Innspill til kapittelet om protein NNR 2022
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Protein intake in our diet is high. Plant protein sources – more healthy and nutritionally adequate, should be chosen more often.
From Physicians’ and nutrition association Food for health
1. Protein intake in younger children
On page 12
We suggest to keep, after this sentence “The upper level of healthy protein intake in infancy and childhood has yet to be firmly established.”
the same statement as in NNR 2012:
” In several Nordic countries, mean protein intake is close to 15 E% during the first years of life indicating that a large proportion of young children have a higher protein intake that might contribute to increased risk of later obesity (22)”.
Then I suggest writing following:
“Too high protein intake among the yongest children?
According to nationwide dietary survey among 2-year-olds in Norway, conducted by Norwegian Institute for public health, 2020, we can see that the energy-percent intake from protein is as recommended between 10 and 20 E%. Nonetheless, the intake of protein per kilogram BW is 3 grams protein per 1 kg BW. (Total energy intake was about 1313 kcal per day, and intake of protein was 52 gram per day. A 2-year-old child weighs about 16 – 17 kg.). 3 grams protein per 1 kg BW is 3 times higher then necessary and may pose a risk for obesity and other health problems in the future.
The newest meta-analysis and SR, Arnesen 2022, where 21 studies from 27 publications were included, examined the evidence for an association between the dietary protein intake in children and the growth and risk of overweight or obesity up to 18 years of age in settings relevant for the Nordic countries.
Total protein intake and BMI were assessed in 12 cohorts, of which 11 found positive associations.
–The evidence for a positive relationship between total protein intake and BMI was considered probable.
–Furthermore, there was probable evidence for an association between higher intake of animal protein and increased BMI.
–There was limited, suggestive evidence for an effect of total protein intake and higher risk of overweight and/or obesity,
The conclusion in the SR is that in healthy, well-nourished children of Western populations, there is probably a causal relationship between a high-protein intake in early childhood (≤ 18 months) – particularly protein of animal origin – and higher BMI later in childhood, with consistent findings across cohort studies. A lack of RCTs precluded a stronger grading of the evidence.”
Sources:
Astrup H, Myhre JB, Andersen LF, Kristiansen AL.[Småbarnskost 3. Nationwide dietary survey among 2-year-olds in Norway]
Rapport 2020. Oslo: Folkehelseinstituttet og Universitetet i Oslo, 2020.Arnesen E. K., Thorisdottir B., Lamberg-Allardt C., Bärebring L., Nwaru B., Dierkes J., Ramel A., & Åkesson A. (2022). Protein intake in children and growth and risk of overweight or obesity: A systematic review and meta-analysis. Food & Nutrition Research, 66. https://doi.org/10.29219/fnr.v66.8242 (Food & Nutrition Research 2022, 66: 8242 – http://dx.doi.org/10.29219/fnr.v66.8242 )
Nordic Council of Ministers. Nordic Nutrition Recommendations 2012: integrating nutrition and physical activity. Copenhagen: Nordic Council of Minsters; 2014.
Hornell A, Lagstrom H, Lande B, Thorsdottir I. Protein intake from 0 to 18 years of age and its relation to health: a systematic literature review for the 5th Nordic Nutrition Recommendations. Food Nutr Res. 2013;57. https://www.norden.org/en/publication/nordic-nutrition-recommendations-2012
2. Intake in Nordic and Baltic countries
On page 6, in the first paragraf, after sentence nr 2, I suggest adding following :
“These outcomes are uncommon in Nordic and Baltic countries, among general/healthy population.”
On page 8, below the table 4.5, I suggest writing following:
“Adults on average get up to 18% of their energy, which is in line with recommendations. About 60 % protein comes from animal sources. Daily intake in Norway is 96 grams on average. The biggest sources in Norwegian diet, for example, is meat and meat products, contributing 27% of the total intake. Dairy products account for 22% and fish – 10 %. (1,2,3)
High protein inntake from animal sources leads to several undesireble health outcomes, see sources 60,61,62,63,64,65 (in your draft) and Zhong 2020 (source 4 below). It could be nutritionally safe, and healthy, to reduce the total amount protein, and then – especially from read and processed meat.
It is not necessary to replace all the amount of animal protein with (the same amount of) plant protein. This is because the intake is already quite high. Theoretically, read and processed meat can be cut out completely, and populations will still get enough protein.
Almost the same applies to children 12 – 14 months. They get about 3 grams of protein per 1 kg of BW daily, and this amounts to about 16 E%. The recommended safe intake is 0.8 – 0.9 grams of protein per 1 kg of BW.”
I therefore propose the following sentence from NNR 2012: “In several Nordic countries, the average protein intake is close to 15 E% during the first years of life, which indicates that a large proportion of young children have a higher protein intake which can contribute to an increased risk of later obesity (22)”.
“Half of the meat intake in Norway comes from sausages, meat pies, spreads, chicken nuggets and other processed finished meat products (source 5 below). These belong to the category processed meat, which both WHO, WCRF, Harvard T.H. Chan medical school and some others advise against eating on a regular basis. It is because these cause cancer – primarily in the colon. The evidence is high – convincing.
It would be very beneficial for the public to reduce the consumption of these products. (source 6-10 below).”
“It is both healthy and nutritionally safe to reduce consumption of meat and dairy. These can be replaced with legumes and nuts. But this is not necessary until the reduction is quite substantial – as in vegan diets. In general, and for those who do not follow aforementioned diets, the substitution with protein rich plant foods is not necessary.”
Sources:
Matprat.no. Proteins https://www.matprat.no/artikler/ernaring/proteiner/
Norwegian Directorate of Health. Utviklingen i norsk kosthold 2022.
Zhong VW, Van Horn L, Greenland P, et al. Associations of Processed Meat, Unprocessed Red Meat, Poultry, or Fish Intake With Incident Cardiovascular Disease and All-Cause Mortality. JAMA Intern Med. 2020;180(4):503-512. doi:10.1001/jamainternmed.2019.6969
Page 309, chapter 29. (Norwegian Directorate of Health) Kostråd for å fremme folkehelsen og forebygge kroniske sykdommer – Metodologi og vitenskapelig kunnskapsgrunnlag. Nasjonalt råd for ernæring, 2011
Rock CL, Thomson C, Gansler T, et al. American Cancer Society Guideline for Diet and Physical Activity for Cancer Prevention. CA Cancer J Clin. Published online June 9, 2020.
WHO, 2015. Cancer: Carcinogenicity of the consumption of red meat and processed meat.
Healthy Eating Plate. Harvard School of Public Health
American Institute for Cancer Research. Recommendation on Red and Processed Meat
Cancer Research UK. Limit red meat and avoid processed meat revention-recommendations/limit-red-meat-and-avoid-processed-meat/
3. Health outcomes
General comments to the chapter
Thorough and in depth overview. I have a comment about Obesity: I think that NNR2022 should have explaination/comments about popular diets that often contains unhealthy amounts and sources of protein. Especially when it comes to treatment of obesity and diabetes.
Spesific comments to the chapter
On page 8, could you please add the source for this: “However, a large US cross-sectional study found a favourable association between both animal and plant-sourced protein, particularly with central adiposity.” And what amounts of protein? How strong is the evidence here? It sounds like “protein is generally good for maintaining a healthy weight”. And “high protein diets is good for maintaining a healthy weight”.
If so, it contrasts with other health outcomes – especially mortality. Should we treat/prevent obesity with diets that lead to higher mortality, diabetes and cancer?
I suggest adding an explanation about low carb, paleo and keto diets. In practice, they are misunderstood, both by the public and by physicians, nutritionsts and PTs (personal trainers). In these diets, carbohydrates should be replaced with fat, not with protein. And at least not with protein from red and processed meat.
I suggest you write following in Health outcomes, Obesity (or after Obesity, as a separate section):
“Low carb, keto and paleo diets with high protein intake, especially from meat, gives undesireble health outcomes
Low carbohydrate diets and keto-diets are popular among the general public. These are used to treat obesity, and sometimes diabetes. These diets do not initially need to contain a lot of protein, and at least protein from red and processed meat, to give desired results. Increaseing the amount of protein is not necessary, as carbohydrates can be replaced with fat for the same desired results.
High intake of protein from meat leads to increased mortality from cardiovascular disease and other adverse health outcomes (source 1,2 below, and sources on mortality section, number 60 – 66 in current draft).
Some plant protein sources – some nuts and seeds, edamame beans, soy milk and tofu can be included in many low carb, keto and paleo diets. Some low carb diets may also contain other plant protein sources.
Sources:
Song, Mingyang et al. “Association of Animal and Plant Protein Intake With All-Cause and Cause-Specific Mortality.” JAMA internal medicine vol. 176,10 (2016): 1453-1463. doi:10.1001/jamainternmed.2016.4182
Zhong VW, Van Horn L, Greenland P, et al. Associations of Processed Meat, Unprocessed Red Meat, Poultry, or Fish Intake With Incident Cardiovascular Disease and All-Cause Mortality. JAMA Intern Med. 2020;180(4):503-512. doi:10.1001/jamainternmed.2019.6969 https://pubmed.ncbi.nlm.nih.gov/32011623/
Chen Z, Glisic M, Song M, et al. Dietary protein intake and all-cause and cause-specific mortality: results from the Rotterdam Study and a meta-analysis of prospective cohort studies. Eur J Epidemiol. 2020;35(5):411-429. doi:10.1007/s10654-020-00607-6 https://pubmed.ncbi.nlm.nih.gov/32076944/
Low-Carbohydrate Diets https://www.hsph.harvard.edu/nutritionsource/carbohydrates/low-carbohydrate-diets/
Jenkins DJ, Wong JM, Kendall CW, et al. The effect of a plant-based low-carbohydrate (“Eco-Atkins”) diet on body weight and blood lipid concentrations in hyperlipidemic subjects. Arch Intern Med. 2009;169:1046-54.
Elliott PS, Kharaty SS, Phillips CM. Plant-Based Diets and Lipid, Lipoprotein, and Inflammatory Biomarkers of Cardiovascular Disease: A Review of Observational and Interventional Studies. Nutrients. 2022 Dec 17;14(24):5371. doi: 10.3390/nu14245371. PMID: 36558530; PMCID: PMC9787709.
Diabetes UK. Low-carb diet and meal plan. https://www.diabetes.org.uk/guide-to-diabetes/enjoy-food/eating-with-diabetes/meal-plans/low-carb
Mortality
4.General comments to the chapter
Section about Health outcomes is incredibly comprehensive and complete.
The opening sentences on page 10 under Mortality, as well as sources 60,61,62,63,64,65, is very important:
“Several meta-analyses on high animal protein intake suggested a positive association with cardiovascular mortality while high plant protein intake was inversely associated with all-cause and cardiovascular mortality, especially among individuals with at least one lifestyle risk factor.
Where, the substitution of plant protein for animal protein, especially that from processed red meat, was associated with lower mortality, suggesting the importance of protein sources 60,61,62,63,64,65″.
How relevant is our lands protein intake to these health outcomes?
Specific comment:
In Mortality you write following: “Several meta-analyses on high animal protein intake suggested a positive association with cardiovascular mortality”.
The current consumption of the protein in Nordic and Baltic countries is up to 16 – 18 E%. And the biggest sources are read and processed meat and dairy products.
How relevant is this for the public, as it comes to increased mortality?
Could you comment on this, or write something about how high is the current level/amount of protein intake is in Nordic and Baltic countries, regarding to mortality and other health outcomes?
I think that this is relevant for Northen and Baltikum. On page 10, in section Mortality, I suggest therefor adding following as the first sentence:
“The current consumption of protein in Nordic and Baltic countries is quite high up to 16 – 18 E%. And the biggest sources are read and processed meat and dairy products. This amount/intake increase mortality and morbidity.”
4. “Plant protein sources – more healthy and nutritionally adequate, should be chosen more often
General comment:
Comprehensive, in depth and good overview.
However, concepts as “complete proteins”, digestibility and antinutrients in plants protein sources are given too much significance.
Even vegans gets more than enough of all the essential aminoacids, in developed countries
Specific comment
I suggest adding a separate section, and writing following on page 11:
“Plant protein sources – more healthy and nutritionally adequate, should be chosen more often
Many studies (as above in this Protein chapter in NNR 2022) show that plant protein is preferable, as it results in reduced morbidity and mortality. Plant sources of protein and essential amino acids are nutritionally safe.
Concepts such as complete proteins, digestibility and anti-nutrients in plant protein sources are important theoretically. But the practical meaning of these terms is very limited in the Nordic and Baltic countries.
Studies on vegans in developed countries, including those on blood analysis of amino acid content (EPIC-Oxford cohort, Schmidt, 2016), show that vegans get enough of essential amino acids, including lysine. This is because vegan diets in developed countries include various plant sources of protein.
Total intake of protein tends to exceed the requirement (Mariotty, 2019). This results in the intake of all 20 amino acids which are more than sufficient to cover the need. This means that protein digestibility is not an issue in the Nordic and Baltic countries.”
My explanation
Mariotti an Gardner writes in the study:
“It is commonly, although mistakenly, thought that the amino acid intake may be inadequate in vegetarian diets. As we and others have argued, the amounts and proportions of amino acids consumed by vegetarians and vegans are typically more than sufficient to meet and exceed individual daily requirements, provided a reasonable variety of foods are consumed and energy intake needs are being met. The claim that certain plant foods are “missing” specific amino acids is demonstrably false.”
“Lysine is present in much lower than optimal proportions for human needs in grains, and similarly the sulfur containing amino acids (methionine and cysteine) are proportionally very slightly lower in legumes than would be optimal for human needs. This would be important for someone who ate only rice or only beans, for sustenance, every day. This classic implementation of a protein quality assessment framework focusing on isolated single proteins remains an erroneous approach in practice [36,37]. The terms “complete” and “incomplete” are misleading [33,38].
In developed countries, plant proteins are mixed, especially in vegetarian diets, and total intake of protein tends to greatly exceed requirement. This results in intakes of all 20 amino acids that are more than sufficient to cover requirements. In the EPIC-Oxford study, amino acid intakes were estimated in both meat-eaters and vegetarians [24]. For the lacto-ovo-vegetarian and vegans assessed, based on an average body weight of 65 kg, we calculated that lysine intakes were 58 and 43 mg/kg, respectively, largely higher than the 30 mg/kg estimated average requirement [39].”
Sources:
Mariotti F, Gardner CD. Dietary Protein and Amino Acids in Vegetarian Diets-A Review. Nutrients. 2019 Nov 4;11(11):2661. doi: 10.3390/nu11112661. PMID: 31690027; PMCID: PMC6893534.
Schmidt JA, Rinaldi S, Scalbert A, Ferrari P, Achaintre D, Gunter MJ, Appleby PN, Key TJ, Travis RC: Plasma concentrations and intakes of amino acids in male meat-eaters, fish-eaters, vegetarians and vegans: a cross-sectional analysis in the EPIC-Oxford cohort. European journal of clinical nutrition 2016, 70(3):306-312.
Young VR, Pellett PL: Plant proteins in relation to human protein and amino acid nutrition. The American journal of clinical nutrition 1994, 59(5 Suppl):1203S-1212S.
de Gavelle E, Huneau JF, Bianchi CM, Verger EO, Mariotti F: Protein Adequacy Is Primarily a Matter of Protein Quantity, Not Quality: Modeling an Increase in Plant:Animal Protein Ratio in French Adults. Nutrients 2017, 9(12).
Old-fashioned about protein quality
General comment
Good and in depth overview. But this with protein-quality, digestibility and animal sources vs plant sources is not in line with the last 10 years international scientific publications. Northern guidelines 2023 should be worlds mest modern and updated, not old-fashioned. “Everybody” agrees in 2023 that animal protein is not necessary, and even vegans get more than enough EEA
I would like to refer to the following article (David L Katz et al, in Advances in Nutrition,) on this subject, together with its references:
David L Katz, Kimberly N Doughty, Kate Geagan, David A Jenkins, Christopher D Gardner, Perspective: The Public Health Case for Modernizing the Definition of Protein Quality, Advances in Nutrition, Volume 10, Issue 5, September 2019, Pages 755–764, https://doi.org/10.1093/advances/nmz023
To summarise some of the points authors make (these are citations from the article above):
“Prevailing definitions of protein quality are predicated on considerations of biochemistry and metabolism rather than the net effects on human health or the environment of specific food sources of protein. … The popular concept that protein is “good” and that the more the better, coupled with a protein quality definition that favors meat, fosters the impression that eating more meat, as well as eggs and dairy, is desirable and preferable. This message, however, is directly opposed to current Dietary Guidelines for Americans, which encourage consumption of more plant foods and less meat, and at odds with the literature on the environmental impacts of foods, from carbon emissions to water utilization, which decisively favor plant protein sources. Thus, the message conveyed by the current definitions of protein quality is at odds with imperatives of public and planetary health alike. “
“The word “quality” implies superiority, but food sources of “high-quality” protein, as defined by existing metrics, do not reliably improve the quality of the diet or health. For example, consumption of certain animal sources of protein is associated with higher chronic disease risk (12), whereas consumption of protein-rich plant foods and adherence to plant-based dietary patterns are associated with more favorable health outcomes (12–14). “
“The definition of protein quality is both misleading and antiquated.
… the rationale for defining protein quality as a function of a food’s essential amino acid composition is of questionable validity, at least for the populations of developed countries.”
“If PDCAAS is replaced by DIAAS in the United States, as proposed by the FAO, eligibility for protein content claims will change for some plant foods; some that were not eligible will become eligible and vice versa (27). Animal foods will continue to score highly.
Regardless of which method is used, measures of protein quality that consider only content and distribution of essential amino acids can be misleading because they represent the biological value of a single nutrient in isolation, not the net effects of consuming the source of that nutrient. “
“In light of this evidence, alternative regulatory frameworks have already been adopted by some other developed countries. … There is no evidence that a policy of ignoring protein quality while prioritizing overall dietary quality has led to any adverse effects on population health status in these countries. “
“Although it has been argued that the DRIs should be increased for those consuming a vegetarian diet, to account for the reduced digestibility of plant proteins (41), they have not been increased because the findings of a meta-analysis of nitrogen balance studies showed no significant effect of dietary protein source on protein requirements (42). It is also the position of the Academy of Nutrition and Dietetics that vegetarian and vegan diets generally supply adequate protein and essential amino acids when protein is consumed from a variety of plant sources throughout each day and energy needs are met (9).”
Specific comment to the chapter, reg old-fashioned about protein quality and sources
Page 5, first paragraph. The following claim is made:
“However, protein digestibility and bioavailability may become an issue in protein transition towards more plant-based diets in vulnerable groups such as the elderly, as protein bioavailability is known to decrease with age.”
This claim is not supported by relevant evidence. You are using an article referring to developing countries, as well as evidence in rats and/or pigs. Please provide a scientific reference including evidence (not an opinion) that suggests that digestibility and bioavailability are a cause of concern for the elderly in western countries.
Page 6-8. Dietary intake in Nordic and Baltic countries. Please provide recommended reference values in the tables so that the reader can compare directly.
Page 8, Obesity. You have used a lot of large SR else, but why do you use a cross-sectional study here? And without warning the reader about the limitations of such study design.
Pages 8-9. Cardiovascular diseases and diabetes. This section on CVD and type 2 diabetes has to be more clearly structured and the evidence needs to be updated with recent large cohort studies (also in this section):
your source 65 and 68, and these
Budhathoki S et al; Japan Public Health Center–based Prospective Study Group. Association of Animal and Plant Protein Intake With All-Cause and Cause-Specific Mortality in a Japanese Cohort. JAMA Intern Med. 2019 Nov 1;179(11):1509-1518. doi: 10.1001/jamainternmed.2019.2806. Erratum in: JAMA Intern Med. 2019 Oct 1;179(10):1448. PMID: 31682257; PMCID: PMC6714005.
Song M, et al. Association of Animal and Plant Protein Intake With All-Cause and Cause-Specific Mortality. JAMA Intern Med. 2016 Oct 1;176(10):1453-1463.
Page 13, Old adult. The sentence starting with “Frailty84 and sarcopenia85” lacks a verb. Proper epidemiological background should be provided – how many old adults are affected by frailty and sarcopenia? Who is particularly at risk and should be wary of their protein intake?
Page 13, the title “The reasoning behind the upper intake range” should be changed into “Potential adverse effects of high protein intake”. The title “The reasoning behind the upper intake range” can be moved two paragraphs upwards, when you are actually discussing the intake range. I assume you no longer discuss the old adult in these two paragraphs (?), but that is not completely clear for the reader. It would be best to actually conclude with the discussion on the range rather than potential adverse effects of high protein intake, so that discussion on adverse effects comes before.
CONCLUDING SENTENCE: “WHO and Institute of Medicine recommendations recognize higher-protein diets as safe in individuals without CKD108,109.”
The references you are providing here are outdated (18 and 16 years old, respectively) and have to be replaced. Institute of Medicine no longer exists.
Also, do you think this statement is still a valid conclusion, given your summary of associations between high meat intake, chronic diseases and increased mortality (pages 8-10)? Or are certain adjustments to this statement, like advising more caution about certain protein sources, warranted?
It is not sufficiently justified why protein quality is used as a measure in this chapter, in spite of the method being highly controversial, and designed to favour the protein of animal origin, which, according to many studies, is associated with increased mortality and chronic disease risk.
There is no evidence that would support the assumption that food items with higher protein digestibility are to be preferred in the western diets because their regular intake would result in positive health impacts – when compared to foods with lower protein digestibility.
If protein quality will be used, it should be highlighted that the PDCAAS and DIAAS can be misleading (see the reference and justifications in general comment). Thus, full disclosure of the method limitations is warranted.
(Plant protein gives better health – this is included in one of the comments ebove)
Several studies shows that plant protein is preferable, as it gives reduced morbidity and mortality
Huang https://pubmed.ncbi.nlm.nih.gov/32658243/
Budhathoki – In this large prospective study, higher plant protein intake was associated with lower total and CVD-related mortality. Although animal protein intake was not associated with mortality outcomes, replacement of red meat protein or processed meat protein with plant protein was associated with lower total, cancer-related, and CVD-related mortality.
* higher total protein intake was associated with higher all-cause mortality
* in the meta-analysis a higher plant protein intake was associated with lower all-cause and CVD mortality
Evidence from prospective cohort studies to date suggests that total protein intake is positively associated with all-cause mortality, mainly driven by a harmful association of animal protein with CVD mortality. Plant protein intake is inversely associated with all-cause and CVD mortality. Our findings support current dietary recommendations to increase intake of plant protein in place of animal protein.)