Nutrition and MenopauseFévrier 2012 Service de Nutrition – Institut Pasteur de Lille
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NUTRITION AND MENOPAUSE
Docteur Jean-Michel LECERF Service de Nutrition - Institut Pasteur de LilleService de Médecine Interne – CHRU de Lille
Nutrition and MenopauseFévrier 2012 Service de Nutrition – Institut Pasteur de Lille
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PHYSIOLOGICAL CHANGES WITH NUTRITIONAL IMPACT
Increase of bone loss
Reduction of lean mass
Resting energy expenditure
Change in adipose tissue distribution
Glucose tolerance
Changes in lipid metabolism
LDL TG HDL
No menstruation Decrease of iron requirements
Nutrition and MenopauseFévrier 2012 Service de Nutrition – Institut Pasteur de Lille
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PSYCHOLOGICAL AND DIETARY CONTEXT
Psychological frailty Depressive mood
- Familial disturbance
- Loss of feminity and/or women status
- Disturbance of bodily image Restrictive regimen
Dietary adjustement
Disturbance of dietary behavious
Weight gain Cognitive restriction
Nutrition and MenopauseFévrier 2012 Service de Nutrition – Institut Pasteur de Lille
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DISEASES WITH A NUTRITIONAL COMPONENT
Weight gain – Metabolic syndrome
Metabolic diseases : diabetes – dyslipidémia
Cardiovascular diseases (atherosclerosis)
Degenerative disease : breast and endometrial cancer – colon cancer
Osteoporosis
Age related macular degeneration and age related cognitive decline
Nutrition and MenopauseFévrier 2012 Service de Nutrition – Institut Pasteur de Lille
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FACTORS IMPLIED IN WEIGHT GAIN
LEAN MASS
PHYSICAL ACTIVITY
DIETARY INTAKE
HORMONAL FACTORS
GENETIC FACTORS
PSYCHOLOGICAL FACTORS
Physical activity expenditure
Resting energy expenditure Fat mass
Dietary intake in restreint subjects in case of stress
Adipose tissue distribution
Early obesity
Dietary adjustement for the mood
Nutrition and MenopauseFévrier 2012 Service de Nutrition – Institut Pasteur de Lille
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BODY SHAPES AND OVERWEIGHT
MORPHOTYPE UPPER BODY OVERWEIGHT LOWER BODY OVERWEIGHT
ADIPOSE TISSUE ABDOMINAL AND VISCERAL FEMORAL
METABOLIC RISK ++++ -
CARDIOVASCULAR +++
CANCER ++ +
OSTEOPOROSIS +
APPLE PEAROR
Nutrition and MenopauseFévrier 2012 Service de Nutrition – Institut Pasteur de Lille
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BODY CHANGES DURING PERIMENOPAUSAL PERIOD
543 WOMEN OF 42 – 52 YEARSFOLLOW UP DURING 6 YEARS7 MEASUREMENTS
/ year Total on 6 years
WEIGHT + 0,6 % (0,5 kg) + 3,4 % (+ 2,9 kg)
HEIGHT - 0,064 cm - 0,38 cm
BMI + 0,7 % + 4 % (+ 1,2 kg/m2)
Warst circumference + 1% + 6,2 % (+ 5,7 cm)
Fat mass + 1,6 % (+ 0,57 kg) + 10,1 % (+ 3,4 kg)
Lean mass – 0,18 % 1 1,08 % (- 0,23 kg)
Waist circumference increase is correlated to ovarian age
J. Clin Endocrinol Metab 2007, 92, 895-901
Nutrition and MenopauseFévrier 2012 Service de Nutrition – Institut Pasteur de Lille
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Nutrition and MenopauseFévrier 2012 Service de Nutrition – Institut Pasteur de Lille
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Int J Obes 2001, 25, 844-879
Nutrition and MenopauseFévrier 2012 Service de Nutrition – Institut Pasteur de Lille
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Int J Obes 2001, 25, 874-879
Nutrition and MenopauseFévrier 2012 Service de Nutrition – Institut Pasteur de Lille
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CHANGES IN ADIPOSE TISSUE DISTRIBUTION
MENOPAUSE ABDOMINAL ADIPOSE TISSUE
CARDIOVASCULAR RISK FACTORS
CORONARY HEART DISEASE RISKHormonal factorsNutritional factorsPhysical activitySocial stress
In primates- < menopause intra abdominal in dominates- > menopause intra abdominal in dominants
- Sub cutaneous- Perivisceral +++
Blood pressure Triglycerides HDL C Glycemia
Nutrition and MenopauseFévrier 2012 Service de Nutrition – Institut Pasteur de Lille
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ENERGY BALANCE
PHYSICAL ACTIVITY
THERMOGENESIS
RESTING ENERGY EXPENDITURE
ENERGY EXPENDITURE
ALCOHOL
FAT
CARBOHYDRATES
PROTEINS
+++
NOT IMPLIED
++
BENEFICIAL EFFECT
5 to 40%
10 –15%
65 to 70%
30 to 40%
15 to 20%
40 to 55%
FIBRES
Nutrition and MenopauseFévrier 2012 Service de Nutrition – Institut Pasteur de Lille
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ENERGY DENSITY
ENERGY / VOLUME
Chocolate 550 KcalCake 400 KcalSweetened bars 350 KcalBread 220 KcalVegetables 30 KcalFruits 50 Kcal
100 g
18 g25 g30 g40 g
300 g200 g
100 Kcal
Dietary intake controlSatiation
Nutrition and MenopauseFévrier 2012 Service de Nutrition – Institut Pasteur de Lille
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DIETARY RECOMMENDATIONS
Increase of physical activity
Lean mass
Energy expenditure
Reasonable decrease of energy intake carbohydrates and fats
Progressive changes of dietary habits
Daily protein intake
Dietary balance
Variety and regularity
To change the food relation and to have a positive behaviour
Nutrition and MenopauseFévrier 2012 Service de Nutrition – Institut Pasteur de Lille
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WEIGHT AND MENOPAUSE
ADIPOSE TIDDUE DISTRIBUTION
Change in lifestyle (dietary habits, physical activity)
Prevent WEIGHT GAIN
WAIST CIRCUMFERENCE INCREASE(Women’s Healthy Lifestyle Project)
Hormonal Replacement Treatment (HRT) increase visceral adipose tissue loss observed in case of weight loss
Nutrition and MenopauseFévrier 2012 Service de Nutrition – Institut Pasteur de Lille
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INTERVENTION
OBJECTIVE
- PREVENT MENOPAUSAL WEIGHT GAIN
- DECREASE WAIST CIRCUMFERENCE
METHODS
DECREASE SATURATED FATTY ACIDS AND CHOLESTEROL
EXERCICE
RESULTS
WEIGHT AND WAIST CIRCUMFERENCE DECREASE / COMPARISON GROUP
LESSER PROGRESSION OF ATHEROSCLEROSIS
WOMEN HEALTHY LIFESTYLE PROJECTCirculation 2001, 103, 32-37JACC 2004, 44, 579-85
Nutrition and MenopauseFévrier 2012 Service de Nutrition – Institut Pasteur de Lille
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PHYSICAL ACTIVITY AND ENERGY EXPENDITURE AFTER MENOPAUSE
POEHLMAN Energy expenditureDirectIndirect : lean mass
Dietary intakes Physical activity during the day
MURIO Fat oxydation (nocturnal and diurnal)
ENDURANCE PHYSICAL ACTIVITY
PHYSICAL ACTIVITY (walking 3 x / week)
+ MODERATE RESTRICTION
Muscular fat
Improve glycemic and lipid metabolic parameters
ENERGY BALANCE =
EQUILIBRIUM
– 8 % WEIGHT (RYAN)
Nutrition and MenopauseFévrier 2012 Service de Nutrition – Institut Pasteur de Lille
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SEVERE RESTRICTION INDUCE SARCOPENIA IN OBESE SUBJECTS
78 ♀ menopausal women50 – 70 yearsBMI 25 – 40 kg/m²Waist circumference > 88 cm- 400 Kcalories/EE
Regimen Regimen + mild physical activity
Regimen + intense physical
activity5 months Weight 11,5 kg
Fat mass 8,2 kgLean mass 3,6 kg
12 months If weight gain 2 kg
Fat mass gain + 26%Lean mass gain + 6%
- 1 kg fat = - 260g muscle
+ 1 kg fat = + 120g muscle AJCN 2011, 94, 767-74
Nutrition and MenopauseFévrier 2012 Service de Nutrition – Institut Pasteur de Lille
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HORMONAL MODIFICATIONS INDUCING WEIGHT GAIN AND HUNGER SENSATION ARE MAINTENED AT 62 WEEKS
50 OBESE SUBJECTSVERY LOW CALORIE DIET8 WEEKS
If weight loss > 10% (moy 13,5 kg)
Stabilisation 2 weeks
Follow-up 62 weeks
Weight gain 5,5 kg
Weeks Hunger Leptin PYY CCK INS Amyline Ghrelin GIP PP
1062
NEJM 2011, 365, 1597-604
Nutrition and MenopauseFévrier 2012 Service de Nutrition – Institut Pasteur de Lille
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VICIOUS CIRCLE OF COGNITIVE RESTRICTION
I don’t feel well
I want to do a regimen
I have to do a regimen
I STOP
Forbidden
foods
Frustration
Depression
Weight (re)gain
I eat more again
Guilt complex
Nutrition and MenopauseFévrier 2012 Service de Nutrition – Institut Pasteur de Lille
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UPPER BODY OBESITYRISK FACTORS
MENOPAUSETESTOSTERONE DEFICIENCY
HIGH GLUCOCORTICOIDS
SECRETION
SOCIAL STRESS
THRIFTY GENOTYPE LOW BIRTH WEIGHT
ALCOHOL SMOKING
INACTIVITY
DIETARY FACTORS (excess)
MICROBIOTA
PSYCHOTIC DISEASES NEUROLEPTIC DRUGS
Nutrition and MenopauseFévrier 2012 Service de Nutrition – Institut Pasteur de Lille
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METABOLIC SYNDROME
HIGH TRIGLYCERIDES
LOW HDL C
HIGH WAIST CIRCUMFERENCE
HIGH BLOOD PRESSURE
HIGH GLYCEMIA
LOW DENSITY LDLINSULINO RESISTANCE
LOW GRADE INFLAMMATIONPOST PRANDIAL HYPERLIPIDEMIA
OXYDATIVE STRESSHYPERINSULINEMIA
LDL OXYDATION
DIETARY FACTORS
YOYO SYNDROME
INACTIVITY
STRESS (GLUCOCORTICOIDS)
INTRA UTERINE RETARDATION
GENETIC FACTORS
OESTROGEN OR TESTOSTERONE
DEFICIENCY
MICROBIOTA
Nutrition and MenopauseFévrier 2012 Service de Nutrition – Institut Pasteur de Lille
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CARDIOVASCULAR PREVENTION
NUTRITION
ABDOMINAL
ADIPOSITYHTA DIABETES DYSLIPIDEMIA OXIDATIVE
STRESSSMOKING
INACTIVITY – STRESS – GENETIC – HORMONAL DEFICIENCY - AGE
Nutrition and MenopauseFévrier 2012 Service de Nutrition – Institut Pasteur de Lille
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WOMEN’S HEALTH INITIATIVE JAMA 2006, 295, 655-65648 835 W 62,3 years 2 groups – 8,1 years – BMI (mean) 29 kg/m²
PREVENTION GENERAL POPULATION
INTERVENTION CONTROLOBJECTIVE INITIAL REAL
Fat 20 % 37,8 % 28,8 % 37,8SFA 12,7 % 9,5 % 12,7TFA 2,8 % 1,6 % 2,8
PUFA 7,8 % 6,1 % 7,8MUFA 14,4 % 10,8 % 14,4
+ 5 fruits and vegetables/day6 grains /day
RESULTSINTERVENTION CONTROL HRCHD 0,63 % 0,65 % 0,97
Stroke 0,28 % 0,27 % 1,02CVD 0,86 % 0,88 % 0,98
MAJOR EVENTS RISK in women with previous cardiovascular disease (3,4 %) +26%
Nutrition and MenopauseFévrier 2012 Service de Nutrition – Institut Pasteur de Lille
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WEIGHT CHANGE IN W H I
Nutrition and MenopauseFévrier 2012 Service de Nutrition – Institut Pasteur de Lille
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CARDIOVASCULAR PREVENTIONReduction Saturated fats : butter, meat, cheese, processed meat and
trans (fatty acids in pastry, hard margarines, cakes, biscuits…)
Increase of polyunsaturated fatty acids
Rapeseed or walnut oils
Fatty fish
5 fruits and vegetables/day, half a plate
Fibers (bread and wholegrains - leguminous)
Decrease salt
Abdominal weight loss
Low glycemic index carbohydrates
Particularly omega 3
Nutrition and MenopauseFévrier 2012 Service de Nutrition – Institut Pasteur de Lille
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NUTRITIONAL ADVICES
FOR METABOLIC SYNDROME MANAGEMENT
WEIGHT LOSS (MODERATE) (5%)
INCREASE PHYSICAL ACTIVITY
DECREASE ENERGY INTAKE
DECREASE CARBOHYDRATES > FATS (CHO 40-45% et F 35-40%)
FATTY ACIDS CHOICE - SFA 12% - Dairy fat +
- 6 not too much
- 3 ++ (ALA – EPA – DHA)
CARBOHYDRATE QUALITY : LOW GLYCEMIC – FEW FRUCTOSE
GLOBAL NUTRITION +++ (F & V…) MEDITERRANEAN DIET
Nutrition and MenopauseFévrier 2012 Service de Nutrition – Institut Pasteur de Lille
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73 743 women 50 – 79 yearsW.H.I. Study5,9 years (follow-up)
VIGOROUS WALK IS ASSOCIATED WITH A LOWER CARDIOVASCULAR RISK EVEN FOR A SHORT DURATION
NEJM 2002, 347, 716-25
Nutrition and MenopauseFévrier 2012 Service de Nutrition – Institut Pasteur de Lille
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CARBOHYDRATES FOODS
FRUCTOSE HIGH GLYCEMIC INDEX FOODS OR PURIFIED CARBOHYDRATES
LOW GLYCEMIC INDEX FOODS AND HIGH NUTRITIONAL DENSITY FOODS
RICH IN FIBERS
SWEETENED DRINKS
White breadPotatoes
Lentils LeguminousFruits
Whole breadWhole grainOats
FAT AND SWEETENED FOODSCakesLOW NUTRITIONAL DENSITY FOODSSweets
AVOID MODERATE FAVOUR FAVOUR
Nutrition and MenopauseFévrier 2012 Service de Nutrition – Institut Pasteur de Lille
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SALT
ADDED NOT VISIBLE
COOKINGLow salt (at the beginning of cooking)
ON THE TABLEAvoid
BreadCheeseProcessed meatCanned foodsSoupsReady cooked dishes
POTASSIUMFruits
Vegetables
Nutrition and MenopauseFévrier 2012 Service de Nutrition – Institut Pasteur de Lille
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Nutrition and MenopauseFévrier 2012 Service de Nutrition – Institut Pasteur de Lille
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OSTEOPOROSIS – MECHANISMS WITH AGE
Bone mass peak
MAX 20 – 30 years = higher bone mass
Bone mass loss after 30-35 years
- 0,2 à 1,3% /year
- 2 à 3% /year > menopause
Between 30 and 80 years
- 50% trabecular mass pool
- 30% bone mass pool
GeneticCalciumVit DPhysical activity
OsteoformationStable Resorption
Cellular ageingOestrogens resorption
Decrease of cutaneous vit D synthesisLow intake of Vit D
and calcium
PTH
Bone resorption
Nutrition and MenopauseFévrier 2012 Service de Nutrition – Institut Pasteur de Lille
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SUN SHINE
VITAMINES D and K
PHYSICAL ACTIVITY AND GRAVITY
ALCALINIC FOODS
TEA
PROTEINS
VITAMINE AEXCESS OF
SALT
EXCESS OF ANIMAL
PROTEINS
CALCIUM
LOW BMI
SMOKING
STRESS
CORTISOL
ACIDIFIC FOODS
OSTEOPOROSIS
COFFEE
CALCIURIA
SILICE
VITAMINE C
SOFT DRINKS (SODAS)
Nutrition and MenopauseFévrier 2012 Service de Nutrition – Institut Pasteur de Lille
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IS THERE A BONE BENEFIT OVERWEIGHT AFTER MENOPAUSE ?
PERIPHERAL ADIPOSE TISSUE
4A OESTRONE BMD
LESS PREVALENCE OF OSTEOPOROSIS FOR A BMI 25-28/LOWER BMI
AROMATASE
OSTEOPOROSIS
HIGH BMI HIGH
CALCIUM INTAKES
MUSCULAR STRENGHT
Low mineral bone density at menopause Mortality
= low oestrogenic impregnation ?
BUT FAT MASS PLAYS A LESSER ROLE THAN
MENOPAUSE
Nutrition and MenopauseFévrier 2012 Service de Nutrition – Institut Pasteur de Lille
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WEIGHT LOSS IN PREMENOPAUSAL WOMEN HAS A FAVORABLE IMPACT ON CARDIOVASCULAR RISK BUT NOT
ON BONE MASS
WOMEN’S HEALTHY LIFESTYLE PROJECT373 ♀ 44 – 50 years2 groups - Control
- 1 with dietary changes + physical activity and weight lossControl Intervention
WeightBone mass
2,6 kg- 0,03 % / year
- 0,4 kg p < 0,01
- 0,20 % / year p < 0,01
NS after intervention (54 78 months)
J Clin Endocrinol Metab 2007, 92, 3809 - 3815
If HRTWEIGHT LOSS + 3%WEIGHT GAIN
Bone mass 0,25 % / an 0,02 % / an
54 months
Nutrition and MenopauseFévrier 2012 Service de Nutrition – Institut Pasteur de Lille
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PREVENTION OSTEOPOROSIS
(2) – 3 dairy products (1 cheese)
Vitamin D (sun – fatty fish)
Sufficient protein intake = one source of animal proteins
Acide – base balance : fruits and vegetables
Phytoestrogens - Lignans (cereals)
- Soy isoflavones very early in youth
Decrerase urinary calcium loss (less salt)
Maintain moderate fat mass (BMI 25-28)
Nutrition and MenopauseFévrier 2012 Service de Nutrition – Institut Pasteur de Lille
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PREVENTION OF AGE RELATED MACULAR DEGENERATION
LUTEINZEAXANTHIN CAROTENOIDS INCREASE MACULAR
PIGMENTCABBAGELETTUCESPINACH
TURN OVER OF PHOTORECEPTOR DISKS
AGAINST OXIDATIVE STRESS
POISSONS GRAS
VEGETABLES, FRUITS, FISH, VEGETABLE OILS
EPADHA LONG CHAIN OMEGA 3 PUFA
ANTIOXIDANTS Vitamins E, CSelenium, zinc
Nutrition and MenopauseFévrier 2012 Service de Nutrition – Institut Pasteur de Lille
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LIPIDSTRANS FA SATURATED
FAMONO
UNSATURATED FAPOLYUNSATURATED FA
OMEGA 6 OMEGA 3
Hard margarinesPastryBiscuitsCakes
ButterCheeseMeatProcessed meat
OliveRapeseedPeanutPorkPoultry
LINOLEIC ACIDSun flowerCornSoyPork Poultry
linolenic acidrapeseedwalnutsoybeanlinseedrabbitspinach pursle
EPAFish
DHAAvoid Moderate Moderate Moderate Favour
Nutrition and MenopauseFévrier 2012 Service de Nutrition – Institut Pasteur de Lille
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OXIDATIVE STRESS
Iron
Mercury
UV – excess of sunshine
Tobacco
Excess of exercice
Grilled foods (Maillard reaction)
PRODUCTION OF FREE
RADICALS
Vitamin C
Vitamin E 8 isomers
Betacarotene
Carotenoids (600)
Polyphenols (4000)
Ferulic acid
FruitsVegetablesNutsCocoaTeaWineVirgin olive oilGrainsSoySpices
ANTIOXIDANT NUTRIENTS AND PHYTOCHEMICALS
in excess
Nutrition and MenopauseFévrier 2012 Service de Nutrition – Institut Pasteur de Lille
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CANCER PREVENTIONIron
(moderate)Calcium
(sufficient)Physical activity
Weight Fat Fiber Alcohol
Omega 3
LUNG
COLORECTAL ENDOMETRIAL BREAST
ANTIOXIDANTS – POLYPHENOLS - CAROTENOIDS
FRUITS AND VEGETABLES
SMOKING
Nutrition and MenopauseFévrier 2012 Service de Nutrition – Institut Pasteur de Lille
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PHYSICAL ACTIVITY
Energy expenditure for physical activity
Lean mass
Osteoporosis prevention
Total energy expenditure
Immune defenses
Cardiovascular and metabolic risk
factorsWeight control More
micronutrients
Nutrition and MenopauseFévrier 2012 Service de Nutrition – Institut Pasteur de Lille
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BASIC PRINCIPLES OF PREVENTION NUTRITION
- WEIGHT GAINENERGY BALANCE FATS AND CARBOHYDRATE
- HYPERLIPIDEMIA
- GLUCOSE TOLERANCE
- OXIDATIVE STRESS
- HOMOCYSTEINEMIA
- PLATELET AGREGATION INFLAMMATION ARRYTHMIA
- HYPERTENSION
AVOID EXCESS OF SATURATED AND TRANS FATTY ACIDS
CHOICE OF CARBOHYDRATES HIGH IN FIBERS AND LOW GLYCEMIC INDEX
FAVOUR ANTIOXIDANT FOODS
VITAMIN B9
OMEGA 3 FATTY ACIDSOMEGA 6 / OMEGA 3 RATIO
REDUCE SALTAVOID ALCOHOL
Nutrition and MenopauseFévrier 2012 Service de Nutrition – Institut Pasteur de Lille
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IN PRACTICE EMPTIED CALORIES
PORTION SIZE
HELP AGAIN TO A DISH
COOKING
FAT USE
BETWEEN THE MEALS
ALCOHOL
SOFT DRINKS ++
FOOD CHOICE
Nutrition and MenopauseFévrier 2012 Service de Nutrition – Institut Pasteur de Lille
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DIETARY BEHAVIOURS
COOKING HERSELF
TIME SPENT FOR THE MEALS + WITHOUT WATCHING TV
EAT WITH PLEASURE
MANAGE THE EXCESS INTO THE REGIMENS
LISTEN THE BODY AND THE SENSES – SATIATION + HUNGER
CHANGE THE TASTE FOR SOME FOODS