Nutricia · Estimating Protein Requirements Recommendations from the ESPEN Expert Group • Protein intake for optimal muscle function with aging: ―1.0-1.2 g protein/kg body weight/day

Nutricia

The importance of protein: an update on the latest evidence

Outline

• Introduction

• Review the definition, function and dietary sources of

protein

• Protein Requirements

• High Protein ONS

• Evidence

• Case study

Introduction

1

Definition

• Protein is a macronutrient

• Primary source of amino acids, which are essential for the growth

and repair of body tissues and enzymes

• Dietary proteins are broken down by digestive enzymes into their

constituent amino acids which are then absorbed and utilised

• Some amino acids can be synthesised by the body but others

must be supplied by the diet, known as essential amino acids

Source: Thomas., et al. Manual of dietetic Practice. 4th Ed. Blackwell Publishing Ltd, 2007.

Main Protein Functions

Protein Functions Characteristics

Structural Protein is vital for the structure of the body and about half

of the body’s protein is in structural tissues such as skin

and muscle

Transport Proteins act as transport carriers in the blood and body

fluids for many molecules and nutrients, e.g. haemoglobin,

lipoproteins

Hormonal Some hormones are made up of proteins or their

constituents, peptides and amino acids e.g. insulin

Enzymes All enzymes are proteins. Extracellular enzymes include

the digestive enzymes, e.g. amylase. Intracellular

enzymes are involved in metabolic pathways

Immune functions Antibodies are protein molecules. Proteins are also

involved in the acute phase response of

inflammation/infection

Buffering function Albumin acts as a buffer in the maintenance of blood pH

Source: Thomas., et al. Manual of dietetic Practice. 4th Ed. Blackwell Publishing Ltd, 2007.

Protein

Requirements

2

Estimating Protein Requirements

Current Guidelines for Estimating Protein Requirements

• The RNI for healthy adults (both male and female) aged 19-50

years and 50+ years is estimated at 0.75g protein/kg of body

weight per day1

―A male 50+years (70kg) the RNI for protein is approximately

53g/d

• The World Health Organisation (WHO) recommend that healthy

older people need 0.9-1.1g protein/kg body weight per day2

―A male 50+years (70kg) the WHO recommendation for protein is

63-77g/d

1. Department of Health. Dietary Reference Values for Food Energy and Nutrients for the United Kingdom 41, HMSO, London, 1991.

2. World Health Organization. Keep fit for life: Meeting the nutritional needs of older persons, WHO library, 2002.


Revision of protein requirements by the ESPEN Expert Group

Source: Deutz et al. Clin Nutr. 2014;33:929-36.


Key conclusions from the ESPEN Expert Group

• “Good nutrition, especially adequate protein intake, also helps

limit and treat age-related declines in muscle mass, strength, and

functional abilities.”

• “Older adults need high protein intake to sustain healthy aging

and longevity”

• “In order to help prevent or delay adverse consequences, we

encourage increased intake of dietary protein for older adults (65

years)”



Recommendations from the ESPEN Expert Group

• Protein intake for optimal muscle function with aging:

―1.0-1.2 g protein/kg body weight/day for healthy older adults

―1.2-1.5 g protein/kg body weight/day may be indicated for

certain older adults who have acute or chronic illnesses

―Even higher intake for individuals with severe illness or injury

• A male 50+years (70kg) the ESPEN recommendation for protein

is:

―70-84g/d (healthy)

―84-105g/d (acute or chronic illness)



52.5

63-77

70-84

84-105

0

10

20

30

40

50

60

70

80

90

100

110

RNI WHO ESPEN (Healthy) ESPEN (Illness)

Pro

tein

(g/d

ay)

*

Up to 52.5g deficit during illness

when compared to ESPEN

recommendations

1. Department of Health. Dietary Reference Values for Food Energy and Nutrients for the United Kingdom 41, HMSO, London, 1991.

2. World Health Organization. Keep fit for life: Meeting the nutritional needs of older persons, WHO library, 2002.

3. Deutz et al. Clin Nutr. 2014;33:929-36.

*based on a 50+ year old male who weighs 70kg

1 2 3 3

Evidence

3

Effects of inadequate protein intake

• Muscle wasting1

― When the body requires extra energy, muscle is broken down in order to release

protein

• Poor wound healing1,2

― Protein is integral to the management of any wound as it is required for wound to

heal

• Increased susceptibility to infection1

― As antibodies are proteins synthesised by white blood cells, a protein deficit may

impact on the body’s ability to fight infection

• Anaemia1

― Protein deficiency can result in reduced levels of haemoglobin

• Oedema (excess fluid in the tissues)3

― When protein is low, the osmotic pressure is disrupted, drawing fluid from the

blood into the surrounding tissues and causing oedema

1. Thomas., et al. Manual of dietetic Practice. 4th Ed. Blackwell Publishing Ltd, 2007.

2. Stratton R et al. Disease-related malnutrition: an evidence-based approach to treatment. CABI publishing, 2003.

3. Wingate P, et al. Medical Encyclopaedia. 4th Ed. Penguin Books, 1997.

Factors affecting protein intake

Reduced protein intake & stores

Inadequate intake

Reduced ability to utilise protein

Physical dependence

Poor food security

Change in food preference

Commercially available

supplements instead of prescribed

supplements

Effects of High Protein Oral Nutrition Support (ONS)

Carwood et al. 2012 Systematic review and meta-analysis

• Aim

―Examine whether high protein ONS have beneficial effects in

clinical practice and the extent to which these are associated

with increased protein intake.

• Methods

―36 randomised controlled trials (n=4659)

―Intervention and follow up periods ranging from 2 weeks to 1

year

―High protein ONS energy density ranged from 0.75-3.85kcal/ml

―Percentage from protein ranged from 20-54%

Source: Cawood, et al. Ageing Res Rev. 2012;11:278–96.

Effects of High Protein ONS


• Results using high protein ONS

―19% absolute reduction in incidence of complications

―3 day reduction in hospital length of stay

―30% overall reduction in hospital readmissions

―Improvements in quality of life

―Increase in energy and protein intake

By an average of 314kcal and 22g protein per day

―1.76kg improvement in hand grip strength


Effects of High Protein ONS


• Common concerns re: increased protein intake

― Osteoporosis

― Renal failure

• Seven studies involved longer follow-up periods (7 to 18 months)

― No significant detrimental effects of ONS were identified

― Benefits were indicated:

Improved handgrip strength

Improved clinical course

Period of time spent in hospital

• Overall intake was not high in protein

― Energy from protein in diet increased from 55g (15.5% of energy) to 74g (17.2%

of energy)

“ONS make a small but important contribution to total protein intake”


Support for High Protein ONS

High Protein ONS recommended within the Malnutrition Pathway

www.malnutritionpathway.co.uk

1. http://malnutritionpathway.co.uk/downloads/Managing_Malnutrition.pdf. Mar 14, 2016.

There are a number of different ONS which may be of benefit in specific groups1:

• High protein ONS are suitable for individuals with wounds, post-operative patients, some types of cancer and the elderly

• Fibre-containing ONS are suitable for those with constipation (not suitable for those requiring fibre-free diet)

• Pre-thickened ONS and puddings are available for individuals with neurological conditions that affect their swallow

• Small volume high energy dense ONS may aid compliance, and may be better tolerated by patients who cannot consume

larger volumes

Case Study

4

Case Study

Mrs. S

• 84 year old female admitted to hospital

• Presenting condition: infective exacerbation of COPD

• Inpatient referral to Dietitian for oral nutrition support

• MHx: Hypercholesterolaemia, COPD

• Medications: seretide, ventolin, atorvastatin

• SHx: lives at home alone, supportive family

Case Study

• Anthropometry

―Weight: 43kg / 6st 11lb

―Height: 159cm / 5ft 2.5in

―BMI: 17.0kg/m2 (underweight, reference range: 20-25kg/m2)

―Wt Hx: 2/12 ago 45.5kg (5.5% weight loss 2/12)

―Moderate signs of muscle wasting and subcutaneous fat loss

• Biochemistry

―Nil current issues, checked and replete

Case Study

• Clinical

― Anorexia daily last 2/52

― Increasing SOB 1/12

― Receiving IV Abx

― O2 via nasal prongs

― Nil nausea, vomiting or diarrhoea

― Nil oedema or ascites

― MUST = 4 (high risk of malnutrition)

1. Henry. Public Health Nutr. 2005;8:1133-52. (Activity factor: 20%, Stress factor: 20%)

2. Deutz et al. Clin Nutr. 2014;33:929-36. (1.2-1.5g/kg/day )

3. Todorovic, et al. A pocket guide to clinical nutrition. 4th ed. British Dietetic Association, 2011.(30-35ml/kg/day)

Energy: 1450kcal1

Protein: 60g2

Fluid: 1400ml3

Estimated

Requirements

Case Study: Diet History

Meal Food Consumed Energy (kcal) Protein (g)

Breakfast

¼ bowl porridge with milk

1 slice bread with butter + jam

½ cup orange juice

Tea with milk and 1 sugar

60

146

29

40

2.5

2.1

0.4

0.8

Lunch

¼ tuna and mayonnaise sandwich

½ pot fruit yoghurt

½ cup orange juice

98

68

29

5.0

2.5

0.4

Dinner

Small bowl of tomato soup

1 slice of bread with butter

½ serve custard

66

107

59

1.2

2.0

1.6

Snacks 2 biscuits

Tea with milk and 1 sugar

140

40

1.9

0.8

Total 881 21.3

Case Study

Nutritional diagnosis

Inadequate energy and protein intake

Related to:

• Anorexia

• Increased requirements with infective exacerbation of COPD

As evidenced by:

• BMI: 17kg/m2

• 5.5% weight loss 2/12

• Current intake ~65% estimated energy requirement (600kcal

deficit) and ~40% estimated protein requirement (36g deficit)

Case Study

Nutritional intervention:

1. Educate patient on the importance of good nutrition for

overcoming infection and preventing further weight loss

2. Change to HEHP diet with fortified snacks and determine diet

preferences to tailor food service provision

3. Initiate high protein ONS, such as Fortisip Compact Protein BD

(600kcal, 36g protein)

4. Discuss with nursing staff the importance of encouraging oral

intake and assisting with feeding

5. Commence food chart

6. Weekly body weights

7. Review

Benefits of ONS

• ONS have an important role to play in the treatment of

undernutrition but are only effective when used appropriately

• Ways to achieve appropriate use of ONS:

‒ Any ONS must be used in conjunction with encouraging

appetite and food fortification

‒ ONS are not intended to be meal replacements

‒ ONS are best used between meals along with other snacks if

the individual can manage these

‒ ONS must only be given to the individual for whom they are

prescribed

Nutritional Supplementation

• ONS are a convenient and easy way of taking a concentrated source of

both macro- and micro-nutrients

• ONS are available in liquid, semi-solid and powdered form

• Liquid ONS are available as milk style, juice-style and yogurt tasting

drinks in a variety of flavours

• ONS are available in both fibre containing and fibre free variants

• ONS that are low volume and ready to drink ensure people with appetite

loss are able to get the calories and protein they need

• High protein ONS can be particularly useful in patients with increased

protein and micronutrient requirements during wound healing

• ONS served ice-cold are often more palatable and soothing

if the patient’s mouth is sore and help if the patient is nauseous

• ONS can also be heated, frozen or incorporated into recipes

Summary

• Protein is a macronutrient essential for the growth and

repair of body tissues and enzymes

• Current UK RNI for protein is 0.75g/kg/day for adults of

all ages

• Recent ESPEN review suggests an increase in protein

requirements of 1.0 – 1.5g/kg/day for elderly

populations

• Use of high protein ONS has been shown to have

significant benefits, including reduction in

complications, length of stay and readmissions

• Malnutrition Pathway supports the use of high protein

ONS for elderly patients and those with certain

conditions

References

• Cawood AL, Elia M, Stratton RJ. Systematic review and meta-analysis of the effects of high protein oral nutritional

supplements. Ageing Res Rev. 2012;11:278–96.

• Department of Health and Panel on Dietary Reference Values of the Committee on Medical Aspects of Food Policy. Dietary

Reference Values for Food Energy and Nutrients for the United Kingdom 41, HMSO, London, 1991.

• Deutz N, Bauer JM, Barazzoni R, et al. Protein intake and exercise for optimal muscle function with aging:

Recommendations from the ESPEN Expert Group. Clin Nutr. 2014;33:929-36.

• Henry CJ. Basal metabolic rate studies in humans: measurement and development of new equations. Public Health Nutr.

2005;8:1133-52.

• Multi-professional consensus panel. Managing Adult Malnutrition in the Community: Including a pathway for the appropriate

use of oral nutritional supplements (ONS). May 2012. Available at www.malnutritionpathway.co.uk

• Stratton R et al. Disease-related malnutrition: an evidence-based approach to treatment. Oxford: CABI publishing, 2003.

• Thomas B, Eds. Manual of dietetic Practice. 4th ed. Oxford: Blackwell, 2008.

• Todorovic VE, Micklewright A, Eds. A pocket guide to clinical nutrition. 4th ed. British Dietetic Association, 2011.

• Wingate P, Wingate R, Eds. Medical Encyclopedia. 4th ed. London. 1997, Penguin Books

• World Health Organization, Keep fit for life: Meeting the nutritional needs of older persons, WHO library, 2002.

Thank you

Documents

Nutricia · Estimating Protein Requirements Recommendations from the ESPEN Expert Group • Protein intake for optimal muscle function with aging: ―1.0-1.2 g protein/kg body weight/day