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Nutritional Adequacy of Essential Nutrients in Low Protein Animal-Based and Plant-Based Diets in the United States for Chronic Kidney Disease Patients

Tallman DA, Khor BH, Karupaiah T, Khosla P, Chan M, Kopple JD

J Ren Nutr, 2023 Mar;33(2):249-260.
PMID: 36460269 DOI: 10.1053/j.jrn.2022.10.007

OBJECTIVES: The nutritional adequacy of both animal-based and plant-based low protein diets (LPDs) and moderate protein diets that are recommended for patients with chronic kidney disease have not been well examined. We therefore analyzed the nutrient content of three representative LPDs and moderate protein diets (lacto-ovo vegetarian, omnivorous, and vegan) containing foods that are likely to be prescribed for nondialyzed chronic kidney disease or chronic dialysis patients in the United States to determine the nutritional adequacy at different levels of protein intake.
METHODS: Theoretical 3-day menus were developed as per current renal dietary guidelines to model each diet at 7 different levels of protein intake (0.5-1.2 g/kilograms body weight/day [g/kg/d]). The diets were analyzed for their content of essential amino acids (EAAs) and other essential nutrients.
RESULTS: At an a priori recognized inadequate dietary protein level of 0.5 g/kg/d, all 3 diets failed to meet the Recommended Dietary Allowances (RDAs) for the following EAAs: histidine, leucine, lysine, and threonine. The omnivorous LPD met both the RDA and Estimated Average Requirement at levels of 0.6 g protein/kg/d or more. The lacto-ovo and vegan diets at 0.6 and 0.8 g protein/kg/d, respectively, were below the RDA for lysine. The amounts of several other vitamins and minerals were not uncommonly reduced below the RDA or Adequate Intake with all 3 LPDs.
CONCLUSION: In comparison to omnivorous LPDs, both vegan and lacto-ovo LPDs are more likely to be deficient in several EAAs and other essential nutrients. To provide sufficient amounts of all EAA, vegan and lacto-ovo LPDs must be carefully planned to include adequate amounts of appropriate dietary sources. Supplements of some other essential nutrients may be necessary with all three LPDs.

Matched MeSH terms: Diet, Protein-Restricted*
Fulltext Caring for Patients With Advanced Chronic Kidney Disease: Dietary Options and Conservative Care Instead of Maintenance Dialysis

Kalantar-Zadeh K, Bellizzi V, Piccoli GB, Shi Y, Lim SK, Riaz S, et al.

J Ren Nutr, 2023 Jul;33(4):508-519.
PMID: 36796502 DOI: 10.1053/j.jrn.2023.02.002

An expert advisory board discussed the prevention and treatment of chronic kidney disease (CKD), with a focus on dietary options. This is timely, given the uptake of value based models for kidney care in the United States. Timing of dialysis start is influenced by patients' clinical status and complex patient-clinician interactions. Patients value personal freedom and quality of life and may want to delay dialysis, whilst physicians are sometimes more concerned with clinical outcomes. Kidney-preserving therapy can prolong the dialysis-free period and preserve residual kidney function, thus patients are asked to adjust their lifestyle and diet, to follow a low- or very low-protein diet, with or without ketoacid analogues. Multi-modal approaches include pharmacotherapies, management of symptoms, and a gradual, individualized dialysis transition. Patient empowerment is vital, including CKD education and involvement in decision making. These ideas may help patients, their families, and clinical teams to improve the management of CKD.

Matched MeSH terms: Diet, Protein-Restricted
Individual non-essential amino acids fortification of a low-protein diet for broilers under the hot and humid tropical climate

Awad EA, Zulkifli I, Soleimani AF, Loh TC

Poult Sci, 2015 Nov;94(11):2772-7.
PMID: 26371331 DOI: 10.3382/ps/pev258

A study was conducted to investigate the effects of feeding low-protein diets fortified with individual non-essential amino acids (NEAA) on growth performance, serum metabolites (uric acid, UA; triglycerides, TG; total protein, TP; and albumin, Alb), organ weight, breast yield, and abdominal fat weight in broiler chicks raised under the hot and humid tropical climate. Eight isocaloric (3,017 kcal/kg) experimental diets were formulated and fed to male broiler chicks from d 1-21 as follows: 1) 22.2% crude protein (CP) (positive control; PC); 2) 16.2% CP + mixture essential amino acids (EAA) to meet or exceed the National Research Council (1994) recommendations (negative control; NC); 3) NC + glycine (Gly) to equal the total glycine + serine level in the PC; diets 4 through 7 were obtained by supplementing NC diet with individual glutamic acid, proline, alanine, or aspartic acid (Glu, Pro, Ala, or Asp, respectively); 8) NC + NEAA (Gly + Glu + Pro + Ala + Asp) to equal the total level of these NEAA in the PC. Fortifying NC diet with mixture NEAA resulted in a similar growth performance as PC. However, fortification of low-CP diet with individual NEAA failed to improve body weight (BW) (P < 0.0001), feed intake (FI) (P = 0.0001), and feed conversion ratio (FCR) (P = 0.0001). Serum uric acid (UA) was lower (P = 0.0356) in NC birds and NC diet supplemented with individual NEAA birds, whereas serum triglyceride (TG) (P = 0.007) and relative weight of abdominal fat (P = 0.001) were higher in these birds. In conclusion, no single NEAA fortification may compensate the depressed growth performance attributed to a low-CP diet. However, fortification with Gly may improve FCR. There is a possibility that broilers raised under the hot and humid climate require higher Gly fortification than the level used in this study.

Matched MeSH terms: Diet, Protein-Restricted/veterinary*
Growth performance, duodenal morphology and the caecal microbial population in female broiler chickens fed glycine-fortified low protein diets under heat stress conditions

Awad EA, Idrus Z, Soleimani Farjam A, Bello AU, Jahromi MF

Br Poult Sci, 2018 Jun;59(3):340-348.
PMID: 29433333 DOI: 10.1080/00071668.2018.1440377

1. This study was undertaken to examine the effect of feeding glycine (Gly)-fortified low protein (LP) diets on the growth performance, duodenal morphology and caecal microbial populations of broiler chickens raised under unheated, cyclic or constant heat stress environmental conditions. 2. From d 1 to 21 (starter phase), an equivalent number of birds were fed either a normal protein (NP) diet or a LP diet fortified with Gly. From d 22 to 42 (grower phase), an equivalent number of birds from each starter diet were distributed to one of the following dietary groups: (i) an NP diet during the starter and grower phases (NPNP), (ii) an NP diet during the starter phase and a LP diet during the grower phase (NPLP), (iii) an LP diet during the starter phase and an NP diet during the grower phase (LPNP) or (iv) LP diets during both phases (LPLP). 3. Commencing from d 22, an equivalent number of birds from each dietary group were exposed to (i) 23 ± 1°C throughout (unheated), (ii) 34 ± 1°C for 7 h each day from 10:00 to 17:00 (cyclic heat) or (iii) 34 ± 1°C throughout (constant heat). 4. Feeding the LP diet during the starter phase resulted in feed intake (FI), weight gain (WG), feed conversion ratios (FCR) and energy efficiency ratios (EER) similar to those for the NP diet. The birds fed the LP diet had a significantly higher protein efficiency ratio (PER) compared with the birds fed the NP diet. 5. During the grower phase, there were significant diet × temperature interactions for F, WG, FCR, PER, EER, villus height, crypt depth and caecal Clostridia. The birds fed the NPLP and LPLP diets had lower FI, WG and EER, higher FCR, shorter villus height and crypt depth and higher caecal Clostridia compared with the birds fed LPNP and NPNP diets under constant heat stress. However, feeding birds the NPLP and LPLP diets resulted in FI, WG, EER, FCR, morphology parameters and caecal Clostridia equivalent to the birds fed LPNP and NPNP diets, as well as improved PER, under unheated and cyclic heat stress conditions. 6. In conclusion, our results indicate that Gly-fortified LP diets can be fed to broilers under normal and acute heat stress environmental conditions without any adverse effects on performance. However, the use of such LP diets can be detrimental to broilers under chronic heat stress conditions.

Matched MeSH terms: Diet, Protein-Restricted/veterinary*
Fulltext Effects of lysine and methionine in a low crude protein diet on the growth performance and gene expression of immunity genes in broilers

Lee CY, Song AA, Loh TC, Abdul Rahim R

Poult Sci, 2020 Jun;99(6):2916-2925.
PMID: 32475425 DOI: 10.1016/j.psj.2020.03.013

Globally, the poultry industry is 1 of the most advanced livestock industries. Feed contributes to the biggest proportion (65-70%) of the production cost. Most feed ingredients in Malaysia are imported, which contributes to the high food bill annually, and alternative feed formulation may help decrease the cost of poultry feed. Feed formulation are improved to efficiently meet the dietary requirements of the broilers and 1 of the ways is by reducing the level of crude protein in the diet while supplementing essential amino acids. In this study, the effects of methionine and lysine, which are the 2 most limiting amino acids in the chicken diet, were supplemented in a low crude protein diet, and its effects on the growth and expression of immunity genes such as MUC2, SLC, GAL6, and LEAP-2 were studied. A total of 300 Cobb500 broilers were tested with 10 different dietary treatments. Experimental treatment diets consist of high, standard, and low levels of methionine and lysine in the diet with reduced crude protein. The control group consists of diet with standard levels of lysine, methionine, and crude protein as recommended for Cobb500 broilers. Ribonucleic acid was extracted from the jejunum, spleen, and liver for gene expression analysis which was performed with real-time polymerase chain reaction using SYBR Green chemistry. Results of the growth performance at 6 wk showed improved feed conversion ratio when lysine was increased by 0.2% in a low crude protein diet at 1.96 ± 0.11. Gene expression of MUC2 gene in the jejunum showed a significant increase across all experimental diets with the treatment with higher lysine in low crude protein diet with the highest increase of 3.8 times as compared with the control diet. The other genes expressed in the spleen and liver were mostly downregulated. It was concluded that supplementation of high lysine with standard methionine in a low crude protein diet performed better in terms of lowest feed conversion ratio and high upregulation of MUC2 gene.

Matched MeSH terms: Diet, Protein-Restricted/veterinary*
Effects of low-protein diets on acute phase proteins and heat shock protein 70 responses, and growth performance in broiler chickens under heat stress condition

Zulkifli I, Akmal AF, Soleimani AF, Hossain MA, Awad EA

Poult Sci, 2018 Apr 01;97(4):1306-1314.
PMID: 29381776 DOI: 10.3382/ps/pex436

A study with a 4 × 2 factorial arrangement was conducted to investigate the effects of 4 dietary protein levels and 2 environmental conditions on acute phase proteins (APP), brain heat shock protein (HSP) 70 density, and growth performance of broiler chickens. Day-old broiler chicks (Cobb 500) were fed isocaloric diets but with various levels of crude protein (CP), namely, (1) 21.0 and 19.0% CP in starter and finisher diets, respectively (control), (2) 19.5 and 17.5% CP in starter and finisher diets, respectively (Diet A), (3) 18.0 and 16.0% CP in starter and finisher diets, respectively (Diet B), and (4) 16.5 and 14.5% CP in starter and finisher diets, respectively (Diet C). Equal numbers of birds from each diet were subjected to either 23±1°C throughout or 33±1°C for 6 h per d from 22 to 35 d of age. From d 1 to 21, feed intake (FI) and weight gain (WG) decreased linearly (P = 0.021 and P = 0.009, respectively), as CP level was reduced. During the heat treatment period (d 22 to 35), there were significant (P = 0.04) diet × heat treatment interactions for FCR. Diet had no effect on FCR among the unheated birds, but the ratio increased linearly (P = 0.007) as dietary CP level decreased. Irrespective of ambient temperature, there was a significant linear decrease in FI (P = 0.032) and WG (P < 0.001) as dietary CP level decreased. Low-CP diets improved the survivability of heat-stressed broilers when compared to those fed control diets. Low-CP diets linearly decreased (P < 0.01) APP (ovotransferrin and alpha-acid glycoprotein) responses. Both APP and HSP 70 reactions were elevated following heat treatment. In conclusion, feeding broilers with low-CP diets adversely affect the growth performance of broilers under heat stress condition. However, low-CP diets were beneficial in improving the survivability. Because APP are involved in the restoration of homeostasis, the adverse effect of low-CP diet on the synthesis of these proteins could be of concern.

Matched MeSH terms: Diet, Protein-Restricted/veterinary*
Fulltext Factors associated with adherence to low protein diet among patients with stage iii-v of chronic kidney disease in an outpatient clinic at Hospital Pakar Sultanah Fatimah

Sim-Kian Leong, Yi-Loon Tye, Nik Mahani Nik Mahmood, Zulfitri Azuan Mat Daud

Malaysian Journal of Medicine and Health Sciences, 2020;16(106):131-139.
MyJurnal

Introduction: Although the benefit of low protein diet (LPD) on chronic kidney disease (CKD) progression is well documented, patients’ adherence remains as the main challenge. Therefore, this study sought to identify adherence towards LPD among CKD patients and determine possible associating factors. Methods: This cross-sectional study was done at the Hospital Pakar Sultanah Fatimah in Muar, Johor, among stage III to V CKD patients. Three-day dietary recalls were used to quantify dietary energy (DEI) and protein intake (DPI). Factors investigated include socio-demo- graphic characteristics, medical history, anthropometry and body composition measurements, dietary knowledge, appetite level, handgrip strength, perceived stress, and health locus of control. Associating variables were analysed with logistic regression analysis. Results: The final analysis included 113 patients (54% male) with a mean estimated glomerular filtration rate of 17.5±11.2mL/min/1.73m2 and the average age of 56.3±12.8 years. Mean DEI and DPI were 22.4±5.9kcal/kg/day and 0.83±0.28g/kg/day, respectively. Only 34.5% of patients adhere to the LPD diet with 59% exceeding the DPI recommendation. Poorer LPD adherence was associated with longer duration of hospitaliza- tion (OR 0.707, 95%CI 0.50-1.00, p=0.048), higher energy intake (OR 0.744, 95%CI 0.65-0.85, p

Matched MeSH terms: Diet, Protein-Restricted