Skip to main content Accessibility help

Assessment of protein adequacy in developing countries: quality matters

  • Shibani Ghosh (a1) (a2), Devika Suri (a2) and Ricardo Uauy (a2) (a3)


Dietary protein and amino acid requirement recommendations for normal “healthy” children and adults have varied considerably with 2007 FAO/WHO protein requirement estimates for children lower, but dietary essential AA requirements for adults more than doubled. Requirement estimates as presented do not account for common living conditions, which are prevalent in developing countries such as energy deficit, infection burden and added functional demands for protein and AAs. This study examined the effect of adjusting total dietary protein for quality and digestibility (PDCAAS) and of correcting current protein and AA requirements for the effect of infection and a mild energy deficit to estimate utilizable protein (total protein corrected for biological value and digestibility) and the risk/prevalence of protein inadequacy. The relationship between utilizable protein/prevalence of protein inadequacy and stunting across regions and countries was examined. Data sources (n = 116 countries) included FAO FBS (food supply), UNICEF (stunting prevalence), UNDP (GDP) and UNSTATS (IMR) and USDA nutrient tables. Statistical analyses included Pearson correlations, paired-sample/non-parametric t-tests and linear regression. Statistically significant differences were observed in risk/prevalence estimates of protein inadequacy using total protein and the current protein requirements versus utilizable protein and the adjusted protein requirements for all regions (p < 0·05). Total protein, utilizable protein, GDP per capita and total energy were each highly correlated with the prevalence of stunting. Energy, protein and utilizable protein availability were independently and negatively associated with stunting (p < 0·001), explaining 41 %, 34 % and 40 % of variation respectively. Controlling for energy, total protein was not a statistically significant factor but utilizable protein remained significant explaining~45 % of the variance (p = 0·017). Dietary utilizable protein provides a better index of population impact of risk/prevalence of protein inadequacy than crude protein intake. We conclude that the increased demand for protein due to infections and mild to moderate energy deficits, should be appropriately considered in assessing needs of populations where those conditions still prevail.

  • View HTML
    • Send article to Kindle

      To send this article to your Kindle, first ensure is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle. Find out more about sending to your Kindle.

      Note you can select to send to either the or variations. ‘’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

      Find out more about the Kindle Personal Document Service.

      Assessment of protein adequacy in developing countries: quality matters
      Available formats

      Send article to Dropbox

      To send this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Dropbox.

      Assessment of protein adequacy in developing countries: quality matters
      Available formats

      Send article to Google Drive

      To send this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Google Drive.

      Assessment of protein adequacy in developing countries: quality matters
      Available formats


Corresponding author

*Corresponding author: Dr Ricardo Uauy, fax +1 617 636 3771, email


Hide All
1WHO (2007) Protein and amino acid requirements in human nutrition. Report of a Joint WHO/FAO/UNU Expert Consultation. Geneva: World Health Organization (WHO Technical Report Series, No. 935); 2007 Contract No.: Document Number.
2Dewey, KG, Beaton, G, Fjeld, C, et al. (1996) Protein requirements of infants and children. Eur J Clin Nutr 50, S119S150.
3Scrimshaw, NS, Taylor, CE & Gordon, JE (1959) Interactions of nutrition and infection. Am J Med Sci 237, 367403.
4Pellett PL & Young VR (editors) (1991) The effects of different levels of energy intake on protein metabolism and of different levels of protein intake on energy metabolism: A statistical evaluation from the published literature. International Dietary Energy Consultancy Group. NH, USA: Waterville Valley.
5Garza, C, Scrimshaw, N & Young, V (1976) Human protein requirements: the effect of variations in energy intake within the maintenance range. Am J Clin Nutr 29, 3, 280287.
6Garza, C, Scrimshaw, NS & Young, VR (1978) Human Protein Requirements: Interrelationships between Energy Intake and Nitrogen Balance in Young Men Consuming the 1973 FAO/WHO Safe Level of Egg Protein, with Added Non-Essential Amino Acids. J Nutr 108, 1, 9096.
7Kishi, K, Miyatani, S & Inoue, G (1978) Requirement and utilization of egg protein by Japanese young men with marginal intakes of energy. J Nutr 108, 4, 658669.
8Hoppe, C, Molgaard, C, Thomsen, BL, et al. (2004) Protein intake at 9 mo of age is associated with body size but not with body fat in 10-y-old Danish children. Am J Clin Nutr 79, 3, 494501.
9FAO/WHO (1991) Protein quality evaluation. Joint FAO/WHO. 66.
10Pellett, PL (2004) The prediction and tabulation of countries where a significant proportion of the population may be at risk of lysine deficiency: International Nutrition Foundation.
11Pellett, PL (1996) World essential amino acid supply with special attention to South-East Asia. Food Nutr Bull 17, 3, 204234.
12Sasaki, S & Kesteloot, H (1992) Value of Food and Agriculture Organization data on food-balance sheets as a data source for dietary fat intake in epidemiologic studies. Am J Clin Nutr 56, 4, 716723.
13UNICEF (2005) State of the World's Children 2005. New York.
14(UNDP) UNDP, Human Development Report 2009 Overcoming barriers: Human mobility and development 2009: Available from:
15UNSTATS, 2010 [updated 2010; cited 2010]; Available from: = 562.
16USDA Nutrient Data : Home. = 12-35-45-00. Accessed November 1, 2009. 2009 [updated 2009; cited November 1, 2009]; Available from: = 12-35-45-00 .
17Young, V & Pellett, P (1994) Plant proteins in relation to human protein and amino acid nutrition. Am J Clin Nutr 59, 5, 1203S12012.
18Pellett, PL & Ghosh, S (2004) Lysine fortification: Past, present, and future. Food Nutr Bull 25, 2, 7.
19Ghosh, S, Pellett, PL, Aw-Hassan, A, et al. (2008) Impact of lysine-fortified wheat flour on morbidity and immunologic variables among members of rural families in northwest Syria. Food Nutr Bull 29, 3, 163171.
20Pellett, PL & Young, VR (1988) The contribution of livestock products to human dietary needs with special reference to West Asia and North Africa. In Increasing Small Ruminant Productivity in Semi-Arid Areas, [, editor]. Dortrecht, The Netherlands: Kluwer Academic Publishers for ICARDA, Aleppo, Syria.
21Young, V, Bier, D & Pellett, P (1989) A theoretical basis for increasing current estimates of the amino acid requirements in adult man, with experimental support. Am J Clin Nutr 50, 1, 8092.
22Gabert, VM, Brunsgaard, G, Eggum, BO, et al. (1995) Protein quality and digestibility of new high-lysine barley varieties in growing rats. Plant Foods Hum Nutr 48, 2, 169179.
23UNU, WHO, FAO (2004) Human Energy Requirements: UNU/WHO/FAO; 2004.
24Wuehler, SE, Peerson, JM & Brown, KH (2005) Use of national food balance data to estimate the adequacy of zinc in national food supplies: methodology and regional estimates. Public Health Nutr 8, 7, 812819.
25Ghosh, S, Smriga, M, Vuvor, F, et al. (2010) Effect of lysine supplementation on health and morbidity in subjects belonging to poor peri-urban households in Accra, Ghana. Am J Clin Nutr 92, 928939.
26Black, RE, Allen, LH, Bhutta, ZA, et al. (2008) Maternal and child undernutrition: global and regional exposures and health consequences. Lancet 371, 9608, 243260.
27WHO (2008) The global burden of disease: 2004 update Geneva: World Health Organization.
28Mata, L (1983) Breast-feeding, Health, and Growth. In Diarrha and Malnutrition: Interactions, mechanisms and interventions, pp. 177202 [, editor]. New York: UNU Plenum Press.
29Mata, L (1995) The Santa Maria Cauque study: health and survival of Mayan Indians under deprivation, Guatemala. In Community-based longitudinal nutrition and health studies: Classical examples from Guatemala, Haiti and Mexico, [, editor]. Boston: International Foundation for Developing Countries.
30Victora, CG, Adair, L, Fall, C, et al. (2008) Maternal and child undernutrition: consequences for adult health and human capital. Lancet 371, 9609, 340351, PMCID: 2258311.
31Kurpad, AV, Regan, MM, Nazareth, D, et al. (2003) Intestinal parasites increase the dietary lysine requirement in chronically undernourished Indian men. Am J Clin Nutr 78, 6, 11451151.
32Kurpad, AV, Regan, MM, Raj, T, et al. (2003) Lysine requirements of chronically undernourished adult Indian men, measured by a 24-h indicator amino acid oxidation and balance technique. Am J Clin Nutr 77, 1, 101108.
33Black, RE, Brown, KH & Becker, S (1984) Malnutrition is a determining factor in diarrheal duration, but not incidence, among young children in a longitudinal study in rural Bangladesh. Am J Clin Nutr 39, 1, 8794.
34WHO (2007) Protein and Amino Acid Requirements in Human Nutrition. [WHO/FAO/UNU, editor]. Geneva: World Health Organization.
35van Vught, AJ, Heitmann, BL, Nieuwenhuizen, AG, et al. (2010) Association between intake of dietary protein and 3-year-change in body growth among normal and overweight 6-year-old boys and girls (CoSCIS). Public Health Nutr 13, 647653.
36Smith, WJ, Underwood, LE & Clemmons, DR (1995) Effects of caloric or protein restriction on insulin-like growth factor-I (IGF-I) and IGF-binding proteins in children and adults. J Clin Endocrinol Metab 80, 2, 443449.
37Matsukawa, T, Inoue, Y, Oishi, Y, et al. (2001) Up-Regulation of Upstream Stimulatory Factors by Protein Malnutrition and Its Possible Role in Regulation of the IGF-Binding Protein-1 Gene. Endocrinology 142, 11, 46434651.
38Takenaka, A, Oki, N, Takahashi, S-I, et al. (2000) Dietary Restriction of Single Essential Amino Acids Reduces Plasma Insulin-Like Growth Factor-I (IGF-I) but Does Not Affect Plasma IGF-Binding Protein-1 in Rats. J Nutr 130, 12, 29102914.
39Katsumata, M, Kawakami, S, Kaji, Y, et al. (2002) Differential Regulation of Porcine Hepatic IGF-I mRNA Expression and Plasma IGF-I Concentration by a Low Lysine Diet. J Nutr 132, 4, 688692.
40Ferreira, F, Barbosa, HCL, Stoppiglia, LF, et al. (2004) Decreased Insulin Secretion in Islets from Rats Fed a Low Protein Diet Is Associated with a Reduced PKA{alpha} Expression. J Nutr 134, 1, 6367.
41Hoppe, C, Molgaard, C, Juul, A, et al. (2004) High intakes of skimmed milk, but not meat, increase serum IGF-I and IGFBP-3 in eight-year-old boys. Eur J Clin Nutr 58, 9, 12111216.
42Larnkjaer, A, Hoppe, C, Molgaard, C, et al. (2009) The effects of whole milk and infant formula on growth and IGF-I in late infancy. Eur J Clin Nutr 63, 8, 956963.
43van Vught, AJAH, Heitmann, BL, Nieuwenhuizen, AG, et al. (2009) Association between dietary protein and change in body composition among children (EYHS). Clin Nutr 28, 6, 684688.
44S Ghosh, D Suri and F Vuvoret al.(editors) Dietary protein quality is associated with risk of being stunted in peri-urban children in Greater Accra. 2nd World Public Health Congress on Nutrition; 2010; Porto, Portugal.
45Uauy, R & Kain, J (2002) The epidemiological transition: need to incorporate obesity prevention into nutrition programmes. Public Health Nutr 5, 1a, 223229.
46van Vught, AJAH, Nieuwenhuizen, AG, Brummer, R-JM, et al. (2008) Effects of Oral Ingestion of Amino Acids and Proteins on the Somatotropic Axis. J Clin Endocrinol Metab 93, 2, 584590.
47Thissen, J, Pucilowska, J & Underwood, L (1994) Differential regulation of insulin-like growth factor I (IGF-I) and IGF binding protein-1 messenger ribonucleic acids by amino acid availability and growth hormone in rat hepatocyte primary culture. Endocrinology 134, 3, 15701576.
48Jousse, C, Bruhat, A, Ferrara, M, et al. (1998) Physiological concentration of amino acids regulates insulin-like-growth-factor-binding protein 1 expression. Biochem J 334, 1, 147153.
49Pao, C, Farmer, P, Begovic, S, et al. (1993) Regulation of insulin-like growth factor-I (IGF-I) and IGF-binding protein 1 gene transcription by hormones and provision of amino acids in rat hepatocytes. Mol Endocrinol 7, 12, 15611568.
50Straus, D, Burke, E & Marten, N (1993) Induction of insulin-like growth factor binding protein-1 gene expression in liver of protein-restricted rats and in rat hepatoma cells limited for a single amino acid. Endocrinology 132, 3, 10901100.
51van Vught, AJAH, Nieuwenhuizen, AG, Brummer, R-JM, et al. (2008) Somatotropic responses to soya protein alone and as part of a meal. Eur J Endocrinol 159, 1, 1518.
52Van Vught, AJAH, Nieuwenhuizen, AG, Veldhorst, MAB, et al. (2009) Growth hormone responses to ingestion of soyprotein with or without fat and/or carbohydrate in humans. E Spen Eur E J Clin Nutr Metab 4, 5, e239e244.
53Zulfiqar, AB, Tahmeed, A, Robert, EB, et al. (2008) What works? Interventions for maternal and child undernutrition and survival. Lancet 371, 9610, 417440.



Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed