Should postmenopausal women eat more protein? Or do the elite just exercise and eat better?

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Look good, be strong, grow wise, and live long. For those of us over 50 years old, we think about these lifestyle goals often, but many do not know what to actively do to make a meaningful difference. Maintaining strength throughout life is associated with fewer debilitating fractures1 and longer life,2 especially in postmenopausal women. Women are more susceptible to major osteoporotic fractures than men earlier in life.3 Exercise on a regular basis is one approach to maintaining strength and its surrogate skeletal muscle mass. A popular muscle index is skeletal muscle index (SMI) defined as the sum of the lean masses in the arms and legs divided by height squared. But what about diet? The right diet to promote longevity and strength is a constant debate topic. Should we eat meat or be vegetarian? Low carbs, low fats, high protein?
In this issue, the Silva and Spritzer4 paper titled, “Skeletal muscle mass is associated with higher dietary protein intake and lower body fat in postmenopausal women: a cross-sectional study,” asks a relatively simple exploratory question: do postmenopausal women who consume more protein benefit in terms of common health markers including body composition (percent body fat [%fat], SMI), metabolism, and cardiovascular biomarkers? Healthy postmenopausal women were recruited to participate in this observational cross-sectional study. The investigators collected nutrient data using a validated food frequency questionnaire, body composition using dual-energy X-ray absorptiometry (DXA), and a battery of other measures including anthropometry, pedometry, indirect calorimetry, and blood biomarkers. Some of the key findings with statistically significant trends by tertiles of protein consumed are summarized in Figure 1. They conclude, “SMI was positively associated with protein intake and negatively associated with % body fat in the present sample of healthy postmenopausal women … the emerging evidence suggests that healthy postmenopausal Brazilian women with low protein intake and no medical contraindications should be encouraged to increase their protein intake to reduce the risk of low skeletal muscle mass.” But let's look closer at the characteristics of the three groups. First, the high protein group stayed in school longer (11 years) versus the mid and lowest tertiles (8 and 5 years). Secondly, they consumed more daily calories, 30% more than the mid group and 50% more than the low protein consumers, without consuming more fats or carbohydrates. Lastly, the protein levels are only marginally higher when viewed as percentage of the total diet, only 1% to 2% differences between groups. So, the highest tertile of protein consumers are also better educated, exercise more, and eat larger meals with slightly more protein content than their counterparts. Does consuming the slightly higher fraction of protein cause one to stay in school longer, exercise more, and eat a higher volume of food? Maybe. But an alternative causal pathway is suggested: Women with more education may exercise more and this would lower their %fat and increase their SMI. Increased lean mass requires more energy to maintain body weight so they eat more. The higher protein content of their food may also be a consequence of their higher education since one can presume this would translate to a higher income and the ability to afford a slightly higher protein content.
Although there is an association of protein intake, and SMI and % fat in these postmenopausal women, it may be premature to conclude that Brazilian women with low protein intake would see marked gains in their muscle mass after increasing their protein intake with all other confounders held constant. Short-term studies, especially observational studies like this, cannot conclude this.

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