The challenges associated with a low protein diet (Review)&nbsp;

Qi,Xin; Tester,Richard

doi:10.3892/ijfn.2025.43

The challenges associated with a low protein diet (Review)

Authors:
- Xin Qi
- Richard Tester
View Affiliations

Affiliations: Glycologic Limited, Reading, RG7 1PQ, UK
Published online on: January 20, 2025 https://doi.org/10.3892/ijfn.2025.43
Article Number: 2
Copyright : © Qi et al. This is an open access article distributed under the terms of Creative Commons Attribution License [CC BY 4.0].

Metrics: Total Views: 0 (Spandidos Publications: | PMC Statistics: )

Metrics: Total PDF Downloads: 0 (Spandidos Publications: | PMC Statistics: )

Cited By (CrossRef): 0 citations Loading Articles...

Abstract

Low‑protein diet regimes, not necessarily focused on coeliac disease management, as individuals with this condition can consume alternative non‑gluten protein sources, but for individuals carrying in‑born errors of metabolism gene defects, such as phenylketonuria and certain kidney/liver diseases, are challenging. Protein provides texture in foods, setting aside its critical role in nutrition, which is difficult to replicate using other molecular systems. In fact, it is impossible to do so in reality. However, a number of low‑protein products have been developed for individuals with the low protein need and many have proven to be acceptable, better than the metered consumption of specific amino acid blends alone. Although critical in the diet, these amino acid blends are not only monotonous with a generally unattractive taste, but they also never replace the eating experience as both a pleasurable personal activity and social activity. The present mini‑review considers the challenges and potential management options of low‑protein foods and diets.

View Figures

View References

1	Wu G: Dietary protein intake and human health. Food Funct. 7:1251–1265. 2016.PubMed/NCBI View Article : Google Scholar
2	British Nutrition Foundation (BNF): 2022. https://www.nutrition.org.uk.
3	Kitada M, Ogura Y, Monno I and Koya D: The impact of dietary protein intake on longevity and metabolic health. EBioMedicine. 43:632–640. 2019.PubMed/NCBI View Article : Google Scholar
4	Pezeshki A and Chelikani PK: Low protein diets and energy balance: Mechanisms of action on energy intake and expenditure. Front Nutr. 8(655833)2021.PubMed/NCBI View Article : Google Scholar
5	Kang JS: Dietary restriction of amino acids for cancer therapy. Nutr Metab (Lond). 17(20)2020.PubMed/NCBI View Article : Google Scholar
6	Ling ZN, Jiang YF, Ru JN, Lu JH, Ding B and Wu J: Amino acid metabolism in health and disease. Signal Transduct Target Ther. 8(345)2023.PubMed/NCBI View Article : Google Scholar
7	Dipasquale V, Cucinotta U and Romano C: Acute malnutrition in children: Pathophysiology, clinical effects and treatment. Nutrients. 12(2413)2020.PubMed/NCBI View Article : Google Scholar
8	May T, de la Haye B, Nord G, Klatt K, Stephenson K, Adams S, Bollinger L, Hanchard N, Arning E, Bottiglieri T, et al: One-carbon metabolism in children with marasmus and kwashiorkor. EBioMedicine. 75(103791)2022.PubMed/NCBI View Article : Google Scholar
9	De Waele E, Jakubowski JR, Stocker R and Wischmeyer PE: Review of evolution and current status of protein requirements and provision in acute illness and critical care. Clin Nutr. 40:2958–2973. 2021.PubMed/NCBI View Article : Google Scholar
10	Delimaris I: Adverse effects associated with protein intake above the recommended dietary allowance for adults. ISRN Nutr. 2013(126929)2013.PubMed/NCBI View Article : Google Scholar
11	Piccoli GB, Vigotti FN, Leone F, Capizzi I, Daidola G, Cabiddu G and Avagnina P: Low-protein diets in CKD: How can we achieve them? A narrative, pragmatic review. Clin Kidney J. 8:61–70. 2015.PubMed/NCBI View Article : Google Scholar
12	Verzola D, Picciotto D, Saio M, Aimasso F, Bruzzone F, Sukkar SG, Massarino F, Esposito P, Viazzi F and Garibotto G: Low protein diets and plant-based low protein diets: Do they meet protein requirements of patients with chronic kidney disease? Nutrients. 13(83)2021.PubMed/NCBI View Article : Google Scholar
13	Nguyen DL and Morgan T: Protein restriction in hepatic encephalopathy is appropriate for selected patients: A point of view. Hepatol Int. 8:447–451. 2015.PubMed/NCBI View Article : Google Scholar
14	Piccoli GB and Cupisti A: ‘Let food be thy medicine…’: Lessons from low-protein diets from around the world. BMC Nephrol. 18(102)2017.PubMed/NCBI View Article : Google Scholar
15	Dalangin R, Kim A and Campbell RE: The role of amino acids in neurotransmission and fluorescent tools for their detection. Int J Mol Sci. 21(6197)2020.PubMed/NCBI View Article : Google Scholar
16	Sheikhi A, Siassi F, Djazayery A, Guilani B and Azadbakht L: Plant and animal protein intake and its association with depression, anxiety, and stress among Iranian women. BMC Public Health. 23(161)2023.PubMed/NCBI View Article : Google Scholar
17	Li Y, Zhang C, Li S and Zhang D: Association between dietary protein intake and the risk of depressive symptoms in adults. Br J Nutr. 123:1290–1301. 2020.PubMed/NCBI View Article : Google Scholar
18	Oh J, Yun K, Chae JH and Kim TS: Association between macronutrients intake and depression in the United States and South Korea. Front Psychiatry. 11(207)2020.PubMed/NCBI View Article : Google Scholar
19	Gerber M, Jakowski S, Kellmann M, Cody R, Gygax B, Ludyga S, Müller C, Ramseyer S and Beckmann J: Macronutrient intake as a prospective predictor of depressive symptom severity: An exploratory study with adolescent elite athletes. Psychol Sport Exerc. 67(102442)2023.PubMed/NCBI View Article : Google Scholar
20	Boyer SW, Barclay LJ and Burrage LC: Inherited metabolic disorders: Aspects of chronic nutritional management. Nutr Clin Pract. 30:502–510. 2015.PubMed/NCBI View Article : Google Scholar
21	Ezgu F: Inborn errors of metabolism. Adv Clin Chem. 73:195–250. 2016.PubMed/NCBI View Article : Google Scholar
22	Agana M, Frueh J, Kamboj M, Patel DR and Kanungo S: Common metabolic disorder (inborn errors of metabolism) concerns in primary care practice. Ann Transl Med. 6(469)2018.PubMed/NCBI View Article : Google Scholar
23	Aliu E, Kanungo S and Arnold GL: Amino acid disorders. Ann Transl Med. 6(471)2018.PubMed/NCBI View Article : Google Scholar
24	Arnold GL: Inborn errors of metabolism in the 21st century: Past to present. Ann Transl Med. 6(467)2018.PubMed/NCBI View Article : Google Scholar
25	Saudubray JM and Garcia-Cazorla A: Inborn errors of metabolism. Overview, pathophysiology, manifestations, evaluation, and management. Pediatr Clin North Am. 65:179–208. 2018.PubMed/NCBI View Article : Google Scholar
26	Ferreira CR and Van Karnebeek CDM: Inborn errors of metabolism. Handb Clin Neurol. 162:449–481. 2019.PubMed/NCBI View Article : Google Scholar
27	Ferreira CR, Rahman S, Keller M and Zschocke J: ICIMD Advisory Group. An international classification of inherited metabolic disorders (ICIMD). J Inherit Metab Dis. 44:164–177. 2020.PubMed/NCBI View Article : Google Scholar
28	Hsu CK, Su SC, Chang LC, Shao SC, Yang KJ, Chen CY, Chen YT and Wu IW: Effects of low protein diet on modulating gut microbiota in patients with chronic kidney disease: A systematic review and meta-analysis of international studies. Int J Med Sci. 18:3839–3850. 2021.PubMed/NCBI View Article : Google Scholar
29	Yao CK, Muir JG and Gibson PR: Review article: Insights into colonic protein fermentation, its modulation and potential health implications. Aliment Pharmacol Ther. 43:181–196. 2016.PubMed/NCBI View Article : Google Scholar
30	Singh RK, Chang HW, Yan D, Lee KM, Ucmak D, Wong K, Abrouk M, Farahnik B, Nakamura M, Zhu TH, et al: Influence of diet on the gut microbiome and implications for human health. J Transl Med. 15(73)2022.PubMed/NCBI View Article : Google Scholar
31	Bartlett A and Kleiner M: Dietary protein and the intestinal microbiota: An understudied relationship. iScience. 25(105313)2022.PubMed/NCBI View Article : Google Scholar
32	Wu S, Bhat ZF, Gounder RS, Ahmed IA, Al-Juhaimi FY, Ding Y and Bekhit AEDA: Effect of dietary protein and processing on gut microbiota-A systematic review. Nutrients. 14(453)2022.PubMed/NCBI View Article : Google Scholar
33	Foegeding EA and Davis JP: Food protein functionality: A comprehensive approach. Food Hydrocolloids. 25:1853–1864. 2011.
34	Delcour JA, Joye IJ, Pareyt B, Wilderjans E, Brijs K and Lagrain B: Wheat gluten functionality as a quality determinant in cereal-based food products. Annu Rev Food Sci Technol. 3:469–492. 2011.PubMed/NCBI View Article : Google Scholar
35	Martins JT, Bourbon AI, Pinheiro AC, Fasolin LH and Vicente AA: Protein-based structures for food applications: From macro to nanoscale. Front Sustain Food Syst. 2(77)2018.
36	Nwachukwua ID and Aluko RE: Food protein structures, functionality and product development. In: Food Chemistry, Function and Analysis No. 27. Food Proteins and Peptides: Emerging Biofunctions, Food and Biomaterial Applications. Udenigwe CC (ed). Royal Society of Chemistry, London, pp1-33, 2021.
37	Małecki J, Muszyński S and Sołowiej BG: Proteins in food systems-Bionanomaterials, conventional and unconventional sources, functional properties and development opportunities. Polymers (Basel). 13(2506)2021.PubMed/NCBI View Article : Google Scholar
38	Tan M, Nawaz MA and Buckow R: Functional and food application of plant proteins-a review. Food Rev Int. 39:2428–2456. 2021.
39	He J, Evans NM, Liu H and Shao S: A review of research on plant-based meat alternatives: Driving forces, history, manufacturing and consumer attitudes. Compr Rev Food Sci Food Saf. 19:2639–2656. 2020.PubMed/NCBI View Article : Google Scholar
40	Ismail I, Hwang YH and Joo ST: Meat analogue as future food: A review. J Anim Sci Technol. 62:111–120. 2020.PubMed/NCBI View Article : Google Scholar
41	Rubio NR, Xiang N and Kaplan DL: Plant-based and cell-based approaches to meat production. Nat Commun. 11(6276)2020.PubMed/NCBI View Article : Google Scholar
42	Santo RE, Kim BF, Goldman SE, Dutkiewicz J, Biehl EMB, Bloem MW, Neff RA and Nachman KE: Considering plant-based meat substitutes and cell-based meats: A public health and food systems perspective. Front Sustain Food Syst. 4(134)2020.
43	Onwezen MC, Bouwman EP, Reinders MJ and Dagevos H: A systematic review on consumer acceptance of alternative proteins: Pulses, algae, insects, plant-based meat alternatives and cultured meat. Appetite. 159(105058)2021.PubMed/NCBI View Article : Google Scholar
44	EFSA Panel on Food Additives and Nutrient Sources added to Food (ANS): Guidance for submission for food additive evaluations. EFSA J. 10(2760)2012.
45	Himashree P, Sengar AS and Sunil CK: Food thickening agents: Sources, chemistry, properties and applications-A review. Int J Gastron Food Sci. 27(100468)2022.
46	Hadde EK, Mossel B, Chen J and Prakash S: The safety and efficacy of xanthan gum-based thickeners and their effect in modifying bolus rheology in the therapeutic medical management of dysphagia. Food Hydrocoll Health. 1(100038)2021.
47	Duncan DR, Larson K and Rosen RL: Clinical aspects of thickeners for pediatric gastroesophageal reflux and oropharyngeal dysphagia. Curr Gastroenterol Rep. 21(30)2022.PubMed/NCBI View Article : Google Scholar
48	Yang Y, Xu J, Sang TT and Wang HY: A review and evidence based recommendations on starch- and gum-based thickeners for dysphagic patients. J Food Meas Charact. 16:3140–3152. 2022.
49	Tester RF and Karkalas J: Starch, In: Steinbüchel A. series ed. Vandamme E.J. De Baets S. Steinbüchel A. volume Editors, Biopolymers Volume 6, Polysaccharides II: Polysaccharides from Eukaryotes, Weinheim, Wiley-VCH, 381-438, 2002. ISBN 3-527-30227-1.
50	Tester RF and Kakalas J: Carbohydrates: Classification and Properties, In: Encyclopaedia of Food Sciences and Nutrition. Caballero B, Trugo L and Finglas P (eds). Academic Press, pp862-875, 2003.
51	Tester RF and Karkalas J: Carbohydrates: Interactions with other Food Components. In: Encyclopaedia of Food Sciences and Nutrition. Caballero B, Trugo L and Finglas P (eds). Academic Press, pp875-881, 2003.
52	Tester RF and Karkalas J: Starch. In: Polysaccharides and Polyamides in the Food Industry. Steinbüchel A and Rhee SK (eds). Wiley-VCH, Weinheim, pp423-480, 2005.
53	Ferrero C: Hydrocolloids in wheat breadmaking: A concise review. Food Hydrocolloids. 68:15–22. 2017.
54	Anton AA and Artfield SD: Hydrocolloids in gluten-free breads: A review. Int J Food Sci Nutr. 59:11–23. 2018.PubMed/NCBI View Article : Google Scholar
55	Culetu A, Duta DE, Papageorgiou M and Varzakas T: The role of hydrocolloids in gluten-free bread and pasta; Rheology, characteristics, staling and glycaemic index. Foods. 10(3121)2021.PubMed/NCBI View Article : Google Scholar
56	Baker RC, Darfler J and Lifshitz A: Factors affecting the discoloration of hard-cooked egg yolks. Poult Sci. 46:664–672. 1967.
57	Sohail A, Al-Dalali S, Wang J, Xie J, Shakoor A, Asimi S, Shah H and Patil P: Aroma compounds identified in cooked meat: A review. Food Res Int. 157(111385)2022.PubMed/NCBI View Article : Google Scholar
58	Lund MN and Ray CA: Control of Maillard reactions in foods: Strategies and chemical mechanisms. J Agric Food Chem. 65:4537–4552. 2017.PubMed/NCBI View Article : Google Scholar
59	Starowicz M and Zielińsk H: How Maillard reaction influences sensorial properties (colour, flavour and texture) of food products? Food Rev Int. 35:707–725. 2019.
60	Qi X and Tester RF: Effect of native starch granule size on susceptibility to amylase hydrolysis. Starch/Stärke. 68:807–810. 2016.
61	Qi X and Tester RF: Effect of composition and structure of native starch granules on their susceptibility to hydrolysis by amylase enzymes. Starch/Stärke. 68:811–815. 2016.
62	Qi X and Tester RF: Heat and moisture modification of native starch granules on susceptibility to amylase hydrolysis. Starch/Stärke. 68:816–820. 2016.
63	Evenepoel P, Geypens B, Luypaerts A, Hiele M, Ghoos Y and Rutgeerts P: Digestibility of cooked and raw egg protein in humans as assessed by stable isotope techniques. J Nutr. 128:1716–1722. 1998.PubMed/NCBI View Article : Google Scholar
64	van Lieshout GAA, Lambers TT, Bragt MCE and Hettinga KA: How processing may affect milk protein digestion and overall physiological outcomes: A systematic review. Crit Rev Food Sci Nutr. 60:2422–2445. 2020.PubMed/NCBI View Article : Google Scholar
65	Sá AGA, Morenob YMF and Carciofia BAM: Food processing for the improvement of plant proteins digestibility. Crit Rev Food Sci Nutr. 60:3367–3386. 2020.PubMed/NCBI View Article : Google Scholar
66	Joye I: Protein digestibility of cereal products. Foods. 8(199)2019.PubMed/NCBI View Article : Google Scholar
67	Swaisgood HE and Catignani GL: Protein digestibility. In vitro methods of assessment. Adv Food Nutr Res. 35:185–236. 1991.PubMed/NCBI View Article : Google Scholar
68	Weijzen MEG, van Gassel RJJ, Kouw IWK, Trommelen J, Gorissen SHM, van Kranenburg J, Goessens JPB, van de Poll MCG and Verdijk LB: Ingestion of free amino acids compared with an equivalent amount of intact protein results in more rapid amino acid absorption and greater postprandial plasma amino acid availability without affecting muscle protein synthesis rates in young adults in a double-blind randomised trial. J Nutr. 152:59–67. 2022.PubMed/NCBI View Article : Google Scholar
69	Morell P and Fiszman S: Revisiting the role of protein-induced satiation and satiety. Food Hydrocolloids. 68:199–210. 2017.
70	MacDonald A, van Wegberg AMJ, Ahring K, Beblo S, Bélanger-Quintana A, Burlina A, Campistol J, Coşkun T, Feillet F, Giżewska M, et al: PKU dietary handbook to accompany PKU guidelines. Orphanet J Rare Dis. 15(171)2020.PubMed/NCBI View Article : Google Scholar
71	De Mauri A, Carrera D, Vidali M, Bagnati M, Rolla R, Riso S, Torreggiani M and Chiarinotti D: Compliance, adherence and concordance differently predict the improvement of uremic and microbial toxins in chronic kidney disease on low protein diet. Nutrients. 14(487)2022.PubMed/NCBI View Article : Google Scholar
72	Yagudina R, Kulikov A, Serpik V, Protsenko M and Kopeyka K: Factors affecting adherence to a low phenylalanine diet in patients with phenylketonuria: A systematic review. Nutrients. 16(3119)2024.PubMed/NCBI View Article : Google Scholar
73	Scala I, Brodosi L, Rovelli V, Noto D and Burlina A: Management of patients with phenylketonuria (PKU) under enzyme replacement therapy: An Italian model (expert opinion). Mol Genet Metab Rep. 39(101065)2024.PubMed/NCBI View Article : Google Scholar
74	Wood G, Pinto A, Evans S, Daly A, Adams S, Costelloe S, Gribben J, Ellerton C, Emm A, Firman S, et al: Special low protein foods prescribed in England for PKU patients: An analysis of prescribing patterns and cost. Nutrients. 13(3977)2021.PubMed/NCBI View Article : Google Scholar
75	Qi X, Ta MN and Tester RF: Savoury cracker development for blood glucose control and management. Bioact Carbohydr Diet Fibre. 24(100249)2020.
76	Anon: 2021 https://www.biospace.com/article/medical-foods-for-inborn-errors-of-metabolism-market-increasing-incidences-of-inborn-errors-of-metabolism/.
77	Food and Agriculture Organisation/World Health Organisation: Protein quality evaluation; Report of the joint FAO/WHO expert consultation. FAO Food and Nutrition Paper 52, Rome, 1990.
78	Schaafsma G: The protein digestibility-corrected acid score. J Nutr. 130:1865S–1867S. 2000.PubMed/NCBI View Article : Google Scholar
79	Hoffman JR and Falvo MJ: Protein-Which is best? J Sports Sci Med. 3:118–130. 2004.
80	Food Standards Agency: Approved additives and E numbers. Food Standards Agency, 2018. https://www.food.gov.uk/business-guidance/approved-additives-and-e-numbers.