1. Dietary Consideration in Podiatric Practice
Midwest Podiatry Meeting, 2017
Maggie Fournier, DPM

2. Dietary Consideration & Bone Health
Vitamin D and Calcium
Relative Energy Deficiency (FAT)

3. 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

4. Bone Health & Vitamin D

5. Bone Mineral Density & Vitamin D
The other side of fractures…

6. Vitamin D: essential Facst
Hormone-like
Synthesized from sunlight
Normal Vitamin D levels= Bone mineralization
Receptors found in other organs
Food not adequate source

7. Vitamin D Metabolism

8. 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

9. Sources Sunlight (main source) Food Sources (minimal)
Salmon/Fatty fish
Vitamin D fortified food (milk)
Egg yolks
Mushrooms

10. Vitamin D Level Deficient: 0-30ng/mL Insufficient: 31-39 ng/mL
Toxic: >150 ng/mL
Vitamin D Levels
ng/mL
Deficient
0-30
Insufficient
31-39
Sufficient
40-80
Toxic
>150

11. Vitamin D and Bone Health
Terminology:
Vitamin D: Calciferol (either D2 or D3)
Vitamin D2 :Ergocalciferol
Vitamin D3 :Cholecalciferol (active form)
RDA:
600 IU daily

12. Hypovitaminosis D Do I check levels? How do we treat? Is Endocrinology
referral necessary?

13. 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

14. Accepted Supplementation Protocols
If know deficiency:
50,000 IU weekly x 8weeks
If unknown deficiency:
4000 IU daily X 8 weeks
Daily maintenance:
IU daily
Toxic levels:
> 10,000 IU daily

15. Vitamin D preparation IM/oral preparation
400, 800, 1000, 2000, 5000, ,
4000 daily is safe (up to )
If deficient: weekly x 8 weeks, then 2000 thereafter

16. 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

17. Women, Nutrition and Bone Health

18. 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

20. 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

21. Female Athlete Triad -1992 ACSM Definition: Amenorrhea
Anorexia Nervosa
Osteoporosis
*** outdated ***

22. Female Athlete Triad -2007
Relationship between three interrelated components of energy availability, menstrual function and bone health

23. Female Athlete Triad -2007 ACSM Definition: 1992 2007
Anorexia → Energy Availability
Amenorrhea → Menstrual Function
Osteoporosis → Bone Health

24. Relative Energy Deficiency in Sport (RED-S)
New terminology -2014
Relative Energy Deficiency in Sport (RED-S)

25. Spectrum of RED

26. Terminology 1992 Definition (ACSM): 2014 Definition (IOC):
“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.”

27. E intake- E expenditure ≥ 30kcal/kg
Energy Availability
Cornerstone of RED/FAT
Defined as:
E intake- E expenditure ≥ 30kcal/kg
Lean mass

28. Epidemiology ♀ running, ballet, gymnastics
Up to 78% of HS female athlete
Male athlete unknown incidence
♀ running, ballet, gymnastics
♂ cycling, wrestling, jockeying

30. 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

31. What to do if I suspect FAT/RED?
Endocrinology referral?
Bone densitometry?
Referral to PCP/Sports physician

32. 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

33. Treatment recommendation for stress fractures with underlying ED
Bisphosphonates ?
Birth Control Pill?
Estrogen replacement?
Ca++: 1500mg/daily (up from 800mg)
Vitamin D: 2000 IU/daily (up from 600 IU)

34. Thank You