Article

Effects of Supplementation with Beef or Whey Protein Versus Carbohydrate in Master Triathletes

Authors:
  • Fundación Canaria Instituto de Investigación Sanitaria de Canarias
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Abstract

Objective: The present study compares the effect of ingesting hydrolyzed beef protein, whey protein, and carbohydrate on performance, body composition (via plethysmography), muscular thickness, and blood indices of health, including ferritin concentrations, following a 10-week intervention program. Methods: After being randomly assigned to one of the following groups-beef, whey, or carbohydrate-24 master-age (35-60 years old) male triathletes (n = 8 per treatment) ingested 20 g of supplement mixed with plain water once a day (immediately after training or before breakfast). All measurements were performed pre- and postinterventions. Results: Only beef significantly reduced body mass (p = 0.021) along with a trend to preserve or increase thigh muscle mass (34.1 ± 6.1 vs 35.5 ± 7.4 mm). Both whey (38.4 ± 3.8 vs 36.9 ± 2.8 mm) and carbohydrate (36.0 ± 4.8 vs 34.1 ± 4.4 mm) interventions demonstrated a significantly (p < 0.05) decreased vastus medialis thickness Additionally, the beef condition produced a significant (p < 0.05) increase in ferritin concentrations (117 ± 78.3 vs 150.5 ± 82.8 ng/mL). No such changes were observed for the whey (149.1 ± 92.1 vs 138.5 ± 77.7 ng/mL) and carbohydrate (149.0 ± 41.3 vs 150.0 ± 48.1 ng/mL) groups. Furthermore, ferritin changes in the beef group were higher than the modification observed in whey (p < 0.001) and carbohydrate (p = 0.025) groups. No differences were found between whey and carbohydrate conditions (p = 0.223). No further changes were observed. Conclusion: Ingesting a hydrolyzed beef protein beverage after workout or before breakfast (nontraining days) can be effective in preserving thigh muscle mass and in improving iron status in male master-age triathletes.

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... Different studies have shown that beef protein intake stimulates muscle protein synthesis (10)(11)(12), especially when combined with physical exercise (13). Even though some studies have reported increases in muscle thickness or lean body mass after using beef protein supplementation compared to the ingestion of carbohydrate (14)(15)(16), such effects have not been observed by others (15)(16)(17). A recent meta-analysis suggested that beef protein supplementation might induce small albeit significant gains in muscle mass and lower-body muscle strength (18). ...
... Different studies have shown that beef protein intake stimulates muscle protein synthesis (10)(11)(12), especially when combined with physical exercise (13). Even though some studies have reported increases in muscle thickness or lean body mass after using beef protein supplementation compared to the ingestion of carbohydrate (14)(15)(16), such effects have not been observed by others (15)(16)(17). A recent meta-analysis suggested that beef protein supplementation might induce small albeit significant gains in muscle mass and lower-body muscle strength (18). ...
... Another potential benefit of beef is that, due to its higher content in heme-iron, it could potentially serve to improve iron status (18). Indeed, beef protein supplementation has been reported to enhance the iron status of master-age triathletes (15) and to increase hematocrit levels in collegiate distance runners (19), which is of potential clinical and athletic relevance for endurance athletes who are usually at a higher risk of iron deficiency which negatively influences performance (20). Protein supplementation might also benefit training-induced adaptations in endurance athletes. ...
Article
Objective: Beef protein extracts are growing in popularity in recent years due to their purported anabolic effects as well as to their potential benefits on hematological variables. The present randomized, controlled, double-blind, cross-over study aimed to analyze the effects of beef protein supplementation on a group of male elite triathletes (Spanish National Team). Methods: Six elite triathletes (age, 21 ± 3 years; VO 2max , 71.5 ± 3.0 mlÁkgÁmin À1) were randomly assigned to consume daily either 25 g of a beef supplement (BEEF) or an isoenergetic carbohydrates (CHO) supplement for 8 weeks, with both conditions being separated by a 5-week washout period. Outcomes, including blood analyses and anthropometrical measurements, were assessed before and after each 8-week intervention. Results: No effects of supplement condition were observed on body mass nor on skinfold thicknesses , but BEEF induced significant and large benefits over CHO in the thigh cross-sectional area (3.02%, 95%CI ¼ 1.33 to 4.71%; p ¼ 0.028, d ¼ 1.22). Contrary to CHO, BEEF presented a significant increase in vastus lateralis muscle thickness (p ¼ 0.046), but differences between conditions were not significant (p ¼ 0.173, d ¼ 0.87). Although a significantly more favorable testosterone-to-cortisol ratio (TCR) was observed for BEEF over CHO (37%, 95% CI ¼ 5 to 68%; p ¼ 0.028, d ¼ 1.29), no significant differences were found for the hematological variables (i.e., iron, ferritin, red blood cell count, hemoglobin or hematocrit). Conclusion: Beef protein supplementation seems to facilitate a more favorable anabolic environment (i.e., increased TCR and muscle mass) in male elite triathletes, with no impact on hemato-logical variables.
... Our search identified 5250 results in addition to another 49 that were collected from the bibliographic references of these studies, totaling 5299 articles. At the end of the screening, 10 studies met all the eligibility criteria to compose the systematic review [31][32][33][34][35][36][37][38][39][40]. However, in two cases [39,40], data collection was incomplete even after successive contacts with the authors, which resulted in eight studies included in the meta-analysis. ...
... All studies evaluated in the meta-analysis had experimental design performed only in men [31][32][33][34][35][36][37][38]. Two RCTs had women in their sample [39,40], however, these studies were the same that could be included only in the qualitative evaluation due to data incompleteness. ...
... Studies were all performed in healthy adults, and all used some method to certify the candidates' health status: 50% of studies used questionnaire or interview during screening [31][32][33]36,37,39] and the others also used physical or laboratory tests [34,35,38,40]. In all cases, none of the randomized individuals presented life habits, diagnoses, or pathologies that influenced their cardiometabolic health and/or body composition. ...
Article
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Whey protein (WP) is a dairy food supplement and, due to its effects on fat-free mass (FFM) gain and fat mass (FM) loss, it has been widely consumed by resistance training practitioners. This review analyzed the impact of WP supplementation in its concentrated (WPC), hydrolyzed (WPH) and isolated (WPI) forms, comparing it exclusively to isocaloric placebos. Random effect meta-analyses were performed from the final and initial body composition values of 246 healthy athletes undergoing 64.5 ± 15.3 days of training in eight randomized clinical trials (RCT) collected systematically from five scientific databases. The weighted mean difference (WMD) was statistically significant for FM loss (WMD = −0.96, 95% CI = −1.37, −0.55, p < 0.001) and, in the analysis of subgroups, this effect was maintained for the WPC (WMD = −0.63, 95% CI = −1.19, −0.06, p = 0.030), with protein content between 51% and 80% (WMD = −1.53; 95% CI = −2.13, −0.93, p < 0.001), and only for regular physical activity practitioners (WMD = −0.95; 95% CI = −1.70, −0.19, p = 0.014). There was no significant effect on FFM in any of the scenarios investigated (p > 0.05). Due to several and important limitations, more detailed analyses are required regarding FFM gain.
... However, the evidence on the effectiveness of BP supplementation for increasing muscle mass or performance is mixed, with some studies reporting benefits compared to no protein supplementation [17,18] but others finding no such benefits [19,20]. Moreover, the effectiveness of BP for improving body composition or performance compared to WP remains unclear [18,19,21,22]. ...
... On the other hand, owing to its high content in heme iron, BP supplementation could also increase total iron intake and thus theoretically benefit hematological parameters, and indeed some benefits have been reported [20,22]. However, to our knowledge, there is not yet meta-analytical evidence on the potential benefits of BP supplementation. ...
... From the retrieved articles, seven (including 270 participants in total) [17][18][19][20][21][22]26] met all inclusion criteria and were included in the systematic review ( Figure 1, Table 1). ...
Article
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Protein supplementation might improve body composition and exercise performance. Supplements containing whey protein (WP) have received the most attention, but other protein sources such as beef protein (BP) are gaining popularity. We conducted a systematic review and meta-analysis of randomized controlled trials that compared the effects of exercise training combined with BP, WP or no protein supplementation (NP), on body composition or exercise performance. Secondary endpoints included intervention effects on total protein intake and hematological parameters. Seven studies (n = 270 participants) were included. No differences were found between BP and WP for total protein intake (standardized mean difference (SMD) = 0.04, p = 0.892), lean body mass (LBM) (SMD = −0.01, p = 0.970) or fat mass (SMD = 0.07, p = 0.760). BP significantly increased total daily protein intake (SMD = 0.68, p < 0.001), LBM (SMD = 0.34, p = 0.049) and lower-limb muscle strength (SMD = 0.40, p = 0.014) compared to NP, but no significant differences were found between both conditions for fat mass (SMD = 0.15, p = 0.256), upper-limb muscle strength (SMD = 0.16, p = 0.536) or total iron intake (SMD = 0.29, p = 0.089). In summary, BP provides similar effects to WP on protein intake and body composition and, compared to NP, might be an effective intervention to increase total daily protein intake, LBM and lower-limb muscle strength.
... For example; carbohydrate intake during exercise maintains high levels of carbohydrate oxidation and prevents hypoglycemia [56]. Similarly, a balanced diet of iron is essential for endurance athletes as they have a higher tendency to develop both iron depletion and deficiency, which sooner or later can cause anemia and lead to reduction in training capabilities [57]. Dietary supplements are widely used by athletes in different sport disciplines as part of their regular training or competition routine to fulfill the requirement of having a balanced nutritional diet [58]. ...
Conference Paper
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... RICYDE.Revista internacional de ciencias del deporte. 57(15),[249][250][251][252][253] https://doi.org/10.5232/ricyde2019.05703 ...
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Masters athletes are typically older than 35years of age and systematically train for, and compete in, organized forms of sport specifically designed for older adults. They are motivated to participate in masters sport for a wide variety of reasons. Age-related declines in endurance performance are observed across the endurance sports of running, orienteering, rowing, and swimming. These declines are curvilinear from age 35years until approximately age 60–70years and exponential thereafter. The decline in endurance performance appears primarily due to an age-related decrease in VO2max secondary to an age-related decrease in HRmax and possible age-related declines in stroke volume and arteriovenous oxygen difference. While performance velocity at lactate threshold decreases with age in masters endurance athletes, it appears to increase relative to VO2max while exercise economy is maintained. There also appears an age-related decrease in active muscle mass, type II muscle fiber size, and blood volume that contribute to decreased endurance performance. However, research suggests that maintenance of training intensity and volume into older age may mediate the rate of age-related decline in VO2max, stroke volume, arteriovenous oxygen difference, blood volume, and muscle mass in masters endurance athletes.
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Age-related skeletal muscle loss is thought to stem from suboptimal nutrition and resistance to anabolic stimuli. Impaired microcirculatory (nutritive) blood flow may contribute to anabolic resistance by reducing delivery of amino acids to skeletal muscle. In this study, we employed contrast-enhanced ultrasound, microdialysis sampling of skeletal muscle interstitium, and stable isotope methodology, to assess hemodynamic and metabolic responses of older individuals to endurance type (walking) exercise during controlled amino acid provision. We hypothesized that older individuals would exhibit reduced microcirculatory blood flow, interstitial amino acid concentrations, and amino acid transport when compared with younger controls. We report for the first time that aging induces anabolic resistance following endurance exercise, manifested as reduced (by ∼40%) efficiency of muscle protein synthesis. Despite lower (by ∼40-45%) microcirculatory flow in the older than in the younger participants, circulating and interstitial amino acid concentrations and phenylalanine transport into skeletal muscle were all equal or higher in older individuals than in the young, comprehensively refuting our hypothesis that amino acid availability limits postexercise anabolism in older individuals. Our data point to alternative mediators of age-related anabolic resistance and importantly suggest correction of these impairments may reduce requirements for, and increase the efficacy of, dietary protein in older individuals.
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The prevalence of iron deficiency anemia is likely to be higher in athletic populations and groups, especially in younger female athletes, than in healthy sedentary individuals. In anemic individuals, iron deficiency often not only decreases athletic performance but also impairs immune function and leads to other physiologic dysfunction. Although it is likely that dietary choices explain much of a negative iron balance, evidence also exists for increased rates of red cell iron and whole-body iron turnover. Other explanations of decreased absorption and increased sweat or urine losses are unlikely. The young female athlete may want to consider use of low-dose iron supplements under medical and dietary supervision to prevent a decline in iron status during training.
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Continuing improvements in the performance of female endurance runners and increasing levels of participation have generated the need to know more about the physiology of this group. Specific research is needed in this area, as data referring to male endurance runners cannot legitimately be applied to the female endurance runner because of their markedly different physiological and hormonal profiles. Recent developments in our understanding of an athlete's physiology (mainly in relation to the male endurance runner) have revealed new areas of interest that need to be assessed with specific reference to the female athlete. Relatively little attention has been directed towards identifying the major physiological characteristics of the highly trained/elite female endurance runner in general, and that which has been published on such factors and the effects of the menstrual cycle have produced equivocal results. Moreover, the impact of such training upon the menstrual cycle and endurance running performance is a controversial area, especially when assessing its subsequent impact on health-related issues. Reports of the condition referred to as the 'female athlete triad' have increased in recent years, with a decrease in bone mineral density predisposing the female athlete to increased risks of stress fractures. The aetiology of this triad is multifactorial, with such risk factors including nutrition, menstrual status, training intensity and frequency, body size and composition and psychology/physical stress. However, research limitations and flaws have lead to controversy in the literature regarding the immediate and long term effects of the triad on the female athlete. Likewise, the effects of the oral contraceptive pill on health and endurance performance also remain elusive, with a dearth of research pertaining to how oral contraceptive agents can aid athletic performance and the long term health of the female athlete. The purpose of this paper is to critically appraise the existing literature to provide a current review of the physiological scientific knowledge base in relation to the female athlete, health, training and performance, with suggestions for future areas of research. It is well known that certain menstrual and health-related performance factors of the female athlete, that is, physiological predictors of performance and body fat, have been extensively investigated over the last 30 years. However, a variety of methodological flaws and inconsistencies are present within the research and thus only the most prominent and well controlled studies within this area over the past 30 years will be referred to.
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There is a wide body of literature reporting red cell hemolysis as occurring after various forms of exercise. Whereas the trauma associated with footstrike is thought to be the major cause of hemolysis after running, its significance compared with hemolysis that results from other circulatory stresses on the red blood cell has not been thoroughly addressed. To investigate the significance of footstrike, we measured the degree of hemolysis after 1 h of running. To control for the potential effects of oxidative and circulatory stresses on the red blood cell, the same subjects cycled for 1 h at equivalent oxygen uptake. Our subjects were 10 male triathletes, who each completed two separate 1-h sessions of running and cycling at 75% peak oxygen uptake, which were performed in random order 1 wk apart. Plasma free hemoglobin and serum haptoglobin concentrations were measured as indicators of hemolysis. We also measured methemoglobin as a percentage of total hemoglobin immediately postexercise as an indicator of red cell oxidative stress. Plasma free hemoglobin increased after both running (P < 0.01) and cycling (P < 0.01), but the increase was fourfold greater after running (P < 0.01). This was reflected by a significant fall in haptoglobin 1 h after the running trials, whereas no significant changes occurred after cycling at any sample point. Methemoglobin increased twofold after both running and cycling (P < 0.01), with no significant differences between modes of exercise. The present data indicate that, whereas general circulatory trauma to the red blood cells associated with 1 h of exercise at 75% maximal oxygen uptake may result in some exercise-induced hemolysis, footstrike is the major contributor to hemolysis during running.
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The purpose of this study was to compare the effect of 2 training programs differing in the relative contribution of training volume, clearly below vs. within the lactate threshold/maximal lactate steady state region on performance in endurance runners. Twelve subelite endurance runners (who are specialists in track events, mostly the 5,000-m race usually held during spring-summer months and who also participate in cross-country races [9-12 km] during fall and winter months) were randomly assigned to a training program emphasizing low-intensity (subthreshold) (Z1) or moderately high-intensity (between thresholds) (Z2) training intensities. At the start of the study, the subjects performed a maximal exercise test to determine ventilatory (VT) and respiratory compensation thresholds (RCT), which allowed training to be controlled based on heart rate during each training session over a 5-month training period. Subjects performed a simulated 10.4-km cross-country race before and after the training period. Training was quantified based on the cumulative time spent in 3 intensity zones: zone 1 (low intensity; <VT), zone 2 (moderate intensity; between VT and RCT), and zone 3 (high intensity; >RCT). The contribution of total training time spent in zones 1 and 2 was controlled to have relatively more low-intensity training in Z1 (80.5 +/- 1.8% and 11.8 +/- 2.0%, respectively) than in Z2 (66.8 +/- 1.1% and 24.7 +/- 1.5%, respectively), whereas the contribution of high-intensity (zone 3) training was similar (8.3 +/- 0.7% [Z1] and 8.5 +/- 1.0% [Z2]). The magnitude of the improvement in running performance was significantly greater (p = 0.03) in Z1 (-157 +/- 13 seconds) than in Z2 (-121.5 +/- 7.1 seconds). These results provide experimental evidence supporting the value of a relatively large percentage of low-intensity training over a long period ( approximately 5 months), provided that the contribution of high-intensity training remains sufficient.
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Objectives: The objective of the present meta-analysis was to examine the effect of whey protein (WP), with or without resistance exercise, on body weight and body composition in randomized controlled trials (RCTs) conducted in generally healthy adult study populations. Methods: A comprehensive literature search was conducted to identify RCTs that investigated WP (concentrate, isolate, or hydrolystate) and body weight, body mass index (BMI), body fat, lean body mass (LBM), fat-free mass (FFM), and waist circumference. Random effects meta-analyses were conducted to generate weighted group mean differences (WGMD) for between-group comparisons (WP vs other protein sources or carbohydrates) and within-WP group comparisons (i.e., differences from baseline to trial end). Studies were classified into 2 distinct groups-WP as a supplement without dietary modification (WPS) and WP as a replacement for other sources of calories (WPR)-and were meta-analyzed separately. Subgroup analyses included examining the effect of resistance exercise and type of WP on the relationship between WP and body composition. Results: Fourteen RCTs were included, with a total of 626 adult study completers. Five studies examined the effects of WPR and the remaining 9 studies examined the effects of WPS. Body weight (WGMD: -4.20 kg, 95% confidence interval [CI], -7.67, -0.73) and body fat (WGMD: -3.74 kg, 95% CI, -5.98, -1.50) were significantly decreased from baseline in the WPR within-group analyses. In the between-group analyses, the effects of WP were more favorable when compared with carbohydrates than protein sources other than whey, although findings did not reach statistical significance. Results from the subgroup analyses indicated a statistically significant increase in LBM (WGMD: 2.24 kg, 95% CI, 0.66, 3.81) among studies that included a resistance exercise component along with WP provision. Conclusion: The current body of literature supports the use of WP, either as a supplement combined with resistance exercise or as part of a weight loss or weight maintenance diet, to improve body composition parameters.
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Gender-based differences in the physiological response to exercise have been studied extensively for the last four decades, and yet the study of post-exercise, gender-specific recovery has only been developing in more recent years. This review of the literature aims to present the current state of knowledge in this field, focusing on some of the most pertinent aspects of physiological recovery in female athletes and how metabolic, thermoregulatory, or inflammation and repair processes may differ from those observed in male athletes. Scientific investigations on the effect of gender on substrate utilization during exercise have yielded conflicting results. Factors contributing to the lack of agreement between studies include differences in subject dietary or training status, exercise intensity or duration, as well as the variations in ovarian hormone concentrations between different menstrual cycle phases in female subjects, as all are known to affect substrate metabolism during submaximal exercise. If greater fatty acid mobilization occurs in females during prolonged exercise compared with males, the inverse is observed during the recovery phase. This could explain why, despite mobilizing lipids to a greater extent than males during exercise, females lose less fat mass than their male counterparts over the course of a physical training programme. Where nutritional strategies are concerned, no difference appears between males and females in their capacity to replenish glycogen stores; optimal timing for carbohydrate intake does not differ between genders, and athletes must consume carbohydrates as soon as possible after exercise in order to maximize glycogen store repletion. While lipid intake should be limited in the immediate post-exercise period in order to favour carbohydrate and protein intake, in the scope of the athlete’s general diet, lipid intake should be maintained at an adequate level (30%). This is particularly important for females specializing in long-duration events. With protein balance, it has been shown that a negative nitrogen balance is more often observed in female athletes than in male athletes. It is therefore especially important to ensure that this remains the case during periods of caloric restriction, especially when working with female athletes showing a tendency to limit their caloric intake on a daily basis. In the post-exercise period, females display lower thermolytic capacities than males. Therefore, the use of cooling recovery methods following exercise, such as cold water immersion or the use of a cooling vest, appear particularly beneficial for female athletes. In addition, a greater decrease in arterial blood pressure is observed after exercise in females than in males. Given that the return to homeostasis after a brief intense exercise appears linked to maintaining good venous return, it is conceivable that female athletes would find a greater advantage to active recovery modes than males. This article reviews some of the major gender differences in the metabolic, inflammatory and thermoregulatory response to exercise and its subsequent recovery. Particular attention is given to the identification of which recovery strategies may be the most pertinent to the design of training programmes for athletic females, in order to optimize the physiological adaptations sought for improving performance and maintaining health.
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Iron is one of the essential micronutrients, and as such, is required for growth, development, and normal cellular functioning. In contrast to some other micronutrients such as water-soluble vitamins, there is a significant danger of toxicity if excessive amounts of iron accumulate in the body. A finely tuned feedback control system functions to limit this excessive accumulation by limiting absorption of iron. This chapter will discuss systemic and brain iron homeostasis.
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There is a great demand for perceptual effort ratings in order to better understand man at work. Such ratings are important complements to behavioral and physiological measurements of physical performance and work capacity. This is true for both theoretical analysis and application in medicine, human factors, and sports. Perceptual estimates, obtained by psychophysical ratio-scaling methods, are valid when describing general perceptual variation, but category methods are more useful in several applied situations when differences between individuals are described. A presentation is made of ratio-scaling methods, category methods, especially the Borg Scale for ratings of perceived exertion, and a new method that combines the category method with ratio properties. Some of the advantages and disadvantages of the different methods are discussed in both theoretical-psychophysical and psychophysiological frames of reference.
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A new device based on the plethysmographic measurement of body volume has been developed for the purpose of estimating human body composition. The device, the BOD POD Body Composition System, uses the relationship between pressure and volume to derive the body volume of a subject seated inside a fiberglass chamber. Derivation of body volume, together with measurement of body mass, permits calculation of body density and subsequent estimation of percent fat and fat-free mass. Critical issues which have hampered prior plethysmographic approaches are discussed. The present system's ability to measure the volume of inanimate objects was evaluated for accuracy, reliability, and linearity. Twenty successive tests of a known volume (50,039 ml) on two separate days produced values of 50,037 +/- 12.7 ml and 50,030 +/- 13.5 ml (mean +/- SD) for each day, respectively. The CV for these series were 0.025% and 0.027%. Further testing across a wide range of volumes approximating human size (25-150 1) produced the following regression equation where y = measured volume (1) and x = actual volume (1): y = 0.9998x - 0.0274, r2 = 1.0, SEE = 0.004 1. The resultant device is likely to enhance opportunities for the quick, simple and noninvasive measurement of body composition for both research and clinical applications.
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Body composition changes as people get older. One of the noteworthy alterations is the reduction in total body protein. A decrease in skeletal muscle is the most noticeable manifestation of this change but there is also a reduction in other physiologic proteins such as organ tissue, blood components, and immune bodies as well as declines in total body potassium and water. This contributes to impaired wound healing, loss of skin elasticity, and an inability to fight infection. The recommended dietary allowance (RDA) for adults for protein is 0.8 grams of protein per kilogram of body weight. Protein tissue accounts for 30% of whole-body protein turnover but that rate declines to 20% or less by age 70. The result of this phenomenon is that older adults require more protein/kilogram body weight than do younger adults. Recently, it has become clear that the requirement for exogenous protein is at least 1.0 gram/kilogram body weight. Adequate dietary intake of protein may be more difficult for older adults to obtain. Dietary animal protein is the primary source of high biological value protein, iron, vitamin B(12), folic acid, biotin and other essential nutrients. In fact, egg protein is the standard against which all other proteins are compared. Compared to other high-quality protein sources like meat, poultry and seafood, eggs are the least expensive. The importance of dietary protein cannot be underestimated in the diets of older adults; inadequate protein intake contributes to a decrease in reserve capacity, increased skin fragility, decreased immune function, poorer healing, and longer recuperation from illness.
Physiological Testing of High Performance Athlete
HJ, editors. Physiological Testing of High Performance Athlete. Champaign, IL: Human Kinetics, pp 223-308 1991.
Atlas of musculoskeletal ultrasound anatomy London Greenwich Medical Media
  • M Bradley
  • O' Donnell
Bradley M, O'Donnell P. Atlas of musculoskeletal ultrasound anatomy London Greenwich Medical Media 2002