Prediction of skeletal muscle and fat mass in patients with advanced cancer using a metabolomic approach

Urine and plasma metabolites originate from endogenous metabolic pathways in different organs and exogenous sources (diet). Urine and plasma were obtained from advanced cancer patients and investigated to determine if variations in lean and fat mass, dietary intake, and energy metabolism relate to variation in metabolite profiles. Patients (n = 55) recorded their diets for 3 d and after an overnight fast they were evaluated by DXA and indirect calorimetry. Metabolites were measured by NMR and direct injection MS. Three algorithms were used [partial least squares discriminant-analysis, support vector machines (SVM), and least absolute shrinkage and selection operator] to relate patients' plasma/urine metabolic profile with their dietary/physiological assessments. Leave-one-out cross-validation and permutation testing were conducted to determine statistical validity. None of the algorithms, using 63 urine metabolites, could learn to predict variations in individual's resting energy expenditure, respiratory quotient, or their intake of total energy, fat, sugar, or carbohydrate. Urine metabolites predicted appendicular lean tissue (skeletal muscle) with excellent cross-validation accuracy (98% using SVM). Total lean tissue correlated highly with appendicular muscle (Pearson r = 0.98; P < 0.0001) and gave similar cross-validation accuracies. Fat mass was effectively predicted using the 63 urine metabolites or the 143 plasma metabolites, exclusively. In conclusion, in this population, lean and fat mass variation could be effectively predicted using urinary metabolites, suggesting a potential role for metabolomics in body composition research. Furthermore, variation in lean and fat mass potentially confounds metabolomic studies attempting to characterize diet or disease conditions. Future studies should account or correct for such variation.

Protein requirement of healthy school-age children determined by the indicator amino acid oxidation method

BACKGROUND

The current Dietary Reference Intake (DRI) recommendations for protein requirements in children are based on a factorial estimate and have not been directly determined.

OBJECTIVE

The objective of the current study was to determine the protein requirement in healthy, school-age children by measuring the oxidation of L-[1-(13)C]-phenylalanine to (13)CO(2) [label tracer oxidation (F(13)CO(2))] in response to graded intakes of protein.

DESIGN

Seven healthy children (6-11 y old) each randomly received a minimum of 7 protein intakes (range: 0.1-2.56 g · kg(-1) · d(-1)) for a total of 56 studies. The diets provided energy at 1.7 times the resting energy expenditure and were made isocaloric by using carbohydrate. Protein was given as an amino acid mixture on the basis of the egg-protein pattern, except for phenylalanine and tyrosine intakes, which were maintained constant across intakes. The mean protein requirement was determined by applying a 2-phase linear regression crossover analysis on F(13)CO(2) data, which identified a breakpoint (requirement) at minimal F(13)CO(2) in response to graded amounts of protein intake.

RESULTS

Mean and population-safe (upper 95% CI) protein requirements were determined to be 1.3 and 1.55 g · kg(-1) · d(-1), respectively. These results are significantly higher than the mean and population-safe protein requirements currently recommended by the DRI 2005 for macronutrients (0.76 and 0.95 g · kg(-1) · d(-1), respectively).

CONCLUSION

To our knowledge, this study was the first to directly estimate protein requirements in children by using stable isotopes and indicated that current recommendations are severely underestimated.

Arginine can be synthesized from enteral proline in healthy adult humans

There is considerable controversy recently in identifying dietary precursors for arginine synthesis. We have previously shown in human neonates and piglets that proline is the sole dietary precursor for arginine synthesis. It is unclear in adult humans whether proline is a dietary precursor for arginine. We performed a multi-tracer stable isotope study in adults using (15)N(2)-ureido arginine and (15)N proline to elucidate synthesis of citrulline and arginine and determine whether proline is a precursor for arginine. Primed, intermittent infusions of the labeled amino acids were given enterally to 5 healthy men consuming a standardized milkshake diet. Blood was sampled during plateau enrichment between 1.5 and 3 h. Plasma enrichment occurred for both tracers, giving enteral turnover estimates of 93 μmol · kg(-1) · h(-1) for arginine and 154 μmol · kg(-1) · h(-1) for proline. Appearance of the label from proline in arginine and the intermediaries, ornithine and citrulline, was measured in all participants. The rate of synthesis of arginine from proline was 3.7 μmol · kg(-1) · h(-1), which is estimated to be ~40% of newly synthesized arginine. In this first study in adult humans using an enteral proline tracer, we have demonstrated synthesis of arginine from this dietary amino acid. Therefore, as in newborns, proline must now be considered a dietary precursor for arginine in healthy adults.

Arginine synthesis from enteral glutamine in healthy adults in the fed state

Recent studies have documented transfer of labeled nitrogen from [2-(15)N]glutamine to citrulline and arginine in fasting human adults. Conversely, in neonates and piglets we have shown no synthesis of arginine from [2-(15)N]glutamate, and others have shown in mice that glutamine is a nitrogen, but not a carbon donor, for arginine synthesis. Therefore, we performed a multitracer study to determine whether glutamine is a nitrogen and/or carbon donor for arginine in healthy adult men. Two glutamine tracers, 2-(15)N and 1-(13)C, were given enterally to five healthy men fed a standardized milkshake diet. There was no difference in plasma enrichments between the two glutamine tracers. 1-(13)C isotopomers of citrulline and arginine were synthesized from [1-(13)C]glutamine. Three isotopomers each of citrulline and arginine were synthesized from the [2-(15)N]glutamine tracer: 2-(15)N, 5-(15)N, and 2,5-(15)N(2). Significantly greater enrichment was found of both [5-(15)N]arginine (0.75%) and citrulline (3.98%) compared with [2-(15)N]arginine (0.44%) and [2-(15)N]citrulline (2.62%), indicating the amino NH(2) from glutamine is mostly transferred to arginine and citrulline by transamination. Similarly, the enrichment of the 1-(13)C isotopomers was significantly less than the 2-(15)N isotopomers, suggesting rapid formation of α-ketoglutarate and recycling of the nitrogen label. Our results show that the carbon for 50% of newly synthesized arginine comes from dietary glutamine but that glutamine acts primarily as a nitrogen donor for arginine synthesis. Hence, studies using [2-(15)N]glutamine will overestimate arginine synthesis rates.

The metabolic availability of threonine in common feedstuffs fed to adult sows is higher than published ileal digestibility estimates

Amino acid (AA) requirements for sows during pregnancy are currently under review. However, requirement recommendations must be accompanied by an estimate of the bioavailability of AA from feeds to ensure adequate supply of AA and to minimize excess nitrogen excretion. Current ileal AA digestibility estimates are based on growing pig data; however, availability of AA in adult pigs may be different from that in growing pigs. The metabolic availability (MA) of threonine (Thr) in corn and barley was determined in 6 pregnant sows using the indicator AA oxidation method and L-[1-(13)C]phenylalanine as the tracer AA. Sows were fed reference diets formulated from 30 to 75% of the breakpoint derived in Expt. 1; all other nutrients were set at 120% of requirement. Test ingredients diets were formulated to supply Thr at 75% of the determined requirement. Tracer phenylalanine was given orally in 8 one-half-hourly meals and expired (13)CO(2) was quantified. The determined MA of Thr from corn and barley fed to pregnant sows was 88.0 and 89.3%, respectively. The determined MA was 7 and 9% greater than the published standard ileal digestibility estimates of Thr in corn (82%) and barley (81%), respectively. Mature animals have a greater capacity to digest and absorb nutrients from feed ingredients than previously assumed based on ileal digestibility studies. Sow diets formulated based on published ileal digestibility estimates are overformulated with respect to available protein and AA and thus increase excess nitrogen excretion and potential environmental concerns.

Arginine is synthesized from proline, not glutamate, in enterally fed human preterm neonates

In neonatal mammals, arginine is synthesized in the enterocyte, with either proline or glutamate as the dietary precursor. We have shown several times in piglets that proline is the only precursor to arginine, although in vitro evidence supports glutamate in this role. Because of this uncertainty, we performed a multitracer stable isotope study to determine whether proline, glutamate, or both are dietary precursors for arginine in enterally fed human neonates. Labeled arginine (M + 2), proline (M + 1), and glutamate (M + 3) were given enterally to 15 stable, growing preterm infants (GA at birth 30-35 wk) at 1-3 wk postnatal age. Enrichment in urine of the tracer amino acids and the M + 1 and M + 3 isotopomers of arginine were measured by LC-tandem mass spectrometry to determine the contribution of proline and glutamate to arginine synthesis. Plateau enrichments of arginine and proline tracers were measurable in urine. Urinary glutamate enrichment was not detected. Conversion of proline to arginine was detected. However, the M + 3 isotopomer of arginine, which would have been synthesized from glutamate, was not detected. We conclude that, in contrast to the current consensus in the literature based on in vitro studies, proline is the major contributor to arginine synthesis in human preterm infants.

Lysine requirement in parenterally fed postsurgical human neonates

BACKGROUND

The lysine requirement of human neonates receiving parenteral nutrition (PN) has not been determined experimentally.

OBJECTIVE

The objective was to determine the parenteral lysine requirement for human neonates by using the minimally invasive indicator amino acid oxidation technique with l-[1-(13)C] phenylalanine as the indicator amino acid.

DESIGN

Eleven postsurgical neonates were randomly assigned to 15 lysine intakes ranging from 50 to 260 mg . kg(-1) . d(-1). Breath and urine samples were collected at baseline and at plateau for (13)CO(2) (F(13)CO(2)) and amino acid enrichment, respectively. The mean lysine requirement was determined by applying a 2-phase linear regression crossover analysis to the measured rates of F(13)CO(2) release and l-[1-(13)C]phenylalanine oxidation.

RESULTS

The mean parenteral lysine requirement determined by F(13)CO(2) release oxidation was 104.9 mg . kg(-1) . d(-1) (upper and lower CIs: 120.6 and 89.1 mg . kg(-1) . d(-1), respectively). The mean lysine parenteral requirement determined by phenylalanine oxidation was 117.6 mg . kg(-1) . d(-1) (upper and lower CIs: 157.5 and 77.6 mg . kg(-1) . d(-1), respectively). Graded intakes of lysine had no effect on phenylalanine flux.

CONCLUSION

We recommend a mean lysine requirement for the postsurgical PN-fed neonate of 104.9 mg . kg(-1) . d(-1), which is 32-43% of the lysine concentration presently found in commercial PN solutions (246-330 mg . kg(-1) . d(-1)). This trial was registered at clinicaltrials.gov as NCT00779753.

The addition of cysteine to the total sulphur amino acid requirement as methionine does not increase erythrocytes glutathione synthesis in the parenterally fed human neonate

Controversy exists as to whether the parenterally (PN) fed human neonate is capable of synthesizing adequate cysteine from methionine if the total dietary requirement for sulfur amino acid (SAA) is provided as methionine only. The goal of this study was to gather data on whether glutathione (GSH) synthesis is maximized at a methionine intake previously shown to be adequate for protein synthesis in the PN-fed human neonate. We measured GSH concentration, fractional, and absolute synthesis rate in five PN-fed human neonates. Each neonate underwent two isotope infusion studies of 7 h duration after a 2-d adaptation to the total SAA requirement (methionine only) and again after a further 2-d adaptation to the same methionine intake supplemented with cysteine at 10 mg x kg(-1) x d(-1). Cysteine supplementation did not significantly affect GSH synthesis. These data suggest that term infants are capable of synthesizing cysteine from methionine, not only for protein but also for GSH synthesis.

The significance of d-isomers in stable isotope studies in humans is dependent on the age of the subject and the amino acid tracer

d-Amino acids (d-AAs) in stable isotope tracers may result in erroneous estimates of enrichment, particularly if urine is used as a surrogate for plasma enrichment. Previous studies suggest that a d-AA content of less than 0.2% will not result in significant error in studies with adult humans. To describe the effects of d-AA content of less than 0.2%, in 3 different AA tracers, on isotope enrichment in urine and plasma, arginine, proline, and phenylalanine (Phe) tracers were given enterally to human neonates. Enrichment was measured in urine and plasma using chiral chromatography and tandem mass spectrometry. The Phe tracer was also given parenterally to human neonates and enterally to children and adults to further characterize the d-AA effect. All isotopes had a confirmed d-AA content of less than 0.2%. Labeled d-arginine resulted in an overestimate for enrichment of 20% in plasma and 87% in urine. A smaller effect was seen for d-Phe, which resulted in a 5% overestimate for plasma and 40% in urine. d-Proline had no significant effect. Using the same Phe tracer, a developmental effect was found, with a reduction in the overestimate in children compared with infants and no effect on enrichment in adults. Investigators using commercially produced, stable isotope-labeled AAs need to be aware that there is no safe level of d contamination; a d-AA content less than 0.2% may result in significant overestimate for enrichment, even in plasma, for infants and children. This source of error can be avoided by the use of chiral chromatography.

Evidence that protein requirements have been significantly underestimated

PURPOSE OF REVIEW

This review discusses recent evidence that suggests a significant underestimation of protein requirements in adult humans.

RECENT FINDINGS

Traditionally, total protein requirements for humans have been determined using nitrogen balance. The recent Dietary Reference Intake recommendations for mean and population-safe intakes of 0.66 and 0.8 g/kg/day, respectively, of high-quality protein in adult humans are based on a meta-analysis of nitrogen balance studies using single linear regression analysis. We reanalyzed existing nitrogen balance studies using two-phase linear regression analysis and obtained mean and safe protein requirements of 0.91 and 0.99 g/kg/day, respectively. The two-phase linear regression analysis is considered more appropriate for biological analysis of dose-response curves. Considering the inherent problems associated with the nitrogen balance method, we developed an alternative method, the indicator amino acid oxidation technique, to determine protein requirements The mean and population-safe requirements in adult men were determined to be 0.93 and 1.2 g/kg/day and are 41 and 50%, respectively, higher than the current Dietary Reference Intakes recommendations.

SUMMARY

The indicator amino acid oxidation-based requirement values of 0.93 and 1.2 g protein/kg/day and the reanalysis of existing nitrogen balance studies are significantly higher than current recommendations. Therefore, there is an urgent need to reassess recommendations for protein intake in adult humans.

Lysine requirement of healthy, school-aged Indian children determined by the indicator amino acid oxidation technique

We recently reported the lysine requirement of school-aged children living in Canada consuming a mixed diet to be 35 mg.kg(-1).d(-1). Because the majority of children in the world live on cereal-based diets in developing countries, we measured the daily lysine requirement in healthy children living in India and consuming a mostly cereal-based diet. Our objective in this study was to determine the lysine requirement in healthy, school-aged children in the developing world by using the indicator amino acid oxidation method with l-[1-(13)C] phenylalanine. Six healthy, school-aged children consumed 7 levels of lysine (5, 15, 25, 35, 50, 65, and 80 mg.kg(-1).d(-1)) each in a random order along with an amino acid mixture providing energy and protein intakes of 1.7 x resting energy expenditure and 1.5 g.kg(-1).d(-1), respectively. The mean lysine requirement was determined by applying a 2-phase linear regression crossover analysis on tracer oxidation (F(13)CO(2)) data, which identified a breakpoint (requirement) at minimal F(13)CO(2) in response to the graded lysine intakes. The mean lysine requirements with the upper 95% CI for children were determined to be 33.5 and 46.6 mg.kg(-1).d(-1), respectively, by breakpoint analysis of the F(13)CO(2) data. The mean lysine requirements of Indian children were almost identical to that of Canadian children (35 mg.kg(-1).d(-1)). There is no evidence for any adaptation in lysine requirements in children from developing countries such as India.

Indicator amino acid oxidation is not affected by period of adaptation to a wide range of lysine intake in healthy young men

The number of days of adaptation to a specific amino acid intake required prior to the determination of amino acid requirements using the indicator amino acid oxidation method (IAAO) is still in debate. In this study, our objective was to determine whether adaptation for 8 h, 3 d, and 7 d to a wide range of lysine intakes had any effect on the oxidation of the indicator amino acid, l-[1-(13)C]phenylalanine, to (13)CO(2) (F(13)CO(2)). Five healthy young men randomly received each of 4 levels of lysine (5, 20, 35, and 70 mg x kg(-1) x d(-1)) along with an amino acid mixture to achieve a protein intake of 1.0 g x kg(-1) x d(-1) and energy intake of 1.5x resting energy expenditure during 4 separate 7-d study periods. IAAO studies were conducted on d 1, 3, and 7. During each study day, oral consumption of l-[1-(13)C]phenylalanine was followed by collection of breath for F(13)CO(2) and plasma for measurement of phenylalanine enrichment. F(13)CO(2) was affected by lysine intake but did not differ among adaptation periods of 8 h, 3 d, or 7 d. Phenylalanine flux was not significantly affected by period of adaptation. These results suggest that the minimally invasive IAAO model, where participants are adapted prior to protein intake for 2 d followed by study day adaptation to the test amino acid intake for 8 h, may be sufficient to estimate individual amino acid requirements in healthy young men.

Amino acid requirements in humans: with a special emphasis on the metabolic availability of amino acids

Due to advances made in the development of stable isotope based carbon oxidation methods, the determination of amino acid requirements in humans has been an active area of research for the past 2 decades. The indicator amino acid oxidation (IAAO) method developed in our laboratory for humans has been systematically applied to determine almost all indispensable amino acid requirements in adult humans. Nutritional application of experimentally derived amino acid requirement estimates depends upon the capacity of food proteins to meet the amino acid requirements in humans. Therefore, there is a need to know the proportion of dietary amino acids which are bioavailable, or metabolically available to the body for protein synthesis following digestion and absorption. Although this concept is widely applied in animal nutrition, it has not been applied to human nutrition due to lack of data. We developed a new in vivo method in growing pigs to identify the metabolic availability of amino acids in foods using the IAAO concept. This metabolic availability method has recently been adapted for use in humans. As this newly developed IAAO based method to determine metabolic availability of amino acids in foods is suitable for rapid and routine analysis in humans, it is a major step forward in defining the protein quality of food sources and integrating amino acid requirement data with dietary amino acid availability of foods.

Threonine requirement of parenterally fed postsurgical human neonates

BACKGROUND

The threonine requirement of human neonates who receive parenteral nutrition (PN) has not been determined experimentally.

OBJECTIVE

The objective was to determine the parenteral threonine requirement for human neonates by using the minimally invasive indicator amino acid oxidation technique with L-[1-(13)C]phenylalanine as the indicator amino acid.

DESIGN

Nine postsurgical neonates were randomly assigned to 16 threonine intakes ranging from 10 to 100 mg . kg(-1) . d(-1). Breath and urine samples were collected at baseline and at plateau for (13)CO(2) and amino acid enrichment, respectively. The mean threonine requirement was determined by applying a 2-phase linear regression crossover analysis to the measured rates of (13)CO(2) release (F(13)CO(2)) and L-[1-(13)C]phenylalanine oxidation.

RESULTS

The mean threonine parenteral requirement determined by using phenylalanine oxidation was 37.6 mg . kg(-1) . d(-1) (upper and lower confidence limits, respectively: 29.9 and 45.2 mg . kg(-1) . d(-1)) and by using F(13)CO(2) oxidation was 32.8 mg . kg(-1) . d(-1) (upper and lower confidence limits, respectively: 29.7 and 35.9 mg . kg(-1) . d(-1)). Graded intakes of threonine had no effect on phenylalanine flux.

CONCLUSION

This is the first study to report on the threonine requirement for human neonates receiving PN. We found that the threonine requirement for postsurgical PN-fed neonates is 22-32% of the content of threonine that is presently found in commercial PN solutions (111-165 mg . kg(-1) . d(-1)).

Methionine-adequate cysteine-free diet does not limit erythrocyte glutathione synthesis in young healthy adult men

Most methods of determining amino acid (AA) requirements are based on endpoints that determine adequacy for protein synthesis. However, the sulfur AA (SAA) cysteine is believed to be the rate-limiting substrate for synthesis of the most abundant intracellular antioxidant, glutathione (GSH). Our objectives were to determine whether supplementation of cysteine in a diet containing adequate SAA for protein synthesis, as methionine, increased GSH synthesis by measuring the fractional and absolute synthesis rates, and if concentration of GSH changed in response to feeding 5 graded intakes of cysteine (0, 10, 20, 30, and 40 mg x kg(-1) x d(-1)) in a random order with a fixed methionine intake of 14 mg x kg(-1) x d(-1) and a protein intake of 1 g x kg(-1) x d(-1). Each subject received a multivitamin and choline supplement during the study. Four healthy adult men each underwent 5 isotope infusion studies of 7-h duration after a 2-d adaptation to the level of cysteine intake being studied on the isotope infusion day. The isotope used was [U-(13)C(2)-(15)N]glycine. Analyses included erythrocyte GSH synthesis rates and concentration and urinary sulfate excretion. The GSH synthesis rates and concentration, measured at a methionine intake of 14 mg x kg(-1) x d(-1), did not change with increasing intakes of cysteine. Urinary sulfate excretion showed a significant positive relationship with cysteine intake (r = 0.92; P < 0.01). In conclusion, this study provides preliminary evidence that consumption of SAA adequate to meet the requirement for protein synthesis does not limit GSH synthesis in healthy adult men receiving an otherwise adequate diet.

An approach to defining the upper safe limits of amino acid intake

The existing data on the safe upper limits of amino acid intake in humans is essentially observational; how much do individuals ingest and what side effects do they have? There are numerous studies in humans comparing the effects of high doses of amino acids given as protein bound vs. as free amino acids. These studies have shown that protein-bound amino acids have much less effect on plasma levels of the test amino acid, because protein intake stimulates protein synthesis as another sink for the increased amino acid intake. In practice, the highest amino acid intakes occur with free amino acid supplements that may be ingested by athletes who believe that the amino acids will benefit them in training and/or performance. Previously, in a piglet study, we were able to define the point at which maximal phenylalanine oxidation occurred, above which plasma phenylalanine concentration and body balance rose exponentially. We regard this value of maximal disposal (oxidation) of an amino acid as one metabolic marker of the upper limit of intake. Recently, others have demonstrated a similar maximal oxidation rate for leucine in rats. Based on these experimental data and the paucity of published human data in controlled experiments, we think that a systematic approach needs to be undertaken to define the maximal oxidation rate for all dietary indispensable amino acids and other amino acids that may be ingested in excess by humans. We believe that this will provide a rational basis to begin to define the upper limits of tolerance for dietary amino acids. However, some amino acids, such as threonine and methionine, will be more difficult to study, because they have more than 1 route of disposal or very complex metabolic regulation, in which case defining their upper limits will be more multifaceted.