Protein: A New Perspective

Speaker: Mara Lee Beebe, MS, RD, LD, CNSCDeveloped by: Ainsley Malone, MS, RD, LD, CNSC, FAND,

FASPEN

Speaker Disclaimer

• Opinions and positions expressed by the speaker are solely thoseof the speaker and do not necessarily reflect the views, opinionsor positions of Nutricia North America or any employee thereof.

Objectives• Outline the essential role protein plays in nutrition intervention• Describe current evidence supporting protein provision in specific

populations– The older adult– Critically ill patients– The obese patient

• Outline current guideline recommendations for proteinrequirements

• Define practical strategies for achieving protein requirements viacase application

Protein – Essential Facts• Essential components of all living organisms• Most important macronutrient• Amino acids – building blocks and

intermediates– Essential, non-essential, conditionally essential

• Peptides– Di and tri peptides

• Complex proteins– Structure variation impacts function

Protein Functions Protein Digestion and Absorption

Protein Requirements• RDA: 0.8 g/kg BW/d for adults

– «Minimal amount»• Acceptable Macronutrient

Distribution Range (AMDR)– 10-35% total calories

• Research supports some may benefitfrom protein intakes greater than theRDA– Athletes / highly active adults– Older adults

Protein Requirements

• The RDA – “minimal amount” is based onmetabolic equilibrium concept

• Nitrogen balance study method utilized– 0.65 g/kg/d body weight for healthy adult– 2 standard deviations to account for

individual variation• Requirement reflects “safe” requirement

to avoid a deficiency leading to loss ofLBM

Selected Protein Requirements

Malone AM, Russell MK. NutrientRequirements. Pocket Guide to NutritionAssessmentAcademy of Nutrition and Dietetics 2015,3rd Ed.

Protein Requirements in Specific Populations

Older Adult

Critical Illness Obesity

The Older Adult

Age Related Causes of Protein Deficits

JAMDA 2013;14:542-559

Re-examination of Protein Requirements in OlderAdults• Negative nitrogen balance demonstrated with lower protein intake

in older adults1– Study compared 0.8 to 1.62 g/kg/d protein– Negative N balance of -4.6 ±3.4 vs positive 3.6 ±1

• Three weeks of consuming 0.8 g/kg/d resulted in loss of leanbody mass2– Diet controlled study of 10 ambulatory men/women (55 – 77 yrs)– Decreased urinary nitrogen– Decreased thigh muscle area

1Am J Clin Nutr 1994;60:501-09; 2J Gerontol A Biol Sci Med Sc 2001;56:M373-80

“It is fundamental, as the basis for assessing itsadequate intake, to move from a focus on meetingthe dietary protein requirement when it is defined bybody nitrogen balance studies to defining optimalintakes for health and reduction of chronic disease.”

Nutrients 2015, 7, 6874-6899; doi:10.3390/nu7085311

Recommendations for Protein in the Older Adult

ESCEO: European Society for Clinical andEconomic Aspects of Osteoporosis andOsteoarthritisESPEN: The European Society for ClinicalNutrition and MetabolismPROT-AGE: International study group to reviewdietary protein needs with aging Clin Geriatr Med 2015;31:327-338

Critical Illness

Critical Illness – Protein Catabolism

http://clinicalgate.com/nutritional-support-for-the-pediatric-patient/

Nitrogen Excretion

JPEN1979;3:452-456

Nitrogen Balance in Critical Illness• Prospective randomized trial in 50

critically ill patients - CRRT• Control group = 2 g/kg/day for 6d• Treatment group = 1.5 g to 2.5 g for 6

d – stepwise intake• Nitrogen balance on days 2, 4 and 6

– Via urine and/or dialysate analysis• Neutral and/or + nitrogen balance more

likely with > 2 g/kg/d (p=0.0001)• Nitrogen balance associated with

positive clinical outcomes Nutrition 2003:19:909-916

Protein Intake and Outcomes – ObservationalStudies

Protein Intake and Outcomes – RCT

• Ferrie S. JPEN 2015; epub• 12 month study in Australian medical/surgical ICU (n=119)• Randomized to two PN formulas

– 0.8 g/kg/d or 1.2 g/kg/d• Outcomes

– Primary: hand grip strength at discharge– Secondary: fatigue score, nitrogen balance, arm/leg anthropometrics and

ultrasound, hospital LOS and mortality

Ferrie, et al 2015 - Results

Ferrie S. JPEN 2015;epub

Conclusion: A higher amount of amino acids demonstratedimprovements in several outcomes and provides support for anincreased protein recommendation

Amino Acid Infusion and Protein Balance• Pilot study – Liebau F. Crit Care 2015;19:106• Aim: Can supplemental parenteral amino acids (AA) improve

protein turnover in critically ill patients?• 13 patients received 1 g/kg/d AA over 3 hrs in addition to

standard care during 1st week in the ICU• AA plasma concentrations increased• Protein synthesis and protein balance increased• No changes in protein breakdown

“Supplemental parenteral amino acids can be used in critically ill patients forbody protein accretion during the first week of ICU treatment”

Guidelines for Protein Intake

J Parent Ent Nutr 2016;40:159-211;http://www.criticalcarenutrition.com/docs/CPGs%202015/4.2c%202015.pdfClin Nutr 2009;28:359-479

ASPEN/SCCM Protein Recommendations

Taylor B. CCM 2016:44:390-438; McClave S. JPEN2016;40:159-211

Obesity

Rationale for Underfeeding with High Protein in Obesity Choban and Dickerson - 2005

• Combined data sets from individual studies using alower calorie, high protein regimen

• Evaluated morbidly obese (Class III = BMI 40) N =70– 44 provided hypocaloric regimen– 26 provided eucaloric regimen– Via regression determined higher protein intake is needed

• 1.9 - 2.5 g/kg/IBW in critically ill patients– Trend toward worsening hyperglycemia in Class III

compared to less obese Nutr Clin Pract 2005;20:480

Protein Intake and Nitrogen Balance

Choban, Dickerson (NCP 2005;20:480)

Types I,II(BMI 30-40)

ProteinRequirements

18

Type III(BMI>40)

Protein in Obese Trauma – Dickerson2013● Prospective evaluation in critically ill older trauma

patients requiring EN or PN• Question: differences in nutrition response and clinical

outcomes in older vs younger patients● Stratified by age• 18-59 yrs (n=41); !60 yrs (n=31)

Variable ! 60 years 18-59 years P value

Kcal/kg IBW/day 21±5 18±4 0.002

Protein, g/kg IBW/day 2.1± 0.4 1.9±0.3 0.016

Serum urea nitrogen (SUN) 30±14 20±9 0.001

SUN Max 43±19 28±12 0.001

±

J Parent Ent Nutr 2013;37:342

Dickerson - 2013

● No significant clinicaloutcome differences betweenolder and younger groups

● Those who achieved apositive N Balance morelikely to survive

p=.363

● NitrogenBalance(mean) - NS

● 2.3 ± 0.3 g/kgJ Parent Ent Nutr 2013;37:342

A trial of hypocaloric high protein feeding issuggested in patients who do not have severerenal or hepatic dysfunction (Weak and EC)

Guidelines – What Do They Tell Us?

Obesity: High protein feeding may be started with 1.2 g/kg actualweight or 2-2.5 g/kg ideal body weight, with adjustment of goalprotein intake by the results of nitrogen balance studies

Critical Care: Suggest protein should be provided in a range:• BMI 30 – 40: 2 g/kg/IBW/day• BMI > 40: 2.5 g/kg/IBW/day

J Parent Ent Nutr 2013;37:714-744; J Parent Ent Nutr 2016;40:159-211

Hypocaloric HighProtein Regimens in ObesePatients - ??’s Guidelines – What Do They Tell Us?

• Observational cohort study of ICU patients• 2722 patients – 333 with Class II or III obesity• Average calorie intake – 1009 kcals• Average protein intake – 46 g/day

– 0.4 g/kg/day (IBW)• Mortality higher in the Class II obesity group (0.039)

Hypocaloric low protein feedings are associated withunfavorable outcomes. Clinical vigilance for adequate proteinprovision is suggested – A.S.P.E.N. 2013 Clinical Guidelines for the Obese Patient

Intens Care Med 2009;35:1728.

Putting It All Together How To Achieve High ProteinRequirements

• TPN formulas– Requires high amino acid base formulation– 15%– Lower base AA formulations result in increased fluid intakes– Difficulty with standardized (pre-mix) formulas

• Enteral formulas

– Improved options with introduction of very high protein EN formulas• Protein content = 35% - 37% (87.3 - 92.5 g/liter)

– Additional formulas to consider (25% protein) – Modular protein supplementation likely needed

Protein Modulars - Practicalities

• Available as powdered or liquid formulations– Powdered form requires mixing with 30 - 60 mL water– Liquid forms are typically mixed with 30 mL water

• Source of protein– Whey protein isolate– Whey/casein isolate blend– Hydrolyzed collagen with added tryptophan

• Content ranges from 6 - 15 g/serving– 1 ounce liquid or 1 packet powder

Practicalities in Achieving ProteinRequirements

BMI ProteinRequirements (75kg IBW)

EN Formula18% protein

EN Formula25% protein

EN Formula37% protein

Proteinsupplement

Per Guideline Energy Recommendations

30-40

150 g/day 55 g 83 g 115 g 35 g – 55 g/d

40+ 188 g/day 55 g 83 g 115 g 73 g – 133g/d

50+ 188 g/day 76-87 g 103-117 g 144-164 g 24 g – 112g/d

• 14 kcals/kg actual weight (200#/90.9kg) – 1270 kcals (BMI 30-50)• 22-25 kcals/kg IBW (70”/166#/75kg) – 1650 – 1875 kcals (BMI

>50)Taylor B. CCM 2016:44:390-438; McClave S. JPEN2016;40:159-211

Meeting Current Protein Guidelines Using aProtein Modular• Study aim: examine ASPEN/ESPEN protein critical care

guidelines can be met with standard/high protein formulas– Without overfeeding calories– 1.2 -1.5 g protein/kg/d– 2-2.5 g protein/kg (IBW)/d

• 139 patients on full enteral nutrition– Achieved protein requirements in 75% of patients– Using a modular protein supplement increased achieving requirements

to range of 82% to 100%

Taylor S. Clin Nutr 2016;11:e55-e62

Use of Protocols to Achieve Desired Protein Intakes

• Pep Up Protocol – Critical CareNutrition– Two options for feeding

• Volume based feeding• Trophic feeding

– Semi-elemental formula at initiation– Protein modular supplementation at

initiation– Prokinetic at initiation– All components reviewed daily

http://www.criticalcarenutrition.com/pepup/study-tools

Pep Up Protocol Effectiveness• Multicenter quality improvement

initiative• ICU’s using protocol compared with

concurrent control group of ICU’s– Respiratory and sepsis top two admission

diagnosis– APACHE 11 scores of 21.7 and 24.2

Heyland DK. J Parent Ent Nutr 2015;39:698-706

Feed Me Protocol*

• Feed Early Enteral DietAdequately for MaximumEffect

• Volume based feedingapproach

• Implemented as an alternativeto traditional “rate-based”feeding approach

* Taylor B. Nutr Clin Pract 2014;29:639-648

Feed Me Protocol Effectiveness*

• Protein – g/kg/actual weight: 1.1 (0.3) vs 1.3 (0.4) – (p=0.36)

Pt BK is a 44 yo male admitted with SBO. Consult for TPN POD# 1 from ex-lap with partialcolectomy, end ileostomy, intraperitoneal drain placement, and wound vac due to bowelperforation.Patient Information• Ht: 6’0”• Wt: 111kg• BMI 33• PMH: diverticulitis, partial colectomy

ileosigmoid anastomosis and VHR 6months ago due to colonic obstruction,Roux-en-y gastric bypass 9 years ago,peripheral neuropathy, gout, alcohol abuse.

Clinical Information• Intubated and sedated• NPO since admission (6 days).• Medications: protonix, propofol, levophed,

vasopressin, NS MIV• Pertinent labs: Na 142, K 3.5, Cl 118, CO2

20, BUN 23, creat 1.37, phos 2.3, mg 2.1,ionized calcium 1.12, WBC 14.9, PH7.314

Case Application

Nutrition Assessment

• Unable to obtain full nutritionhistory due to vent.

• Per H&P, symptoms started dayof admission. No reported wtloss.

• No signs of muscle or fat wasting.• + Edema but was severely fluid

positive at time of assessment.• History of alcohol abuse-8

beers/day but recently reduced toa few beers 3-4 days per week perH&P.

• At risk for malnutrition.

Estimated Energy Needs:• 1215-1554Kcals/day (11-14kcals/kg actual wt)*• 1361Kcals/day (60% of Penn State ’03)Estimated protein needs:• 162g (2g/kg IBW)* Additional needs:• Thiamine/folate for alcohol hx *Per Critical Care Guidelines

Hospital Course and NutritionInterventionDay 1-3• Consult to Nutrition Support Team to start parenteral nutrition (PN). Intervention:• Goal PN (including propofol) provided 1450kcals (14kcals/kg actual wt) and 165g pro

(2g/kg IBW).• Lipids held due to propofol (300kcals/day).• Multiple electrolyte abnormalities addressed. • Trophic tube feeds (TF) initiated on day 3 by surgery team.

Hospital Course and NutritionInterventionDay 4• Consult to advance tube feeding slowly to goal. Propofol weaned off. Intervention:• Very high protein formula increased 10ml every 8 hrs to goal of 60ml/hr with a protein

modular 3x per day to provide 1560kcals and 160g pro per day.• Wean PN per with TF advancement.

Hospital Course and NutritionInterventionDay 7• Emergently taken to OR for abdominal washout with temporary abdominal closure due

to intraabdominal abscess and wound dehiscence. Intervention:• TF held and PN resumed previous goal.

Hospital Course and NutritionInterventionDay 9• Pt returned to the OR on day 9 for complex wound closure. Consult to restart tube feeds

post-op. Intervention:• TF continued per previous goal (14kcals/kg actual wt and 2g pro/kg IBW).• PN wean ordered per protocol.• Pt continued to tolerate TF at goal rate while on the ventilator.• Nitrogen balance study obtained after 3 days at goal TF.• Protein increased to 2.3g/kg IBW due to negative result.

Conclusion

• BK tolerated both parenteral and enteral nutrition withouthyperglycemia while on the hypocaloric regimen.

• A protein modular was required to meet the patient’s proteinneeds while on tube feedings despite using a very high proteinenteral formula.

• BK transition to a skilled nursing facility at discharge on both TFand an oral diet.

Conclusion and Take Away

• Protein is an essential component of nutritionintervention

• Re-examination of requirements for the older adult• Increasing evidence toward improved outcomes

with early protein intakes in the critically ill• High protein with lower calories of potential

benefit in the obese patient• Higher protein enteral formulas and/or modular

protein supplementation necessary

References1. Wolfe RR, Miller SL. The recommended dietary allowance of protein: A misunderstood concept. JAMA 2008;299:2891-2893.2. Campbell WW, Crim MC, Dallal GE, et al. Increased protein requirements in elderly people: new data and retrospective reassessments. Am J Clin Nutr 1994;60:501-09.3. Campbell WW, Trappe TA, Wolfe RR, Evans WJ. The recommended dietary allowance for protein may not be adequate for older people to maintain skeletal muscle. J

Gerontol A Biol Sci Med Sci 2001; 56:M373-80.4. Nowson C, O’Connell S. Protein requirements and recommendations for older people: a review. Nutrients 2015;7:6874-6899.5. Bauer JM, Diekmann R. Protein and older persons. Clin Geriatr Med 2015;31(3):327-338.6. Long CL, Schaffel BS, Geiger JW, et al. Metabolic response to injury and illness: estimation of energy and protein needs from indirect calorimetry and nitrogen balance.

JPEN J Parenter Enteral Nutr 1979;3:452-456.7. Scheinkestel CD, Kar L, Marshall K, et al. Prospective randomized trial to assess caloric and protein needs of critically Ill, anuric, ventilated patients requiring continuous

renal replacement therapy. Nutrition 2003;19:909-916.8. Weijs PJ, Stapel SN, deGroot SD, et al. Optimal protein and energy nutrition decreases mortality in mechanically ventilated, critically ill patients: a prospective

observational cohort study. JPEN J Parenter Enteral Nutr 2012;36:60-68.9. Allingstrup MJ, Esmailzadeh N, Knudsen AW, et al. Provision of protein and energy in relation to measured requirements in intensive care patients Clin Nutr 2012;31:462-

468.10. Nicolo M, Heyland DK, Chittam J, et al. Clinical Outcomes Related to Protein Delivery in a Critically Ill Population: A Multicenter, Multinational Observation Study.

JPEN J Parenter Enteral Nutr 2016;40:45-51.11. Ferrie S, Allman-Farinelli M, Daley M, Smith K. Protein Requirements in the Critically Ill: A Randomized Controlled Trial Using Parenteral Nutrition. JPEN J Parenter

Enteral Nutr 2016;40:795-805.12. Liebau F, Sundstrom M, van Loon LJ, et al. Short-term amino acid infusion improves protein balance in critically ill patients. Crit Care 2015;19:106.13. Choban PS, Dickerson RN. Morbid obesity and nutrition support: is bigger different? Nutr Clin Pract 2005;20:480-487.14. Dickerson RN, Medline TL, Smith AC, et al. Hypocaloric, high-protein nutrition therapy in older vs younger critically ill patients with obesity. JPEN J Parenter Enteral

Nutr 2013;37:342-351.15. Choban P, Dickerson R, Malone A, Compher C. A, American Society for Parenteral and Enteral Nutrition Clinical Guideline: Adult Obesity. JPEN J Parent Ent Nutr

2013; 37: 714-744.

References 1. Alberda C, Gramlich L, Jones N, et al. The relationship between nutritional intake and clinical outcomes in critically ill patients: results of an international multicenter

observational study. Intensive Care Med 2009;35:1728-1737.2. Taylor ST, Dumont N, Clemente R, et al. Critical care: Meeting protein requirements without overfeeding energy. Clin Nutr ESPEN 2016;11:e55-e62.3. Heyland DK, Dhaliwal R, Lemieux M, Wang M, Day AG. Implementing the pep up protocol in critical care units in canada: results of a multicenter, quality improvement

study. JPEN J Parenter Enteral Nutr 2015;39:698-706.4. Taylor B, Brody R, Denmark R, Southard R, Byham-Gray L. Improving enteral delivery through the adoption of the “feed early enteral diet adequately for maximum effect

(feed me)” protocol in a surgical trauma ICU: a quality improvement study. JPEN J Parenter Enteral Nutr 2015;39:698-706.

Thank You!!