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Low Protein Intake Is Associated with a Major Reduction in IGF-1, Cancer, and Overall Mortality in the 65 and Younger but Not Older Population
Summary
Mice and humans with growth hormone receptor/IGF-1 deficiencies display major reductions in age-related diseases. Because protein restriction reduces GHR-IGF-1 activity, we examined links between protein intake and mortality. Respondents aged 50–65 reporting high protein intake had a 75% increase in overall mortality and a 4-fold increase in cancer death risk during the following 18 years. These associations were either abolished or attenuated if the proteins were plant derived. Conversely, high protein intake was associated with reduced cancer and overall mortality in respondents over 65, but a 5-fold increase in diabetes mortality across all ages. Mouse studies confirmed the effect of high protein intake and GHR-IGF-1 signaling on the incidence and progression of breast and melanoma tumors, but also the detrimental effects of a low protein diet in the very old. These results suggest that low protein intake during middle age followed by moderate to high protein consumption in old adults may optimize healthspan and longevity.
Discussion
Here, using a major nationally representative study of nutrition in the United States population, our results show that among those ages 50 and above, the level of protein intake is associated with increased risk of diabetes mortality, but not associated with differences in all-cause, cancer, or CVD mortality. Nevertheless, we found an age interaction for the association between protein consumption and mortality, both overall and from cancer, with subjects ages 50–65 years potentially experiencing benefits from low protein intake, and subjects ages 66+ experiencing detriments. This may explain why previously the strong association between protein intake, IGF-1, disease, and mortality has been poorly understood and controversial (Saydah et al., 2007). Furthermore, among 2,253 subjects, the risks of all-cause and cancer mortality for those with high protein intake compared to the low protein intake group were increased even further for those who also had high levels of IGF-1. This is in agreement with previous studies associating IGF-1 levels to various types of cancer (Giovannucci et al., 2003,Guevara-Aguirre et al., 2011,Pollak et al., 2004).
Notably, our results showed that the amount of proteins derived from animal sources accounted for a significant proportion of the association between overall protein intake and all-cause and cancer mortality. These results are in agreement with recent findings on the association between red meat consumption and death from all-cause and cancer (Fung et al., 2010,Pan et al., 2012). Previous studies in the U.S. have found that a low carbohydrate diet is associated with an increase in overall mortality and showed that when such a diet is from animal-based products, the risk of overall as well as cancer mortality is increased even further (Fung et al., 2010,Lagiou et al., 2007). Our study indicates that high levels of animal proteins, promoting increases in IGF-1 and possibly insulin, is one of the major promoters of mortality for people age 50–65 in the 18 years following the survey assessing protein intake.
Our results from yeast and mice may explain at least part of the fundamental connection between protein intake, cancer, and overall mortality by providing a link between amino acids, stress resistance, DNA damage, and cancer incidence/progression. In mice, the changes caused by reduced protein levels had an effect potent enough to prevent the establishment of 10%–30% of tumors, even when 20,000 tumor cells were already present at a subcutaneous site. Furthermore, the progression of both melanoma and breast cancer was strongly attenuated by the low protein diet, indicating that low protein diets may have applications in both cancer prevention and treatment, in agreement with previous studies (Fontana et al., 2006,Fontana et al., 2008,McCarty, 2011,Youngman, 1993).
Although protein intake is associated with increased mortality for adults who were middle-aged at baseline, there was also evidence that a low protein diet may be hazardous for older adults. Both high and moderate protein intake in the elderly were associated with reduced mortality compared to that in the low protein group, suggesting that protein intake representing at least 10% of the calories consumed may be necessary after age 65 to reduce age-dependent weight loss and prevent an excessive loss of IGF-1 and of other important factors. In fact, previous studies have noted that an increased protein intake and the resulting increase in IGF-1 may prove beneficial in older adults (Heaney et al., 1999), and the switch from the protective to the detrimental effect of the low protein diet coincides with a time at which weight begins to decline. Based on previous longitudinal studies, weight tends to increase up until age 50–60, at which point it becomes stable before beginning to decline steadily by an average of 0.5% per year for those over age 65 (Villareal et al., 2005,Wallace et al., 1995). We speculate that frail subjects who have lost a significant percentage of their body weight and have a low BMI may be more susceptible to protein malnourishment. It is also possible that other factors such as inflammation or genetic factors may contribute to the sensitivity to protein restriction in elderly subjects, in agreement with our mouse studies.
Although other studies have noted age-associated declines of nutrient absorption in rodents related to changes in the pH microclimate, impaired adaptive response in the aged gut, and changes in the morphology of the intestine, there is still no clear association between food absorption and mortality (Chen et al., 1990,Woudstra and Thomson, 2002). In humans, some studies have shown that dietary protein digestion and absorption kinetics are not impaired in vivo in healthy, elderly men. However, these studies have also reported increased splanchnic extraction of amino acids, which might result in decreased availability to peripheral tissues, and speculated that in the case of low protein intake or increased protein requirement, the limited systemic availability of dietary amino acids may contribute to decreased muscle protein synthesis (Boirie et al., 1997,Koopman et al., 2009). Furthermore, in humans factors like poor dentition, medication, and psychosocial issues also play a significant role in rates of malnourishment (Woudstra and Thomson, 2002).
IGF-1 has been previously shown to decrease at older ages (Iranmanesh et al., 1991), possibly increasing the risk of frailty (Lamberts et al., 1997) and mortality (Cappola et al., 2003). Thus our findings may explain the controversy related to IGF-1 and mortality indicating that a minimum level of proteins and possibly IGF-1 is important in the elderly, or that low circulating IGF-1 reflects a state of malnourishment, frailty, and/or morbidity (Maggio et al., 2007). In fact, inflammation and other disorders are known to decrease IGF-1 levels, raising the possibility that the low protein and low IGF-1 group may contain a significant number of both malnourished and frail individuals having or in the process of developing major diseases (Fontana et al., 2012).
There are some limitations to our study, which should be acknowledged. First, the use of a single 24 hr dietary recall followed by up to 18 years of mortality assessment has the potential of misclassifying dietary practice if the 24 hr period was not representative of a participant's normal day. However, 93% of our sample reported that the 24 hr period represented a normal day. We also include this variable as a control in our analysis. Furthermore, the 24 hr dietary recall has been shown to be a valid approach to identify the “usual diet” of subjects (Blanton et al., 2006,Conway et al., 2004,Coulston and Boushey, 2008,Prentice et al., 2011). While we must admit that the lack of longitudinal data on dietary consumption is a potential limitation of our study, study of dietary consistency over six years among older people revealed little change over time in dietary habits (Garry et al., 1989). Another study looking at dietary habits over 20 years showed that while energy intake decreased for protein, fat, and carbohydrates as people aged, the decreases were equal across the three types (Flynn et al., 1992).
Another limitation of our study is classification of respondents into protein intake groups and small sample sizes, especially for analyses involving diabetes mortality among persons without diabetes at baseline, or participants in the IGF-1 subsample. As a result, our hazard ratios and 95% confidence intervals may be much larger than what would have been seen with a larger sample size. Nevertheless, one would expect a small sample size to decrease statistical power and make it harder to detect associations. Therefore, our ability to detect significance indicates that the associations between protein and mortality are robust. Furthermore, the lower limits of the 95% confidence intervals from our mortality analyses were well above 1.0, signifying that the increased risk is probably large. Finally, given these limitations, our study was strengthened by its use of reliable cause-specific mortality data, as well as its inclusion of a large nationally representative sample, a feature often missing from the previous literature.
Overall, our human and animal studies indicate that a low protein diet during middle age is likely to be beneficial for the prevention of cancer, overall mortality, and possibly diabetes through a process that may involve, at least in part, regulation of circulating IGF-1 and possibly insulin levels. In agreement with other epidemiological and animal studies (Estruch et al., 2013,Linos and Willett, 2007,Michaud et al., 2001,Willett, 2006), our findings suggest that a diet in which plant-based nutrients represent the majority of the food intake is likely to maximize health benefits in all age groups. However, we propose that up to age 65 and possibly 70, depending on health status, the 0.7 to 0.8 g of proteins/kg of body weight/day reported by the Food and Nutrition Board of the Institute of Medicine, currently viewed as a minimum requirement, should be recommended instead of the 1.0–1.3 g grams of proteins/kg of body weight/day consumed by adults ages 19–70 (Fulgoni, 2008). We also propose that at older ages, it may be important to avoid low protein intake and gradually adopt a moderate to high protein, preferably mostly plant-based consumption to allow the maintenance of a healthy weight and protection from frailty (Bartali et al., 2006,Ferrucci et al., 2003,Kobayashi et al., 2013).