Nutrition and Musculoskeletal Health

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1 Nutrition and Musculoskeletal Health Helen Macdonald Musculoskeletal Programme, Health Sciences Building

2 Nutrition and Bone Health Calcium Vitamin D Other minerals and protein Fruit and vegetables Other vitamins and fatty acids

3 National Osteoporosis Society

4 Nutrition and Balance Nerve and muscle function Calcium Vitamin D Protein Other minerals and vitamins Fatty acids Cofactors for energy metabolism and muscle function

5 Calcium

6 Calcium 99% body s calcium is in our bones Since wartime bread has been fortified with calcium School milk /71 The School Milk Act gave one-third of a pint of free milk daily to every pupil under 18 years. Meta-analyses calcium and vitamin D show that fracture prevention is driven by the calcium

7 UK Calcium Recommendations Healthy Adults 700 mg a day More may be required for osteoporosis sufferers 1200 mg a day England 1000 mg a day Scotland

8 SIGN 71 (2003) An average daily intake of 1000 mg of calcium can most easily be obtained from 600 ml (1 pint) of milk with either 50 g (2 oz) hard cheese (eg Cheddar or Edam), one pot of yoghurt, or 50 g (2 oz) sardines. Scottish Intercollegiate Guidelines Network (SIGN). Management of osteoporosis. Edinburgh: SIGN; (SIGN publication no. 71). [February 2012]. Available from URL:

9 What about calcium supplements? Important if not getting enough in the diet Concerns Calciuria Kidney stones Other side effects? Calcium pills 'increase heart attack risk'

10 Statement from the American Society of Bone and Mineral Research August 12, 2010 There are numerous large studies of calcium plus vitamin D that have shown no increased risk of cardiovascular events. Persons currently taking calcium supplements should not necessarily discontinue their use. Rather, they should discuss the decision to use these agents with their health provider, and understand that food remains the best source of calcium. Supplements should be used only when adequate dietary intake of calcium cannot be achieved. The beneficial effects of calcium are found with relatively low doses. More is not necessarily better. Individuals should discuss the amount of their calcium intake with their health provider. In almost every modern study of osteoporosis treatment, adequate calcium and vitamin D were required for medications to have anti-fracture efficacy. Elderly individuals and others with impaired renal (kidney) function who take calcium supplements may be at higher risk of cardiovascular problems.

11 Other minerals and other nutrients

12 Beneficial nutrients from fruit and vegetables Anti-oxidants vitamin C (watch supplements - too high can act as a pro-oxidant), folate, flavonoids Vitamins Vitamin C Vitamin K Folate (B vitamin) Minerals Calcium, magnesium, iron, manganese boron, silicon Other nutrients Flavonoids, Phytoestrogens

13 Whole grain foods, fish/ lean meat Provide key B vitamins (B6, B12) Minerals zinc, magnesium, iron, manganese, silicon, boron Protein

14 Detrimental nutrients Vitamin A (as preformed retinol) Important for bone growth Associated with increased fracture risk Advice is to limit intake of liver/ products (pate) to once a week or smaller portions and avoid supplements containing vitamin A. Salt Caffeine Excess protein Increase urinary calcium Excess alcohol moderate amounts are beneficial Fat Dietary pattern

15 Healthy diet as we get older Think nutrient dense not energy dense Still need to eat enough. If less mobile, less hungry Cereal and banana/ or dried fruit Soups containing vegetables Wholemeal rather than white Fish and lean meat Some people prefer main meal in the middle of the day Milky drinks at bedtime

16 Importance of dairy for calcium Milk and dairy naturally good source of calcium well absorbed Soya milk has to have calcium added not there naturally, but well absorbed Oily fish with bones Pulses not very much calcium and not very well absorbed Green vegetables some types (broccoli) do not contain much calcium but Ca is well absorbed also provides other nutrients Rhubarb and spinach may contain lots of calcium but NOT a good source as very little absorbed tightly bound by oxalates Information from Weaver C et al AJCN 1994, 1999

17 Falls and vitamin D

18 Observational data shows that low vitamin D status is associated with poorer muscle function Bischoff Ferrari Am J Clin Nutr m walk Sit to stand

19 Randomized Controlled Trial data Pfeiffer et al (JBMR 2000) compared Ca only (1200 mg) with Ca & vit D (800 IU) 8 weeks Vitamin D decreased body sway No difference in falls Dhesi et al (age ageing 2004) compared single vitamin D2 injection (600,000 IU) with placebo Improvement in reaction time and balance Not muscle function

20 Short-Term Oral Nutritional Intervention with Protein and Vitamin D Decreases Falls in Malnourished Older Adults 73 vit D 74 control Falls assessment Neelemaat JAGS 2012

21 Too much vitamin D may be detrimental? Sanders et al JAMA 2010

22 Vitamin D where do we get it from?

23 Vitamin D LIVER Sunlight source or dietary source of vitamin D Converted to 25-hydroxyvitamin D KIDNEY Converted to 1,25-dihydroxyvitamin D Estimate 80-90% from sunlight

24 Joint Statement Cancer Research UK, British Association of Dermatologists and the National Osteoporosis Society Recognise that sunlight is important for vitamin D synthesis but it is important not to burn Suggest 10 minutes once or twice a day in the summer Criticism about giving minutes but need to give ball-park figure

25 Websites for exposure times

26 Vitamin D and diet

27 Foods containing vitamin D Food Oily fish: mackerel Vitamin D μg/100g 8.2 Tuna 3.6 Salmon Eggs 1.8 Egg yolks 4.9 Milk 5.9 Atlantic 12.5 Pacific Tr-0.1 Butter 0.9 Fortified Food Hard Margarine 7.9 Vitamin D μg/100g Soft margarine Breakfast cereals All bran, cornflakes, frosties, museli, fruit & fibre Bran flakes Shreddies Ricicles Special K 10 ug=400iu McCance and Widdowson s v (1.3)

28 UK dietary guidelines Children: 0-6 mo: 8.5 ug/d, 6 mo- 3 y: 7 ug/d Older children & adults: no RNI except those of risk of deficiency and over 65y: 10 ug Threshold for deficiency 25(OH)D< 25 nmol/l

29 Dietary intakes UK population has limited dietary vitamin D intakes Survey data 3μg/d (120 IU) The mean daily vitamin D intake of older women was 3.5μg (140 IU) and addition of supplements increased this by 46% to 5.1μg (200 IU) Study data - low intakes 2.5 μg (100 IU) Increased with supplements (cod liver oil 5 μg) Over 65 y: diet does not reach the vitamin D RNI of 400 IU for most people so supplements may be required.

30 25(OH)D nmol/l 25(OH)D nmol/l Aberdeen: holidays abroad and cod liver oil associated with improved vit D status 25(OH)D holiday vs no holiday goers CLO users vs non-clo users ALL 25(OH)D no hols 25(0H)D hols 25(OH)D ALL 25(OH)D Non CLO CLO Spring 06 Summer 06 Autumn 06 Winter 06/07 Spring 07 Spring Spring 06 Summer 06 Autumn 06 Winter 06/07 Spring 07 Spring 08 visits visits Mavroeidi, Macdonald et al i. Small amounts make a difference ii. Consistency between measurements at the nadir

31 Conclusions Balanced diet for bone, nerve and muscle function Diet best source for most nutrients Vitamin D sunlight Supplements may be required Vitamin D recommend >65y 400 IU a day Calcium if not getting enough and have with food Vitamin D evidence may be confounded But those at risk of falling are likely to have low vitamin D status High dose appears inappropriate Mechanism unclear Possible that more active means fall more?