Increased protein requirements in elderly people: new data

and retrospective reassessment&

Wayne W C’ampbell, Marilyn C Crim, Gerard E Dallal, Vernon R Young, and William J Evans

ABSTRACT Dietary protein requirements of elderly people ing results, with some studies concluding that 0.8 g pro-
were determined by short-term nitrogen-balance techniques and tein kg ‘ . d is adequate (3, 4) and others finding this protein
using calculations recommended by the 1985 Joint FAOIWHO/ intake to be inadequate for nitrogen equilibrium (5-7). Three of
UNU Expert Consultation. Twelve men and women aged 56-80 these controlled balance studies determined nitrogen balance in
y were randomly assigned to groups that consumed either 0.80 subjects given more than one protein intake level, thus providing
:t 0.01 or I .62 ± 0.02 g protein . kg . d ‘ (1 ± SEM). Net ni- for direct assessment of protein requirements of elderly people
trogen balance was negative for the lower-protein group (-4.6 (3-5). Zanni et al (3) concluded that the 1973 FAO/WHO safe
± 3.4 mg N . kg ‘ . d ‘ ) and positive for the higher-protein group intake of 0.57 g protein . kg ‘ . d ‘ was adequate for apparently
( I 3.6 ± I .0 mg N kg ‘ . d ‘ ); the intake required for nitrogen healthy elderly men. Cheng et a! (4) determined that the NRC
equilibrium was estimated to be I .00 g kg ‘ . d ‘ . Nitrogen-bal- protein allowance of 0.8 g kg ‘ . d was adequate to maintain
ance data from three previous protein requirement studies in el- nitrogen balance in elderly male nursing home residents. Uauy
derly people were recalculated by using the same balance for- et al (5) calculated a mean protein requirement of 0.83
mula and combined with the current study data to provide an g -
d ‘ for elderly women, and suggested a protein intake
overall weighted mean protein requirement estimate of 0.91 range of 0.7-0.85 g kg ‘ . d for elderly men.
± 0.043 gkg ‘ d ‘. Together, the current and retrospective ni- Previous reviews (8- 1 2) discussing the results and conclu-
trogen-balance data suggest that the mean protein requirement in sions of these studies have highlighted differences in physiologic
elderly adults is considerably greater than the 0.60 gkg’ d’ and metabolic status of subjects within each study and between
established by the 1985 Joint FAOIWHO/UNU Expert Consul- the studies as reasons why each of these studies, assessed sepa-
tation. A safe protein intake for elderly adults would be 1.0-1.25 rately, is insufficient to directly establish protein requirements
g kg ‘ . d ‘ of high-quality protein. Am J Clin Nutr and allowances of elderly men and women. Indeed, the elderly
l994;60:501 -9. subjects involved in each of the studies varied in different ways,
including physical functional capacity, metabolic status, total en-
KEY WORDS Proteins, nitrogen balance, recommended di- ergy intake, physical activity, and medication usage. all of which
etary allowance, elderly people might alter protein requirements. However, all subjects were con-
sidered apparently healthy with no acute illnesses or diseases and
were able to successfully complete the rigors of a metabolic bal-
Introduction
ance study. Together, these elderly subjects may well represent
The current estimated mean dietary protein requirement for a realistic sampling of the whole elderly population. Differences

healthy adult men and women of all ages is 0.6 g d C I),

with a suggested safe protein intake set at 0.75 gkg d by
I From the Human Physiology Laboratory, US Department of Agri-
the Joint FAO/WHO/UNU Expert Consultation (WHO) ( I ) and
culture Human Nutrition Research Center on Aging at Tufts University.
at 0.8 gkg ‘ d’ by the Food and Nutrition Board of the US
Boston: the Laboratory of Human Nutrition, Massachusetts Institute of
National Research Council (NRC) (2). Nitrogen balance is the
Technology, Cambridge. MA: and the Noll Physiological Research Cen-
current standard method used for establishing total protein (ni- ter, The Pennsylvania State University. University Park.
trogen) requirements and allowances (I, 2). Both the WHO (I) 2 The contents of this publication do not necessarily reflect the views
and NRC (2) indicate that insufficient data were available from or policies of the US Department of Agriculture. nor does mention of
studies conducted with elderly subjects to determine protein re- trade names, commercial products. or organizations imply endorsement
quirements with confidence, thus the current recommendations by the US Government.

for elderly men and women are largely extrapolations from ni- Supported
C in part by the US Department of Agricultural Research
Service, contract number 53-3K06-0l : NIH grant ROI AGI 181 1-01 : and
trogen-balance studies conducted in healthy young men. Yet, sig-
the Kraft General Foods Predoctoral Fellowship, awarded in conjunction
nificant changes in body composition. physical functional capac-
with the American Institute of Nutrition (WWC).
ity, physical activity, food intake, and the frequency of disease
4 Address reprint requests to WJ Evans. Noll Physiological Research
in elderly people may all contribute to altered protein require-
Center, The Pennsylvania State University. I 19 Noll Laboratory. Uni-
ments in this population ( I). versity Park. PA 16802-6900.
Previous research into the protein requirements of elderly sub- Received April 26, 1993.
jects by using nitrogen-balance techniques has provided conflict- Accepted for publication April 1 1. 1994.

Am J Cli,, Nuir 1994:60:501-9. Printed in USA. © 1994 American Society for Clinical Nutrition 501

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 502 CAMPBELL ET AL

in study design and the assumptions used in calculating nitrogen and four women were recruited to participate in the study. Men
balance also contributed greatly to differences in results and the and women were both studied with the assumption that protein
conclusions drawn from these studies. In fact, each study used a requirements should be similar for both groups when expressed
different formula to calculate nitrogen balance. per kilogram body weight ( I ). Each volunteer lived in the met-
The present study utilized short-term nitrogen-balance tech- abolic ward at the US Department of Agriculture Human Nutri-
niques and the 1985 WHO nitrogen-balance formula ( I ) to de- tion Research Center on Aging (HNRCA) at Tufts University,
termine protein requirements in healthy elderly men and women. Boston, for the duration of the study.
In addition, nitrogen-balance data from three previous studies in
elderly subjects-Zanni et al (3), Cheng et al (4), and Uauy et Diet
al (5)-have been recalculated by using the same balance for-
All meals were provided by the Metabolic Nutrition Labora-
mula and were combined with data from the current study to
tory at the HNRCA. Subjects in both groups consumed a basal
provide a ‘ ‘meta’ ‘ estimate of the protein requirements of healthy
diet consisting of lactoovovegetarian foods designed to provide
elderly subjects.
0.6 g proteinkg ‘ d ‘, cycled as a 3-d rotating menu. The corn-
position and protein distribution of a representative 3-d basal
Subjects and methods menu is presented in Table 2. The exact portioning and compo-
sition of the basal diet was adjusted to maintain the study protein
Subjects
amounts and to meet the energy needs of each subject. The re-
Twelve men and women age 56-80 y volunteered for this maining 0.2 or I .0 g protein . . d was provided as one of
metabolic study. A complete physical examination of each sub- two milk-based liquid formulas. The liquid formulas were made
ject, including medical history, electrocardiogram, routine blood from varying quantities of nonfat dried skim milk powder, non-
and urine chemistries, and a psychosocial evaluation were corn- dairy creamer, glucose polymers (Polycose; Ross Laboratories,
pleted before enrollment to exclude subjects with medical con- Columbus, OH), sugar, saccharin-based sweetener (Sweet Plus;
ditions that might have interfered with the study or placed the Sysco Corp. Houston, TX), water, and vanilla flavoring (Table
person at physical risk. Each subject received a complete expla- 3). Water was allowed ad libitum. Total dietary energy was set
nation of the purpose and procedures of the investigation and to meet each subject’s basal energy needs [predicted from the
signed an informed consent agreement. The study protocol and sex-specific Harris-Benedict equation (13)], plus an energy cost
informed consent were approved by the Tufts University-New of activity allowance of 0.5 times basal energy expenditure (ie,
England Medical Center Human Investigation Review Commit- total energy intake equalled 1.5 times basal energy needs). Minor
tee. Subject physical characteristics are given in Table 1. adjustments to this estimate were made for several subjects on
Subjects were randomly assigned to groups that consumed ci- the basis of subject-specific data available from their participa-
ther a diet providing the recommended dietary allowance (RDA) tion in previous research studies at the HNRCA. Body weights
for protein (0.8 g kg . d ) or twice the RDA for protein ( I .6 remained stable over the 1 1-d study period. The protein, carbo-
g kg ‘ . d ‘) for a total of I I d (2). Both the subjects and primary hydrate, and fat content of each cycle menu was calculated from
investigators were blinded to the dietary treatment. Eight men the USDA-ARS Database GRAND (release 867; USDA-HNRC,

TABLE I
Physical characteristics and energy intakes of study subjects

Subject and sex Age Height Weight BMI FFM’ Muscle mass2 Energy intake

y cm kg kg kg U . kg ‘ .d ‘

Lower-protein group (0.8 g kg ‘ .d ‘)

l,male 65 171.8 74.6 25.3 53.1 23.7 122.1
2. male 56 175.5 79.2 25.6 59.7 29.5 143.1
3, male 57 183.0 92.6 27.6 72.4 29.2 135.2
4, female 80 162.5 74.6 28.2 43.3 16.9 1 1 1.4
5, female 68 173.3 65.9 21.8 40.6 17.6 127.0
6,female 70 161.4 78.3 29.7 42.2 14.4 110.3
Mean 66 171.3 77.5 26.4 51.9 21.9 124.9
SEM 4 3.3 3.6 1.1 5.1 2.7 5.3
Higher-protein group (1.6 gkg . d ‘)

I, male 63 181.6 79.6 24.1 64.9 30.2 131.8

2, male 56 183.0 90.0 26.8 68.7 31.0 140.3
3, male 65 179.6 85.5 26.5 58.6 31.3 123.2
4, male 63 176.9 80.4 25.6 59.3 24.2 131.1
5, female 66 154.2 59.7 24.8 36.5 16.6 126.6
6. male 68 175.9 74.4 23.9 51.4 22.3 129.9
Mean 64 175.2 78.3 25.3 56.6 25.9 130.5
SEM 2 4.3 4.3 0.5 4.7 2.4 2.4

I Determined from hydrostatic weighing.

2 Determined from 24-h urinary creatinine excretion.

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 PROTEIN REQUIREMENTS IN ELDERLY PEOPLE 503

TABLE 2
Composition and protein content of a representative basal 3-d cycle menu’

Menu I Menu 2 Menu 3

Meal Food item Food item Food item

g/d g/d gld

Breakfast Orange juice 62.0 Orange juice 62.0 Whole milk 244.0
Blueberry muffin 69.7 Whole milk 195.2 Oat cereal 21.3
Margarine (corn) 4.5 Eggs (scrambled) 50.0 Coffee (decaffeinated) I 80.0
Whole milk 195.2 Wheat bread 21 .4 Nondairy creamer 15.0
Coffee (decaffeinated) 180.0 Margarine (corn) 9.0 Raw bran 7.0
Nondairy creamer 15.0 Coffee (decaffeinated) 180.1)
Raw bran 7.0 Nondairy creamer 15.0
Raw bran 7.0
Lunch Cream of mushroom soup 206.() Cheddar cheese 60.0 Humus 34.1
Rice casserole 138.92 Wheat bread 42.8 Pita bread 38.0
Apple juice 124.0 Lettuce 50.0 Swiss cheese 3 I .0
Lettuce 50.0 Soy oil 15.0 Walnuts 20.0
Soy oil 13.8 Cider vinegar 10.0 Lettuce 50.0
Cider vinegar 10.0 Tomato soup 206.() Soy oil 15.5
Cooked egg white 33.1) Cooked egg white 49.5 Cider vinegar 10.0
Dinner Vegetarian chef salad 267.0 Spaghetti 100.1) Vegetarian chili 401 4

Soy oil 18.0 Spaghetti sauce I 15.0 Dinner roll 28.2

Cider vinegar 10.0 Margarine (corn) 9.0 Margarine (corn) 9.0
Peach slices 100.0 Pear halves 50.0 Soy oil 6.0
Tapioca pudding 50.0 Spice cookies 14.0 Ginger pears l2l.9
Soyoil Ill)
Proteinintake(gkg ‘d ‘) 0.53 0.57 0.60
Protein source (e/( of total protein)
milk-based 57.4 46. 1 39.1
egg-based 19.2 22.6 0.0
non-milk. non-egg 23.4 31.3 60.9

‘ Menu for higher-protein subject no. 3 (85.5-kg male).

2 The main ingredients in the rice casserole were Swiss cheese. 26.3 g: low-fat milk, 58.7 g: almonds, 6.3 g: white rice. 16.8 g: and broccoli spears.

25.0 g.
3 The vegetarian chef salad consisted of Swiss cheese. 30.0 g: hard-boiled egg. 50.0 g: lettuce, I 30 g: tomato. 30.0 g: raw carrot, I 5.0 g: and raw
green pepper. 12.0 g.
4 The main ingredients in the vegetarian chili were kidney beans. 195.6 g: corn. 3 1 .2 g: tomato paste. 8.6 g: raw green pepper. 26.2 g: and onions.
16.9 g.

Grand Forks, ND). Total energy intake was calculated assuming Hydrostatic weighing
16.7, 16.7, and 37.7 kJ/g protein, carbohydrate, and fat, respec-
Body density was determined by hydrostatic weighing by us-
tively ( 1 kcal - 4. 1 84 kJ). The nonprotein energy of each cycle
ing a Sauter scale (model kizo; Denshore Scale, Holbrook, MA).
menu (food + formula) was provided as 55% carbohydrates and
Lung residual volume was determined by nitrogen dilution just
45% fats. One multivitamin-multimineral supplement tablet (Ad-
before hydrostatic weighing, with the subject seated out of the
vanced Formula Centrum; Lederle Laboratories, Pearl River,
water in the same bent-forward position as used during the
NY) was taken daily by each subject. Lactase enzyme tablets
weighing (14). Body fat and fat-free mass (FFM) were calculated
(Dairy Ease; Winthrop Consumer Products, Glenbrook Labora-
from body density by using the equation of Sin (15).
tories, New York) were consumed just before each meal by two
subjects with symptoms of lactose intolerance (lower-protein
Urinary creatinine
subject no. 5 and higher-protein subject no. 4) to aid digestion
of the milk products. Each subject collected 24-h urine samples daily throughout the
study. Urinary creatinine was measured by using the colorimetric
Anthropometric measurements reaction of Jaffe ( I 6). Whole-body muscle mass was calculated
from the average of six consecutive 24-h urine collections during
Body weight of each subject was measured daily, after an over-
the nitrogen-balance period, by assuming an equivalence of 18.5
night fast and soon after voiding, to the nearest 0. 1 kg on a To-
kg muscle/g urinary creatinine (17).
ledo Weight-Plate (model 8138; Bay State Scale Co. Cambridge,
MA). Nude body weights of the subjects were calculated as total
Nitrogen balance
body weight minus robe or johnny weight. Body height without
shoes was measured to the nearest 0. 1 cm by using a wall- Nitrogen balance (mg N kg C . d ‘ ) was measured during days
mounted ruler and horizontal bar. Body mass index (BMI) was 6 to 1 1 and calculated as [IN - (UN + FN + M5)], where ‘N 5

calculated as weight/height2 (kg/m2). dietary nitrogen intake, UN is daily urinary nitrogen excretion, FN

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 504 CAMPBELL ET AL

TABLE 3 trogen-balance studies of elderly subjects by Zanni et al (3),

Composition and protein content of the liquid-formula beverages’ Cheng et al (4), and Uauy et al (5). All of these reports in-
eluded a complete listing of each subject’s body weight, di-
Lower-protein formu Ia Highe r-protein formula
etary nitrogen intake, urinary nitrogen excretion, and fecal ni-
(0.26 ± 0.02 g ( I .09 ± 0.04 g
Ingredient proteinkg ‘d ‘) pro teinkg d ‘)
trogen excretion, but each study used a somewhat different
balance formula, as shown in Table 4. To standardize the re-
% b’ it suits, nitrogen balance was recalculated as I’N - (UN + FN
+ MN)], with MN assumed to equal 8 mgkgdt (1). En-
Skim milk powder 3.24 18.85 dogenous nitrogen excretion data obtained during the protein-
Nondairy creamer 22.71 6.41
free diet period by Zanni et al (3) were excluded.
Sugar - 0.64
Saccharin-based
sweetener 0.26 -
Statistical methods
Glucose polymers2 l9.46 -
Current study data. Values are reported as means ± SEM.
Vanilla 0.81 0.80
Group differences were analyzed by Student’s t test. Linear-re-
Distilled water 53.52 73.29
gression analysis of the data from all 12 subjects was used to

‘ it 6 per group. The amount of dietary protein provided

= to each determine the relationship between dietary protein intake and ni-
subject from the formula was regulated by adjusting the quantity of liquid trogen balance, with a 95% CI for the protein intake required to
formula provided. achieve nitrogen equilibrium determined by inverse prediction
2 Glucose polymers from Polycose (Ross Laboratories. Columbus, (ie, nitrogen equilibrium was regressed on protein intake and the
OH). resulting equation was used to predict protein requirements) (19).
All calculations were performed by using SAS version 6.07 (SAS
Institute, Cary, NC) and RS/J (BBN Software Products Corp.
is daily fecal excretion, and MN is miscellaneous nitrogen losses,
Cambridge, MA). Statistical tests were considered significant
assumed to be 8 mg Nkg’d’ (1). Foreach subject, one du-
when P was < 0.05 (two-sided).
plicate composite of each cycle menu was homogenized, dis-
Retrospective analysis. For the studies of Zanni et al (3),
pensed, and stored frozen for subsequent nitrogen analysis. Daily
Cheng et al (4), and Uauy et al (5), the protein intake required
fecal nitrogen excretion was determined from a 6-d pooled fecal
for nitrogen equilibrium was determined for each subject sepa-
sample collected between fecal dye markers consumed at the start
rately by fitting the subject-specific linear-regression equation of
and end of the balance period. Food, formula, urine, and fecal
nitrogen balance on protein intake and solving for the intake that
nitrogen samples were analyzed by the Kjeldahl method with
would give a nitrogen balance of zero. These estimates were used
microwave digestion (18). The National Institute of Standards
to give a mean and SE for protein requirement from each study.
and Technologies Total Diet standard reference material and in-
The mean protein requirement estimates from these three studies
house pooled food and urine standards were used as quality con-
were then combined as a weighted average to calculate an overall
trols. Dietary protein intake (gkgt d’) was calculated for the
mean protein requirement (20). The weights were equal to the
food and milk-based liquid formulas by assuming that each gram
inverse of the square of the SEs to minimize the variance of the
of nitrogen was equivalent to 6.25 and 6.38 g protein, respec-
overall estimate. Similar calculations were performed with the
tively.
current study data included, as well. The SE associated with the
estimated mean protein requirement was used as the weighting
Retrospective reassessment of nitrogen-balance data
factor for the current study data in this calculation. The validity
Table 4 summarizes the subject characteristics, dietary en- of this approach for generating overall protein requirement esti-
ergy and protein intakes, and formulas used to calculate nitro- mates rests on the comparability of these groups of study subjects
gen balance of the three previously published controlled ni- with each other and with the general elderly population. Insofar

TABLE 4
Subject characteristics, energy and protein intakes. and balance formulas for previouslypublished nitrogen-balance studies of elderly subjects

Formula used for

Reference and subjects Age’ Weighr’ Energy intake2 Protein intake nitrogen balance3

V kg kJkg ‘d ‘ gkg ‘d

Zanni et al (3) (a = 6 M) 63-77 83.2 ± 5.6 128 ± 5 0.36-0.41, 0.42-0.46 IN (UN + FN + MN)4

Cheng et al (4) (a = 7 M) 60-73 61.6 ± 10.5 167 0.4, 0.8, 1.6 IN - (UN + FN)

Uauy et al (5)
(a = 7 F) 71 -78 68.9 ± 5.7 1 15 ± 26 0.52. 0.65. 0.80 IN (UN + FN + MN)5

(a = 7 M) 68-74 73.7 ± 17.2 132 ± 17 0.57, 0.70, 0.85

‘ Range.
SD.
.1 . dietary
‘N nitrogen intake: UN . daily urinary nitrogen excretion: FN . daily fecal nitrogen excretion: MN . miscellaneous nitrogen losses.
4 MN directly measured from a variety of body and personal hygiene-related samples.
S MN assumed to equal 5 mg Nkg ‘ d

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 PROTEIN REQUIREMENTS IN ELDERLY PEOPLE 505

as the subjects from each study were not a random sample from N-kgt ‘d’), with three of six subjects below nitrogen equilib-
the general elderly population or the conceptual elderly popula- rium. In contrast, all higher-protein subjects were in positive ni-
tions differed for each study, the combined estimate may be bi- trogenbalance(l3.6 ± l.OmgN’kgt’dt).
ased or the SE may be artificially small. Regression of nitrogen balance (y = mg N ‘ kg ‘ . d ‘ ) on die-
tary protein intake (x = g protein ‘ kg ‘ d t) established the fol-
lowing relationship: y = -22.136 + 22.190 x (P = 0.0005; R2
Results
= 0.71 8). Inverse prediction established that the mean protein
Current study intake required to achieve nitrogen equilibrium was 1.00
g’kgt d’, with the lower and upper 95% confidence limits be-
The mean total dietary protein intakes provided to the lower-
ing 0.72 and 1.18 g protein ‘ kg ‘ ‘ d, respectively.
and higher-protein groups were 0.80 ± 0.01 and 1.62 ± 0.02
The dietary protein consumed was highly digestible, with ap-
g kg ‘ . d , respectively (P < 0.001). The basal lactoovovege-
parent digestibility for the lower- and higher-protein groups be-
tarian food diet provided 0.54 ± 0.02 and 0.53 ± 0.03 g pro-
ing 85% and 91%, respectively (Table 5).
tein ‘ kg ‘ d ‘, and the milk-based liquid formulas provided 0.26
± 0.02 and 1.09 ± 0.04 g protein’kgt’d (P < 0.001; Table
Retrospective assessment ofpreviously published nitrogen-
3), to the lower- and higher-protein groups, respectively.
balance studies
Each of the higher-protein subjects and five of the six lower-
protein subjects were shown to be in steady-state during the ni- The mean protein requirement to achieve nitrogen balance
trogen-balance period, as assessed by the lack of a significant and the number of subjects at or above nitrogen equilibrium
change in each individual subject’s daily 24-h urinary nitrogen at each protein intake, based on the original and revised cal-
excretion during the 6-d balance period (ie, no significant slope culations, are shown for each previously published study in
was observed when regression analysis was performed; data from Table 6. Zanni et a! (3) determined protein requirements in
lower-protein subject no. 3 showed a negative slope during the six elderly men by measuring nitrogen balance while the men
6-d balance period, R2 = 0.706, P = 0.036). The CV (1 ± SEM) consumed either a protein-free diet for I 7 d, or diets providing
for daily urinary nitrogen excretion during the 6-d balance period egg white protein at 1 .34- 1 .54 or I .58- 1 .88 times the mea-
was 1 1 .0 ± 1 .0% for the lower-protein group and 6.2 ± 0.6% sured endogenous nitrogen output ( 15 d each period). The
for the higher-protein group. mean protein intake required for nitrogen equilibrium (0.46
Table 5 summarizes the nitrogen-balance data for elderly sub- g’kg ‘d’) was originally calculated from regression analy-
jects who consumed either the RDA or twice the RDA for pro- sis by using data from all three dietary periods. Recalculation
tein. When the data were expressed per kilogram body weight of these data by using the 1985 WHO balance formula and
the responses for men and women normalized, and these data excluding the protein-free diet period increased the mean pro-
support the assumption that protein requirements are similar for tein requirement 41%, to 0.65 ± 0.19 gkg d’, with none
both sexes. Urinary nitrogen excretion was greater in the higher- of the subjects at or above nitrogen equilibrium at either pro-
protein group than in the lower-protein group. Fecal nitrogen tein intake. Most of this increase was due to a shift in the
excretion was not different in the two groups. Net nitrogen bal- regression lines by excluding data collected during the pro-
ance was negative for the lower-protein group (-4.6 ± 3.4 mg tein-free period. The increase in miscellaneous nitrogen losses

TABLES
Mean daily nitrogen intake, excretion, and balance of elderly study subjects

Group and subject Nitrogen intake Urinary nitrogen Fecal nitrogen Nitrogen balance Apparent digestibility

mgkg’d’ mgkg’d’ mgkg’d ‘ mgkg ‘d’ %

Lower-protein group (0.8 gkg’ d’)

l,male 122.8 111.6 17.5 -14.3 85.8
2, male I 29.5 1 18.9 17.0 - 14.5 86.9
3, male 137.8 1 10.7 16.4 2.8 88.1
4, female I 19.6 97.9 1 1.7 2.1 90.2
5, female 128.6 96.1 31.1 -6.5 75.8
6, female 123.7 93.6 19.1 3.0 84.6
Mean 127.0’ 104.8’ 18.8 -4.6’ 85.22

SEM 2.7 4.2 2.7 3.4 2.0

Higher-protein group (I .6 g kg . d )
I, male 262.0 224.7 13.4 15.9 94.9
2, male 267.4 221.4 24.3 13.7 90.9
3, male 253.1 209.5 21.0 14.6 91.7
4, male 256.5 205.3 32.3 10.9 87.8
5, female 253.8 208.2 27.5 10.1 89.1
6, male 249.8 207.9 17.7 16.2 92.9
Mean 257.1 212.8 22.7 13.6 91.2
SEM 2.7 3.3 2.8 1.0 1.1

/,2 Significantly different from higher-protein group: ‘ P < 0.001, 2 p < 0.05.

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 506 CAMPBELL ET AL

TABLE 6
Retrospective assessment of protein requirements of elderly subjects: original and revised nitrogen-balance calculations

Original calculation Revised calculation

Subjects Protein intake’ Subjects Protein intake2

Reference and subjects Protein intakes nitrogen balance fr nitrogen balance nitrogen balance for nitrogen balance

gkg ‘d ‘ ?1 gkg ‘J ‘ ii gkg ‘d

Zanni et al (3) 0.36-0.41 1/6 0.46 0/6 1)65 ± 0.19

(a = 6 M) 0.42-0.46 4/6 t)/6
Cheng et al (4) 0.4 0/7 0.77 0/7 0.93 ± 0.05
(1’ = 7 M) 0.8 4/7 0/7
1.6 7/7 7/7
Uauy et al (5)
(a = 7 F) 0.52 0/7 0.83 0/7 0.8 I ± 0.09’
0.65 2/7 1/7
0.80 2/7 2/7
(a = 7 M) 0.57 4/7 0.7-0.85 4/7
0.70 4/7 4/7
0.85 4/6 4/6

I Results based on balance formulas used in the original publications (set’ Table 2).
2 Results based on balance formula: ‘N (UN + FN + MN). where ‘N is dietary nitrogen intake. UN is daily urinary nitrogen excretion, FN is daily

fecal nitrogen excretion, MN is miscellaneous nitrogen losses (assumed to he 8 mgkg ‘ d ‘). i SEM.
C Combined estimate for women and men.

from 5.2 mgkg ‘ d ‘, established by direct measurement of teinkg’ d ‘ diet was consumed, and in positive nitrogen bal-
subjects, to a uniform 8 mg . kg ‘ . d ‘ contributed little to the ance when the I .6 g protein . kg d ‘ . ‘ diet was consumed. At 0.8
increased estimate of the protein requirement. g proteinkg ‘ d ‘, the mean nitrogen balance was slightly pos-
Cheng et al (4) measured nitrogen balance in seven elderly itive (0.03 :!: 0.19 g N/d) with four of the seven men in positive
male nursing home residents consuming either 0.4, 0.8, or 1 .6 g nitrogen balance. A mean dietary protein intake of 0.77
protein . kg ‘ ‘ d ‘ from a wheat-soy-milk mixture. All the elderly gkg ‘ d was required for nitrogen equilibrium, based on re-
men were in negative nitrogen balance when the 0.4 g pro- gression analysis of the published data. Cheng et al (4) concluded
that an intake of 0.8 g kg ‘ . d ‘ high-biological-value protein
was adequate for adults of all ages. However, these data over-
estimated each subject’s nitrogen balance (underestimated mean
0
protein requirement) by not including miscellaneous nitrogen
losses in the balance equation. Recalculation to include miscel-
0
laneous nitrogen losses increased the mean protein requirement
8 21%, to 0.93 ± 0.05 gkg’ d ‘, with none of the subjects
a. = 0
achieving nitrogen equilibrium when consuming 0.8 g pro-
a.-
teinkg ‘d
0
. >. Uauy et al (5) examined the changes in nitrogen balance in
Co w’
E a2 response to feeding graded amounts of whole-egg protein in
-
20) . seven elderly men and seven elderly women with each protein
0) amount fed for 10 d. Five women remained in negative nitrogen
C)
balance at a protein intake of 0.8 g kg . d ‘. The mean protein
a-u- intake for elderly women to achieve nitrogen equilibrium was
calculated by these investigators to be 0.83 gkg d ‘. The ni-
trogen-balance response to protein intakes of0.57, 0.70, and 0.85
Zanni Cheng Uauy Campbell Combined
et al et al et al etal data gkg ‘ d’ was more variable in elderly men, in part because
(Cu t rent four men were in positive balance at all protein intakes, whereas
study)
two men remained in negative balance at each intake. A protein
FIG I . Dietary protein intakes required to achieve nitrogen equilib- intake range between 0.7 and 0.85 g kg ‘ . d was recommended
rium in elderly subjects. Individual subject (0) and group mean protein
as sufficient for elderly men to maintain body nitrogen equilib-
intakes (± 2 SEMs: solid bars) at nitrogen equilibrium were calculated
rium. Because protein requirements are similar for men and
from data by Zanni et al (3) (a = 6), Cheng et al (4) (ii = 7). Uauy et al
women when expressed per kilogram body weight ( I ), we corn-
(5) (a = 14), and the current study based on the 1985 FAO/WHOIUNU
bined data for men and women and recalculated an overall mean
nitrogen-balance formulas ( I ). The dashed line (-- - -) represents the cur-
rent estimated mean protein requirement for all adults ( I ), and the dotted protein requirement of0.81 ± 0.09 gkg ‘ d , This is very sim-
line ( ) represents the current recommended dietary allowance (2) ilar to the protein requirement originally calculated for women
k)r elderly men and women. and within the requirement range originally estimated for men:

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 PROTEIN REQUIREMENTS IN ELDERLY PEOPLE 507

this is to be expected because the only change in formula used sign has been criticized for possibly not providing adequate time
was an increase in estimated miscellaneous nitrogen losses from for subjects to adjust to a new steady-state at a given protein
5 to 8 mgkg’d. intake (1 ), contributing to increased day-to-day variability in un-
The differences in precision with which protein requirements nary nitrogen excretion. That the major adjustments in protein
were measured between studies may be evident from the sum- metabolism consequent to consuming the defined protein intakes
mary of data presented in Figure 1. In the study by Zanni et al, had occurred during the first 5 d of the current study, and that
it was necessary to extrapolate beyond the two closely spaced these older subjects were in steady-state, is supported by the sta-
protein intakes at which each subject’s nitrogen balance was bility of the daily urinary nitrogen excretions during the 6-d bal-
measured. The SD of the required protein intake (0.45 ance period. Studies in young adults demonstrate that 90% of
g.kg_t d’) was the largest of any of the studies. In the study the total daily variability in urinary nitrogen excretion observed
by Cheng et al, nitrogen balance was measured at protein intakes in short-term balance studies is truly random and present in
that spanned the intake required for nitrogen equilibrium. The longer-term balance studies as well (23). The close similarity of
SD was 0. 12 g kg C ,d ‘ . In the study by Uauy et al, seven sub- estimated average protein requirements from short- and longer-
jects remained in negative balance and three subjects remained term balance studies in young adults, 0.63 and 0.58 gkg’ d,
in positive balance at all protein intakes. The SD of the protein respectively ( I ), supports the conclusion that short-term balance
requirement for nitrogen equilibrium was 0.34 g kg ‘ . d ‘.
studies are predictive of protein requirements that would be cx-
The estimated mean protein requirements from the three ret- pected from longer-term studies. Longer-term nitrogen-balance
rospectively assessed studies and the current study can be com- studies designed to determine protein requirements in elderly
bined by weighted averaging to produce an overall protein re- subjects have not been reported to date and would be desirable.
quirement estimate of0.9l1 ± 0.043 gkg d. The combined It is not known whether the elderly can successfully adapt to
estimate excluding the data from the present study is 0.894 protein intakes lower than those shown to be adequate in this
± 0.048 g proteinkg’d’. report.
Once a mean protein requirement is established, an upward Our study design allowed for both men and women to be stud-
adjustment should be made based on the CV of the mean re- ied together with random assignments to each dietary treatment
quirement to establish a safe protein intake (recommended allow- group. We based the decision to study both men and women on
ance) for most of the elderly population. The variability intro-
the premise that the current protein requirement and allowance
duced by the study designs makes it difficult to establish pre-
recommendations ( I , 2) are the same for both groups when cx-
cisely an overall mean CV in elderly subjects. The CV of protein
pressed per kilogram body weight and that previous nitrogen-
requirement for all adults has been estimated at I 2.5%, based on
balance studies in elderly subjects report similar nitrogen-balance
short-term nitrogen-balance studies in young men ( 1 ). Based on
results for men and women (5-7). Our nitrogen-balance data
this estimate, adequate dietary protein for 97.5% of the elderly
(Table 5) support this assumption of similarity between sexes,
population would be provided by an intake of 25% (twice the
also.
SD) above the mean protein requirement. Using this estimate, the
Nitrogen balance was measured for each subject in the current
current study suggests that the safe protein intake for elderly
study at only one protein intake. This study design eliminated
adults is 1.25 gkg’ d. Similarly, the combined data from the
the opportunity to calculate separate protein requirements for
three retrospectively reassessed studies and the current study sug-
each subject but still allowed for the calculation of an overall
gest a safe protein allowance of 1.14 g ‘ kg . d ‘. Both of these
mean protein requirement based on the combined data from all
allowance estimates are clearly higher than the 0.75 g pro-
12 subjects. Bunker et al (7) studied protein balance in elderly
tein kg ‘ . d ‘ allowance set in the WHOIFAOIUNU report (1).
subjects using a somewhat similar one-level protein intake study
Neither Cheng et al, nor Uauy et al adjusted the mean protein
design. Nitrogen balance was measured for 5 d in 24 healthy
requirement upward to provide a safe protein intake for nearly
elderly men and women, aged 70-86 y, who consumed self-
all elderly adults when they recommended that 0.8 g pro-
selected diets providing protein intakes ranging from 0.55 to I .25
tein ‘ kg ‘ . d was adequate to meet the protein needs of the
whole elderly population. Assuming that a safe protein intake (or g mixed protein . kg ‘ . d ‘ . A mean protein intake of 0.97
recommended allowance) is 25% greater than the mean require- g ‘ ‘ maintained these healthy elderly subjects in nitrogen
ment, the original results from Cheng et al suggest a safe protein equilibrium. This value is very similar to the I .00 g
intake of 0.97 g kg ‘ . d ‘, and those from Uauy et al suggest an mean protein requirement calculated for the healthy elderly in
intake of I .04 g kg ‘ . d ‘ (based on a protein requirement of the current study.
0.83 gkgt d’). The recalculated results with the 1985 WHO The use of the current study data to estimate the mean protein
balance formula establish a safe protein intake from these studies requirement requires the assumption that the regression of nitro-
of 1.16 and 1.01 gkg’ dt, respectively. gen balance on nitrogen intake is reliable and linear in the tested
range. Insofar as this relationship is not linear, or the slope of the
regression becomes flatter, the estimated protein requirement
Discussion would be overestimated. Although it is a reasonable biological
postulate that the slope of the relationship between nitrogen bal-
The uses and limitations of nitrogen-balance techniques for ance and nitrogen intake declines as submaintenance intakes ap-
establishing protein requirements are well known (10, 1 1 , 21, proach physiological requirements, as the analysis of a large
22). This study and the three retrospectively reassessed studies number of nitrogen-balance studies by Young et al (24) suggest,
are all considered short-term balance studies, with nitrogen-bal- the fact is that there is considerable question as to the quantitative
ance measurements made 5 - I 0 d after each subject began con- extent to which this might be true. Munro (25) supports this view.
suming a given protein intake. The short-term balance study de- These issues also were reviewed critically by Millward et al (26).

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 508 CAMPBELL ET AL

The problem also applies to the higher range of intake from Uauy et al (5) have been criticized for including three subjects
the maintenance amount to perhaps a usual or low surfeit amount who had each undergone a partial gastrectomy as treatment for
of protein. Hegsted’s (27) evaluation of nitrogen-balance data peptic ulcer (3). However, there were iio significant differences
and the results of Millward et al (28) on nitrogen retention in in nitrogen-balance results between these subjects and others in
adults at supramaintenance nitrogen intakes suggest continued the study, despite a somewhat lower apparent nitrogen digesti-
linearity of nitrogen balance at surfeit nitrogen intakes. The pres- bility. The one subject in the present study (lower-protein subject
ent data do not allow for an analysis of how high the upper limit no. 5) who had a history ofa partial gastrectomy as treatment for
of protein intake would have to be to affect significantly or, in- peptic ulcer also had a net nitrogen balance similar to the other
deed, overestimate the minimum physiological requirement of subjects provided a similar protein intake (Table 3).
these elderly subjects. To date, Gersovitz et al (6) conducted the only longer-term
Millward et al (26) characterized the use of the nitrogen-bal- nitrogen-balance study in elderly subjects. They evaluated the
ance technique to determine protein requirements as a ‘ ‘blunt adequacy of 0.8 g whole-egg protein . kg ‘ . d ‘ during a 30-d
tool,’ ‘ a view with which we would agree. Nevertheless, until metabolic period in seven elderly men and eight elderly women.
satisfactory alternative measurements are established for evalu- Nitrogen balance was calculated during the last 5 d of three con-
ating the protein needs of elderly subjects. the nitrogen-balance secutive l0-d periods as L’N - (UN + FN + MN)l, with miscel-
technique continues to be the standard for determining protein laneous nitrogen losses assumed to equal 5 mgkg ‘ d . All
requirements and has served as the foundation for arriving at the seven men and four of eight women were in negative balance
currently accepted national (2) and international ( I ) estimates for during the initial l0-d period, and three men and four women
dietary protein requirements. were in negative balance during the last lO-d period. Recalcu-
Each of the three previously published studies that have been lation of the data based on the 1985 WHO nitrogen-balance for-
reassessed in the present report possessed unique aspects, some mula did not appreciably change the results. Although all of the
of which were critiqued in previous reviews of protein require- subjects studied had chronic metabolic or physiologic disorders,
ments in elderly subjects (8- 12). Criticisms ofthe study by Zanni most of which required medication treatment. all were ‘ fit for
et al (3) include 1) enhancing nitrogen retention by measuring their age’ ‘ with no acute clinical problems. Because nitrogen
nitrogen balance immediately after adapting each subject to a equilibrium was not achieved by a majority of these elderly sub-
protein-free diet for 17 d. with no dietary restabilization period jects who consumed 0.8 g proteinkg ‘ d ‘. the authors con-
between balance periods (8): 2) attempting to measure differ- eluded that the current RDA for protein was inadequate for the
ences in nitrogen balance over a small range of protein intakes elderly population.
(0.36-0.46 g kg ‘ . d ) all below the protein requirement (1 1); On the basis of the current and recalculated short-term nitro-
and 3) including the balance data obtained during the protein- gen-balance results, a safe recommended protein intake for el-
free period in the linear-regression analysis of mean protein re- derly adults would be set at I .00- 1 .25 g high-quality pro-
quirement, thus lowering the protein-requirement estimate be- tein kg ‘ . d ‘. A recent nutritional status survey report showed
cause the nitrogen balance response is not linear in this sub- that ‘50% of 946 healthy free-living men and women > age 60
maintenance range ( I ). All of these may have contributed to an y living in the Boston area consume less than this amount of
underestimation of actual protein requirements and may be rca- protein (30). Indeed, 25% of the elderly men studied consume
sons to exclude this study from the combined analysis. In fact, < 0.86 g proteinkg d’, and 25% of the elderly women con-
because subject variability was greatest in this study (Fig I )- sume < 0.81 g protein . kg ‘ . d (30). A large percentage of
compared with the studies by Cheng et al, Uauy et al, and the homebound elderly people consuming their habitual dietary pro-
current study-these data contributed the least weight to the tein intake (0.67 g mixed protein . kg ‘ . d ) have been shown to
combined mean protein-requirement estimate and exclusion of be in negative nitrogen balance (7). The consequences for elderly
these data would increase the combined estimated protein re- individuals of consuming marginally low amounts of protein are
quirement only slightly. not known, but it has been suggested that immunocompetence
A criticism of the study by Cheng et al (4) has been that pro- and recovery from illness or surgery may be compromised
viding the elderly men an energy intake of 167 kJkg ‘ d (31, 32).
similar to that of the young men also studied and approximately Together, the current and recalculated retrospective nitrogen-
one-third greater than amounts recommended for healthy elderly balance data provide the strongest support to date that elderly
men (2), may have led to enhanced nitrogen retention (8, 1 1). adults have a higher protein requirement than that reported for
Consuming less energy would have further increased the esti- young adults, and a significantly higher one than the current rec-
mated protein requirement. Interestingly, muscle mass, calcu- ommendations. The mean protein requirement for elderly adults
lated from 24-h urinary creatinine excretion data reported by the to maintain nitrogen equilibrium is 0.8 g ‘ kg ‘ . d and may be
investigators, averaged 26.5 kg (43% of body weight) in the el- as high as 1.0 g proteinkg ‘ d ‘.This is much greater than 0.6
derly men, similar to the 27.2 kg muscle (41% of body weight) g protein . kg . d ‘, established by the Joint FAO/WHOIUNU
calculated for the young men. Assuming no age-related differ- Expert Consultation (I ). The results from the longer-term meta-
ences in nonmuscle FFM (29), the young adult and elderly men bolic balance study by Gersovitz et al (6) are fully consistent with
appear to have had similar body composition and thus may have this conclusion. This higher requirement for dietary protein in el-
had similar basal energy requirements. Because both groups of derly people occurs despite generally decreased muscle mass, sug-
men lived in confined environments (a prison and a nursing gesting a lower efficiency of dietary protein utilization. A
home, for young and elderly men, respectively), the energy re-
quirements for activity may also have been similar. These factors We acknowledge the cooperation and dedication of the volunteers in
suggest that energy expenditure was similar in the young and this study. This study would not have been possible without the dedicated
older men studied. work of the staff members of the Metabolic Research Unit, the Nutrient

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 PROTEIN REQUIREMENTS IN ELDERLY PEOPLE 509

Evaluation Laboratory. the Metabolic Nutrition Laboratory. and the l6. Bousnes R. Taussky H. On the colorimetric determination of creat-
Physiology Laboratory at the HNRCA. mine by the Jaffe reaction. J Biol Chern I 945: I 58:58 I -91.
17. Heymsfield SB, Arteaga C. McManus C. Smith J, Moffitt S. Mea-
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