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

Deutz NEP, Clin Nutr 2014Bauer J, J Am Med Dir Assoc 2013

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


• 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)


• 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

Burd NA, Exercise and Sport Sciences Reviews 2013

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


• Timing




Characteristics and

specific needs of the

individuals

• Age

• Gender

• Health status

• Physiological status

• Energy balance

Qualitative needs in food

protein?

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)


Characteristics of

dietary protein

• Protein sources

• Food matrix

• Cooking


• Timing




Characteristics and

specific needs of the

individuals

• Age

• Gender

• Health status


• Energy balance


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

Tang JE, J Appl Physiol 2009

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


Characteristics of

dietary protein

• Protein sources

• Food matrix

• Cooking


• Timing




Specific needs

of the individuals

• Age

• Gender

• Health status


• Energy balance


protein?

Faster and higher!

Boirie Y, Proc Natl Acad Sci 1997

Boirie Y, Curr Opin Clin Nutr Metab Care 2018

« 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


Characteristics of

dietary protein

• Protein sources

• Food matrix

• Cooking


• Timing




Specific needs

of the individuals

• Age

• Gender

• Health status


• Energy balance


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

Timing of protein ingestion and exercise

Paddon-Jones D, Am J Clin Nutr 2015


Characteristics of dietary

protein

• Protein sources

• Food matrix

• Cooking


• Timing




Specific needs

of the individuals

• Age

• Gender

• Health status


• Energy balance


protein?

Boutrou R, AJCN 2013

Central and/or peripheral actions• CN system• Immune system• Cardiovascular system• Metabolism


Characteristics of

dietary protein

• Protein sources

• Food matrix

• Cooking


• Timing




Specific needs

of the individuals

• Age

• Gender

• Health status


• Energy balance


protein?

Multimodal approach to counteract sarcopenia

JAMDA, 2015

AJCN, 2016

Clin Nutr 2018

Am J Clin Nutr 2005

Lavigne C, AJP 2000

Pal S, Br J Nutr 2010

Jakubowicz D, J Nutr Biochem 2013

J Am Coll Nutr 2007

Br J Nutr 2003

FASEB J, 2018

Nutrients, 2018


Characteristics of

dietary protein

• Protein sources

• Food matrix

• Cooking


• Timing




Specific needs

of the individuals

• Age

• Gender

• Health status


• Energy balance


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…)

Unité de Nutrition Humaine, UMR 1019

Clermont-Ferrand - Theix

Thank you

Team “diet, muscle health

and sarcopenia”

qualitative needs in clinical situations y. boirie (fr) · qualitative needs in clinical situations...

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