The daily phenylalanine requirement of healthy Indian adults

Evaluating change in diet with pegvaliase treatment in adults with phenylketonuria: Analysis of phase 3 clinical trial data

Phenylketonuria (PKU), a genetic disorder characterized by phenylalanine hydroxylase (PAH) deficiency and phenylalanine (Phe) accumulation, is primarily managed with a protein-restricted diet and PKU-specific medical foods. Pegvaliase is an enzyme substitution therapy approved for individuals with PKU and uncontrolled blood Phe concentrations (>600 μmol/L) despite prior management. This analysis assessed the effect of pegvaliase on dietary intake using data from the Phase 3 PRISM-1 (NCT01819727), PRISM-2 (NCT01889862), and 165-304 (NCT03694353) clinical trials. Participants (N = 250) had a baseline diet assessment, blood Phe ≥600 μmol/L, and had discontinued sapropterin; they were not required to follow a Phe-restricted diet. Outcomes were analyzed by baseline dietary group, categorized as >75%, some (>0% but ≤75%), or no protein intake from medical food. At baseline, mean age was 29.1 years, 49.2% were female, mean body mass index was 28.4 kg/m2, and mean blood Phe was 1237.0 μmol/L. Total protein intake was stable up to 48 months for all 3 baseline dietary groups. Over this time, intact protein intake increased in all groups, and medical protein intake decreased in those who consumed any medical protein at baseline. Of participants consuming some or >75% medical protein at baseline, 49.1% and 34.1% were consuming no medical protein at last assessment, respectively. Following a first hypophenylalaninemia (HypoPhe; 2 consecutive blood Phe measurements <30 μmol/L) event, consumption of medical protein decreased and consumption of intact protein increased. Substantial and sustained Phe reductions were achieved in all 3 baseline dietary groups. The probability of achieving sustained Phe response (SPR) at ≤600 μmol/L was significantly greater for participants consuming medical protein versus no medical protein in an unadjusted analysis, but no statistically significant difference between groups was observed for probability of achieving SPR ≤360 or SPR ≤120 μmol/L. Participants with alopecia (n = 49) had longer pegvaliase treatment durations, reached HypoPhe sooner, and spent longer in HypoPhe than those who did not have alopecia. Most (87.8%) had an identifiable blood Phe drop before their first alopecia episode, and 51.0% (n = 21/41) of first alopecia episodes with known duration resolved before the end of the HypoPhe episode. In conclusion, pegvaliase treatment allowed adults with PKU to lower their blood Phe, reduce their reliance on medical protein, and increase their intact and total protein intake. Results also suggest that HypoPhe does not increase the risk of protein malnutrition in adults with PKU receiving pegvaliase.

Amino acid oxidation methods to determine amino acid requirements: do we require lengthy adaptation periods?

Determination of indispensable amino acid (IAA) requirements necessitates a range of intakes of the test IAA and monitoring of the physiological response. Short-term methods are the most feasible for studying multiple intake levels in the same individual. Carbon oxidation methods measure the excretion of 13CO2 in breath from a labelled amino acid (AA) in response to varying intakes of the test AA following a period of adaptation. However, the length of adaptation to each AA intake level has been a source of debate and disagreement among researchers. The assertion of the minimally invasive indicator amino acid oxidation (IAAO) technique is that IAA requirements can be estimated after only a few hours (8 h) of adaptation to each test AA intake, suggesting that adaptation occurs rapidly in response to dietary adjustments. On the contrary, the assertion of most other techniques is that 6–7 d of adaptation is required when determining IAA needs. It has even been argued that a minimum of two weeks is needed to achieve complete adaptation. This review explores evidence regarding AA oxidation methods and whether long periods of adaptation to test IAA levels are necessary when estimating IAA requirements. It was found that the consumption of experimental diets containing lower test IAA intake for greater than 7 d violates the terms of a successful adaptive response. While there is some evidence that short-term 8 h IAAO is not different among different test amino acid intakes up to 7 d, it is unclear whether it impacts assessment of IAA requirements.

In vitro digestion characteristics of cereal protein concentrates as assessed using a pepsin-pancreatin digestion model

An alkaline extraction method has been used in many studies to extract total protein from cereal samples. Wheat bran protein concentrate (WBPC), oat bran protein concentrate (OBPC), and barley protein concentrate (BPC) were prepared by alkaline extraction and isoelectric precipitation to study their functional and nutritional properties. The three protein concentrates were hydrolysed by an in vitro pepsin-pancreatin digestion model. Their digestibility (%) and degree of hydrolysis (DH%) were evaluated, and SDS-PAGE electrophoresis was used to illustrate the protein and peptides patterns. The change of the particle sizes and the release of the essential amino acids was followed during the digestion process. The in vitro digestibility of WBPC, OBPC and BPC was 87.4%, 96.1% and 76.9%, respectively. The DH% of protein concentrates were between 50 and 60%. The change of the particle size distribution values Dv(50) was assumed to be related to protein aggregations during the digestion. The protein fractions were identified and the degradation during the digestion and were analysed by SDS-PAGE; the gels of WBPC and OBPC digestion showed virtually complete degradation whereas the intensive bands of undigested protein were presented for BPC. The generation of the free amino acids and short chain peptides were significantly higher at the end of the intestinal digestion compared to the stages of before and after gastric digestion. Higher content of the deficient amino acids such as lysine and threonine were found comparing to the level of deficient amino acids in cereal grains but does not meet the daily recommended intake.

Intakes of Total and Branched-Chain Essential Amino Acids are Positively Associated with Handgrip Strength in African American and White Urban Younger and Older Adults

Essential amino acids (EAAs) initiate amino acid-induced stimulation of muscle protein synthesis. Study objectives were to calculate intake of EAAs after creating an EAA database, to explore the association of EAAs and branched-chain amino acids (BCAAs) with handgrip strength (HS) in a younger (<50 y) and older (≥50 y) sample, and to identify major food groups contributing EAAs. The sample consisted of African American and White adults aged, 33-71 years from the Healthy Aging in Neighborhoods of Diversity across the Life Span study, 2009-2013. Intake of total EAAs and BCAAs/kg body weight were positively associated (p < 0.001) with HS per body mass index (HS/BMI) ratio. Being male, African American, a nonsmoker, physically active, euglycemic, and normotensive were associated with higher HS/BMI ratio. EAAs were mainly obtained from red meats/poultry and mixed dishes groups. Findings support the role of high-quality proteins and being active in promoting HS.

Dietary Aromatic Amino Acid Requirements During Early and Late Gestation in Healthy Pregnant Women

BACKGROUND

Phenylalanine and tyrosine (referred to as total aromatic amino acids; TAAs) are essential for protein synthesis, and are precursors for important catecholamines. Current estimated average requirement (EAR) recommendations for TAA during pregnancy are 36 mg·kg-1·d-1, and has not been experimentally determined.

OBJECTIVES

The aim was to determine TAA requirements (dietary phenylalanine in the absence of tyrosine) during early and late gestation using the indicator amino acid oxidation (IAAO, with L-[1-13C]leucine) technique.

METHODS

Nineteen healthy pregnant women (age 22-38 y) were studied at a range of phenylalanine intakes (5 to 100 mg·kg-1·d-1) in early (13-19 wk) and/or late (33-39 wk) pregnancy for a total of 51 study days. Graded test intakes were provided as 8 hourly isonitrogenous and isocaloric meals. Breath samples were collected for 13C enrichment analysis on an isotope ratio mass spectrometer. A plasma sample was collected and analyzed for phenylalanine and tyrosine concentrations on an amino acid analyzer. The TAA requirement in early and late pregnancy was calculated using 2-phase linear regression crossover analysis that identified breakpoints in 13CO2 production (the requirement) in response to phenylalanine intakes.

RESULTS

TAA requirement during early pregnancy was 44 mg·kg-1·d-1 (95% CI: 28.3, 58.8) and during late pregnancy was 50 mg·kg-1·d-1 (95% CI: 36.1, 63.1). In early and late pregnancy, plasma phenylalanine and tyrosine concentrations rose linearly in response to graded phenylalanine intakes.

CONCLUSIONS

Our results suggest that the current EAR of 36 mg·kg-1·d-1 for TAAs is underestimated. When compared with results previously determined in nonpregnant adults, early pregnancy requirements were similar (43 compared with 44 mg·kg-1·d-1, respectively). During late pregnancy, a 14% higher TAA requirement was observed when compared with early pregnancy. The results from this study have potential implications for creating gestation stage-specific TAA recommendations.

Protein quality & amino acid requirements in relation to needs in India

The relevance of protein and its constituent amino acids (AAs) in the structure and function of the human body is well known. Accumulating evidence has conferred specific functional and regulatory roles for individual AAs, adding relevance to their requirements across different age groups. The methods for measuring AA requirements have progressed from the classical nitrogen balance to the current stable isotope-based AA balance methods. Requirements of most of the indispensable AA (IAA) have been estimated in healthy Indian population by the best available balance method and has shown to be higher than earlier 1985 WHO/FAO/UNU (World Health Organization/Food and Agriculture Organization/United Nations University) recommendations. In addition, potential changes in the requirement, through adaptation to chronic undernutrition or to infection, have also been evaluated. In 2007, the WHO/FAO/UNU released a recommendation that increased the daily IAA requirement, based on primary evidence from Indian balance studies. This meant that to ensure that the new IAA requirements were met, individual foods or mixed diets needed to be assessed for their protein quality, or their ability to deliver the required amount of IAA. The recent FAO report on protein quality evaluation recommends the use of a new chemical AA score, the digestible IAA score (DIAAS), to replace the earlier protein digestibility corrected AA score. The DIAAS requires the determination of individual AA digestibility at the ileal level. A minimally invasive dual stable isotope tracer-based approach has been developed in India and has been used to determine digestibility of various foods in Indian adults and children. The increase in IAA requirements and subsequent protein quality requirements have implications for national regulatory frameworks, growth and development, and in turn, for economic and agricultural policy.

Current issues in determining dietary protein and amino-acid requirements

Pregnancy and the first two years of life are periods of rapid growth and yet the knowledge of requirements for protein and dietary indispensable amino acids is very limited. The development of carbon oxidation methods opens the way to studies that should fill these important gaps in knowledge.

The relationship between consumption of tyrosine and phenylalanine as precursors of catecholamine at breakfast and the circadian typology and mental health in Japanese infants aged 2 to 5 years

Background

This study aims to examine the relationship between tyrosine and phenylalanine intake at breakfast as precursors of dopamine, and scores on the Torsvall-Åkerstedt Diurnal Type Scale and of mental health in Japanese infants aged 2 to 5 years.

Results

An integrated questionnaire was administered to parents of 1,367 infants attending one of ten nursery schools governed by Kochi City or a kindergarten affiliated with the Faculty of Education at Kochi University (775 answers for analysis: 56.7%) in May and June 2008. Questionnaires included the Torsvall-Åkerstedt Diurnal Type Scale and questions on sleep habits (onset, offset, quality, quantity, and so on), meal habits (content and regularity of timing), and mental health (depressive states). Amount of tyrosine and phenylalanine intake was calculated based on a breakfast content questionnaire and data on the components of amino acids in foods. Infants who ingested more than 800 mg of tyrosine or phenylalanine at breakfast per meal were more morning-type than those who ingested less than 800 mg (ANOVA: P= 0.005). However, this relationship disappeared in the ANCOVA analysis (with the covariance of tryptophan intake, P= 0.894). Infants who ingested more than 800 mg of the two amino acids at breakfast showed significantly higher mental health scores (lower frequency of depressive states) than those who ingested less than 800 mg (ANOVA: P = 0.004). This relationship remained significant when ANCOVA analysis was performed with the covariance of tryptophan (ANCOVA: P= 0.017).

Conclusions

These results suggest that tyrosine and phenylalanine ingested at breakfast are not related with circadian phase, but are relate with mental health in infants.

Identifying recommended dietary allowances for protein and amino acids: a critique of the 2007 WHO/FAO/UNU report

The WHO/FAO/UNU (2007) report examines dietary protein and amino acid requirements for all age groups, protein requirements during pregnancy, lactation and catch-up growth in children, the implications of these requirements for developing countries and protein quality evaluation. Requirements were defined as the minimum dietary intake which satisfies the metabolic demand and achieves nitrogen equilibrium and maintenance of the body protein mass, plus the needs for growth in children and pregnancy and lactation in healthy women. Insufficient evidence was identified to enable recommendations for specific health outcomes. A meta analysis of nitrogen balance studies identifies protein requirements for adults 10 % higher than previous values with no influence of gender or age, consistent with a subsequently published comprehensive study. A new factorial model for infants and children, validated on the basis of the adequacy of breast milk protein intakes and involving a lower maintenance requirement value, no provision for saltatory growth and new estimates of protein deposition identifies lower protein requirements than in previous reports. Higher values for adult amino acid requirements, derived from a re-evaluation of nitrogen balance studies and new stable isotope studies, identify some cereal-based diets as being inadequate for lysine. The main outstanding issues relate to the biological implausibility of the very low efficiencies of protein utilisation used in the factorial models for protein requirements for all population groups especially pregnancy when requirements may be overestimated. Also considerable uncertainty remains about the design and interpretation of most of the studies used to identify amino acid requirement values.

Recent advances in determining protein and amino acid requirements in humans

During the past 25 years a significant amount of research has been conducted to determine amino acid requirements in humans. This is primarily due to advancements in the application of stable isotopes to examine amino acid requirements. The indicator amino acid oxidation (IAAO) method has emerged as a robust and minimally invasive technique to identify requirements. The IAAO method is based on the concept that when one indispensable dietary amino acid (IDAA) is deficient for protein synthesis, then the excess of all other IDAA, including the indicator amino acid, will be oxidized. With increasing intakes of the limiting amino acid, IAAO will decrease, reflecting increasing incorporation into protein. Once the requirement for the limiting amino acid is met there will be no further change in the indicator oxidation. The IAAO method has been systematically applied to determine most IDAA requirements in adults. The estimates are comparable to the values obtained using the more elaborate 24h-indicator amino acid oxidation and balance (24h-IAAO/IAAB) model. Due to its non-invasive nature the IAAO method has also been used to determine requirements for amino acids in neonates, children and in disease. The IAAO model has recently been applied to determine total protein requirements in humans. The IAAO method is rapid, reliable and has been used to determine amino acid requirements in different species, across the life cycle and in disease. The recent application of IAAO to determine protein requirements in humans is novel and has significant implications for dietary protein intake recommendations globally.

Methods to assess amino acid requirements in humans

PURPOSE OF REVIEW

There are now different stable isotopic methods to measure minimum daily human indispensable amino acid (IAA) requirements. There has been debate on the appropriateness of statistical methods used to define the nature of change in the response.

RECENT FINDINGS

Current isotopic methods measure daily amino acid oxidation and balance of the IAA under test, or of a selected indicator amino acid, to graded intakes of the test IAA. A key concern is how response curves of oxidation/balance are analyzed to find the inflection point (breakpoint) at which the intake requirement is identified. Evaluating the pattern of the response to identify a breakpoint by a two-phase regression appears best. The indicator amino acid oxidation method has also been shortened and developed into a noninvasive protocol suitable for different populations and age groups.

SUMMARY

The indicator amino acid oxidation and balance method might be considered the best approach currently available, but it is challenging. The short-term indicator oxidation method is noninvasive and nondemanding. IAA requirements, based on these methods, have implications for the quality of protein in the dietary intake of populations. Methods that assess the IAA requirements to support optimal body function also need to be developed.

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.

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.

Individual amino acid requirements in humans: an update

PURPOSE OF REVIEW

To discuss recent amino acid requirement studies in adult humans and school-age children, primarily determined using the indicator amino acid oxidation technique.

RECENT FINDINGS

Using the minimally invasive indicator amino acid oxidation model, requirements for most indispensable amino acids have been defined in adult humans. The estimates are comparable to the values obtained using the more elaborate 24-h indicator amino acid oxidation and balance model. The less-invasive indicator amino acid oxidation model has also been successfully applied to define requirements in healthy school-age children and children with disease. A recent adaptation of the indicator amino acid oxidation method to determine protein requirements in adult humans resulted in mean and safe values of 0.93 and 1.2 g protein/kg/day, respectively. These estimates are 40-50% higher than current recommendations and suggest an urgent need to reassess recommendations for protein intake in humans.

SUMMARY

In summary, indicator amino acid oxidation is a robust technique, and has resulted in the definition of amino acid and protein requirements in adult humans and children. A wider application of the technique in other vulnerable populations across life stages and in other diseases is now possible.

Aromatic amino acid requirements in healthy human subjects

Dietary aromatic amino acids are needed to meet the requirements for phenylalanine and tyrosine for protein synthesis. The amounts needed for neurotransmitter synthesis and other biological processes are small and quantitatively negligible. The earlier nitrogen balance-based estimates were judged to be inadequate. Very recently, there have been 3 estimates published based on the indicator amino acid oxidation technique, which average 42 mg.kg(-1).d(-1). This average value was obtained by feeding subjects a tyrosine-free diet and hence is an estimate of the mean maximum phenylalanine requirement. The mean minimum phenylalanine requirement estimate in the presence of an excess of tyrosine is 9.1 mg.kg(-1).d(-1). Hence, tyrosine can spare 78% of the dietary phenylalanine need. Finally the optimal proportions of dietary phenylalanine and tyrosine have been shown to be 60:40, respectively.