Maryam S. Makowski, Ph.D., FACN, NBC-HWC is a clinical assistant professor in the Stanford University Department of Psychiatry and Behavioral Sciences, the Associate Director of Scholarship and Health Promotion of the Stanford Medicine WellMD & WellPhD, and a nutrition and physician well-being coach at Stanford University. Dr. Makowski is a member of the WellConnect Program, Lifestyle Psychiatry Clinic, Metabolic Psychiatry Clinic, and Measurement-Based Care (CHOIR) team in the Department of Psychiatry and Behavioral Sciences. She is a member of the Well-being Advisory Committee and a Stanford School of Medicine alternate faculty senate of the Department of Psychiatry and Behavioral Sciences. Dr. Makowski has particular expertise in nutrition and physician well-being. She has been leading many initiatives to promote physician well-being at Stanford via personal and organizational strategies for over 6 years.
Dr. Makowski completed her master's and doctoral studies in clinical nutrition, nutritional epidemiology, and medical science at the University of Toronto in Canada. Prior to joining Stanford, she served as a scientific associate at Toronto General Hospital-University Health Network in Toronto, and as an advisor to Air Canada rouge pilots and cabin crew on optimal nutrition for fatigue mitigation. Over the course of her career, she has authored many highly cited scientific papers on nutrition and well-being.
She is a National Board-Certified Health and Wellness Coach, a Fellow of the American College of Nutrition, a professional member of the Academy of Nutrition and Dietetics, American and Canadian Nutrition Societies, American Nutrition Association, and The Institute of Coaching at McLean (a Harvard Medical School Affiliate).
Clinical Assistant Professor, Psychiatry and Behavioral Sciences
Associate Director of Scholarship and Health Promotion, Stanford Medicine WellMD & WellPhD (2016 - Present)
Boards, Advisory Committees, Professional Organizations
Department of Psychiatry and Behavioral Sciences- Alternate Senator, School of Medicine Faculty Senate (2021 - Present)
Member, National Board for Health and Wellness Coaching (2021 - Present)
Member, Department of Psychiatry and Behavioral Sciences Well-Being Advisory Committee Member (2020 - Present)
Member, Institute of Coaching (2020 - Present)
Fellow, American Nutrition Association (2019 - Present)
Member, Academy of Nutrition and Dietetics (2019 - Present)
Member, American Society for Nutrition (2008 - Present)
Member, Canadian Nutrition Society (2002 - Present)
NBC-HWC, National Board for Health and Wellness Coaching, Health and Wellness Coaching (2021)
Certification, Wellcoaches School of Coaching, Certified Health and Wellness Coach (2020)
Certification, American College of Lifestyle Medicine, Lifestyle Medicine Certified Health Coach (2020)
PhD, University of Toronto, Institute of Medical Science, Nutritional Epidemiology (2012)
MSc, University of Toronto, Department of Nutritional Sciences, Clinical Nutrition (2002)
Assessment, Testing and Measurement
Brain and Learning Sciences
Leadership and Organization
Performance Nutrition for Residents and Fellows
Currently, residents commonly experience dehydration and poor nutrition during nighttime duty hours as a result of heavy work load, lack of time to take nutrition and hydration breaks, or limited or no access to healthy food and drinks which may affect residents' work performance. The goal of this study is to compare the effects of two different meal compositions with no typical dietary practices (existing conditions) on work performance of the on-call residents during night shifts.
Stanford is currently not accepting patients for this trial.
Performance Nutrition for Physician Trainees Working Overnight Shifts: A Randomized Controlled Trial.
Academic medicine : journal of the Association of American Medical Colleges
PURPOSE: To compare acute effects of 2 dietary interventions with usual dietary habits on physician trainees' alertness during overnight shifts.METHOD: This registered, controlled, block-randomized crossover trial (NCT03698123) was conducted between October 2018 and May 2019 at Stanford Medicine. Physician trainees working at least 3 overnight shifts during a 1-week period were recruited. During the first overnight shift, participants followed their usual dietary habits. During the intervention nights (low carbohydrate-to-protein ratio and high carbohydrate-to-protein ratio interventions), participants received healthy dinners, snacks, water, and, upon request, caffeinated beverages, at the beginning of their shifts and were instructed to eat meals before 10 p.m. The sequence of interventions on the second and third nights were block-randomized across study weeks. Outcome measures (a priori) were overnight changes in validated measures of specific neurobehavioral dimensions: psychomotor vigilance, sensory-motor speed, working memory, and risk decision-making, as well as self-reported sleepiness and work exhaustion.RESULTS: Sixty-one physician trainees participated in this study. Compared to usual dietary habits, overnight changes in psychomotor vigilance scores (scale 0-1,000) improved by 51.02 points (95% confidence interval [CI]: 12.08, 89.96); sleepiness (scale 1-7) improved by 0.69 points (95% CI: 0.33, 1.05) under the low carbohydrate-to-protein ratio intervention. Compared to usual dietary habits, overnight changes in sleepiness (scale 1-7) improved by 0.61 points (95% CI: 0.25, 0.96) under the high carbohydrate-to-protein ratio intervention. Neither intervention had beneficial effects relative to usual dietary habits with respect to sensory-motor speed, working memory, risk decision-making, or work exhaustion. There were no differences in outcomes between low carbohydrate-to-protein ratio and high carbohydrate-to-protein ratio interventions.CONCLUSIONS: Dietary interventions may mitigate negative effects of physician trainee sleep deprivation during overnight shifts. Future studies are warranted to further examine the effectiveness of nutritional strategies on physician alertness during overnight shifts.
View details for DOI 10.1097/ACM.0000000000004509
View details for PubMedID 34753859
Physician Task Load and the Risk of Burnout Among US Physicians in a National Survey.
Joint Commission journal on quality and patient safety
2021; 47 (2): 76–85
Cognitive task load can affect providers' ability to perform their job well and may contribute to burnout.The researchers evaluated whether task load, measured by the National Aeronautics and Space Administration (NASA) Task Load Index (TLX), correlated with burnout scores in a large national study of US physicians between October 2017 and March 2018 with a 17.1% response rate. Burnout was measured using the Emotional Exhaustion and Depersonalization scales of the Maslach Burnout Inventory, and a high score on either score was considered a manifestation of professional burnout. The NASA-TLX was chosen to evaluate physician task load (PTL) due to its robust validation and use across many industries, including health care, over the past 30 years. The domains included in the PTL were mental, physical, and temporal demands, and perception of effort.Mean score in task load dimension varied by specialty. In aggregate, high emotional exhaustion, depersonalization, and one symptom of burnout was seen in 38.8%, 27.4%, and 44.0% of participants, respectively. The mean PTL score was 260.9/400 (standard deviation = 71.4). The specialties with the highest PTL score were emergency medicine, urology, anesthesiology, general surgery subspecialties, radiology, and internal medicine subspecialties. A dose response relationship between PTL and burnout was observed. For every 40-point (10%) decrease in PTL there was 33% lower odds of experiencing burnout (odds ratio = 0.67, 95% confidence interval = 0.65-0.70, p < 0.0001).The relationship between PTL and burnout may suggest areas of particular focus to improve the practice environment and reduce physician burnout.
View details for DOI 10.1016/j.jcjq.2020.09.011
View details for PubMedID 33168367
Association of Occupational Distress and Sleep-Related Impairment in Physicians With Unsolicited Patient Complaints.
Mayo Clinic proceedings
2020; 95 (4): 719–26
OBJECTIVE: To study the relationship between occupational distress and sleep-related impairment in physicians and unsolicited patient complaints.PARTICIPANTS AND METHODS: We used deidentified data from an academic medical center's physician survey administered in April and May of 2013 to perform a retrospective cohort study. Third-party stewards of the identifiable information regarding unsolicited patient complaints from January 1, 2013, through December 31, 2016, matched these data with corresponding physicians' occupational distress data. Unsolicited patient complaints were used to calculate the Patient Advocacy Reporting System (PARS) score, a validated predictor of malpractice litigation risk and clinical outcomes. Physicians were grouped into 1 of 3 PARS risk categories based on previously defined thresholds: low risk (score of 0), intermediate risk (score of 1-12), or high risk (score ≥13).RESULTS: Each 1-point increase in burnout and sleep-related impairment, on a 5-point scale, was associated with a 69% (odds ratio [OR], 1.69; 95% CI, 1.12-2.54) and 49% (OR, 1.49; 95% CI, 1.08-2.05) increased odds of being in the next higher PARS risk category, respectively, averaged across all 4 years. Professional fulfillment was a protective factor, associated with fewer unsolicited patient complaints. Each 1-point decrease in professional fulfillment was associated with a 68% (OR, 1.68; 95% CI, 1.16-2.44) increased odds of being in the next higher PARS risk category. The effect of depression on PARS risk category was not significant (OR, 1.33; 95% CI, 0.84-2.10).CONCLUSION: Findings from this research suggest that occupational distress and sleep-related impairment in physicians are associated with unsolicited patient complaints.
View details for DOI 10.1016/j.mayocp.2019.09.025
View details for PubMedID 32247345
Association of Burnout, Professional Fulfillment, and Self-care Practices of Physician Leaders With Their Independently Rated Leadership Effectiveness.
JAMA network open
2020; 3 (6): e207961
Although leadership behavior of physician supervisors is associated with the occupational well-being of the physicians they supervise, the factors associated with leadership behaviors are poorly understood.To evaluate the associations between burnout, professional fulfillment, and self-care practices of physician leaders and their independently assessed leadership behavior scores.This survey study of physicians and physician leaders at Stanford University School of Medicine (n = 1924) was conducted from April 1 to May 13, 2019. The survey included assessments of professional fulfillment, self-valuation, sleep-related impairment, and burnout. Physicians also rated the leadership behaviors of their immediate physician supervisors using a standardized assessment. Leaders' personal well-being metrics were paired with their leadership behavior scores as rated by the physicians they supervised. All assessment scores were converted to a standardized scale (range, 0-10). Data were analyzed from October 20, 2019, to March 10, 2020.Association between leaders' own well-being scores and their independently assessed leadership behavior.Of 1924 physicians invited to participate, 1285 (66.8%) returned surveys, including 67 of 117 physician leaders (57.3%). Among these respondents, 651 (50.7%) were women and 729 (56.7%) were 40 years or older. Among the 67 leaders, 57 (85.1%) had their leadership behaviors evaluated by at least 5 physicians (median, 11 [interquartile range, 9-15]) they supervised. Overall, 9.8% of the variation in leaders' aggregate leadership behavior scores was associated with their own degree of burnout. In models adjusted for age and sex, each 1-point increase in burnout score of the leaders was associated with a 0.19-point decrement in leadership behavior score (β = -0.19; 95% CI, -0.35 to -0.03; P = .02), whereas each 1-point increase in their professional fulfillment and self-valuation scores was associated with a 0.13-point (β = 0.13; 95% CI, 0.01-0.26; P = .03) and 0.15-point (β = 0.15; 95% CI, 0.02-0.29; P = .03) increase in leadership behavior score, respectively. Each 1-point increase in leaders' sleep-related impairment was associated with a 0.15-point increment in sleep-related impairment among those they supervised (β = 0.15; 95% CI, 0.02-0.29; P = .03). The associations between leaders' well-being scores in other dimensions and the corresponding well-being measures of those they supervised were not significant.In this survey study, burnout, professional fulfillment, and self-care practices of physician leaders were associated with their independently assessed leadership effectiveness. Training, skill building, and support to improve leader well-being should be considered a dimension of leadership development rather than simply a dimension of self-care.
View details for DOI 10.1001/jamanetworkopen.2020.7961
View details for PubMedID 32543700
- Developing a Portfolio to Support Physicians' Efforts to Promote Well-being: One Piece of the Puzzle. Mayo Clinic proceedings 2019; 94 (11): 2171–77
Self-valuation: Attending to the Most Important Instrument in the Practice of Medicine.
Mayo Clinic proceedings
OBJECTIVE: To measure self-valuation, involving constructive prioritization of personal well-being and a growth mindset perspective that seeks to learn and improve as the primary response to errors, in physicians and evaluate its relationship with burnout and sleep-related impairment.METHODS: We analyzed cross-sectional survey data collected between July 1, 2016, and October 31, 2017, from 5 academic medical centers in the United States. All faculty and medical-staff physicians at participating organizations were invited to participate. The self-valuation scale included 4 items measured on a 5-point (0-4) Likert scale (summative score range, 0-16). The self-valuation scale was developed and pilot tested in a sample of 250 physicians before inclusion in the multisite wellness survey, which also included validated measures of burnout and sleep-related impairment.RESULTS: Of the 6189 physicians invited to participate, 3899 responded (response rate, 63.0%). Each 1-point score increase in self-valuation was associated with-1.10 point lower burnout score (95% CI,-1.16 to-1.05; standardized beta=-0.53; P<.001) and 0.81 point lower sleep-related impairment score (95% CI,-0.85 to-0.76; standardized beta=-0.47; P<.001), adjusting for sex and medical specialty. Women had lower self-valuation (Cohen d=0.30) and higher burnout (Cohen d=0.22) than men. Lower self-valuation scores in women accounted for most of the sex difference in burnout.CONCLUSION: Low self-valuation among physicians is associated with burnout and sleep-related impairment. Further research is warranted to develop and test interventions that increase self-valuation as a mechanism to improve physician well-being.
View details for DOI 10.1016/j.mayocp.2019.04.040
View details for PubMedID 31543254
Estimating institutional physician turnover attributable to self-reported burnout and associated financial burden: a case study.
BMC health services research
2018; 18 (1): 851
BACKGROUND: Awareness of the economic cost of physician attrition due to burnout in academic medical centers may help motivate organizational level efforts to improve physician wellbeing and reduce turnover. Our objectives are: 1) to use a recent longitudinal data as a case example to examine the associations between physician self-reported burnout, intent to leave (ITL) and actual turnover within two years, and 2) to estimate the cost of physician turnover attributable to burnout.METHODS: We used de-identified data from 472 physicians who completed a quality improvement survey conducted in 2013 at two Stanford University affiliated hospitals to assess physician wellness. To maintain the confidentially of survey responders, potentially identifiable demographic variables were not used in this analysis. A third party custodian of the data compiled turnover data in 2015 using medical staff roster. We used logistic regression to adjust for potentially confounding factors.RESULTS: At baseline, 26% of physicians reported experiencing burnout and 28% reported ITL within the next 2years. Two years later, 13% of surveyed physicians had actually left. Those who reported ITL were more than three times as likely to have left. Physicians who reported experiencing burnout were more than twice as likely to have left the institution within the two-year period (Relative Risk (RR)=2.1; 95% CI=1.3-3.3). After adjusting for surgical specialty, work hour categories, sleep-related impairment, anxiety, and depression in a logistic regression model, physicians who experienced burnout in 2013 had 168% higher odds (Odds Ratio=2.68, 95% CI: 1.34-5.38) of leaving Stanford by 2015 compared to those who did not experience burnout. The estimated two-year recruitment cost incurred due to departure attributable to burnout was between $15,544,000 and $55,506,000. Risk of ITL attributable to burnout was 3.7 times risk of actual turnover attributable to burnout.CONCLUSIONS: Institutions interested in the economic cost of turnover attributable to burnout can readily calculate this parameter using survey data linked to a subsequent indicator of departure from the institution. ITL data in cross-sectional studies can also be used with an adjustment factor to correct for overestimation of risk of intent to leave attributable to burnout.
View details for PubMedID 30477483
Improving bone health in men with prostate cancer receiving androgen deprivation therapy: Results of a randomized phase 2 trial.
Strategies to improve bone health care in men receiving androgen deprivation therapy (ADT) are not consistently implemented. The authors conducted a phase 2 randomized controlled trial of 2 education-based models-of-care interventions to determine their feasibility and ability to improve bone health care.A single-center parallel-group randomized controlled trial of men with prostate cancer who were receiving ADT was performed. Participants were randomized 1:1:1 to 1) a patient bone health pamphlet and brief recommendations for their family physician (BHP+FP); 2) a BHP and support from a bone health care coordinator (BHP+BHCC); or 3) usual care. The primary efficacy outcome was receipt of a bone mineral density (BMD) test within 6 months. Secondary efficacy outcomes included guideline-appropriate calcium and vitamin D use and bisphosphonate prescriptions for men at high fracture risk. Feasibility endpoints included recruitment, retention, satisfaction, contamination, and outcome capture. The main analysis used logistic regression with a 1-sided P of .10. The trial is registered at ClinicalTrials.gov (identifier NCT02043236).A total of 119 men were recruited. The BHP+BHCC strategy was associated with a greater percentage of men undergoing a BMD test compared with the usual-care group (78% vs 36%; P<.001). BMD ordering also was found to be increased with the BHP+FP strategy (58% vs 36%; P = .047). Both strategies were associated with higher percentages of patients using calcium and vitamin D, but only the BHP+FP arm was statistically significant (P = .039). No men were detected to be at high fracture risk. All but one feasibility endpoint was met.Educational strategies to improve bone health care appear feasible and are associated with improved BMD ordering in men receiving ADT. Cancer 2017. © 2017 American Cancer Society.
View details for DOI 10.1002/cncr.31171
View details for PubMedID 29211305
Physician Well-Being: The Reciprocity of Practice Efficiency, Culture of Wellness, and Personal Resilience
Think of physician well-being as a three-legged stool. Improvement efforts should focus on all three domains to achieve best results.NEJM Catalyst
A Brief Instrument to Assess Both Burnout and Professional Fulfillment in Physicians: Reliability and Validity, Including Correlation with Self-Reported Medical Errors, in a Sample of Resident and Practicing Physicians.
Academic psychiatry : the journal of the American Association of Directors of Psychiatric Residency Training and the Association for Academic Psychiatry
The objective of this study was to evaluate the performance of the Professional Fulfillment Index (PFI), a 16-item instrument to assess physicians' professional fulfillment and burnout, designed for sensitivity to change attributable to interventions or other factors affecting physician well-being.A sample of 250 physicians completed the PFI, a measure of self-reported medical errors, and previously validated measures including the Maslach Burnout Inventory (MBI), a one-item burnout measure, the World Health Organization's abbreviated quality of life assessment (WHOQOL-BREF), and PROMIS short-form depression, anxiety, and sleep-related impairment scales. Between 2 and 3 weeks later, 227 (91%) repeated the PFI and the sleep-related impairment scale.Principal components analysis justified PFI subscales for professional fulfillment, work exhaustion, and interpersonal disengagement. Test-retest reliability estimates were 0.82 for professional fulfillment (α = 0.91), 0.80 for work exhaustion (α = 0.86), 0.71 for interpersonal disengagement (α = 0.92), and 0.80 for overall burnout (α = 0.92). PFI burnout measures correlated highly (r ≥ 0.50) with their closest related MBI equivalents. Cohen's d effect size differences in self-reported medical errors for high versus low burnout classified using the PFI and the MBI were 0.55 and 0.44, respectively. PFI scales correlated in expected directions with sleep-related impairment, depression, anxiety, and WHOQOL-BREF scores. PFI scales demonstrated sufficient sensitivity to detect expected effects of a two-point (range 8-40) change in sleep-related impairment.PFI scales have good performance characteristics including sensitivity to change and offer a novel contribution by assessing professional fulfillment in addition to burnout.
View details for PubMedID 29196982
Running on empty: a review of nutrition and physicians' well-being
POSTGRADUATE MEDICAL JOURNAL
2016; 92 (1090): 478-481
Resident and physician burnout is a complex issue. Adequate nutrition and hydration play important roles in the maintenance of health and well-being of all individuals. Given the high prevalence of burnout in physicians, we believe that in addition to issues related to heavy workload, structure and length of shifts, the current status of physicians' nutrition and hydration and their effects on their work performance and well-being should also be addressed. In this review, we summarise the current evidence on the potential effects of nutrition and hydration on physicians' occupational well-being and performance, identify gaps and discuss opportunities to address nutrition as one of the important means of improving physicians' well-being.
View details for DOI 10.1136/postgradmedj-2016-134131
View details for Web of Science ID 000380942700011
View details for PubMedID 27215232
Vitamin K and musculoskeletal health in postmenopausal women
MOLECULAR NUTRITION & FOOD RESEARCH
2014; 58 (8): 1647-1657
Aside from its important role in blood clotting, vitamin K is an important dietary factor in regulating bone and cartilage mineralization. The vitamin K requirements to maintain musculoskeletal health may be more than the current recommendations and subclinical vitamin K deficiency may be involved in the pathogenesis of osteoporosis and osteoarthritis. Observational studies suggest that diets low in vitamin K are associated with increased risk of fractures and osteoarthritis in older adults. However, so far randomized controlled trials of vitamin K supplementation in Caucasian populations have not shown clinically significant improvements in bone mineral density at major skeletal sites. Supplementation with vitamin K may reduce the risk of fractures, but this conclusion comes from clinical trials with methodological limitations. At this time, only one randomized controlled trial has examined the effect of vitamin K supplementation on radiographic hand osteoarthritis and found no overall effect. Large well-designed randomized controlled trials are needed to compare the efficacies of vitamin K1 and K2 on fractures and osteoarthritis among older adults. In summary, currently there is not enough evidence to recommend the use of vitamin K supplements for the prevention of bone loss, fractures, or osteoarthritis in postmenopausal women.
View details for DOI 10.1002/mnfr.201300950
View details for Web of Science ID 000340528500007
View details for PubMedID 24956598
Vitamin K and Bone Health
JOURNAL OF CLINICAL DENSITOMETRY
2013; 16 (4): 409-413
Vitamin K has been purported to play an important role in bone health. It is required for the gamma-carboxylation of osteocalcin (the most abundant noncollagenous protein in bone), making osteocalcin functional. There are 2 main forms (vitamin K1 and vitamin K2), and they come from different sources and have different biological activities. Epidemiologic studies suggest a diet high in vitamin K is associated with a lower risk of hip fractures in aging men and women. However, randomized controlled trials of vitamin K1 or K2 supplementation in white populations did not increase bone mineral density at major skeletal sites. Supplementation with vitamin K1 and K2 may reduce the risk of fractures, but the trials that examined fractures as an outcome have methodological limitations. Large well-designed trials are needed to compare the efficacies of vitamin K1 and K2 on fractures. We conclude that currently there is not enough evidence to recommend the routine use of vitamin K supplements for the prevention of osteoporosis and fractures in postmenopausal women.
View details for DOI 10.1016/j.jocd.2013.08.017
View details for Web of Science ID 000326851500006
View details for PubMedID 24090644
Effects of vitamin E on bone turnover markers among US postmenopausal women
JOURNAL OF BONE AND MINERAL RESEARCH
2012; 27 (6): 1368-1380
Increased oxidative stress and inflammation resulting from aging and declining estrogen levels can lead to increased bone loss in postmenopausal women. Alpha-tocopherol and gamma-tocopherol, the two predominant isomers of vitamin E, have antioxidant and anti-inflammatory properties, but their effects on bone metabolism have not been well studied in humans. We examined the associations between dietary and total (diet and supplements) alpha-tocopherol intake, serum alpha-tocopherol and gamma-tocopherol levels and their ratio, and bone turnover markers (BTMs) among postmenopausal women aged ≥45 years. We used cross-sectional data from the National Health and Nutrition Examination Survey 1999–2002. Multiple regression models with adjustments for relevant confounders were used to examine the associations between intake and serum levels of tocopherols, and serum bone-specific alkaline phosphatase (BAP), a biomarker of bone formation, and urinary N-telopeptides/creatinine (uNTx/Cr), a biomarker of bone resorption. The study sample included 497 postmenopausal women who were not taking estrogen, steroids, or osteoporosis medications, were free from kidney and liver disease, cancer, and rheumatoid arthritis, and were fasting >9 hours prior to examination. Participants had a mean age of 65.5 ± 0.6 years and over 45% used vitamin E (alpha-tocopherol) supplements in the past month. Vitamin E supplement users had significantly lower serum gamma-tocopherol, higher serum alpha-tocopherol levels, and higher ratio of serum alpha-tocopherol to gamma-tocopherol than nonusers. High serum gamma-tocopherol levels and low ratio of serum alpha-tocopherol to gamma-tocopherol were associated with increased BAP levels (p < 0.01 for both). There were no associations between any of the vitamin E variables and uNTx/Cr. In conclusion, we hypothesize that gamma-tocopherol may uncouple bone turnover, resulting in more bone formation than resorption. Vitamin E supplements in the form of alpha-tocopherol suppress serum gamma-tocopherol levels and may have negative effects on bone formation. Further research is needed to investigate the potential anabolic effect of gamma-tocopherol from food sources on bone.
View details for DOI 10.1002/jbmr.1566
View details for Web of Science ID 000304141500014
View details for PubMedID 22308007
Association between the Healthy Eating Index and bone turnover markers in US postmenopausal women aged >= 45 y
AMERICAN JOURNAL OF CLINICAL NUTRITION
2011; 94 (1): 199-208
Some studies have reported that overall diet quality affects bone status in postmenopausal women; however, the findings are inconsistent.Our primary objective was to examine the association between overall diet quality and bone turnover markers (BTMs) in postmenopausal women aged ≥45 y by using the Healthy Eating Index 2005 (HEI-2005)-a diet quality-assessment tool-developed by the US Department of Agriculture. Our secondary objective was to explore the associations between the components of the HEI-2005 and the MyPyramid food groups and BTMs.We used cross-sectional data from NHANES 1999-2002. Multiple regression models with adjustments for relevant confounders were used to examine the relation between the total HEI-2005 score and its components and food groups and serum bone-specific alkaline phosphatase (BAP), a biomarker of bone formation, and urinary N-telopeptides/creatinine (uNTx/Cr), a biomarker of bone resorption.No association was found between the total HEI-2005 score and BTMs. The milk group component of HEI-2005 had a significant negative linear relation with uNTx/Cr. Women in the lowest tertile of the MyPyramid milk group had the highest uNTx/Cr. Those in the highest tertile of energy-adjusted added sugar intake had the highest BAP.Our results support the ability of a healthy diet with adequate dairy intake to promote bone health in aging women. However, we found that the HEI-2005 is not a good measure of healthy eating for optimal bone health. Further research is needed to develop an overall dietary assessment tool in relation to bone health for postmenopausal women.
View details for DOI 10.3945/ajcn.110.009605
View details for Web of Science ID 000291794800028
View details for PubMedID 21562084
Fruit and vegetable intake and bone health in women aged 45 years and over: a systematic review
2011; 22 (6): 1681-1693
High fruit and vegetable intake may be associated with improved bone status among women aged ≥ 45 years. This is the first systematic review that specifically assessed this association and identified research gaps. The benefits of fruit and vegetables (F&V) on bone health remain unclear. Further studies are needed.F&V have several components that are beneficial to bones. Some studies report that high F&V intake is associated with improved bone status in middle aged and aged women; however, findings are inconsistent. The objective was to systematically review observational and interventional studies that investigated the effects of F&V intake on incidence of osteoporotic fractures, bone mineral density (BMD), and bone turnover markers (BTM) in women aged ≥ 45 years and to identify potential research gaps.Electronic databases were searched, and peer-reviewed manuscripts published in English, with F&V intake as a main dietary exposure, were included. Data selection, extraction, and evaluation of risk of bias were performed independently by two reviewers.Eight studies were included. One cohort study reported cross-sectional as well as longitudinal data. There was significant between-study heterogeneity in design, definition, and amount of F&V intake, outcomes, analyses, and reporting of results. Two studies had low, two had moderate, and four had high risk of bias. Among reports with low or moderate risk of bias, two cross-sectional analyses reported positive associations between F&V intake and BMD of the forearm, lumbar spine, or total hip, whereas one randomized controlled trial and two prospective cohort analyses reported no effects. One trial reported no associations between F&V and BTM.Based on limited evidence, the benefits of F&V on bone health remain unclear for women aged ≥ 45 years. Further studies with low risk of bias are needed.
View details for DOI 10.1007/s00198-010-1510-0
View details for Web of Science ID 000290544900005
View details for PubMedID 21165601
Validation of a calcium assessment tool in postmenopausal Canadian women
2011; 69 (2): 168-172
Adequate calcium intake is important for optimal bone health. Assessing dietary calcium intake, however, is neither widely done nor standardized in North American clinical practices.Our goal was to validate a calcium assessment tool (CAT), a modified version of the Calcium Calculator™, against the 3-day food record.Data were obtained from 348 participants in the ECKO (Evaluation of the Clinical use of vitamin K supplementation in postmenopausal women with Osteopenia) trial. In this study, CAT data was collected at baseline and 3-day food records (FRs) were collected at baseline and 3 months by trained study coordinators. CAT and 3-day FR data were compared using correlations and Bland-Altman plots. Additionally, receiver operator characteristic (ROC) curves of CAT were constructed to identify subjects with low calcium intake at thresholds of 500 mg/day and 1000 mg/day on the 3-day FR curves.Mean calcium intake values per day were 902 mg for the 3-day FRs and 781 mg for the CAT. The Pearson correlation was 0.57 (95% CI: 0.50-0.64). Areas under the ROC curves at thresholds of 500 and 1000 mg calcium were 0.81 (95% CI: 0.73-0.89) and 0.82 (95% CI: 0.78-0.86), respectively.The CAT is a valid tool for the measurement of dietary calcium intake using cut-off values of 500 mg and 1000 mg in postmenopausal women, even though there is only moderate correlation between the CAT and 3-day FR. This tool may facilitate the determination of whether calcium supplements are needed in the clinical setting.
View details for DOI 10.1016/j.maturitas.2011.02.016
View details for Web of Science ID 000291837600013
View details for PubMedID 21450422
Effect of antibiotics as cholesterol-lowering agents
METABOLISM-CLINICAL AND EXPERIMENTAL
2005; 54 (1): 103-112
Antibiotics were once proposed as hypercholesterolemic agents although the mechanism is unclear, despite broad implications, including providing an alternative approach to cholesterol reduction, with potential relevance for current trials of antibiotics to reduce cardiovascular disease, and possible confounding of routine diagnostic cholesterol measurements. The effect on serum lipids of antibiotics against aerobes and anaerobes, together with possible mechanisms, was therefore explored. Twenty-two men and women took antibiotics for 10 days (either ciprofloxacin for 13 subjects or metronidazole for 10 subjects), with 10 days control in random order separated by 2-week washout periods. Subjects maintained low-fat diets throughout the study. Blood samples and blood pressure were obtained on days 0 and 10 of each phase with 3-day fecal collections and 12-hour breath gas collections at the end of each phase. The results indicated that metronidazole markedly reduced low-density lipoprotein cholesterol (-14.0 +/- 4.0%, P = .006), oxidized low-density lipoprotein (-23.0 +/- 5.1%, P = .002), and the apolipoprotein B/A-I ratio (-18.0 +/- 2.8%, P < .001), whereas the reduction with ciprofloxacin was less pronounced (apolipoprotein B/A-I, -5.0 +/- 1.8%, P = .017). Neither antibiotic altered C-reactive protein or blood pressure. The low-density lipoprotein cholesterol reduction related to an increase in bifidobacteria (r = -0.46, P = .029), but not to markers of colonic fermentation. We conclude that antibiotics can reduce serum lipids acutely. These effects may confound diagnostic measurements but indicate possible links between colonic microflora and blood lipids and the need to study ways of altering colonic microflora by nonantibiotic means as a potential therapeutic option.
View details for DOI 10.1016/j.metabol.2004.07.019
View details for Web of Science ID 000228794600015
View details for PubMedID 15562388
Glycemic index: overview of implications in health and disease
AMERICAN JOURNAL OF CLINICAL NUTRITION
2002; 76 (1): 266S-273S
The glycemic index concept is an extension of the fiber hypothesis, suggesting that fiber consumption reduces the rate of nutrient influx from the gut. The glycemic index has particular relevance to those chronic Western diseases associated with central obesity and insulin resistance. Early studies showed that starchy carbohydrate foods have very different effects on postprandial blood glucose and insulin responses in healthy and diabetic subjects, depending on the rate of digestion. A range of factors associated with food consumption was later shown to alter the rate of glucose absorption and subsequent glycemia and insulinemia. At this stage, systematic documentation of the differences that exist among carbohydrate foods was considered essential. The resulting glycemic index classification of foods provided a numeric physiologic classification of relevant carbohydrate foods in the prevention and treatment of diseases such as diabetes. Since then, low-glycemic-index diets have been shown to lower urinary C-peptide excretion in healthy subjects, improve glycemic control in diabetic subjects, and reduce serum lipids in hyperlipidemic subjects. Furthermore, consumption of low-glycemicindex diets has been associated with higher HDL-cholesterol concentrations and, in large cohort studies, with decreased risk of developing diabetes and cardiovascular disease. Case-control studies have also shown positive associations between dietary glycemic index and the risk of colon and breast cancers. Despite inconsistencies in the data, sufficient, positive findings have emerged to suggest that the dietary glycemic index is of potential importance in the treatment and prevention of chronic diseases.
View details for Web of Science ID 000176378500038
View details for PubMedID 12081850