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The Role of Protein and Amino Acids in Sustaining and Enhancing Performance

Committee on Military Nutrition Research

Committee on Body Composition, Nutrition and Health

Food and Nutrition

Board Institute of Medicine

National Academy Press
Washington, D.C.
1999



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The Role of Protein and Amino Acids in Sustaining and Enhancing Performance The Role of Protein and Amino Acids in Sustaining and Enhancing Performance Committee on Military Nutrition Research Committee on Body Composition, Nutrition and Health Food and Nutrition Board Institute of Medicine National Academy Press Washington, D.C. 1999

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The Role of Protein and Amino Acids in Sustaining and Enhancing Performance NATIONAL ACADEMY PRESS 2101 Constitution Avenue, N.W. Washington, DC 20418 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. The Institute of Medicine was established in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy’s 1863 congressional charter responsibility to be an adviser to the federal government and its own initiative in identifying issues of medical care, research, and education. Dr. Kenneth I. Shine is president of the Institute of Medicine. This report was produced under grant DAMD17-94-J-4046 between the National Academy of Sciences and the U.S. Army Medical Research and Materiel Command. The views, opinions, and/or findings contained in chapters in Parts II through VIII that are authored by U.S. Army personnel are those of the authors and should not be construed as official Department of the Army positions, policies, or decisions, unless so designated by other official documentation. Human subjects who participated in studies described in these chapters gave their free and informed voluntary consent. Investigators adhered to U.S. Army regulation 70-25 and United States Army Medical Research and Development Command regulation 70-25 on the use of volunteers in research. Citations of commercial organizations and trade names in this report do not constitute an official Department of the Army endorsement or approval of the products or services of these organizations. The chapters are approved for public release; distribution is unlimited. Library of Congress Catalog Card No. 98-89750 International Standard Book Number 0-309-06346-9 Additional copies of this report are available from: National Academy Press 2101 Constitution Avenue, N.W. Lock Box 285 Washington, D.C. 20055 Call (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area), or visit the NAP’s on-line bookstore at http://www.nap.edu. Copyright 1999 by the National Academy of Sciences. All rights reserved. Printed in the United States of America. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The image adopted as a logotype by the Institute of Medicine is based on a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.

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The Role of Protein and Amino Acids in Sustaining and Enhancing Performance COMMITTEE ON MILITARY NUTRITION RESEARCH ROBERT O. NESHEIM (Chair, through June 30, 1998), Salinas, California JOHN E. VANDERVEEN (Chair), Rockville, Maryland LAWRENCE E. ARMSTRONG, Departments of Physiology and Neurobiology, and Exercise Science, University of Connecticut, Storrs WILLIAM R. BEISEL, Department of Molecular Microbiology and Immunology, The Johns Hopkins University School of Hygiene and Public Health, Baltimore, Maryland GAIL E. BUTTERFIELD, Nutrition Studies, Palo Alto Veterans Affairs Health Care System and Program in Human Biology, Stanford University, Palo Alto, California WANDA L. CHENOWETH, Department of Food Science and Human Nutrition, Michigan State University, East Lansing JOHN D. FERNSTROM, Department of Psychiatry, Pharmacology, and Neuroscience, University of Pittsburgh School of Medicine, Pennsylvania G. RICHARD JANSEN, (through August 31, 1997), Department of Food Science and Human Nutrition, Colorado State University, Fort Collins ROBIN B. KANAREK, Department of Psychology, Tuffs University, Boston, Massachusetts ORVILLE A. LEVANDER, Nutrient Requirements and Functions Laboratory, U.S. Department of Agriculture Beltsville Human Nutrition Research Center, Beltsville, Maryland ESTHER M. STERNBERG, Neuroendocrine Immunology and Behavior Section, National Institute of Mental Health, Bethesda, Maryland DOUGLAS W. WILMORE, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts Food and Nutrition Board Liaison JOHANNA T. DWYER, Frances Stem Nutrition Center, New England Medical Center Hospital and Departments of Medicine and Community Health, Tuffs Medical School and School of Nutrition Science and Policy, Boston, Massachusetts U.S. Army Grant Officer Representatives LTC KARL E. FRIEDL, Military Operational Medicine Program, U.S. Army Medical Research and Materiel Command, Fort Detrick, Frederick, Maryland Staff MARY I. POOS (from May 23, 1998), Study Director SYDNE J. CARLSON-NEWBERRY, Program Officer MARIZA SILVA (from August 31, 1998), Project Assistant

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The Role of Protein and Amino Acids in Sustaining and Enhancing Performance SUBCOMMITTEE ON BODY COMPOSITION, NUTRITION, AND HEALTH OF MILITARY WOMEN BARBARA O. SCHNEEMAN (Chair), College of Agricultural and Environmental Sciences, University of California, Davis ROBERT O. NESHEIM (Vice Chair), Salinas, California JOHN P. BILEZIKIAN, Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, New York NANCY F. BUTTE, Children's Nutrition Research Center, Baylor College of Medicine, Houston, Texas STEVEN B. HEYMSFIELD, Human Body Composition Laboratory, Weight Control Unit, and Obesity Research Center, St. Luke's-Roosevelt Hospital Center, New York, New York ANNE LOOKER, Division of Health Examination Statistics, National Center for Health statistics, Hyattsville, Maryland GORDON O. MATHESON, Division of Sports Medicine, Department of Functional Restoration, Stanford University School of Medicine, Stanford, California BONNY L. SPECKER, The Martin Program in Human Nutrition, South Dakota State University, Brookings Committee on Military Nutrition Research Liaison GAIL E. BUTTERFIELD, Nutrition Studies, Pale Alto Veterans Affairs Health Care System and Program in Human Biology, Stanford University, Pale Alto, California Food and Nutrition Board Liaison JANET C. KING, U.S. Department of Agriculture Western Human Nutrition Research Center, San Francisco and University of California, Berkeley U.S. Army Grant Representative LTC KARL E. FRIEDL, USA, Army Operational Medicine Research Program, U.S. Army Medical Research and Materiel Command, Fort Detrick, Frederick, Maryland Staff REBECCA B. COSTELLO (through May 22, 1998), Project Director MARY I. POOS (from May 23, 1998), Project Director SYDNE J. CARLSON-NEWBERRY, Program Officer SUSAN M. KNASIAK-RALEY (through April 3, 1998), Research Assistant MELISSA L. VAN DOREN (through, August, 1998), Project Assistant

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The Role of Protein and Amino Acids in Sustaining and Enhancing Performance FOOD AND NUTRITION BOARD CUTBERTO GARZA (Chair), Division of Nutrition, Cornell University, Ithaca, New York JOHN W. ERDMAN, JR. (Vice Chair), Division of Nutritional Sciences, College of Agriculture, University of Illinois at Urbana-Champaign LARRY R. BEUCHAT, Center for Food Safety and Quality Enhancement, University of Georgia, Griffin BENJAMIN CABALLERO, Center for Human Nutrition, The Johns Hopkins School of Hygiene and Public Health, Baltimore, Maryland FERGUS M. CLYDESDALE, Department of Food Science, University of Massachusetts, Amherst ROBERT J. COUSINS, Center for Nutritional Sciences, University of Florida, Gainesville JOHANNA T. DWYER, Frances Stern Nutrition Center, New England Medical Center Hospital and Departments of Medicine and Community Health, Tuffs Medical School and School of Nutrition Science and Policy, Boston, Massachusetts SCOTT M. GRUNDY, Center for Human Nutrition, University of Texas Southwestern Medical Center at Dallas CHARLES H. HENNEKENS, Boca Raton, Florida ALFRED H. MERRILL, JR., Department of Biochemistry, Emory Center for Nutrition and Health Sciences, Emory University, Atlanta, Georgia LYNN PARKER, Child Nutrition Programs and Nutrition Policy, Food Research and Action Center, Washington, D.C. ROSS L. PRENTICE, Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington A. CATHERINE ROSS, Department of Veterinary Science, The Pennsylvania State University, University Park ROBERT M. RUSSELL, USDA Human Nutrition Research Center on Aging, Tuffs University, Boston, Massachusetts ROBERT E. SMITH, R. E. Smith Consulting, Inc., Newport, Vermont VIRGINIA A. STALLINGS, Division of Gastroenterology and Nutrition, The Children's Hospital of Philadelphia, Pennsylvania STEVE L. TAYLOR, Department of Food Science and Technology and Food Processing Center, University of Nebraska, Lincoln Staff ALLISON A. YATES, Director GAIL SPEARS, Administrative Assistant GARY WALKER, Financial Associate

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The Role of Protein and Amino Acids in Sustaining and Enhancing Performance Preface This publication, The Role of Protein and Amino Acids in Sustaining and Enhancing Performance, is the latest in a series of reports based on workshops sponsored by the Committee on Military Nutrition Research (CMNR) of the Food and Nutrition Board (FNB), Institute of Medicine, National Academy of Sciences. Other workshops or symposia have included such topics as nutrition and immune function; emerging technologies in nutrition research; food components to enhance performance; nutritional needs in hot, cold, and high-altitude environments; body composition and physical performance; and fluid replacement and heat stress. These workshops form part of the response that the CMNR provides to the Commander, U.S. Army Medical Research and Materiel Command, regarding issues brought to the committee through the Military Nutrition and Biochemical Division of the U.S. Army Research Institute of Environmental Medicine (USARIEM) at Natick, Massachusetts and the Military Operational Medicine Program at Fort Detrick, Maryland.

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The Role of Protein and Amino Acids in Sustaining and Enhancing Performance HISTORY OF THE COMMITTEE The CMNR was established in October 1982 following a request by the Assistant Surgeon General of the Army that the Board on Military Supplies of the National Academy of Sciences set up a committee to advise the U.S. Department of Defense on the need for and conduct of nutrition research and related issues. The committee was transferred to the FNB in 1983. The committee's current tasks are to identify nutritional factors that may critically influence the physical and mental performance of military personnel under all environmental extremes; to identify deficiencies in the existing database; to recommend research that would remedy these deficiencies, as well as approaches for studying the relationship of diet to physical and mental performance; and to review and advise on standards for military feeding systems. Within this context, the CMNR was asked to focus on nutrient requirements for performance during operational missions rather than on requirements for military personnel in garrison (the latter were judged not to differ significantly from those of the civilian population). Although the membership of the committee has changed periodically, the disciplines represented consistently have included human nutrition, nutritional biochemistry, performance physiology, food science, and psychology. For issues that require broader expertise than exists within the committee, the CMNR has convened workshops or utilized consultants. The workshops provide additional state-of-the-art scientific information and informed opinion for the consideration of the committee. FOCUS OF THE REPORT The request for this review originated with scientists at USARIEM who were concerned about the unique nutritional demands placed on soldiers during combat. They were particularly concerned about the role that dietary protein may play in controlling muscle mass and strength, response to injury and infection, and cognitive performance. Past reports of the CMNR usually have focused on issues of current concern to the military. Traditional methods of research, data gathering, and analysis have provided the factual base for study of a problem and recommended solutions. Several previous CMNR reports have focused on issues of protein nutriture and performance. In 1992, the CMNR noted in an evaluation of Army Ranger training that trainees experienced significant loss of muscle mass during periods of intense physical exertion (IOM, 1992). A follow-up report

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The Role of Protein and Amino Acids in Sustaining and Enhancing Performance (IOM, 1993b) found that increases in energy intake only partially prevented such losses. The report Food Components to Enhance Performance (IOM, 1994) briefly considered the influences of protein and amino acids on physical and cognitive performance and response to stress. The most recent CMNR report, Military Strategies for Sustainment of Nutrition and Immune Function in the Field (IOM, 1999), considered the effects of diet, including protein and individual amino acids such as glutamine, on immune response. This report looks further into the many questions regarding the optimal level of protein intake in a high-stress field environment. How to measure protein balance and estimate protein requirements accurately; how these requirements are affected by physical activity, gender, hormonal factors, and stress; and whether muscle function and cognition are influenced by protein intake and by individual amino acids are all active areas of research. The CMNR decided that the best way to review the state of knowledge in this area was through a workshop. The purpose of this workshop was to bring together leading scientists in the field of protein metabolism to seek their assessment of the current state of knowledge and to determine, based on these assessments, on a careful reading of the literature, and on the expertise of the committee members themselves, whether the recommended intakes of protein or individual amino acids for soldiers should be modified. In May 1996, CMNR and USARIEM personnel met to frame a series of questions, outline the workshop, and identify qualified speakers. A follow-up planning meeting was held in January 1997 and included several members of the Subcommittee on Body Composition, Nutrition, and Health of Military Women. Invited workshop speakers were asked to prepare a paper for presentation and publication that described the key issues of protein metabolism. USARIEM scientists also participated in the workshop, which resulted in a well-rounded group. At the one-day workshop, held in Washington, D.C. in March 1997, each speaker gave a formal presentation, which was followed by questions and a brief discussion period. The proceedings were tape recorded and professionally transcribed. At the end of each group of presentations, a general discussion of the overall topic was held. Immediately after the workshop, the CMNR met in executive session to review the issues, to draft summaries of the presentations, and to provide responses to the sponsor's task questions. Committee members subsequently met with staff in June 1997 and worked separately and together using the authored papers, additional reference materials provided by the staff through limited literature searches, and personal expertise and experience to draft the overview, summary, conclusions, and recommendations.

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The Role of Protein and Amino Acids in Sustaining and Enhancing Performance ORGANIZATION OF THE REPORT A project overview and a summary of the CMNR's responses to the task questions, conclusions, and recommendations, constitute Part I of this volume. Part II includes papers contributed by speakers at the workshop. Part I has been reviewed by an outside group with expertise in the topic areas and experience in military issues. For the most part, the authored papers in Part II appear in the order in which they were presented at the workshop (see workshop agenda in Appendix A). These chapters have undergone limited editorial changes, have not been reviewed by the outside group, and represent the views of the individual authors. Selected questions directed toward the speakers and the speakers' responses are included when they provide a flavor of the workshop discussion. The invited speakers also were requested to submit a brief list of selected background papers prior to the workshop. These recommended readings, relevant citations collected by CMNR staff prior to the workshop, and selected citations from each chapter are included in the selected bibliography (see Appendix D). ACKNOWLEDGMENTS It is my pleasure as chairman of the CMNR to acknowledge the help of Institute of Medicine President Kenneth I. Shine; Food and Nutrition Board Director Allison Yates and former Acting Director Carol Suitor; Study Director Mary Poos; and former FNB staff—Rebecca Costello, study director, and Sydne J. Newberry, staff officer. Also, I wish to acknowledge the excellent editorial efforts and able assistance of Mariza Silva, CMNR project assistant; Susan M. Knasiak-Raley, former research assistant to the CMNR; and Melissa Van Doren, former CMNR project assistant, in word processing and preparing the camera-ready copy for this report. Finally, I wish to acknowledge the assistance of managing editor Michael A. Edington and Reports and Information Office associate Claudia M. Carl; National Academy of Sciences Librarian Susan Fourt and assistant Patricia Kaiser; and editors Judy Grumstrup-Scott and Florence Poillon. I wish to acknowledge as well the excellent contributions by the speakers and their commitment to participating in the workshop and preparing papers on their assigned areas with relatively short notice. Finally, I express my appreciation to the members of the CMNR who have participated in the proceedings of the workshop and the discussions and preparation of summaries and recommendations in this report. Their continued dedication to providing sound, timely recommendations on issues brought to our attention is commendable. I also wish to acknowledge the many years of fine work by Richard Jansen who rotated off the committee prior to the final

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The Role of Protein and Amino Acids in Sustaining and Enhancing Performance preparation of this report, but nevertheless continued to provide his expertise. I especially want to acknowledge the dedicated leadership of the CMNR provided by Robert O. Nesheim who stepped down as chair in July, 1998. Thank you all for your commitment to the success of this program. This report has been reviewed by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the Report Review Committee of the National Research Council. The purpose of this independent review is to provide candid and critical comments that will assist the authors and the Institute of Medicine in making the published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. The CMNR wishes to thank the following individuals for their participation in the review of this report: Elsworth K. Buskirk, Pennsylvania State University; Gerald Combs, Sr. (retired); Melvin Grumbach, University of California, San Francisco; John M. Kinney, Rockefeller University; and T. Peter Stein, University of Medicine and Dentistry of New Jersey. While the individuals listed above have provided many constructive comments and suggestions, it must be emphasized that responsibility for the final content of this report rests entirely with the authoring committee and the IOM. JOHN E. VANDERVEEN, Chair Committee On Military Nutrition Research

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The Role of Protein and Amino Acids in Sustaining and Enhancing Performance CONTENTS PREFACE   vii EXECUTIVE SUMMARY   1 I COMMITTEE SUMMARY AND RECOMMENDATIONS     1   Committee Overview   19 2   Responses to Questions, Conclusions, and Recommendations   77 II AUTHORED PAPERS AND WORKSHOP DISCUSSIONS     3   Protein and Amino Acids: Physiological Optimization for Current and Future Military Operational Scenarios LTC Karl E. Friedl   85 4   Overview of Garrison, Field, and Supplemental Protein Intake by U.S. Military Personnel LTC (ret) Alana D. Cline and John P. Warber   93

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The Role of Protein and Amino Acids in Sustaining and Enhancing Performance 5   The Energy Costs of Protein Metabolism: Lean and Mean on Uncle Sam's Team Dennis M. Bier   109 6   Regulation of Muscle Mass and Function: Effects of Aging and Hormones Niels Moller and K. Sreekumaran Nair   121 7   Effects of Protein Intake on Renal Function and on the Development of Renal Disease Mackenzie Walser   137 8   Infection and Injury: Effects on Whole Body Protein Metabolism Douglas W. Wilmore   155 9   Inherent Difficulties in Defining Amino Acid Requirements D. Joe Millward   169 10   Amino Acid Flux and Requirements: Counterpoint Tentative Estimates Are Feasible and Necessary Vernon R. Young   217 11   Physical Exertion, Amino Acid and Protein Metabolism, and Protein Requirements Michael J. Rennie   243 12   Skeletal Muscle Markers Dympna Gallagher, Steven B. Heymsfield, and Zi-Mian Wang   255 13   Alterations in Protein Metabolism Due to the Stress of Injury and Infection Robert R. Wolfe   279 Discussion I   285 14   Amino Acid and Protein Requirements: Cognitive Performance, Stress, and Brain Function Harris R. Lieberman   289 15   Supplementation with Branched-Chain Amino Acids, Glutamine, and Protein Hydrolysates: Rationale for Effects on Metabolism and Performance Anton J. M. Wagenmakers   309

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The Role of Protein and Amino Acids in Sustaining and Enhancing Performance 16   Dietary Supplements Aimed at Enhancing Performance: Efficacy and Safety Considerations Timothy J. Maher   331 Discussion II   341 APPENDIXES     A   Workshop Agenda   349 B   Biographical Sketches   353 C   Acronyms and Abbreviations   369 D   Proteins and Amine Acids—A Selected Bibliography   373 E   Protein and Energy Content of Selected Operational Rations   411 INDEX   413

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