INTEGRATED PROTEIN METABOLISM N. Deutz (US)Critical analysis of the use of oral tracer/protein to calculate protein synthesis and breakdown • Underestimation of the suppressive effect

ESPEN Congress Krakow 2019

Proteins In Clinical Nutrition

INTEGRATED PROTEIN METABOLISM

N. Deutz (US)

Integrated Protein Metabolism

Nicolaas E Deutz, MD, PhD.Professor, Ponder Endowed Chair

Editor-in-Chief Clinical Nutrition and Clinical Nutrition ESPEN

Director of Clinical Research, Human Clinical Research Facility

Director Center for Translational Research in Aging & Longevity

Chair, Kinesiology Division and Associate Department Head

Department of Health & Kinesiology, Texas A&M University


• Introduction

• Measure protein metabolism in humans

• Protein anabolism

• Can we improve protein anabolism with

specialized components

• Conclusions

The Impact of Dairy Protein Intake in Middle-Aged to Older Adults with or

without existing Sarcopenia

Hanach et al. Adv Nutr. 2019;10(1):59-69. doi: 10.1093/advances/nmy065

Handgrip

Muscle

Strength

Muscle

Mass

Protein Requirements and Optimal Intakes in older adults: Are We Ready to

Recommend More Than the Recommended Daily Allowance?

Traylor et al. Adv Nutr. 2018;9(3):171-82. doi: 10.1093/advances/nmy003

(Estimated Average Requirement)

(Recommended Dietary Allowance)

Increasing RDA/EAR will bring more older adults in a protein deficiency


• Introduction





• Conclusions

How to measure human protein metabolism with

(stable) tracers

Measure appearance in

plasma that relate to

• Essential amino acid

protein synthesis and

breakdown

Need Mass Spectrometry

to measure enrichment

(TTR: tracer/tracee ratio)

Kim et al. Experimental & Molecular Medicine. 2016;48(1):e203

Measuring protein kinetics after a meal

Oral intake of amino acid mixture

and L-[15N]-PHE

-15

t=3 h

Blood sampling (min) -180 -30 0 3015 45 18060 90 120 150

t=0 ht=-3 h

-60

Primed continuous IV infusion of L-[ring-2H5]-PHE and L-[ring-2H2]-TYR

0 3 0 6 0 9 0 1 2 0 1 5 0 1 8 00

5 0 0

1 0 0 0

1 5 0 0

2 0 0 0

2 5 0 0

T im e (m in )

EA

A c

on

ce

ntr

ati

on

(µ

M)

1 4 g E A A m ix tu re 1 4 g T A A m ix tu re

**

********

********

****

********

Jonker et al. Clin Sci (Lond). 2018;132(1):17-31. doi: 10.1042/CS20171068


Oral intake of amino acid mixture

and L-[15N]-PHE

-15

t=3 h

Blood sampling (min) -180 -30 0 3015 45 18060 90 120 150

t=0 ht=-3 h

-60

Primed continuous IV infusion of L-[ring-2H5]-PHE and L-[ring-2H2]-TYR

-3 0 0 3 0 6 0 9 0 1 2 0 1 5 0 1 8 00 .0

0 .0 6

0 .0 7

0 .0 8

0 .0 9

0 .1 0

T im e (m in )

cT

TR

L -[r in g -2H 5 ] -p h e n y la la n in e

1 4 g T A A m ix tu re

1 4 g E A A m ix tu re

-3 0 0 3 0 6 0 9 0 1 2 0 1 5 0 1 8 00 .0 0

0 .0 0 6

0 .0 0 8

0 .0 1 0

0 .0 1 2

0 .0 1 4

0 .0 1 6

0 .0 1 8

L -[r in g -2H 4 ] - ty ro s in e

T im e (m in )

cT

TR

- 3 0 0 3 0 6 0 9 0 1 2 0 1 5 0 1 8 00 .0

0 .0 2

0 .0 3

0 .0 4

0 .0 5

0 .0 6

L -[r in g -2H 2 ] - ty ro s in e

T im e (m in )

cT

TR

0 3 0 6 0 9 0 1 2 0 1 5 0 1 8 00 .0 0

0 .0 2

0 .0 4

0 .0 6

0 .0 8

0 .1 0

T im e (m in )

cT

TR

L -[1 5

N ]-p h e n y la la n in e

A

C D

B



0 9 0 1 2 0 1 5 0 1 8 0 2 1 0 2 4 0 2 7 0 3 0 0 3 3 00 .0 0

0 .0 2

0 .0 4

0 .0 6

0 .0 8

0 .1 0

0

2

4

6

8

1 0

1 2

1 4

T im e (m in )

cT

TR

L -[1 5

N ]-P H E

Inte

gra

l

c T T R s u b je c t A

In te g ra l o f c T T R

0 9 0 2 1 0 3 3 0 4 5 0 5 7 0 6 9 00 .0 0

0 .0 2

0 .0 4

0 .0 6

0 .0 8

0 .1 0

0

2

4

6

8

1 0

1 2

1 4

T im e (m in )

cT

TR

L -[1 5

N ]-P H E

Inte

gra

l

c T T R s u b je c t A

N o n lin e a r f it o f in te g ra l

In te g ra l o f c T T R

A B




Critical analysis of the use of oral tracer/protein to

calculate protein synthesis and breakdown

• Underestimation of the suppressive effect of dietary

protein on protein breakdown, but possibly correct

estimation of protein balance and anabolism

• Classic estimation protein balance (PS+Oxidation =

PB+intake) probably acceptable for bolus feeding per 24h,

not per meal as it is unclear when the end of anabolic

response is present (4h?, 12h?)

Wolfe et al. AJP. 2019;317(1):E74-E84. doi: 10.1152/ajpendo.00294.2018.


Critical analysis of the use of oral tracer/protein to

calculate protein synthesis and breakdown

• SIP feeding protocol is more reliable than a bolus feeding

protocol to study the quality of protein

– Bolus feeding protocol show more anabolism of Whey vs Casein

protein, while sip feeding protocol and 8 weeks intervention

show comparable anabolism (protein quality Whey and Casein is

equal)

• Some estimation of protein digestion (and absorption) is

necessary

Wolfe et al. AJP. 2019;317(1):E74-E84. doi: 10.1152/ajpendo.00294.2018.


Panel of isotopes measuring gut function (protein

digestibility + absorption) and splanchnic extraction

Gut[15N]peptides [15N] spirulina protein [1-13C]phenylalanine

[15N]phenylalanine

[15N]peptides [15N]phenylalanine [1-13C]phenylalanine

Portal circulation

[15N]peptides [15N]phenylalanine / [1-13C]phenylalanine / [2H5]phenylalanine Intravenous

Meal + [15N]spirulina protein + [1-13C]phenylalanine

Mucosa cells

PEPT1AA transporter

AA transporter

Gut function: ratio [15N]phe / [1-13C]phe = % appearance [15N]phe from spirulina protein into circulation

Splanchnic extraction: ratio [1-13C]phe / [2H5]phe = % appearance [1-13C]phe into circulation assuming no AA absorption problem

Colon

Engelen et al, Clin Nutr. 2014;33(6):1024-32

Disturbed gut function in Cystic Fibrosis after

improving digestion with pancreatic enzymes

Principle is to use an enriched protein which can measure digestibility of every amino acid. We used mixture of EnsureHP and 15N-Spirulina protein that was given as 20-min sips

1 2 0 1 8 0 2 4 0 3 0 0 3 6 0 4 2 0 4 8 0

0

2 0

4 0

6 0

8 0

1 0 0

T i m e ( m i n )

% S

pir

uli

na

de

gr

ad

atio

n

P a n c r e a t i c

E n z y m e s

C y s t i c F i b r o s i s

H e a l t h y Y o u n g A d u l t s

Engelen et al, Clin Nutr. 2014;33(6):1024-32

Impairments in protein digestion and absorption attenuate the anabolic

response to feeding in patients with Congestive Heart Failure

Kirschner et al. Current Developments in Nutrition. 2019;In press.

Healthy CHF0.0

0.2

0.4

0.6

0.8

1.015N

-spirulin

a d

egra

dation

[ratio

]

Protein digestion and absorption

p = 0.007

Healthy CHF0

20

40

60

80

Anabolic

response

[µm

ol/kg F

FM

/meal]

Anabolic reponse to high-protein meal

p < 0.001

Healthy CHF0

10

20

30

40

µm

ol/L

Plasma citrulline concentration

Healthy CHF0.00

0.02

0.04

0.06

0.08

Urinary

lactu

lose/r

ham

nose

[ratio

]

Small intestinal permeability

Healthy CHF0

20

40

60

Urinary

3-O

MG

recovery

rate

[%

]

p = 0.128

Active carrier-mediated transport


• Introduction





• Conclusions

Relation between intake of different types of

protein and net protein anabolismJonker et al. Clin Nutr. 2014;33(2):211-20

doi: 10.1016/j.clnu.2013.06.014

Jonker et al Metabolism. 2017;69:120-9

doi: 10.1016/j.metabol.2016.12.010

Kim et al. AJP 2015;308(1):E21-8. doi: 10.1152/ajpendo.00382.2014.

Deutz et al Clin Nutr. 2013;32(2):309-13. doi: 10.1016/j.clnu.2012.11.018

Apparently no upper limit anabolic response and the

role of gut labile protein pool

The muscle anabolic response is not only determined by

protein synthesis but by the balance between protein

synthesis and breakdown and the gut anabolic response

Measure anabolic response at whole body levelProtein intake in one meal

Intake 30 gram protein in meal

Kim et al. Clin Nutr. 2018;37(2):411-8. doi: 10.1016/j.clnu.2017.05.029

Do older adults have anabolic resistance?

Moro et al. J Nutr. 2018;148(6):900-9. doi: 10.1093/jn/nxy064

No muscle anabolic resistance to EAA

in healthy older adults

Engelen et al. Clin Nutr. 2012;31(5):616-24. doi: 10.1016/j.clnu.2012.04.006

Meal (8.1 g Protein

and 21 g CHO)

Morton et al. Curr Opin Crit Care. 2018;24(2):124-30. doi: 10.1097/MCC.0000000000000488

Define anabolic resistance as the reduced stimulation of muscle

protein synthesis to a given dose of protein/amino acids

Anabolic Threshold and Capacity

Jonker et al. Clin Nutr. 2019;38(4):1833-43. doi: 10.1016/j.clnu.2018.07.018





24h balance studies in healthy subjects

No effect of pattern, only of amount of protein intake

• 20 healthy older adult

subjects (52 – 75 y)

• 4 groups

– protein intake of 0.8g

(1*RDA)

– protein intake of 1.5g

(2*RDA)

– and uneven [U:

15/20/65%] or even

distribution (E:

33/33/33%) of protein

intake

Kim et al., 2014

P S P B N B

-1 5 0

-1 0 0

-5 0

0

5 0

1 0 0

1 5 0

Ch

an

ge

s i

n w

ho

le b

od

y p

rote

in t

urn

ov

er

(g

·75

0 m

in-1

)

1 R D A -U

1 R D A -E

2 R D A -U

2 R D A -E

Protein intake distribution pattern does not affect anabolic response, lean

body mass, muscle strength or function over 8 weeks in older adults

Kim et al. Clin Nutr. 2018;37(2):488-93. doi: 10.1016/j.clnu.2017.02.020

EVEN = 33% every meal. ONEVEN = 15/20/65% per meal

There were no differences in any of the functional outcomes between the EVEN and the UNEVEN after 8 weeks of intervention

The anabolic response to a large protein meal

Kim et al. AJP. 2016;310(1):E73-E80. doi: 10.1152/ajpendo.00365.2015

Protein meal: MP (40g), HP (70g) after X:exercise or R: rest

Increase whole body anabolism, but no change in muscle protein synthesis

Dose-dependent increase of whole body protein balance and muscle protein synthesis

with protein intake during exercise recovery in older adult men

Holwerda et al. J Nutr. 2019;149(2):221-30. doi: 10.1093/jn/nxy263


• Introduction





• Conclusions

Meal whole body protein anabolism in healthy older

adults


Plasma Leucine Net protein

anabolism

30 g hCAS ± 15 g CHO ± 3.5 g LEU

Leucine co-ingestion augments the muscle protein synthetic response to

the ingestion of 15 g protein following resistance exercise in older men

Holwerda et al. AJP. 2019;0(0):null. doi: 10.1152/ajpendo.00073.2019

Muscle FSR

Protein Breakdown Protein Synthesis Net Anabolism

0.0

0.2

0.4

0.6

0.8

m

ol/

kg

ffm

/min

15g Protein

15g Protein+1.5g LEU

Whole body protein kinetics

The presence of leucine rather than amount is most

crucial for anabolism in older women

Wilkinson et al. Clin Nutr. 2018;37(6 Pt A):2011-21. doi: 10.1016/j.clnu.2017.09.008

The presence of leucine rather than amount is most

crucial for anabolism in older women

All groups displayed

similar MPS in

response to feeding

(±resistance

exercise) suggesting

only a small dose of

leucine and/or EAA

are required


Excellent relation between intake essential amino

acids and net protein Synthesis

Engelen, Deutz et al. Ann Oncology 2015

1. Quality of Supplement related to amount of EAA

2. Leucine does not seems to make the EAA more anabolic

0 50 100 1500

50

100

150Healthy-EAA/LEU

Healthy-TAA

NSCLC-normal ffm-EAA/LEU

NSCLC-normal ffm-TAA

NSCLC-low ffm-EAA/LEU

NSCLC-low ffm-TAA

PHE intake (umol/kg ffm)

Net

Pro

tein

Syn

thesis

(u

mo

l/kg

ffm

)

Acute effect of HMB on muscle protein synthesis

and breakdown


Protein Synthesis Protein breakdown

Change in lean mass after bedrest

C h a n g e T o t a l L e g L e a n M a s sC

ha

ng

e

in

l

eg

s

le

an

(

kg

)

Bed rest Bed rest+Rehabilitation- 2 . 0

- 1 . 5

- 1 . 0

- 0 . 5

0 . 0

0 . 5

1 . 0

1 . 5

C o n t r o l

H M B

+

*

Deutz et al. Clin Nutr. 2013;32(5):704-12. doi: 10.1016/j.clnu.2013.02.011

HMB or HMB-containing supplements and its impact on skeletal muscle mass and

physical function in clinical practice: a systematic review and meta-analysis

Forest plot for the effect of HMB or supplements containing HMB on change in muscle mass

Bear et al. Am J Clin Nutr. 2019;109(4):1119-32. doi: 10.1093/ajcn/nqy373

Forest plot showing the effect of HMB or supplements containing HMB on change in body weight

Forest plot showing the effect of HMB or supplements containing HMB on absolute strength

NOURISH Study: placebo-controlled nutritional

intervention trial

Deutz et al. Clin Nutr. 2016;35(1):18-26. doi: 10.1016/j.clnu.2015.12.010. Loman et al. JPEN 2019;43(6):794-802. doi: 10.1002/jpen.1467

Older (at risk) malnourished adults (mean 78y).

• Intervention HP-HMB: 700 kcal, 40 g protein, 3.0 g HMB vs Placebo

• Nutrition intervention increased energy (22>28 kcal/kg/day) and protein intake (1.0>1.5 g/kg/day

• At 30 days, 77% of expected intake.

The Effect of early nutritional support on Frailty, Functional Outcomes,

and Recovery of malnourished medical inpatients Trial (EFFORT)

Older (at risk) malnourished adults (mean 72y). Nutrition intervention aimed to calculated EE and protein intake of 1.2-1.5 g/day. Day10 - EE (54%79%), Protein (5576%)

Schuetz et al. EFFORT.. Lancet. 2019;393(10188):2312-21. doi: 10.1016/S0140-6736(18)32776-4

All-cause mortalityComparison of 30 day Mortality of large Nutritional

Intervention Trials

Trial Control Intervention % Reduction

NOURISH (2016) 6.2% 2.9% 47%

EFFORT (2019) 9.9% 7.2% 27%

Deutz et al. NOURISH.. Clin Nutr. 2016;35(1):18-26. doi: 10.1016/j.clnu.2015.12.010


• Introduction





• Conclusions


• Stable tracer methods give essential information

about the digestion and use of dietary protein

• There is a linear relationship between the amount of

protein in the meal and net anabolism

–Even at high protein content in the meal


• On a whole body level, anabolic resistance is

uncommon in older adults and with disease

–Reduced protein digestion could play a role

• Specialized components can improve protein

anabolism

–HMB seems to be more promising than Leucine

Documents

INTEGRATED PROTEIN METABOLISM N. Deutz (US)Critical analysis of the use of oral tracer/protein to calculate protein synthesis and breakdown • Underestimation of the suppressive effect