Nutricia. The importance of protein: an update on the latest evidence

Transcription

1 Nutricia The importance of protein: an update on the latest evidence

2 Outline Introduction Review the definition, function and dietary sources of protein Protein Requirements High Protein ONS Evidence Case study

3 1 Introduction

4 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. 4 th Ed. Blackwell Publishing Ltd, 2007.

5 Main Protein Functions Protein Functions Structural Transport Hormonal Enzymes Immune functions Buffering function Characteristics 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 Proteins act as transport carriers in the blood and body fluids for many molecules and nutrients, e.g. haemoglobin, lipoproteins Some hormones are made up of proteins or their constituents, peptides and amino acids e.g. insulin All enzymes are proteins. Extracellular enzymes include the digestive enzymes, e.g. amylase. Intracellular enzymes are involved in metabolic pathways Antibodies are protein molecules. Proteins are also involved in the acute phase response of inflammation/infection Albumin acts as a buffer in the maintenance of blood ph Source: Thomas., et al. Manual of dietetic Practice. 4 th Ed. Blackwell Publishing Ltd, 2007.

6 2 Protein Requirements

7 Estimating Protein Requirements Current Guidelines for Estimating Protein Requirements The RNI for healthy adults (both male and female) aged years and 50+ years is estimated at 0.75g protein/kg of body weight per day 1 A male 50+years (70kg) the RNI for protein is approximately 53g/d The World Health Organisation (WHO) recommend that healthy older people need g protein/kg body weight per day 2 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, World Health Organization. Keep fit for life: Meeting the nutritional needs of older persons, WHO library, 2002.

8 Estimating Protein Requirements Revision of protein requirements by the ESPEN Expert Group Source: Deutz et al. Clin Nutr. 2014;33:

9 Estimating Protein Requirements 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) Source: Deutz et al. Clin Nutr. 2014;33:

10 Estimating Protein Requirements Recommendations from the ESPEN Expert Group Protein intake for optimal muscle function with aging: g protein/kg body weight/day for healthy older adults 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) g/d (acute or chronic illness) Source: Deutz et al. Clin Nutr. 2014;33:

11 Protein (g/day)* Estimating Protein Requirements Up to 52.5g deficit during illness when compared to ESPEN recommendations RNI WHO ESPEN (Healthy) ESPEN (Illness) *based on a 50+ year old male who weighs 70kg 1. Department of Health. Dietary Reference Values for Food Energy and Nutrients for the United Kingdom 41, HMSO, London, World Health Organization. Keep fit for life: Meeting the nutritional needs of older persons, WHO library, Deutz et al. Clin Nutr. 2014;33:

12 3 Evidence

13 Effects of inadequate protein intake Muscle wasting 1 When the body requires extra energy, muscle is broken down in order to release protein Poor wound healing 1,2 Protein is integral to the management of any wound as it is required for wound to heal Increased susceptibility to infection 1 As antibodies are proteins synthesised by white blood cells, a protein deficit may impact on the body s ability to fight infection Anaemia 1 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. 4 th Ed. Blackwell Publishing Ltd, Stratton R et al. Disease-related malnutrition: an evidence-based approach to treatment. CABI publishing, Wingate P, et al. Medical Encyclopaedia. 4 th Ed. Penguin Books, 1997.

14 Factors affecting protein intake Physical dependence Poor food security Reduced ability to utilise protein Change in food preference Inadequate intake Reduced protein intake & stores Commercially available supplements instead of prescribed supplements

15 Effects of High Protein Oral Nutrition Support (ONS) Carwood et al 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 kcal/ml Percentage from protein ranged from 20-54% Source: Cawood, et al. Ageing Res Rev. 2012;11:

16 Effects of High Protein ONS Carwood et al Systematic review and meta-analysis 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 Source: Cawood, et al. Ageing Res Rev. 2012;11:

17 Effects of High Protein ONS Carwood et al Systematic review and meta-analysis 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 Source: Cawood, et al. Ageing Res Rev. 2012;11:

18 Support for High Protein ONS High Protein ONS recommended within the Malnutrition Pathway There are a number of different ONS which may be of benefit in specific groups 1 : 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 Mar 14, 2016.

19 4 Case Study

20 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

21 Case Study Anthropometry Weight: 43kg / 6st 11lb Height: 159cm / 5ft 2.5in BMI: 17.0kg/m 2 (underweight, reference range: 20-25kg/m 2 ) 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

22 Case Study Clinical Anorexia daily last 2/52 Increasing SOB 1/12 Receiving IV Abx O 2 via nasal prongs Nil nausea, vomiting or diarrhoea Nil oedema or ascites MUST = 4 (high risk of malnutrition) Estimated Requirements Energy: 1450kcal 1 Protein: 60g 2 Fluid: 1400ml 3 1. Henry. Public Health Nutr. 2005;8: (Activity factor: 20%, Stress factor: 20%) 2. Deutz et al. Clin Nutr. 2014;33: ( g/kg/day ) 3. Todorovic, et al. A pocket guide to clinical nutrition. 4 th ed. British Dietetic Association, 2011.(30-35ml/kg/day)

23 Case Study: Diet History Meal Food Consumed Energy (kcal) Protein (g) Breakfast Lunch Dinner ¼ bowl porridge with milk 1 slice bread with butter + jam ½ cup orange juice Tea with milk and 1 sugar ¼ tuna and mayonnaise sandwich ½ pot fruit yoghurt ½ cup orange juice Small bowl of tomato soup 1 slice of bread with butter ½ serve custard Snacks 2 biscuits Tea with milk and 1 sugar Total

24 Case Study Nutritional diagnosis Inadequate energy and protein intake Related to: Anorexia Increased requirements with infective exacerbation of COPD As evidenced by: BMI: 17kg/m 2 5.5% weight loss 2/12 Current intake ~65% estimated energy requirement (600kcal deficit) and ~40% estimated protein requirement (36g deficit)

25 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

26 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

27 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

28 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 g/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

29 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: 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, 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: Henry CJ. Basal metabolic rate studies in humans: measurement and development of new equations. Public Health Nutr. 2005;8: Multi-professional consensus panel. Managing Adult Malnutrition in the Community: Including a pathway for the appropriate use of oral nutritional supplements (ONS). May Available at Stratton R et al. Disease-related malnutrition: an evidence-based approach to treatment. Oxford: CABI publishing, Thomas B, Eds. Manual of dietetic Practice. 4 th ed. Oxford: Blackwell, Todorovic VE, Micklewright A, Eds. A pocket guide to clinical nutrition. 4 th ed. British Dietetic Association, Wingate P, Wingate R, Eds. Medical Encyclopedia. 4 th ed. London. 1997, Penguin Books World Health Organization, Keep fit for life: Meeting the nutritional needs of older persons, WHO library, 2002.

30 Thank you