent purging behavior to influence weight or shape (e.g., self-induced vomiting; misuse of laxatives, diuretics, or other medications) in the absence of binge eating. -Night eating syndrome: Recurrent episodes of night eating, as manifested by eating after awakening from sleep or by excessive food consumption after the evening meal. There is awareness and recall of eating. The night eating is not better explained by external influences such as changes in the individual's sleep-wake cycle or by local social norms. New to the DSM V was the addition officially into this Other Specified Eating Disorder category, "Night Eating Syndrome".

Binge Eating Disorder (BED)

•DSM-V Diagnostic Criteria: -Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: •Eating in a discrete period (e.g. within any 2-hr period) an amount of food that is definitely larger than most people would eat during a similar period •A sense of lack of control over eating during the episode -Binge eating associated with 3 or more of the following: •Eating much more rapidly than normal •Eating until feeling uncomfortably full •Eating large amounts when not physically hungry •Eating alone due to embarrassment by how much one is eating •Feeling disgusted, depressed or guilty after overeating

Other Specified Eating Disorder

•DSM-V Diagnostic Criteria: -This category applies to presentation in which symptoms characteristic of an eating disorder cause clinically significant distress or impairment in social, occupational, or other important areas but do not meet the full criteria for any of the disorders. •Used in situations when the clinician chooses to communicate the specific reason that the presentation does not meet the criteria for any specific eating disorders (e.g., "bulimia nervosa of low frequency") • -Atypical anorexia nervosa: all criteria for AN are met, except that despite significant weight loss, the individual's weight is within or above the normal range

Bulimia Nervosa

•DSM-V Diagnostic Criteria: • -Recurrent binge eating episodes characterized by both: •Eating in a discrete period (e.g. within any 2-hr period) an amount of food that is definitely larger than most people would eat during a similar period •A sense of lack of control over eating during the episode • -Recurrent inappropriate compensatory behavior in order to prevent weight gain •self-induced vomiting, misuse of laxatives, diuretics, enemas, or other medications; fasting, or excessive exercise -The binge eating and inappropriate compensatory behaviors occur, on average, at least once a week for three months -Self-evaluation is unduly influenced by body shape and weight - -The disturbance does not occur exclusively during episodes of anorexia nervosa Lack of control - feeling that one cannot stop eating or control what or how much one is eating Change with the DSM V is the fact that the binge eating occurs on average at least once (not TWICE as it was in DSM IV) for three months

NIH Established Web Sites

•Designed for consumers with latest information on significant topics in women's health research on the National Library of Medicine web site https://www.nlm.nih.gov/medlineplus/womenshealth.html •Women's Health Resources from the ORWH web site http://orwh.od.nih.gov/resources/index.asp Women's Health Resources: variety of health topics: alcohol, abuse, autoimmune diseases, bone and joint, cancer, etc. news and events Office of Research on Women's Health: Coordinated NIH women's health research Promotes and supports efforts to improve the health of women Strengthens and enhances research related to disease, disorders, and conditions that affect women Ensures that research conducted and supported by NIH adequately addresses issues regarding women's health Ensures that women are appropriately represented in biomedical and bio-behavioral research studies

Social and Cognition Development

•Developing an independent identity •Increasing importance of peer acceptance •Limited abstract reasoning and problem-solving skills in early adolescence •Limited ability to think about relationship between present and long-term health Social and cognitive development changes can contribute to the risk of poor nutrition Peer Pressure: Increasing importance of peer acceptance -Comments from parents & peers about physical appearance can influence views of self May adopt unhealthy eating or weight control behaviors Adolescents Dietary habits: tend to skip meals eat more meals outside of their homes may develop strong food beliefs vegetarianism, food fads Diet Fads can be an expression of independence: busy lifestyles - school, activities, athletics problems with body image search for self-identity secondary to peer and social pressures à all friends on latest fat diets; Atkin, South Beach

Definitions of Adolescence

•Dictionary: the period of physical and psychological development from the onset of puberty to maturity • •Dorland's Medical Dictionary: the period between puberty and the completion of physical growth, roughly from 11 to 19 years of age In the Dietary Reference Intakes: Females: 9 - 13 years of age (pre-teen) 14 - 18 years of age (teenagers)

Adolescent Eating Behaviors

•Dieting and weight control common •Eating away from home •Family meals improve the nutritional quality of the diet •Meal skipping: ↓ calcium, iron & zinc intake •Increased snacking •Dieting and weight control common -55% of high school females diet to lose/maintain weight -Females more likely to use extreme measures -Peer dieting, parents concerns, the media - •Eating away from home -More than 50% eat some "fast-food" daily -Higher in lower socioeconomic status, team sports, part-time working Family Meals: Tends to PROTECT female from chronic dieting, unhealthy weight control and binge eating or purging As age increasing, meal skipping increases - usually Breakfast is skipped: 15% of preadolescents and one third of adolescents 14-18 years Female adolescent skip more than males Snacking: has increased related to meal skipping may provide an average of around 600 calories per day

Prevalence of Disease

•Differences in prevalence and severity of a broad range of diseases, disorders, and conditions exist between sexes -Mechanism and origins of sex differences can be explored -How can information on sex differences be translated into preventative, diagnostic, and therapeutic practice? -How can the new knowledge about and understanding of biological sex differences and similarities most effectively be used to positively affect patient outcomes and improve health/health care? An important fact you will learn this semester - the unique heart attack/heart disease symptoms of women versus men: Women Heart Disease: Nausea, vomiting, dizzy, breathless, sweaty Men Heart Disease Chest pain, radiates down left arm, both arms or back; shortness of breath

Multi-factorial Etiology of Eating Disorders

•Genetic Factors •Family Factors • •Psychological Factors - •Socio-cultural Factors Genetic Factors: maybe 50% or more based on twin studies -Family vulnerability to obesity -Family history of eating disorder or other psychiatric disorder -Ovarian hormones may have links to development •Females during puberty may be most susceptible Family Factors: -High levels of family conflict à bulimia -Parental preoccupation with shape & weight -Family eating & exercise behaviors -Unrealistic expectations for achievement Psychological Factors: -Low self-esteem -Perfectionism & unrealistically high standards -Neuroticism or mood modulation -Adverse childhood experience / sexual abuse Socio-cultural Factors: -Overvaluation of thin body ideal - media's preoccupation with thin -Chronic dieting, particularly among young women

Women's Health & Eating Disorders

•Eating problems & concerns - eating, shape and weight for all ages and across social economic status (SES) and ethnic groups • •Little known - "normal eating" or base rates of problem eating • •Obesity has increased dramatically • •Understanding eating and weight-related behavior across weight categories is crucial •Eating problems and concerns about eating, shape and weight are common among women of all ages and across social economic status (SES) and ethnic groups • •Little is known about normal eating or the base rates of problem eating in the general population • •Obesity has increased dramatically and understanding of eating and weight-related behavior across weight categories is crucial • Three categories: high SES, middle SES, and low SES to describe the three areas a family or an individual may fall into. When placing a family or individual into one of these categories any or all of the three variables (income, education, and occupation) can be assessed. income education occupation

WHI: Calcium plus Vitamin D Supplementation and Risk of Fractures

•Efficacy of Calcium + vitamin D supplementation preventing hip and other fractures in postmenopausal women (NEJM 2006; 354:669) -36,282 postmenopausal women aged 50 - 79 yr -Received 1000 mg Calcium + 400 IU Vitamin D or placebo -Fractures were followed for 7 years; bone density measured at 3 of the sites - •Ca + vitamin D resulted in a small but significant improvement in hip bone density -Did not significantly reduce hip fracture -Increased the risk of kidney stones

Nurses' Health Study II

•Established in 1989 by Dr. Walter Willett at Harvard with NIH funding -To study oral contraceptives, diet and lifestyle factors in a population of younger nurses -Initial target was age 25 - 42 years in 1989 - •Every 2 years, cohort members received a follow-up questionnaire with questions about diseases and health-related topics including smoking, hormone use, pregnancy history, menopausal status • •In 1991, food-frequency questionnaire was collected and thereafter every 4 years -Later added quality-of-life questionnaire , blood and urine collections This younger generation included women who started using oral contraceptives during adolescence and were thus maximally exposed during their early reproductive life. The upper age was to correspond with the lowest age group in the Nurses' Health Study. The original goal was to enroll 125,000 women.

Office of Research On Women's Health

•Established in 1990 -http://orwh.od.nih.gov/ •Coordinates NIH women's health research •Promotes and supports efforts to improve the health of women through biomedical and behavioral research •Strengthens and enhances research related to diseases, disorders, and conditions that affect women •Ensures that research conducted and supported by NIH adequately addresses issues regarding women's health -Ensures that women are appropriately represented in biomedical and bio-behavioral research studies Ensures that women are appropriately represented in biomedical and bio-behavioral research studies supported by NIH Develops opportunities for and supports recruitment, retention, re-entry, and advancement of women in biomedical careers; and Supports research on women's health issues.

Prevalence of US Children & Adolescents Obesity 2011-2012

•Estimated prevalence high BMI for age -Body Mass Index = body wt kg/height m2 -Percentile of age- & gender- specific Centers for Disease Control Charts ->85th, >95th, & >97th percentiles categories -Obesity defined at or above 95th of the sex-specific CDC BMI-for-age growth charts •Trends in childhood obesity between 2007 - 2008 through 2015-2016 •In 2007-2008, 16.8% of children 1 to 19 years were obese •Between 2007-2008 and 2015-2016 the prevalence of obesity increased to 18.5% Data from National health and Nutrition Examination Survey (NHANES). High BMI was defined based on the 2000 sex-specific BMI-for-age growth charts from the CDC There is No well accepted standards for body fatness for children. Weight adjusted for height is used rather than measure % fat BMI varies widely with children so generally BMI of a child is compared with the BMI of a reference population of children of the same sex and age 2000 CDC BMI-for-age growth charts are often used in the US to screen for overweight CDC uses: "Healthy " as between 5th to 85th percentile Overweight as between 85th to less than 95th percentile Obese as ≥ 95th percentile

Nurses' Health Study III

•Examine how new hormone preparations, dietary patterns, and nursing occupational exposures impact women's health • •Recruiting female RNs and LPNs age 20-46 from across the country to join the new cohort, which will be entirely web-based • •Important goal for the Nurses' Health Study III is to include women from more diverse ethnic backgrounds -http://www.nhs3.org/ New features will include a closer look at fertility and pregnancy events and a greater focus on adolescent diet and breast cancer risk. As of now nurses are still being recruited to join the Nurses' Health Study III: Nurses' Health Study 3 In 2010, Drs. Walter Willett, Janet Rich-Edwards, Stacey Missmer, and Jorge Chavarro started Nurses' Health Study 3 in collaboration with investigators at the Channing Laboratory and the Harvard School of Public Health. For the first time ever, the study is entirely web-based. Participants include female LPN/LVNs and RNs, and it's also open to nurses in Canada. NHS3 aims to be more representative of nurses' diverse backgrounds. It will closely look at health issues related to lifestyle, fertility/pregnancy, environment, and nursing exposures. 230,000 female nurses have been enrolled in the Nurses Health Studies since 1970's

Folate

•Folate - nucleotides & proteins -Deficiency anemia (megaloblastic) •Folate RDA: is 300mg dietary folate equivalents age 9 - 13 yr and 400mg age 14 - 18 yr -1 DFE = 1μg food folate = 0.6μg folic acid from supplements & fortified foods -Nearly 20% of adolescent females 14-18 yr intake < EAR •Adequate folate peri-conceptual period protects against neural tube defects (NTD) in offspring -NTDs result in malformations of the spine (spina bifida), skull, & brain (anencephaly) NTD risk is significantly reduced with supplemental folic acid Foliate is a water-soluble B vitamin that occurs naturally in food - dark green leafy vegetables. Folic acid is the synthetic form of folate that is found in supplements and added to fortified foods Folates are present in natural foods and tissues as polyglutamates. Enzymes in the small intestine convert the polyglutamate form to the monoglutamate form of the folate, which is absorbed. Folate is needed to make DNA and RNA, the building blocks of cells. Food and Drug Administration (FDA) published required the addition of folic acid to enriched breads, cereals, flours, corn meals, pastas, rice, and other grain products . Since cereals and grains are widely consumed in the U.S., these products have become a very important contributor of folic acid to the American diet. The RDAs for folate are expressed in a term called the Dietary Folate Equivalent. The Dietary Folate Equivalent (DFE) was developed to help account for the differences in absorption of naturally occurring dietary folate and the more bioavailable synthetic folic acid

10 Leading Causes of Death in 2020

•Heart disease: 696,962 •Cancer: 602,350 •COVID-19: 350,831 •Accidents (unintentional injuries): 200,955 •Stroke (cerebrovascular diseases): 160,264 •Chronic lower respiratory diseases: 152,657 •Alzheimer's disease: 134,242 •Diabetes: 102,188 •Influenza and pneumonia: 53,544 •Nephritis, nephrotic syndrome, and nephrosis: 52,547 •Source: Mortality in the United States, 2020, data table for figure 4 Leading causes by ranking; heart disease remains number 1 but diabetes increases the risk of heart disease. "Cerebrovascular diseases" - strokes. As population gets older, the risk of Alzheimer's increases Heart disease has consistently been the leading cause of death in the United States and remained so.

Health Benefits Regular Physical Activity Children and Adolescents

•Improved bone health (ages 3 through 17 years) •Improved weight status (ages 3 through 17 years) •Improved cardiorespiratory and muscular fitness (ages 6 through 17 years) •Improved cardiometabolic health (ages 6 through 17 years) •Improved cognition (ages 6 to 13 years) •Reduced risk of depression (ages 6 to 13 years) This is Table 2 from the 2018 Report. Note: The Advisory Committee rated the evidence of health benefits of physical activity as strong, moderate, limited, or grade not assignable. Only outcomes with strong or moderate evidence of effect are included in this table.

BMI Above 95th Percentile

•In 2011-2014, change over time in obesity (>95th percentile) for both males and females increased with age • •Race/Hispanic and age differences existed -Obesity was higher in non-Hispanic Black children 19.5%, Hispanic 21.9%, non-Hispanic Asian youth 8.6% than non-Hispanic White 14.7% - •There was no significant difference in obesity prevalence between 6 to 11 and 12 to 19 year olds Note that BMI is not a perfect measure of body fat. BMI is highly correlated with body fat but does not account for differences in distribution of body fat or differences between race/Hispanic origin groups, sex, and age Also NOTE: for all groups the estimates were slightly higher with the CDC growth charts than the World Health Organization (WHO) growth charts WHO growth standards represent the growth of children in select settings around the world with optimal feeding practices among other factors

Iron Requirements during Adolescence

•Iron needed to synthesize substantial amounts of new myoglobin (lean muscle) and hemoglobin (blood volume) • •Females require addition after menarche to cover losses •RDA age 9 - 13 yr is 8 mg/d •RDA age 14 - 18 yr is 15 mg/d • •Impact of poor iron intake Females who are at increased risk for iron deficiency include older adolescent female, pregnant adolescent, and female athletes increased needs with menstruation Prevalence of iron deficiency anemia varies from average 2% higher among females age 16-19 than any other age group Impact of poor iron intake (KNOW): -Anemia (hypochromic, microcytic) - 2% prevalence -Reduced exercise tolerance -Impaired cognitive abilities

Biological Phenomenon or Human Idiosyncrasy?

•Is the human female superiority in longevity and resistance to death by many individual diseases seen in the animal kingdom? • •Find same pattern of sex differences in many other species -Chimpanzees -Tarantulas (females 30 yr; males 5 years) -Honey bees (queen bee years; males weeks) In the animal world, Female longevity superiority is quite widespread

Sex Affects Health

•Males and females have different patterns of illnesses and different life spans •Raises questions about relative role of Biology and Environment in these disparities •Dissimilar: -Exposures, susceptibilities -Energy storage and metabolism results in variable responses: •to pharmacologic agents •to development of obesity, autoimmune disorders, and coronary heart disease

NIH Research Priorities for Women's Health and Sex Differences Research

•Mission is to stimulate and encourage research on women's health •Three crosscutting themes that provide a conceptual framework: -Advancing understanding of sex/gender differences in health and disease -Integrating sex/gender perspectives in emerging basic science fields and in translational research and technologies -Fostering partnerships to improve translating and disseminating health information. Each year an ad hoc research subcommittee from NIH institutes and centers considers continuing gaps in knowledge and emerging scientific opportunities for current research priorities in women's health Moving into the Future with New Dimensions and Strategies: A Vision for 2020 for Women's Health Research - lays out the strategic plan

Hypotheses on Female Longevity

•More active immune system •Estrogen somehow protects female animals at a cellular level • •Selecting the better X chromosomes while inactivating the deleterious X chromosome • •Reduction of growth hormone and insulin-like growth factor 1 • •Oxidative stress hypothesis Immune: (con) Lower disease incidence in females is not solely due to immune system differences Estrogen protection: (con) female pilot whales that undergo a true menopause live longer than males X chromosome: female longevity is not universal in the animal world - male guinea pigs and golden hamster live longer than females Free radical formation is higher in males than in female; but in mice Free radical production is higher in males and they live longer

Sex-Specific Biology of the Female Gastrointestinal Tract

•Mouth: "supertasters" and prefer food with less sugar, in part due to greater olfactory abilities •Saliva: flow varies with menstrual cycles (3-9-fold changes with periods) -Glucose content increases, •Buffering capacity of saliva less than men and may increase halitosis especially during periods •Esophagus is shorter and peristaltic activity is higher -Gastroesophageal reflux (GERD) increases during pregnancy •Less gastric acid (estrogen suppresses acid secretion of parietal cells) •More bloating and belching that may reflect progesterone impact on gut motility

Need to Optimize Women's Health 2

•Review some of the recent research on biological and physiological differences among men and women. •How do these differences translate into varying disease trends? -What are the common major diseases or conditions that specifically affect the health of women? -What is the role of nutrition in disease risk reduction and management? •Consider nutritional needs which vary during life cycle: adolescence, pregnancy & lactation, pre-menopause, menopause, mid-life, and elderly •Sex-based nutrition is a relatively new area of research • •Known that men and women have biological and physiological differences throughout the life cycle •in general, differences have not been studied to explain susceptibility to disease or metabolic responses of women compared to men

White Urban-rural Mortality Gap

•New evidence suggest rural white women - in their late 40s - death rates have risen by 30% •Washington Post analysis - clear divide in health of urban and rural Americans -White women mortality changes: more likely than grandmothers to be smokers, obese, or drink alcohol -White women still outlive white men and African Americans of both sexes; but health advantages appear to be evaporating -Epidemics of opioid and heroin overdoses especially in working-class rural communities •Hardest hit places - 21 counties across South and Midwest The Post divided populations into urban and rural categories examining death records from the Centers for Disease Control and Prevention, breaking information down geographically, county by county, by level of urbanization and by cause of death. Suicide rates for white women of all ages has increased; more than doubled for rural white women ages 50 to 54 years. Researchers have also pointed out that this generation of white women has experience changes in gender roles à surging into the workforce while typically retaining traditional duties as domestic caregivers - a dual role that many women of color have long been accustomed. Women are more likely to experience "telescoping" of the negative outcomes of alcohol related diseases than men. Especially deadly when combined with obesity which is very high in rural America. Lung cancer now kills more women than breast cancer. The Woman pictured (58y) died due to liver failure as a result of long-term use of alcohol, painkillers, anti-anxiety medications and illicit drugs. She left $100,000 to Teen Challenge, a faith-based organization that helps teenagers struggling with drug and alcohol addition (Washington Post)

Biological Contributions to Human Health: Does Sex Matter?

•New research in basic human biology suggests that normal and pathological functions are influenced by sex-based differences • •Historically, assumed that beyond reproductive system, differences did not exist or were not relevant • •Evidence suggests that the distinct anatomy and physiology as a result of having two X chromosomes (XX) or an X chromosome and a Y chromosome (XY) can have broader influence than previously thought DRIs in the past used the 70 kg reference man for standards of treatments for women - but there are biological and physiological differences Anatomically obvious why only males develop prostate cancer and only females get ovarian cancer Not obvious why females are more likely than males to recover language ability after suffering a left-hemisphere stroke Or: why females have a greater risk than males of developing life-threatening ventricular arrhythmias in response to a variety of potassium channel-blocking drugs

Micronutrients at Risk During Female Adolescence

•Nutrients often identified as being inadequate: -Calcium & Magnesium -Iron -Zinc -Potassium -Vitamin A, C, E, & more recently D -Folic acid & Vitamin B6 - •The nutrient deficiency commonly seen among adolescents is iron deficiency anemia

Why Do Women Live Longer Than Men?

•Oldest person with valid birth record was Jeanne Calment, a French woman who lived to be 122 years old • •People who have lived to be ≥ 110 years old are called super centenarians • •Your chances of living to ≥ 110 years are ≈ 1 in 3 million -There are about 560 super centenarians worldwide, and almost 90% are women From 1970s through the 1990s three sites in the world were reputed to be of special interest with respect to longevity • Caucasus Mountains - between Black and Caspian seas at southeastern most part of Europe - people were routinely reported to live into their 130s, 140s, 150s, •Second: Vilcabamba in the Ecuadorian Andes Mountains - living "only" into to their 130s •Third: Karakoram Mountains - spanning the common borders between India, China and Pakistan • •When these reports were investigated in detail, none proved to be true •Tell tale clue to the falseness of these claims was that the oldest people in all of these places were supposedly men

Growth During Adolescence

•On set of puberty and the rate of progression through puberty varies •Adolescent growth spurt occurs ≈ 2 years later in boys than in girls •Adequate nutritional intake necessary to assure normal growth and maturation Children vary considerably as to age at onset of puberty and the rate of progression through puberty -Hormonal changes result in alterations in body size, body composition (muscle, fat, bone), and skeletal and sexual maturation -Genetics -Environmental factors -general health -nutrition - Alterations are the basis for the increased dietary requirements associated with adolescence growth spurt for: Energy Protein and Most micronutrients The difference in adolescent growth spurt contributes to boys and girls of similar ages having often different nutritional requirements Under nutrition and chronic disease can delay the onset of puberty

Nurses' Health Study (Original Cohort)

•Original Cohort: NIH study established in 1976 to investigate long term consequences of oral contraceptives -Married, age 30 - 55 -Every 2 years, 122,000 RNs received questionnaires about disease, smoking, hormone use, menopause onset, etc. -Diet questionnaire was added in 1980 -Questionnaires every four years (~ 90% response rate) - •Added quality of life and some biochemical measures The Nurses' Health Study was established by Dr. Frank Speizer in 1976 with funding from the National Institutes of Health. The primary motivation in starting the NHS was to investigate the potential long-term consequences of the use of oral contraceptives, a potent drug that was being prescribed to hundreds of millions of normal women. Registered nurses were selected to be followed prospectively. They anticipated because of their nursing education, nurses would be able to respond with a high degree of accuracy to brief, technically-worded questionnaires and would be motivated to participate in a long-term study. Married registered nurses who were aged 30 to 55 in 1976, who lived in the 11 most populous states and whose nursing boards agreed to supply the study with their members' names and addresses were enrolled in the cohort if they responded to our baseline questionnaire. The original states were California, Connecticut, Florida, Maryland, Massachusetts, Michigan, New Jersey, New York, Ohio, Pennsylvania and Texas. Approximately 122,000 nurses out of the 170,000 mailed responded. Every two years cohort members receive a follow-up questionnaire with questions about diseases and health-related topics including smoking, hormone use and menopausal status.

Key Findings and Recommendations of the Midcourse Report

•School settings hold a realistic and evidence-based opportunity to increase PA among youth and should be a key part of a national strategy to increase PA •Preschool and childcare centers that serve young children are an important setting in which to enhance PA •Changes involving the build environment and multiple sectors are promising •To advance efforts to increase PA among youth, key research gaps should be addressed

Key Guidelines for Preschool, Children, Adolescents

•Preschool-aged children (ages 3 through 5 years): should be physically active throughout the day to enhance growth and development •Adult caregivers of preschool-aged children should encourage active play that includes a variety of activity types. •Children and Adolescents: important to provide young people opportunities and encouragement to participate in physical activities that are appropriate for their age, that are enjoyable, and that offer variety •Children and adolescents ages 6 through 17 years should do 60 minutes (1 hour) or more of moderate-to-vigorous physical activity daily -Aerobic: Most of the 60 minutes or more per day should be either moderate- or vigorous intensity aerobic physical activity and should include vigorous-intensity physical activity on at least 3 days a week -Muscle-strengthening: As part of their 60 minutes or more of daily physical activity, children and adolescents should include muscle-strengthening physical activity on at least 3 days a week -Bone-strengthening: As part of their 60 minutes or more of daily physical activity, children and adolescents should include bone-strengthening physical activity on at least 3 days a week. Full report: https://health.gov/sites/default/files/2019-09/Physical_Activity_Guidelines_2nd_edition.pdf Be familiar with the three types of recommendations which also pertain to adults. •Some physical activity is better than none •Additional health benefits occur with at least 150 minutes per week of moderate physical activity •Both aerobic and muscle strengthening physical activity •Health benefits occur for adolescents in every studies racial and ethnic group

Released by the US Department of Health and Human Services in 2008 - these were the initial guidelines Primary audience for these guidelines were makers and Health professionals

•President's Council of Fitness, Sports & Nutrition (PCFSN), CDC, and NIH concluded 2008 recommendations would still remain current •Recommended a Midcourse Report -Physical Activity Guidelines for Americans Midcourse Report: Strategies to Increase Physical Activity Among Youth -Identification of interventions to help increase physical activity (PA) in youth across a variety of settings The subcommittee focused on physical activity in general, and did not examine specific types of activity such as muscle or bone-strengthening physical activities Focus on five settings which PA interventions for youth have been studied and evaluated : Schools, preschools and childcare centers, community, family and home and primary care

Macronutrient Requirements during Adolescence

•Protein requirements are increased to support linear growth & accrual/maintenance of lean body mass -Greatest per unit of height for females age 15-18 yrs -RDA for 9-13 yr is 0.95 g/kg -RDA for 14-18 yr is 0.85 g/kg - •RDA for CHO is 130 g/d; and Acceptable Macronutrient Distribution Ranges (ADMRs) is 45% - 65% of total kcals -Dietary Guidelines 2020-2025: <10% calories of added sugars - •No RDA of EAR for total fat; AMDR for 4-18 yr is 25% - 35% of total calories Protein: Adolescents in the US usually consume about twice the recommended protein level It may be harder for adolescent living in food insecure homes, following vegetarian/vegan eating patterns, or on diets to lose weight CHO (carbohydrates) Adolescent females consume 55% of energy as CHO - but about 20% of the CHO intake is coming from sweeteners and added sugars Fat Average fat and cholesterol intakes approximate National guidelines approximately 32% of total calories fat; 11% saturated fat, cholesterol 200 mg/d AMDR: Acceptable Macronutrient Distribution Range

Physical Activity Guidelines for Americans - 2nd Edition

•Provides science-based guidance ages 3 years and older improve health through participation in regular physical activity •Reflects new knowledge gained since the publication of the first Physical Activity Guidelines for Americans, released in 2008. •New aspects include discussions of: -Additional health benefits related to brain health, additional cancer sites, and fall-related injuries -Immediate and long-term benefits for how people feel, function, and sleep - Further benefits among older adults and people with additional chronic conditions -Risks of sedentary behavior and their relationship with physical activity -Guidance for preschool children (ages 3 through 5 years) -Elimination of the requirement for physical activity of adults to occur in bouts of at least 10 minutes -Tested strategies that can be used to get the population more active. Addressed younger children and updated since 2008 Listed above are the major changes with the second edition

Initial 2008 Physical Activity Guidelines

•Provides science-based guidance to help Americans aged 6 and older improve health through appropriate physical activity • •US Department of Health & Human Services issues the guidelines • •These guidelines have essentially remained in place since 2008. Released by the US Department of Health and Human Services in 2008 - these were the initial guidelines Primary audience for these guidelines were makers and Health professionals

Review of Dietary Reference Intake (DRI) Definitions

•RDA: daily intake sufficient to meet the needs of nearly all (97-98%) at life-stage and gender *Used to assess individuals •EAR: daily intake sufficient to meet needs of only 50% of persons in life-stage and gender *Best for assessing populations •AI: used in place of RDA and EAR when there is not sufficient scientific evidence to support establishment of a level EAR: estimated average requirement AI: adequate intake

Every Cell Has a Sex

•Rapid advances have revealed genetic and molecular basis of sex differences in health and human disease • -Some attributed to sexual genotype: XX and XY - -The inheritance of either a male or female genotype is influenced by the source (maternal or paternal) of the X chromosome - -Sex chromosome genes and their expression explain X-linked diseases Genes on the sex chromosomes can be expressed differently between males and females because of : •the presence of either single or double copies of the gene •X chromosome inactivation • •X chromosome - is the larger sex chromosome; 1000+ more genes on X that do not have an analogous on the Y; therefore, any deleterious alleles on the X may not have a compensatory allele on the male

Anorexia Nervosa DSM-V Diagnostic Criteria - continued

•Restricting Type -During the last 3 months, the individual has not engaged in recurrent episodes of binge eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas). This subtype describes presentations in which weight loss is accomplished primarily through dieting, fasting and/or excessive exercise. • •Binge-Eating / Purging Type -During the last 3 months, the individual has engaged in recurrent episodes of binge eating or purging behavior ( i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas).

Sex Begins in the Womb

•Sex differences of importance to health and human disease occur throughout life span -Specific expression varies at different stages •Some originate in events occurring in intrauterine environment -Developmental processes differentially organize tissues for later activation in male or female •Prenatal period - sex determination by sequential processes •Prepubertal - behavioral and hormonal changes manifest in secondary characteristics (sexual identity) •Puberty - biological differences important and impact the onset and progression of diseases Hormonal events occurring in puberty lay framework for biological differences that persist through life and contribute to variable onset and progression of disease in males and females Important to study sex differences at all stages of life cycle use animal models of disease and include sex as a variable in basic and clinical research

Institute of Medicine (IOM) Report on Biological Differences

•Sex matters -Variable that should be considered when designing and analyzing studies - •Study of sex differences is evolving into a mature science • •Barriers to the advancement of knowledge about sex differences in health and illness exist and must be eliminated Sex matters: •differences in health and illness are influenced by individual genetic and physiological constitutions •also by interaction with environmental factors •Incidence and severity of diseases varies between sexes: may be related to differences in exposures, routes of entry and processing of a foreign agent, and cellular responses • Mature Science: now sufficient knowledge of biological basis of sex differences to validate difference and allow to generate hypotheses • Barriers: •Variety of barriers to progress, including ethical, financial, sociological, and scientific

Sex Versus Gender

•Sex: refers to the classification of living things, generally as male or female according to their reproductive organs and functions assigned by chromosomal complement • •Gender: refers to a person's self representation as male or female, or how that person is responded to by social institutions based on the individual's gender presentation -Gender is rooted in biology and shaped by environment and experience Biologically, person may have female reproductive organs but may feel "more like a man": may represent themselves as a male; the gender then is male Sex tends now to refer to biological differences. World Health Organization (WHO) - "sex" refers to the biological and physiological characteristics that define men and women and that "male and female are sex categories." WHO - "gender refers to the socially constructed roles, behaviors, activities, and attributes that a given society considers appropriate for men and women" and that "masculine and feminine are gender categories." The Food and Drug Administration (FDA) used to use gender instead of sex when referring to physiological differences between male and female organisms. In 2011, FDA reversed their position and began using sex as the biological classification and gender as "a person's self representation as male or female, or how that person is responded to by social institutions based on the individual's gender presentation."

Women's Health Initiative

•The National Institutes of Health (NIH) established the Women's Health Initiative (WHI) in 1991 to address the most common causes of death, disability and impaired quality of life in postmenopausal women. •The WHI addressed cardiovascular disease, cancer, and osteoporosis. The three major randomized control trials of the WHI were: -Hormone therapy trial -Dietary modification trial -Calcium and vitamin D supplementation trial The WHI was a 15 year multi-million dollar endeavor, and one of the largest U.S. prevention studies of its kind. This was the first major intervention trial in the US with women only.

Anorexia Nervosa

•Think of very thin teenage girls; these people typically seem to be unaffected by food ads, chocolate cravings, pizza, etc. • •DSM-V Diagnostic Criteria: -Restriction of energy intake relative to requirements, leading to a significantly low body weight in context of age, sex, developmental trajectory, and physical health. - -Intense fear of gaining weight or becoming fat -Disturbance in the way in which one's body weight or shape is experienced, or denial of the seriousness of the current low body weight Significantly low weight is defined as a weight that is less than minimally normal or, for children and adolescents, less than that minimally expected. Major Change from DSM - IV: the criterion regarding Amenorrhea (in post-menarcheal females) - the absence of three consecutive menstrual cycles; periods only with hormone therapy - is no longer included.

Eating Disorders: Are they more common now

•Timeline: -1973, Hilde Bruch published the first major work in the field "Eating disorders: Obesity, Anorexia Nervosa, and the Person Within" -1978, Bruch published "The Golden Cage" -1985, Karen Carpenter died from heart failure due to anorexia nervosa •Famous people with eating disorders: Cathy Rigby, Gilda Radner, Princess Diana, Sally Field, Elton John, Jane Fonda, Lady Gaga •Only 12 states have state-mandated insurance coverage for the treatment of eating disorders The first book was written for professionals; the second in 1978 provides a compelling and empathetic understanding of the nature of eating disorders - especially anorexia nervosa Karen Carpenter - pictures of the emaciated singer on the cover of magazines like People Others: Cathy Rigby - Olympic Gold Medal gymnast struggled with anorexia and bulimia Overall trend shows that the number of individuals with Eating Disorders has been increasing continually since their recognition Paralleling Society's growing obsession with being Thin, Losing weight and the Fear of Fat

2019 - 2023 Trans NIH Strategic Plan for Women's Health Research

•To advance rigorous research that is relevant to the health of women •To develop methods and leverage data sources to consider sex and gender influences that enhance research for the health of women •To enhance dissemination and implementation of evidence to improve the health of women •To promote training and careers to develop a well-trained, diverse, and robust workforce to advance science for the health of women •To improve evaluation of research that is relevant to the health of women

Transgender

•Transgender: people who experience a mismatch between their gender identity or gender expression and their assigned sex -An umbrella term that may include people whose gender identity is the opposite of their assigned sex •Trans men; trans women •May include people who are not exclusively masculine or feminine •Transsexual: term sometimes used when people desire medical assistance to transition from one sex to another Transgender celebs. Caitlyn Jenner and Laverne Cox are arguably the biggest names in the transgender community right now Caitlyn Jenner - the former Olympian and reality star made the official announcement of transitioning from Bruce to Caitlyn in 2015. Best known for her role as Sophia Burset on the hit Netflix show Orange is the New Black, Cox was the first transgender person to ever be nominated for a Primetime Emmy Award.

Adolescence Type 2 Diabetes (DM)

• Type 2 diabetes mellitus with rise in overweight •Further tests may be warranted if a BMI > 85th percentile with 2 or more risk factors: -Sign of insulin resistance: hypertension, lipids -Race & ethnicity with high incidence -Family history of Type 2 DM - •Puberty makes diabetes management & control harder • •Treatment approach: -Carbohydrate counting, increase physical activity, & possible weight loss •Increasing risk of Type 2 diabetes mellitus with rise in overweight during adolescence -10-fold increase in type 2 diabetes among adolescents in the 1990s •Further Clinical Testing may be warranted if a BMI > 85th percentile & 2 risk factors: -Sign of insulin resistance: hypertension, lipids -Race & ethnicity with high incidence -Family history of Type 2 DM •Physical & mental changes during puberty make diabetes management & control harder •Treatment approach: -Carbohydrate counting, increase physical activity, & possible weight loss