QUALITATIVE NEEDS IN CLINICAL SITUATIONS Y. Boirie (FR) · Qualitative needs in clinical situations...
Transcript of QUALITATIVE NEEDS IN CLINICAL SITUATIONS Y. Boirie (FR) · Qualitative needs in clinical situations...
ESPEN Congress Krakow 2019
Proteins In Clinical Nutrition
QUALITATIVE NEEDS IN CLINICAL SITUATIONS
Y. Boirie (FR)
wwww.espen.org www.espencongress.com
Proteins in clinical nutrition:
Qualitative needs in clinical situations
Pr. Yves BoirieUniversity of Clermont AuvergneHuman Nutrition Unit, Human Nutrition Research Centre AuvergneClinical Nutrition Department, University Hospital of Clermont-FerrandClermont-Ferrand, France
41st ESPEN Congress
Krakow
1st September, 2019
no conflict of interest to disclose
Weijzen MEG, JNHA 2019
n=101 patients (age: 67±10 y)
Average 6d : 0.59±0.18 (M) and 0.50±0.21 (F) g·kg-1·d-1
Qualitative needs in clinical situations
• Protein intake beyond RDA for optimal health, but qualitative aspects of protein intake underestimated and relevant when intakes are limited
• Traditionally, quality=ability of food proteins to achieve defined actions:
– Ability to provide specific patterns of amino acids (AA)
– Capacity to sustain N balance, growth or maintain body protein mass
• Necessity to expand the concept to integrate newly emerging actions of dietary protein modulating metabolic issues (cell signaling, oxidative stress,
inflammation, digestive functions, microbiota, glucose homeostasis, satiety, …)
• New challenges regarding sustainability of food production systems and climate change (vegetable vs animal protein production/utilization)
Qualitative needs in clinical situations
• Why to define qualitative needs? to respond to specific
qualitative changes in protein metabolism
• How to define qualitative needs? in relation to dietary
proteins characteristics but not only (food matrix, timing,
speed of absorption, non-protein nutritional compounds…)
• Which qualitative needs for which clinical situations? to
respond to qualitative needs of the individuals as influenced
by age, health status, physiological status, energy balance
Cyclic pattern of muscle protein metabolism in response to meal intake in healthy adults
Postabsorptive Postprandial
Muscleproteinbalance
Net catabolism(S < C)
Postabsorptive Postprandial
0
MEAL MEAL
Net synthesis(S > C)
Postabsorptive
C
S
0
MEAL MEAL
Postprandial Postabsorptive Postprandial Postabsorptive
Impaired protein metabolism response to meal intake in older adults: anabolic resistance
Postabsorptive
Blunted muscle
response to regular
protein intakes
Mosoni L, AJP 1995Volpi E, JCEM 2000Guillet C, FASEB J 2004Cuthbertson D, FASEB J 2005Katsanos K, AJCN 2005Burd NA, ESSR 2013Wall BT, PlosOne 2015Moore DR, J Gerontol 2015Dirks ML, JAP 2017
Muscleproteinbalance
Meal
Carbohydrates
Lipids
Proteins AA
Intake Digestion
Absorption
Defect in postprandial availability and/or action
of dietary amino acids for body tissues?
Protein intake: amount/quality
Meal
Carbohydrates
Lipids
Proteins AA
Postprandial availability of dietary amino acids for tissues:
splanchnic extraction of dietary amino acids
AA
Liver
Tissue/secretedgut proteins
Gut
Splanchnic « first pass »
Boirie Y, AJCN 1997
Volpi E, AJP 1999
Jourdan M, PlosOne 2011
Moreau K, JAMDA 2013
Muscle
Inflammatory
proteins
Tissue/secretedliver proteins
AA
?
AA use in the splanchnic area AA availability for muscle
Intake Digestion
Absorption
AA availability
Meal
Carbohydrates
Fat
Proteins AA
Muscle
?
Postprandial availability of dietary amino acids for body tissues:
lower response of muscle protein synthesis to nutrients intake
IntakeDigestion
Absorption
AA pattern, transport,
kinetics, signaling
Muscle
protein
response
Insulin resistance
Mitoch. Dysfct.
Inflammation
Lipotoxicity
Inactivity
Food protein
Biochemical
compositionMatrix
Processing
Amino acid metabolism
in the splanchnic area
(gut, liver)
Amino acid peripheral availability
Dynamics, quantity, quality
Muscle metabolism
Amount
Source
Determinants of dietary protein digestion and AA availability
Cooking
Timing
Meal distribution
Protein digestion in the small intestine
Dynamics, Quantity, End-products
Chewing
Absorption
Clotting
Enzyme
access
Characteristics of
dietary protein
• Protein sources
• Food matrix
• Cooking
• Speed of absorption
• Timing
• Meal Distribution
• Biopeptides production
• Nutrient interactions
2 major aspects of protein qualitative needs
Characteristics of
dietary protein
• Protein sources
• Food matrix
• Cooking
• Speed of absorption
• Timing
• Meal Distribution
• Biopeptides production
• Nutrient interactions
Characteristics and
specific needs of the
individuals
• Age
• Gender
• Health status
• Physiological status
• Energy balance
Qualitative needs in food
protein?
Qualitative needs in clinical situations
• Why to define qualitative needs? to respond to specific
qualitative changes in protein metabolism
• How to define qualitative needs? in relation to dietary
proteins characteristics but not only (food matrix, timing,
speed of absorption, non-protein nutritional compounds…)
• Which qualitative needs for which clinical situations? to
respond to qualitative needs of the individuals as influenced
by age, health status, physiological status, energy balance
Protein content
Oleaginous seeds 30-35Protein Seeds 20-30Cereals = 15Green vegetables = 10
Protein content (g / 100g dry matter):Meat / fish> 70Eggs = 50Cheeses 40-50Milk / yogurts 28-30
The food quality of a protein: the classic criteria
EAA contentMethionine
LysineProfile in EAA
Digestibility
Lower digestibilityand increased gutendogenous losses
Digestibility in
small intestine
Vegetable protein sources:• Network of indigestible carbohydrate
constituents• Protein structure• Presence of antinutritional factors
The food quality of a protein: the classic criteria
Millward DJ, AJCN 2008; Tomé D, Br J Nutr 2012; FAO report 2014
[same AA] (mg/g reference protein)DIAAS % =
[limiting digestible AA] (mg/g tested protein) x100
Digestible Indispensable Amino Acids Score (DIAAS)
2 major aspects of protein qualitative needs
Characteristics of
dietary protein
• Protein sources
• Food matrix
• Cooking
• Speed of absorption
• Timing
• Meal Distribution
• Biopeptides production
• Nutrient interactions
Characteristics and
specific needs of the
individuals
• Age
• Gender
• Health status
• Physiological status
• Energy balance
Qualitative needs in food
protein?
Nitrogen losses by deamination or intestinal loss are higher with vegetable proteins
N splanchnic retention is greaterwith plant proteins
Peripheral availability of nitrogen is lower with plant proteins
Redistribution of nitrogenflux in the body
Model-predicted kinetics of the distribution of retained dietary N and lost dietary N after the ingestion of a meal composed of sucrose with either milk protein (SMP, n = 9, panel A) or soy protein (SSP, n = 10, panel B).
Distribution of dietary nitrogen between splanchnic area and peripheral tissues
Milk proteins Soy proteins
Fouillet H, J Nutr 2002
=> The metabolic orientations of amino acids derived from vegetable and animal proteins are
different
What are the consequences on muscle protein metabolism?
growing rats 20 days Isoproteic diets
BeansGroup 1
Group 2 Lentils
Group 3 Casein
Intestine
Synthesis and protein content
Sleketal muscle
Synthesis and protein content
Pirman T, Ann Nutr Metab 2006
young men isonitrogenous 0.21 g protein/(kg.
4 h) protein-based test meals
Milk proteinsGroup 1
Group 2 Soy protein
Luiking Y, Clin Nutr. 2011
young men 18 g protein
Milk proteinsGroup 1
Group 2 Soy protein
Leg muscle protein synthesis
AA concentration in lower limbs muscles
Wilkinson SB, Am J Clin Nutr. 2007
Mean protein intake was 0.90 g ·kg–1· d–1Mean 5-y change in muscle CSA was −9.8 cm².
No association was observed between energy adjusted total, animal or plant protein intakeand muscle CSA at year 6
Verreijen AM, Am J Clin Nutr 2019
Van Vliet S, J Nutr 2015
1) Increasing protein intake
2) Fortify protein intake by some AAs: limiting AA of foods
(methionine, lysine, and/or leucine)
3) Mixing multiple protein sources to provide a more balanced amino acid profile
4) selective breeding of plant sources to improve amino acid profiles
How to improve the nutritional quality of vegetable proteins for muscle proteins?
Improvement of the peripheral bioavailability of amino acids
Increasing protein intake
In Older Men, 60g of wheat protein increases muscle protein synthesis more than 35g of milk proteins but increase in the oxidation rate of amino acids (and urea synthesis)
Fortify protein intake by some AAs: limiting AA of foods
Fortifying wheat proteins with leucine increases postprandial muscle protein synthesis
Fortification of soy protein with branched chain amino acids reduces splanchnic extraction and increases postprandial protein balance
Gorissen SHM, J Nutr 2016
Norton LE, Nutr Metab 2012
Engelen MPKJ, Am J Clin Nutr. 2007
0
100
200
300
400
500
600
700
Casein gluten-wheatpasta
faba bean-wheat pasta
Muscle weight (mg)
*
*p<0,05 vs C and F
0
2
4
6
8
10
12
14
16
18
20
Casein gluten-wheatpasta
faba bean-wheatpasta
Muscle protein content (%)
*
*p<0,05 vs C and F
The mixture of wheat and faba bean flour helps to balance the Essential AA profile
Mixing multiple sources
Jarzaguet M, Food & Function, 2018
Laleg K, Br J Nutr 2018
2 major aspects of protein qualitative needs
Characteristics of
dietary protein
• Protein sources
• Food matrix
• Cooking
• Speed of absorption
• Timing
• Meal Distribution
• Biopeptides production
• Nutrient interactions
Specific needs
of the individuals
• Age
• Gender
• Health status
• Physiological status
• Energy balance
Qualitative needs in food
protein?
« Fast Protein » concept: postprandial protein anabolism• with the same protein intake
• independently of AA composition
CASEIN
WHEY
Boirie Y , Curr Opin Clin Nutr Metab Care 2018
Boirie Y, PNAS 1997
Dangin M, Am J Physiol 2001
Plasma
post-P
EAA
Bax ML, PlosOne 2013
Healthy natural dentitionComplete dental prosthesis
Remond D, AJCN 2007
Plasma Leucine
Barbé F, Food Chem 2014
Buffière C, AJCN 2018
Plasma Leucine
Plasma Leucine
Chewing
matrix
Cooking
Cooking
CASCAS-H
WHEY
Pennings B, Boirie Y, Am J Clin Nutr 2011
« peak » plasma AA (depending on the speed of absorption) is key for muscle protein synthesis
whey
casein
Muscle protein synthesis
Beneficial effect of fast
protein on muscle
anabolism, strength and
fatigue in elderly
Walrand S, Clin Nutr 2016 Gryson C, JAMDA 2014
10 days
« Fast protein »
4 months
« Fast protein »
+ Exercise
2 major aspects of protein qualitative needs
Characteristics of
dietary protein
• Protein sources
• Food matrix
• Cooking
• Speed of absorption
• Timing
• Meal Distribution
• Biopeptides production
• Nutrient interactions
Specific needs
of the individuals
• Age
• Gender
• Health status
• Physiological status
• Energy balance
Qualitative needs in food
protein?
Lunch
Breakfast
Snack
DinnerBreakfast
Dinner
Lunch
(80%)
Spread-feeding Pulse-feeding Pulse feeding:
nitrogen
retention in
elderly
Arnal MA, AJCN 1999
Bouillanne O, Clin Nutr 2012
Application in patients
Dietary protein distribution and timing?
Muscle anabolic threshold? (young vs elderly?)
Mamerow MM, J Nutr 2014Paddon-Jones D, Am J Clin Nutr 2015
Farsijani, Am J Clin Nutr 2016Farsijani, Am J Clin Nutr 2017
evening?
Chanet A, J Nutr 2017
Basal state 6 weeks supplementation Muscle gain as appendicular
and leg lean mass after 6
weeks supplementation
2 major aspects of protein qualitative needs
Characteristics of dietary
protein
• Protein sources
• Food matrix
• Cooking
• Speed of absorption
• Timing
• Meal Distribution
• Biopeptides production
• Nutrient interactions
Specific needs
of the individuals
• Age
• Gender
• Health status
• Physiological status
• Energy balance
Qualitative needs in food
protein?
Boutrou R, AJCN 2013
Central and/or peripheral actions• CN system• Immune system• Cardiovascular system• Metabolism
2 major aspects of protein qualitative needs
Characteristics of
dietary protein
• Protein sources
• Food matrix
• Cooking
• Speed of absorption
• Timing
• Meal Distribution
• Biopeptides production
• Nutrient interactions
Specific needs
of the individuals
• Age
• Gender
• Health status
• Physiological status
• Energy balance
Qualitative needs in food
protein?
Qualitative needs in clinical situations
• Why to define qualitative needs? to respond to specific
qualitative changes in protein metabolism
• How to define qualitative needs? in relation to dietary
proteins characteristics but not only (food matrix, timing,
speed of absorption, non-protein nutritional compounds…)
• Which qualitative needs for which clinical situations? to
respond to qualitative needs of the individuals as influenced
by age, health status, physiological status, energy balance
2 major aspects of protein qualitative needs
Characteristics of
dietary protein
• Protein sources
• Food matrix
• Cooking
• Speed of absorption
• Timing
• Meal Distribution
• Biopeptides production
• Nutrient interactions
Specific needs
of the individuals
• Age
• Gender
• Health status
• Physiological status
• Energy balance
Qualitative needs in food
protein
The nutritional quality of a protein is primarily determined by itsessential amino acid composition and bioavailability (DIAAS), but manyother aspects of protein nutrition have to be considered (timing, foodpattern, meal distribution, nutrients interactions)
The speed of digestion is an interesting criterion to consider, it isusually not assessed. It depends on food physicochemical criteria,interactions with culinary preparation methods, and individualphysiology (chewing capacity)
Specific 'health' effects could be related to the release of bioactivepeptides during digestion (important field of investigation)
Qualitative needs might be tailored according to the clinical situations (preventive vs recovery conditions) and according to the health impact expected (anabolism, immune, glucose homeostasis, satiety…)