Clinical Nutrition (2008) 27, 675e684

available at www.sciencedirect.com

http://intl.elsevierhealth.com/journals/clnu

REVIEW

Optimal protein intake in the elderly

Robert R. Wolfe a,*, Sharon L. Miller b, Kevin B. Miller c

a
University of Arkansas for Medical Sciences, Department of Geriatrics, Center for Translational
Research in Aging & Longevity, 4301W Markham Street, Slot 806, Little Rock, AR 72205, USA
b
SLM Nutritional Consulting, 62 Duclair Ct., Little Rock, AR 72223, USA
c
Nestle HealthCare Nutrition, 12500 Whitewater Drive, Minneapolis, MN 55343, USA

Received 18 January 2008; accepted 13 June 2008

KEYWORDS Summary
Nutrition; The recommended dietary allowance (RDA) for protein, as promulgated by the Food and Nutrition
Diet; Board of the United States National Academy of Science, is 0.8 g protein/kg body weight/day for
Recommended dietary adults, regardless of age. This value represents the minimum amount of protein required to avoid
allowance progressive loss of lean body mass in most individuals. There is an evidence that the RDA for
elderly may be greater than 0.8 g/kg/day. Evidence indicates that protein intake greater than
the RDA can improve muscle mass, strength and function in elderly. In addition, other factors,
including immune status, wound healing, blood pressure and bone health may be improved by
increasing protein intake above the RDA. Furthermore, the RDA does not address the recom-
mended intake of protein in the context of a balanced diet. Concerns about potential detrimental
effects of increased protein intake on bone health, renal function, neurological function and
cardiovascular function are generally unfounded. In fact, many of these factors are improved
in elderly ingesting elevated quantities of protein. It appears that an intake of 1.5 g protein/
kg/day, or about 15e20% of total caloric intake, is a reasonable target for elderly individuals
wishing to optimize protein intake in terms of health and function.
ª 2008 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights
reserved.

Introduction

Over the last 20 years, mounting scientific evidence has

provided new information on the role and impact of nutri-
* Corresponding author. Tel.: þ1 501 526 5708; fax: þ1 501 686 tional status on functional capacity and health of the aging
8025. individual.1e3 A number of studies have pointed to protein
E-mail addresses: rwolfe2@uams.edu, rdjviane@uams.edu as a key nutrient in the elderly. Protein intake greater than
(R.R. Wolfe). the amount required to avoid negative nitrogen (N) balance

0261-5614/$ - see front matter ª 2008 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.
doi:10.1016/j.clnu.2008.06.008
676
can ameliorate chronic wasting (i.e., rapid loss of muscle
mass) associated with the aging process.4 Other physiolog-
ical processes can also potentially benefit from increased
protein intake. Examples include improved bone health,5
maintenance of energy balance,6 cardiovascular func-
tion,7e10 and wound healing.11 Benefits of increased protein
intake may be reflected on not only improved function and
quality of life in the healthy elderly, but also the ability of
hospitalized elderly patients to recover from disease and
trauma such that health outcomes are improved and cost of
care is decreased.12 Given the importance of the topic,
a discussion of the factors determining the optimal protein
intake in the elderly is warranted.
Current guidelines for protein intake
The most recent Dietary Guidelines for Americans were
issued in 2005 by the United States Department of Agri-
culture (USDA). These guidelines were derived from the
extensive dietary reference intakes (DRIs) recommended by
the Food and Nutrition Board of the Institute of Medicine.
The DRIs for macronutrients include an estimated average
requirement (EAR), a recommended dietary allowance
(RDA) and acceptable macronutrient distribution ranges
(AMDRs).13 In the case of daily protein intake, the Food and
Nutrition Board recommended an RDA of 0.8 g protein/kg/
day for all adults, including the elderly. The RDA was based
on the results of all available studies that estimated the
minimum protein intake necessary to avoid a progressive
loss of lean body mass as determined by nitrogen (N)
balance. The recommendation of 0.8 g protein/kg/day was
the same as the earlier recommendation of the 1985 joint
World Health Organization/FAO/UNU Expert Committee.
The Food and Nutrition Board acknowledged the conceptual
limitation of relying entirely on results from N-balance
studies to determine recommended intake, as this method
does not measure any relevant physiological end point.
Further, the existing data were gathered almost entirely in
college-aged men and a greater N intake is required to
maintain N-balance in the elderly as opposed to younger
individuals.14 The Board nonetheless relied exclusively on
N-balance data for the estimation of the RDA and did not
distinguish between the needs of the young and elderly.
Most individuals do not consider the RDA for protein
when preparing meals or selecting foods to eat. In fact,
most don’t know what the RDA is, or how to calculate the
grams of protein they have eaten in a day even if they were
trying to meet the RDA. However, the RDA is nonetheless of
great importance, because national and international
policies regarding food programs are based on this value as
the target level of protein that should be eaten. Further,
the RDA is assigned great importance by leaders in the
nutrition field as a target for protein intake. In that regard,
it is important to recognize that the expert committees
went beyond the RDA in recommending the amount of
protein that should be eaten. The Food and Nutrition Board
recognized a distinction between the RDA and optimal
protein intake. The recommendation for the AMDRs
included a range of optimal protein intakes in the context
of recommended ranges of carbohydrate and fat intake.
Thus, the AMDR is more relevant to normal dietary intake
R.R. Wolfe et al.
than the RDA. It was recommended that protein constitute
between 10 and 35% of the daily energy intake.13 Using an
equation based on age, weight, gender, height, and activity
level to estimate energy requirements,13 it is possible to
translate the AMDR for protein to the same units as the RDA
(g protein/kg/day). The daily energy requirement of
a sedentary 19-year-old reference man (76 kg, 1.76 m tall)
is calculated to be 37.8 kcal/kg/day. Ten percent of this
caloric intake translates to a protein intake of 0.95 g pro-
tein/kg/day, and 35% of energy intake translates to
3.3 g protein/kg/day. Thus, the RDA is below the lowest
recommended intake when considered in the context of the
overall dietary intake of macronutrients. Expressed differ-
ently, if the reference man was to eat the RDA of protein, it
would constitute only 8.5% of his energy intake, which is
below the lowest recommended percentage.
The Dietary Guidelines published by the USDA also
adopted the RDA of 0.8 g protein/kg/day.15 However, as
was the case with the Food and Nutrition Board, the
Department of Agriculture also recommended levels of
protein intake in the context of the overall diet. The
amount of protein recommended in their proposed food
intake patterns varied as a function of caloric intake. When
caloric ranges appropriate for normal healthy adults are
considered, the recommended protein intake ranges from
1.4 to 2.0 g protein/kg ideal body wt/day.15 The apparent
discrepancy between the RDA and the recommendations of
expert committees on actual dietary intake of protein can
easily be resolved by considering the RDA as the minimal
acceptable intake and the dietary recommendations as
reflecting the optimal protein intake. When viewed in this
light, it is clear that, contrary to popular belief, expert
recommendations for protein intake in the elderly range
from 1.2 to 2.0 g protein/kg/day or higher. Further, current
recommendations for intake of protein not only fail to
address different requirement for healthy elderly, they
disregard a number of clinical conditions common in elderly
(e.g., injury, hospitalization, surgery, trauma, etc.) in
which protein requirements have been shown to be
elevated above normal.
Age associated physiological changes and
benefits of increased protein intake
Physiological changes that occur with aging include a loss of
muscle mass (‘‘sarcopenia’’) that is not dependent on
disease.16 The importance in addressing sarcopenia is clear in
light of its correlation to functional impairment,17,18
disability,19,20 falls,21 frailty,22 and the loss of independence
that increases with aging.23 The etiology of sarcopenia
includes decreased physical activity, malnutrition, increased
inflammatory cytokine production, oxidative stress, and
reductions in both growth hormone and androgens.
Other physical changes with aging may in fact be
secondary to changes in muscle. For example, as muscle
mass decreases with aging, body composition changes to
favor a higher percentage of body fat.24 Elderly with
a greater fat mass are more likely to suffer from impaired
glucose tolerance and diabetes.25 Impaired insulin sensi-
tivity occurs in approximately 43% of individuals over 60
years,26 and this leads to frank diabetes in 16%.27 It has
Optimal protein intake in the elderly
been reported that type-II diabetes is a major health
concern that affects nearly 20% of elderly adults.28e30
Whereas decreased hepatic sensitivity to insulin may be
a component of insulin resistance in elderly, the principal
mechanism for the development of insulin resistance with
aging results from muscle metabolic dysfunction.31
Dysfunction of muscle metabolism is related to reduction of
numbers and metabolic function of mitochondria with age
and as a consequence of reduced activity.32,33 Decreased
bone density, osteoporosis and increased susceptibility to
fracture commonly occur with aging, particularly in
women,34 but also in men.35 Decreased muscle strength and
function may relate to impaired bone health, given the
relation between the torque placed on bone by muscle
contraction and the strengthening of bone.36e38
The elderly suffer from impaired immune status.39
Altered immune function and chronic inflammation have
been claimed by some to underlie catabolic changes in
muscle leading to sarcopenia.40 Cytokines that are corre-
lated with both diabetes and diminished lean muscle mass
in the elderly include tumor necrosis factor (TNF-a),
interleukin-6 (IL-6), and C-reactive protein (CRP).41 These
cytokines are highly correlated with increased rates of
functional disability,42 muscle degradation,43 and mortality
in the elderly.44 In the Framingham Heart Study, higher IL-6
and TNF-a were associated with reduced muscle strength
and increased mortality.45,46 Because most of the inflam-
matory cytokines are derived from adipocytes, an increase
in the proportion of fat to lean body mass may increase the
risk for a heightened inflammatory response. The loss of
muscle mass in obese elderly as originally observed in
elderly with rheumatoid arthritis and osteoarthritis47 has
been termed as ‘‘sarcopenic obesity’’. Research indicates
that the inflammatory cytokines produced by adipose
tissue, especially visceral fat, accelerate muscle catabo-
lism and thus contribute to the vicious cycle that both
initiates and sustains sarcopenic obesity.48 Subjects with
sarcopenic obesity were 2e3 times more likely to report
disability than lean sarcopenic or non-sarcopenic obese
subjects and those with normal body composition.49
Therefore, improved lean mass and reduction of obesity
should decrease inflammatory cytokines, and thus diminish
the signal for continued muscle catabolism.
The fundamental mechanism by which dietary protein
affects muscle and other physiological processes is the
stimulation of muscle protein synthesis by the absorbed
amino acids.50 Muscle protein is particularly responsive to
the stimulatory effect of amino acids. Muscle protein
synthesis is stimulated by a single dose of 15 g of essential
amino acids to a greater extent than any anabolic hormone
tested, including testosterone,51 insulin, 52 and growth
hormone.53 There is a dose dependent response of muscle
protein synthesis to amino acid intake.54 High quality
protein such as whey, casein and beef stimulates
muscle protein synthesis in proportion to the amount of
essential amino acids per dose of protein.55,56 At low doses
of amino acid intake the elderly are less responsive than
younger counterparts,57 perhaps explaining a component of
the development of sarcopenia. However, the lack of
responsiveness in elderly can be overcome with a larger
dose of amino acids.57 Thus, a higher level of protein intake
is likely required in elderly to elicit the same stimulatory
677
effect on muscle protein synthesis as in younger individ-
uals. The requirement for a larger dose of protein to elicit
responses in elderly similar to those in younger individuals
provides the theoretical basis for a beneficial effect of
increased protein intake in elderly individuals.
Recent studies substantiate that the acute stimulatory
effect of amino acid or protein intake on muscle protein
synthesis translates to improvement in lean body mass,
strength and function in elderly.58,59 For example, supple-
mentation of the normal diet with a mixture of essential
amino acids equivalent to the amount in approximately 30 g
of high quality protein twice per day increased lean body
mass, strength, and functional test scores in healthy
elderly subjects without any alteration in normal dietary
intake or exercise.58 Similarly, increasing protein intake
from an average of 0.87 g protein/kg/day in frail women to
1.23 g protein/kg/day as a result of daily supplements
increased muscle mass.60 The recent report of the Health
Aging and Body Composition Study61 confirms the impor-
tance of protein intake in preserving lean body mass on
a large population basis. Changes in body composition were
determined over a 3-year period in over 2000 individuals
aged 70e79 years. After adjustment for potentially con-
founding covariates, individuals in the highest quintile of
protein intake had 40% less loss in lean body mass over the
3-year period than those in the lowest quintile of protein
intake. The other three quintiles of protein intake also
corresponded to the extent of loss of lean body mass. It is
thus not surprising that in a different study62 women with
intake greater than the midrange of 0.8e1.2 g protein/kg/
day (1.20e1.76 g/kg/day) tended to have fewer health
problems over the 10-year follow-up period than those with
protein intakes <0.8 g/kg/day.
It appears that even malnutrition or severe impairment
of tissue delivery of amino acids does not preclude the
beneficial effects of amino acids on protein synthesis in
elderly. Increasing dietary protein intake from 0.5 to 1.0,
1.5, and 2.0 g protein/kg/day in malnourished hospitalized
patients resulted in progressively greater rates of whole
body protein synthesis and improved nitrogen balance.63
Similarly, ingestion of essential amino acids stimulated leg
muscle protein synthesis in elderly individuals with
peripheral artery disease.64
It is possible that the beneficial effect of protein intake
on body composition is in part mediated by stimulation of
insulin-like growth factor 1 (IGF-1) secretion. Levels of IGF-1
have been shown to be decreased in aging individuals.65 Low
IGF-1 levels could contribute to a decrease in protein
synthetic rates and accentuate the loss of muscle mass
leading to cachexia and sarcopenia.66 Nutritional interven-
tion may ameliorate this age-induced effect as a recent
study showed elevated protein intake increases IGF-1 levels
in elderly.12
In addition to the beneficial effects of increasing the level
of protein intake on muscle in the elderly, there are likely
other potential beneficial effects as well. Bone health
appears to be improved by higher levels of protein intake in
the elderly. Thus, a high meat diet was shown to increase
whole body calcium retention, as measured by radiotracer
and whole body counting methodology, especially when
calcium intake was low.67 These findings point to a possible
synergistic interaction between dietary protein and calcium.
678
Similarly, in a supplementation trial5 increased dietary
protein was associated with increased bone mineral density
of the femoral neck and total body in subjects taking
supplemental calcium with vitamin D, but not in those taking
placebo. Further, protein intake likely benefits bone health
via the effect on increasing muscle mass and strength.68
Mechanical force on bone is essential for modeling and
remodeling, processes that increase bone strength and
mass.38 Whereas body weight and weight bearing exercises
provide a direct mechanical force on bones, the largest
voluntary loads on bone are proposed to come from muscle
contractions.38 Correlations between grip strength and bone
area, bone mineral content and bone mineral density in both
healthy athletes69 and stroke patients70 support the notion
that muscle contractions play a significant role in bone
strength and mass. Even the correlation between body
weight and bone mass (e.g., 69) can be explained on the basis
of the force exerted on bone by muscle contraction, in that it
takes more force per unit area to move heavier bodies.
Further, changes in bone mass and muscle strength track
together over the lifespan.38 Although it is debatable
whether it is muscle strength or simply muscle mass that is
important in determining bone strength and mass, it is
significant that in the MINOS study, a prospective study of
osteoporosis and its determinants in men, skeletal muscle
mass was correlated positively with bone mineral content
and bone mineral density.71 Men with the least skeletal
muscle mass also had increased risks of falls due to impaired
static and dynamic balance, presumably at least in part due
to the decrease in muscle strength.71
Whereas high levels of protein intake apparently benefit
bone health either directly or via changes in muscle mass
and strength, protein undernutrition is associated with low
bone mineral density72 and greater fracture risk.73 Further,
protein supplementation after hip fracture in the elderly
has been substantiated to improve outcomes.12,74,75,118
A variety of meta-analyses support a relation between
protein intake and improved wound healing.11 This finding
extends to nursing home patients, in whom protein
supplementation with either 61 or 37 g protein for 8 weeks
significantly improved healing of pressure ulcers.76
Considerable effort has been made to examine the rela-
tion between the level of protein intake and cardiovascular
health using epidemiological approaches. This approach is
complicated by a possible association of the intake of protein
and saturated fat (e.g., with meat and dairy intake). Further,
the epidemiological approach is limited conceptually and
provides no insight into possible mechanism. With these
limitations in mind, it is nonetheless of interest that the
Nurses Health Study, a 14-year tracking of over 80,000 women
aged 34e59 years showed a moderate inverse correlation
between the level of protein intake and the occurrence of
ischemic heart disease.7 More convincing data indicate that
higher levels of protein intake have protective effects on
elevated blood pressure. A variety of epidemiological studies
indicate an inverse relationship between protein intake and
blood pressure.8e10 Recent intervention studies support the
ability of protein intake to ameliorate hypertension. For
example, a recent study showed that ingestion of a protein
supplement lowered blood pressure approximately 10 mm Hg
in patients with essential hypertension.77 Further, a high
(1.9 g protein/kg/day) protein diet was shown to enhance the
R.R. Wolfe et al.
endothelial function of the arterial vessels with a more
pronounced dilation of the lumen in response to an increase in
blood flow,78 thereby providing a mechanistic explanation of
the effect of protein intake in blood pressure.
Clinical and financial impact of nutrition in
elderly
When determining dietary recommendations for dietary
intake in elderly it is reasonable to consider optimizing
health care and those factors influencing health outcomes
because over 40% of hospital admissions occur in individuals
65 years and older. The average length of hospitalized stay
of patients 65 years and older is 2 days longer than younger
age groups79 due in part to a loss of functional capacity
related to depleted muscle mass. Inadequate nutritional
intake prior to hospitalization is common in this segment
and may at least partially explain the depleted muscle
mass. Many elderly patients are institutionalized prior to
hospitalization, and as many as 85% of institutionalized
patients are classified as malnourished. One-half of this
number is protein under-nourished.80e82 Once in the
hospital, post-surgical or stress inflammation coupled with
physical inactivity and inadequate protein-energy intake
results in further loss of muscle mass that delays recovery
in the elderly, all of which contribute to higher readmission
rates following discharge.83,84 The breakdown of muscle in
hospitalized elderly patients provides necessary amino acid
precursors for the accelerated synthesis of proteins
required for a variety of processes essential for recovery.85
In the absence of adequate muscle mass, as is often the
case in the elderly, amino acids must be provided at an
increased rate from dietary protein rather than be derived
from endogenous muscle protein breakdown. Nonetheless,
protein intake is often limited in both institutionalized and
hospitalized elderly individuals.86,87
Implementation of strategies to promote healthy nutri-
tional status in hospitalized elderly patients is critical for
rapid recovery and therefore central to the health care
industry because shortened stays in the hospital translate
to financial savings. A better understanding of optimal
protein intake is central in this goal. A growing number of
scientific publications have described the benefits of
greater protein intake in the elderly (65 years and older),
including stimulation of muscle protein synthesis,88 facili-
tation of recovery from trauma89,90 and surgery,12 and
stimulation of wound healing.76,91 Nonetheless, protein
intake is often insufficient in hospitalized patients. For
example, 21% of elderly patients had an average daily in-
hospital nutrient (including protein) intake of less than 50%
of their maintenance requirements, thereby contributing to
an increased risk of mortality.92 In another report, the
prevalence of protein-energy malnutrition in male and
female patients was reported to be 30 and 41%, respec-
tively.93 The consequence of poor nutritional status prior to
hospitalization, coupled with inadequate nutrition during
hospitalization, leads to preferential mobilization of lean
body mass, as opposed to fat mass, in elderly patients.93
Consistent with these statistics, when protein intake has
been increased in patients, beneficial results have been
observed. For example, in a study of 82 patients with
Optimal protein intake in the elderly
recent hip fracture, patients receiving protein supplements
of 20 g/day had higher levels of IGF-1 and attenuation of
the decrease in proximal femur bone mineral density as
compared to the placebo controls, which translated to
almost a 50% reduction of the median stay in rehabilitation
wards.12
The cost effectiveness of increased nutritional/protein
intake in elderly is validated by improved health outcomes.
The healthcare cost attributed to sarcopenia (in the U.S.) in
2000 was estimated to be $18.5 billion and it was concluded
that the initial treatment to reduce muscle loss should be
to ensure the intake of adequate protein.94 Limiting of the
extent of sarcopenia enables a more robust response to
catabolic states common in hospitalized patients.84 As dis-
cussed above, increased protein intake improves speed of
recovery in hospitalized elderly patients, which in turn
decreases length of stay in the hospital and recovery wards.
Thus, the available evidence indicates that dietary protein
plays a central role in cost effective patient care.
Optimal protein intake in the elderly
The dietary protein requirement for an elderly individual is
dependent upon their health status. An intake of the RDA of
0.8 g protein/kg/day is inadequate to maintain lean body
mass in the average healthy elderly individual.95 Even if
lean body mass could be maintained in elderly given
0.8 g protein/kg/day, the evidence cited above indicates
that the optimal daily intake is considerably higher.
Unfortunately, adequate data do not exist to estimate an
optimal intake of protein based on physiological end points
such as lean body mass, strength and physical function. In
the absence of empirical end-point data, we can consider
the maximal stimulation of muscle protein synthesis as
a surrogate end point. The basis for this approach is
twofold. First, increased muscle protein synthesis is the
metabolic basis for increases in both muscle size and
strength.85 Secondly, sufficient quantitative data exist
regarding the regulation of muscle protein synthesis by
protein and amino acids to allow reasonable estimation of
the optimal protein intake in elderly.
Recent studies have shown that the maximal stimula-
tion of muscle protein synthesis is achieved with 15 g of
EAA.50 Approximately 35 g of high quality protein that
contains all the essential amino acids, such as beef or
whey, contains 15 g of EAA. Delivery of approximately 35 g
of protein per meal in three meals per day should,
therefore, optimize the effect of protein intake on muscle
protein synthesis. A greater amount of a lower quality
protein that does not have as high a content of EAA would
be required. For a 70 kg man, 35 g three times per day
translates to 1.5 g protein/kg/day. If the pattern of intake
is less than optimal, or the quality of protein low (i.e., low
proportion of EAA), the optimal range could extend to 2 g/
kg/day. An intake of 1.5 g/kg/day would provide 15e20%
of total energy requirements, depending on the size, age,
and activity level of the individual. This proportion of
protein in the overall diet is consistent with the DRI
report, which recommended that protein constitute
between 10 and 35% of total energy intake.13 Given prac-
tical limitations of protein consumption in the elderly,
679
specialized nutritional products may be appropriate to
achieve the appropriate target and increase dietary
protein density.87
Relation to other nutrient intake
A change in the proportion of any macronutrient (i.e.,
protein, carbohydrate or fat) dictates a concomitant
change in the proportion of one or both of the other major
components, assuming that total caloric intake remains
constant. In contrast to the case with protein, detrimental
effects of excess intake have been reported in the case of
both carbohydrate and fat.13 Consequently, not only should
the potential beneficial effects of a greater amount of
protein in the diet be considered, but also the associated
beneficial effects of lowering the proportion of carbohy-
drate and/or fat in the diet. For example, evidence indi-
cates that a diet containing 30% or more protein may be
beneficial in ameliorating the effects of type-II diabetes.96
Since both high carbohydrate as well as high fat intake
could contribute to the development of type-II diabetes, it
is difficult to distinguish a direct beneficial effect of
increased protein in the diet in type-II diabetes from
a beneficial effect of a reduction in carbohydrate and/or
fat intake. In practical terms, this is irrelevant, as the
physiological response to the total diet is the outcome of
importance. This perspective is underscored by the results
of the Health Aging and Body Composition Study.61 There
was a direct relation between the extent of loss of lean
body mass and protein intake when protein intake was
expressed as a percent of total caloric intake. When protein
intake was expressed as g protein/kg/day, irrespective of
other caloric intake, the highest quintile of protein intake
still had the least loss of lean body mass, but the relation
between protein intake and loss of lean body mass across
all quintiles was less clear.
The quality of protein is also an important factor for
which account has rarely been taken in studies of optimal
protein intake. The results of studies showing the impor-
tance of the essential amino acids in stimulating muscle
protein synthesis in elderly adults (e.g., Refs.57,97) predict
that protein sources containing a relatively high proportion
of essential amino acids, such as proteins found in meat and
dairy products, would be more effective than vegetable
proteins. This perspective is supported by the observation
that ingestion of milk proteins stimulated muscle protein
synthesis to a greater extent after resistance exercise than
did ingestion of soy protein.98 Consistent with this obser-
vation, the Health, Aging and Body Composition study found
that intake of animal, but not vegetable, protein was
significantly associated with preservation of lean body mass
over 3 years in elderly individuals.61 However, a potential
concern in recommending an increase in animal protein
intake is a potentially associated increase in the intake of
saturated fat. General dietary recommendations include
minimizing the intake of saturated fat, and recommended
protein intake may be influenced simply because of
a presumed relation to dietary fat. The use of specially
formulated high-protein, low-fat supplements is particu-
larly relevant to the aged population, as inadequate protein
intake is often the consequence of factors such as cost,
680
altered taste with aging, difficulty with chewing and swal-
lowing, and difficulty in food preparation. Thus, average
protein intake declines progressively over the lifespan in
both men and women.99 Issues limiting protein in the
elderly can be circumvented by a good-tasting high-protein
supplement.
Common concerns associated with
high protein intake
Evidence was cited above supporting the benefits of a high
protein diet on bone health. Nonetheless, the issue of
dietary protein intake and bone health is a point of debate
in the nutrition community.100 The concept that high
protein intake is detrimental for bone health is largely
based on studies of effects on excretion of calcium and
other biomarkers. For example, high protein diets may
increase urinary calcium excretion100 as a result of the
oxidation of the sulfur-containing amino acids, methionine
and cysteine and resultant production of sulphuric acid.102
High protein diets are thus often cited as a risk for osteo-
porosis.101 However, it is important to distinguish calcium
excretion from calcium retention. Recent evidence from
cross-sectional studies103 and tightly controlled feeding
studies indicates that high protein diets do not adversely
affect calcium retention.104 In fact, when considered in
light of the studies showing a positive effect of protein
intake on bone health in the elderly cited above, it is clear
that there is no reason for concern of a potential negative
impact of protein intake.
Concern is often expressed by healthcare practitioners
about providing extra protein intake to elderly because
they are at risk for decreased kidney function, as reflected
by impaired glomerular filtration. There is a general
agreement that protein intake greater than 1.2 g protein/
kg/day in individuals with renal disease contributes to the
deterioration of kidney function.105 Consequently, a lower
protein diet has been recommended as a method to
prevent exacerbation of renal damage by hyperfiltration
and hypertension in type-II diabetics suffering from renal
disease.105 Even in the circumstance of renal disease,
however, evidence of a beneficial effect of a low protein
diet is questionable. In a recent long-term follow-up of 585
patients with renal disease given either 0.58 or 1.3 g pro-
tein/kg/day, no beneficial effects of the low protein diet
could be demonstrated.106 Importantly, there is no
evidence that a low protein diet is beneficial to individuals
without pre-existent renal disease. To this end, when diets
containing 30% protein were served to otherwise healthy
diabetics there was an increase in removal of amino acids
and urea from the circulation.107 Further, in a group of
healthy subjects with a wide-ranging variation in protein
intake, the glomerular filtration rate was related to
protein intake, but albumin excretion, an indication of
renal disease, was not.108 The decrease in glomerular
filtration rate that occurs with aging is much less than
necessary to elicit symptoms of renal failure.109 In fact,
since restriction of protein intake reduces glomerular
filtration rate, it is possible that the decline in glomerular
filtration that occurs with aging may be simply a conse-
quence of a progressive decrease in protein intake with
R.R. Wolfe et al.
advancing age.110 Thus, limitation of protein intake in
elderly individuals on the basis of possible adverse effects
on renal function is not warranted except in individuals
who are likely to develop kidney failure as a result of
diabetes, hypertension, or polycystic kidney disease.109
Contraindications for high-protein diets are reported for
patients suffering from Parkinson’s disease as a result of
the circulating increase in amino acids on L-dopa and the
increase in bradykinesia.111,112 In this population a more
targeted formulation of specific amino acids as opposed to
intact protein may be preferential to enhance muscle
protein synthesis without affecting neurotransmitter
production. Other potential adverse effects of protein on
neurological function have not been reported.
Increased satiety is usually considered a nutritional
advantage that aids in the maintenance of an appropriate
energy balance. However, in the elderly who may be
undernourished, increased satiety in response to nutrient
ingestion can be a potential problem. In this regard,
protein supplements were reported to maintain satiety
longer in both young and elderly volunteers as compared
to a carbohydrate supplement.6 As a result, an appropriate
supplementation strategy may be necessary to promote
the proper dietary intake in institutionalized elderly.
Whereas provision of a supplement with meals will likely
reduce the intake of other food in the meal,6 this effect
can be circumvented by providing the supplement
between meals. Alternatively, a mixture of essential amino
acids (EAAs) formulated to maximally stimulate muscle
protein synthesis can be given before meals without
affecting either satiety or the metabolic response to the
subsequent meal.113
It is important to dissociate protein effects from asso-
ciated ingestion of saturated fats when evaluating the
relation between protein intake and cardiovascular health.
When the effect of protein intake, per se, on cardiovascular
risk factors and outcome is considered, there appears to be
a beneficial effect of higher protein intakes (see discussion
above). Whereas some could maintain that beneficial effect
of increased protein intake on cardiovascular health is still
controversial, the reverse position, i.e., that high protein
diets have an adverse impact of protein intake on cardio-
vascular health, is not supported by data.
The impact of protein intake on the occurrence of
cancer has been assessed largely by epidemiological
studies. These studies have generally not distinguished
protein intake from specific nutrients high in protein, such
as red meat. This is particularly pertinent when consid-
ering the relevance of such epidemiological data to the
elderly. In contrast to younger individuals, in many elderly
increasing the level of protein intake occurs via nutritional
supplements rather than alteration of dietary patterns.
Thus, whereas some epidemiological studies have attrib-
uted an increased occurrence of colon cancer to higher
intakes of red meat,114,115 this effect may not be mediated
by the protein content of meat and thus not applicable to
those consuming protein supplements. In a prospective
study of almost 30,000 women, no significant association
between cancer mortality and protein intake (regardless of
the source) could be demonstrated.116 In fact, high dietary
protein was shown to result in better survival in women
with breast cancer.117
Optimal protein intake in the elderly
Thus, there is a little reason to believe that a high level
of protein intake increases the incidence of cancer,
although specific sources of protein, such as red meat, may
in certain circumstances contribute to specific types of
cancer. It is not clear if this is the case in elderly.
Issues related to high protein intake and bone health,
renal function neurological factors, cardiovascular health,
cancer and satiating effects have often been cited as
reasons for caution in advocating high protein diets for
elderly. However, a critical review of the literature provides
little support for such concern. In fact, the Food and Nutri-
tion Board of the National Academy of Science reported no
known upper limit of safety for protein intake in the most
recent Dietary Reference Intake report.13 More importantly,
most studies that set out to evaluate the potential adverse
effects of higher protein intake actually documented the
reverse, i.e., that higher protein intakes were beneficial on
the system being studied. Thus, although the primary
metabolic benefit of increased protein intake in the elderly
is related to the stimulation of muscle protein synthesis,
positive effects on virtually all body systems may be
expected in the absence of deleterious effects.
Summary and conclusions
Although dietary data are limited, there is a reasonable
evidence that protein intake at rates higher than 0.8 g/kg/
day is beneficial for the majority of elderly individuals. Not
only is maintenance of muscle mass necessary as a strategic
reserve of amino acids, but muscle mass and muscle func-
tion are correlated with increased physical function. It is
therefore safe to conclude that the optimal protein intake
is greater than the RDA. Many elderly people have reduced
appetite and fail to eat sufficient protein while they suffer
from chronic diseases (e.g., diabetes, low-grade inflam-
mation) that further increase their dietary protein
requirements. Therefore, ensuring adequate dietary
protein intake using high quality proteins is essential for
this special population. Optimal health status, reduced risk
of chronic diseases, and improved outcomes may be ach-
ieved by increasing protein intake to approximately
1.5 g protein/kg/day. Special circumstances, such as dia-
betes, the healing of chronic wounds or muscle wasting as
a result of catabolic situations such as surgery or cancer,
may call for even higher intakes of protein.
Conflict of interest
Dr. Wolfe has previously served as a consultant for Novartis
Medical Nutrition Numico (Dannone) Medical Nutrition, and
the National Cattleman’s Beef Association. Kevin Miller is
an employee of Novartis (now Nestle) Medical Nutrition.
Sharon Miller has previously worked for the National Cat-
tleman’s Beef Association.
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