Protein for Healthy Bones Wendy E. Ward Professor & Canada Research Chair Faculty of Applied Health Sciences All Rights Reserved

Outline What is the current recommendation for protein intake? How to consume? Current Recommendation (RDA) for Protein Intake Why is more needed? Suggested intake Distribution throughout the day Source & contribution to overall nutrition Calcium as a modifier of a beneficial effect Level of Dietary Protein to Support Muscle & Bone During Aging

Outline What is the current recommendation for protein intake? How to consume? Current Recommendation (RDA) for Protein Intake Why is more needed? Suggested intake Distribution throughout the day Is higher protein harmful to bone? Source & contribution to overall nutrition Calcium as a modifier of a beneficial effect Level of Dietary Protein to Support Muscle & Bone During Aging

0.8 g protein/kg body weight/day Recommended Dietary Allowance (RDA) 0.8 g protein/kg body weight/day for all ages!

0.8 g protein/kg body weight/day Recommended Dietary Allowance (RDA) 0.8 g protein/kg body weight/day for all ages! For individuals of 60 – 80 kg body weight 48 – 64 g protein/day

How to consume 48-64 g protein/day? ’Scoop’ of Whey Protein: 25 g protein, 113 kcal

0.8 g protein/kg body weight/day Recommended Dietary Allowance (RDA) 0.8 g protein/kg body weight/day for all ages! For individuals of 60 – 80 kg body weight 48 – 64 g protein/day

0.8 g protein/kg body weight/day But…..likely higher need due to aging Recommended Dietary Allowance (RDA) 0.8 g protein/kg body weight/day for all ages! For individuals of 60 – 80 kg body weight 48 – 64 g protein/day But…..likely higher need due to aging

Outline What is the current recommendation for protein intake? How to consume? Current Recommendation (RDA) for Protein Intake Why is more needed? Suggested intake Distribution throughout the day Is higher protein harmful to bone? Source & contribution to overall nutrition Calcium as a modifier of a beneficial effect Level of Dietary Protein to Support Muscle & Bone During Aging

Why might we need higher levels of dietary protein as we age? Current Recommendation for Protein Sarcopenia: loss of muscle mass & function Ability to absorb and utilize protein is compromised: ↓ protein digestion ↓ absorption of amino acids (building blocks of protein) ↓ uptake into muscle With aging, muscle does not respond as effectively to protein ↓ protein synthesis -Position paper from the PROT-AGE Study Group. JAMDA. 2013:14:542-559 -Recommendations from the ESPEN Expert Group. Clin Nutr. 2014;33:929-936 -Consensus statement of ESCEO. Maturitas. 2014;79:122-132

Maintain Muscle Mass & Strength in 20-25 g protein at each meal for an Current Recommendation for Protein Suggested Intake…….. Maintain Muscle Mass & Strength in Healthy Older Adults: 1.0-1.2 g protein/kg bw/day 20-25 g protein at each meal for an ‘even’ distribution -Position paper from the PROT-AGE Study Group. JAMDA. 2013:14:542-559 -Recommendations from the ESPEN Expert Group. Clin Nutr. 2014;33:929-936 -Consensus statement of ESCEO. Maturitas. 2014;79:122-132

Higher Protein Intake Supports Muscle Mass & Function Higher protein intake (2-6 year follow-up): less loss of mid-arm muscle area, lean mass higher muscle mass, leg lean mass greater arm & leg strength function: walk speed (normal, fast) ‘Even’ protein consumption (2-3 year follow-up): higher lean mass, leg lean mass greater muscle strength, leg strength Position paper from the PROT-AGE Study Group. JAMDA. 2013:14:542-559 Recommendations from the ESPEN Expert Group. Clin Nutr. 2014;33:929-936 Consensus statement of ESCEO. Maturitas. 2014;79:122-132

Stronger Muscle Benefits Bone Health BMD, Fracture? Attenuate loss of muscle mass, strength & performance Greater walking distance Reduced risk of falls

Stronger Muscle Benefits Bone Health BMD, Fracture? Attenuate loss of muscle mass, strength & performance Greater walking distance Reduced risk of falls There may also be direct benefits of protein to bone health

Is higher protein harmful to bone? ↑ dietary protein ↑ urinary Ca excretion ↓ bone mineral ↑ risk of fracture Assuming Ca is from bone….

Do higher protein diets adversely affect bone health? Is higher protein harmful to bone? ↑ dietary protein ↑ Ca absorption ↑ urinary Ca excretion ? ? bone mineral ? risk of fracture

Is higher protein harmful to bone? ↑ dietary protein ↑ Ca absorption ↑ urinary Ca excretion + direct effect ↑ IGF-1 ↑ muscle mass, strength, function ✔️associated with falls ? ? bone mineral ? risk of fracture

Protein Supplementation High Dietary Protein & Calcium Excretion Protein Supplementation Healthy older men & women, > 50 y, n=32 <0.85 g protein/kg or less, <700 mg Ca low vs. high dietary protein (meat), 0.75 vs.1.6 g/kg 9 week intervention No increase in calcium excretion or adverse effect on biochemical markers of bone turnover Some favourable effects: ↑ IGF-1 ↓ N-telopeptide (Dawson-Hughes et al. JCEM. 2004;89:1169)

Protein & Bone Health

2017

Two research questions: Effect of high versus low protein intake 2017 Two research questions: Effect of high versus low protein intake Is there a benefit of Ca with dietary protein?

How do Calcium and Protein work together for bone health? “Building blocks of bone” Bone contains matrix and mineral: Matrix: protein such as collagen Mineral: such as calcium and other minerals Mineralization is the incorporation of mineral within the matrix.

Two research questions: Effect of high versus low protein intake 2017 Two research questions: Effect of high versus low protein intake Is there a benefit of Ca with dietary protein? 16 randomized controlled trials (RCTs) 20 prospective cohort studies Various outcomes: BMD, fracture, markers Different skeletal sites

Positive trends for high vs. low protein intakes to benefit BMD 2017 FINDINGS: 1. High vs. low intakes: Positive trends for high vs. low protein intakes to benefit BMD -spine but not total hip or body, femur neck No adverse effects on BMD 2. Benefit of protein with Ca? Evidence not strong, very different study designs make it difficult to compare findings from the studies

Positive trends for high vs. low protein intakes to benefit BMD 2017 Conclusion: Existing data are not consistent enough to warrant a clinical guideline to recommend that individuals increase their protein intake. FINDINGS: 1. High vs. low intakes: Positive trends for high vs. low protein intakes to benefit BMD -spine but not total hip or body, femur neck No adverse effects on BMD 2. Benefit of protein with Ca? Evidence not strong, very different study designs make it difficult to compare findings from the studies

Calcium & Protein

Calcium Modulates Association of Protein & Hip Fracture Framingham Offspring Cohort Mean age = 75 years 44 hip fractures over 12 years (10 m, 34 f) Assessed intakes of protein and calcium using a diet questionnaire (FFQ) <800 mg Ca/day T3 vs. T1 (60 vs. 34 g/d) ↑ hip fracture risk >800 mg Ca/day (76 vs. 48 g/d) ↓ hip fracture risk (Sahni et al. JBMR. 2010;25:2770)

Calcium Modulates Association of Protein & Hip Fracture Framingham Offspring Cohort Mean age = 75 years 44 hip fractures over 12 years (10 m, 34 f) Assessed intakes of protein and calcium using a diet questionnaire (FFQ) <800 mg Ca/day Highest vs. Lowest Intakes (60 vs. 34 g/d) ↑ hip fracture risk >800 mg Ca/day (76 vs. 48 g/d) ↓ hip fracture risk (Sahni et al. JBMR. 2010;25:2770)

Calcium Modulates Association of Protein & Hip Fracture Framingham Offspring Cohort Mean age = 75 years 44 hip fractures over 12 years (10 m, 34 f) Assessed intakes of protein and calcium using a diet questionnaire (FFQ) <800 mg Ca/day Highest vs. Lowest Intakes (60 vs. 34 g/d) ↑ hip fracture risk >800 mg Ca/day (76 vs. 48 g/d) ↓ hip fracture risk (Sahni et al. JBMR. 2010;25:2770)

Source of Protein

Does Source of Protein Matter? ANIMAL dairy, chicken, pork, beef, fish PLANT legumes (soy), peas, beans, lentils, quinoa Protein:Energy, Fiber, Fat profile, Bioactives *we eat foods, not individual nutrients*

Equal amounts of dietary protein from animal vs. plant sources 2018 Equal amounts of dietary protein from animal vs. plant sources

Equal amounts of dietary protein from animal vs. plant sources 2018 Equal amounts of dietary protein from animal vs. plant sources Outcomes: 1 year: BMD (total body, hip, spine) 6 months: bone formation or resorption markers 7 randomized controlled trials

Equal amounts of dietary protein from animal vs. plant sources 2018 Equal amounts of dietary protein from animal vs. plant sources Outcomes: 1 year: BMD (total body, hip, spine) 6 months: bone formation or resorption markers 7 randomized controlled trials Conclusion: No advantage of either soy or animal protein (BMD, bone markers)

Quality of evidence low Soy as supplement, not whole food 2018 CONSIDERATIONS: Quality of evidence low Soy as supplement, not whole food Low levels of plant protein Future study: other plant & animal sources (legumes, beans, quinoa, pea, egg) Equal amounts of dietary protein from animal vs. plant sources Outcomes: 1 year: BMD (total body, hip, spine) 6 months: bone formation or resorption markers 7 RCTs Conclusion: No advantage of either soy or animal protein (BMD, bone markers)

Foods are more than protein…… Protein Source Foods are more than protein…… ANIMAL dairy, chicken, pork, beef, fish PLANT legumes (soy), peas, beans, lentils, quinoa Protein:Energy, Calcium, Vitamin D, Fiber, Fat profile, Bioactives

Summary Current RDA for Protein 0.8 g protein/kg body weight/day Food sources Current RDA for Protein Aging increases the need for more dietary protein 1 g protein/kg body weight/day Higher intakes support muscle mass and strength; stronger muscle may protect bone from fracture Some evidence for bone health directly Even distribution of protein (muscle) Source: future study needed Consider other nutrients in a food. Importance of adequate Ca for bone at higher protein intakes Level of Dietary Protein to Support Muscle & Bone During Aging

Protein for Healthy Bones Thank you for watching. wward@brocku.ca