Dietary Consideration in Podiatric Practice Midwest Podiatry Meeting

Dietary Consideration in Podiatric Practice Midwest Podiatry Meeting, 2017 Maggie Fournier, DPM mfournie@gundersenhealth. org Gundersen Lutheran Medical Center, Inc. | Gundersen Clinic, Ltd.

Dietary Consideration & Bone Health 1. Vitamin D and Calcium 2. Relative Energy Deficiency (FAT) Gundersen Lutheran Medical Center, Inc. | Gundersen Clinic, Ltd.

Overview • Review mechanism of action of Vitamin D and its effect on bone health • Review Calcium and Vitamin D metabolism, deficiency, treatment and current recommendation • Discuss updated definition of Female Athlete Triad and its impact on bone health • Identify Relative Energy Deficiency syndrome in female athlete • Application to podiatry practice Gundersen Lutheran Medical Center, Inc. | Gundersen Clinic, Ltd.

Bone Health & Vitamin D Gundersen Lutheran Medical Center, Inc. | Gundersen Clinic, Ltd.

Bone Mineral Density & Vitamin D The other side of fractures… Gundersen Lutheran Medical Center, Inc. | Gundersen Clinic, Ltd.

Vitamin D: essential Facst • • • Hormone-like Synthesized from sunlight Normal Vitamin D levels= Bone mineralization Receptors found in other organs Food not adequate source Gundersen Lutheran Medical Center, Inc. | Gundersen Clinic, Ltd.

Vitamin D Metabolism Gundersen Lutheran Medical Center, Inc. | Gundersen Clinic, Ltd.

Vitamin D and Bone Health Why does it matter? • 32 -50% general population has insufficient level of Vitamin D • 60 -80% of patient with F&A fracture are deficient • Correlation of Vitamin D levels and fracture healing Gundersen Lutheran Medical Center, Inc. | Gundersen Clinic, Ltd.

Sources • Sunlight (main source) • Food Sources (minimal) – Salmon/Fatty fish – Vitamin D fortified food (milk) – Egg yolks – Mushrooms Gundersen Lutheran Medical Center, Inc. | Gundersen Clinic, Ltd.

Vitamin D Levels ng/m. L Deficient: 0 -30 ng/m. L Deficient 0 -30 Insufficient: 31 -39 ng/m. L Insufficient 31 -39 Sufficient: 40 -80 ng/m. L Sufficient Toxic: >15040 -80 ng/m. L Toxic Gundersen Lutheran Medical Center, Inc. | Gundersen Clinic, Ltd. >150

Vitamin D and Bone Health • Terminology: – Vitamin D: Calciferol (either D 2 or D 3) – Vitamin D 2 : Ergocalciferol – Vitamin D 3 : Cholecalciferol (active form) • RDA: – 600 IU daily Gundersen Lutheran Medical Center, Inc. | Gundersen Clinic, Ltd.

Hypovitaminosis D • • • Do I check levels? How do we treat? Is Endocrinology referral necessary? Gundersen Lutheran Medical Center, Inc. | Gundersen Clinic, Ltd.

Hypovitaminosis D • • No study to support testing Vitamin D levels No protocol to date on how to treat Recommendation varies Calcium availability is also necessary Gundersen Lutheran Medical Center, Inc. | Gundersen Clinic, Ltd.

Accepted Supplementation Protocols • If know deficiency: – 50, 000 IU weekly x 8 weeks • If unknown deficiency: – 4000 IU daily X 8 weeks • Daily maintenance: – 2000 -4000 IU daily • Toxic levels: – > 10, 000 IU daily Gundersen Lutheran Medical Center, Inc. | Gundersen Clinic, Ltd.

Vitamin D preparation • • IM/oral preparation 400, 800, 1000, 2000, 5000, 10 000, 50 000 4000 daily is safe (up to 10 000) If deficient: 50 000 weekly x 8 weeks, then 2000 thereafter Gundersen Lutheran Medical Center, Inc. | Gundersen Clinic, Ltd.

Take Home Points • • Treat all aspect of a fracture Refer as necessary Recommend Vit D and Ca++ supplements Unless proven otherwise: consider your patient Vit D deficient Gundersen Lutheran Medical Center, Inc. | Gundersen Clinic, Ltd.

Women, Nutrition and Bone Health Gundersen Lutheran Medical Center, Inc. | Gundersen Clinic, Ltd.

Nutrition and Bone Health • Energy Deficiency, especially in the context of sports correlates with increased risks of stress fracture • Homeostasis requires a delicate balance • Correlation between sports, energy deficiency and bone health Gundersen Lutheran Medical Center, Inc. | Gundersen Clinic, Ltd.

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Women, Nutrition and Bone Health Timeline: • 1960: Early research on late menarche seen in undernourished girls • 1992: Female Athlete Triad terminology is coined • 2007: ACSM revised definition of FAT • 2014: New terminology is suggested: Relative Energy Deficiency Gundersen Lutheran Medical Center, Inc. | Gundersen Clinic, Ltd.

Female Athlete Triad -1992 ACSM Definition: – Amenorrhea – Anorexia Nervosa – Osteoporosis *** outdated *** Gundersen Lutheran Medical Center, Inc. | Gundersen Clinic, Ltd.

Female Athlete Triad -2007 Relationship between three interrelated components of energy availability, menstrual function and bone health Gundersen Lutheran Medical Center, Inc. | Gundersen Clinic, Ltd.

Female Athlete Triad -2007 ACSM Definition: 1992 Anorexia → Amenorrhea → Osteoporosis → Gundersen Lutheran Medical Center, Inc. | Gundersen Clinic, Ltd. 2007 Energy Availability Menstrual Function Bone Health

New terminology -2014 Relative Energy Deficiency in Sport (RED-S) Gundersen Lutheran Medical Center, Inc. | Gundersen Clinic, Ltd.

Spectrum of RED Gundersen Lutheran Medical Center, Inc. | Gundersen Clinic, Ltd.

Terminology • 1992 Definition (ACSM): “the combination of disordered eating and irregular menstrual cycles eventually leading to a decrease in endogenous estrogen and other hormones resulting in low bone mineral density”. • 2014 Definition (IOC): “syndrome of RED-S refers to impaired physiological function including, but not limited to, metabolic rate, menstrual function, bone health, immunity, protein synthesis, cardiovascular health caused by relative energy deficiency. ” Gundersen Lutheran Medical Center, Inc. | Gundersen Clinic, Ltd.

Energy Availability • Cornerstone of RED/FAT • Defined as: E intake- E expenditure ≥ 30 kcal/kg Lean mass Gundersen Lutheran Medical Center, Inc. | Gundersen Clinic, Ltd.

Epidemiology • Up to 78% of HS female athlete • Male athlete unknown incidence • ♀ running, ballet, gymnastics • ♂ cycling, wrestling, jockeying Gundersen Lutheran Medical Center, Inc. | Gundersen Clinic, Ltd.

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Effects on Bone Mass • Paucity in research • Potentially irreversible • Currently: there are no treatment protocol for osteoporosis/osteopenia in pre-menopausal women • Treatment is symptomatic • Vitamin D and Calcium supplements Gundersen Lutheran Medical Center, Inc. | Gundersen Clinic, Ltd.

What to do if I suspect FAT/RED? • Endocrinology referral? • Bone densitometry? • Referral to PCP/Sports physician Gundersen Lutheran Medical Center, Inc. | Gundersen Clinic, Ltd.

RED/FAT Summary • New terminology inclusive of all gender, describing a broader spectrum • All 3 components of triad no longer needed for diagnosis • Effect on bone loss can be irreversible • Can be underlying cause of a stress fracture • Early intervention and recognition are essential Gundersen Lutheran Medical Center, Inc. | Gundersen Clinic, Ltd.

Treatment recommendation for stress fractures with underlying ED • • • Bisphonates ? Birth Control Pill? Estrogen replacement? Ca++: 1500 mg/daily (up from 800 mg) Vitamin D: 2000 IU/daily (up from 600 IU) Gundersen Lutheran Medical Center, Inc. | Gundersen Clinic, Ltd.

Thank You Gundersen Lutheran Medical Center, Inc. | Gundersen Clinic, Ltd.