Malnutrition and Protein:

Quality matters
Case study
 Protein module assignment
• Watch the video for the protein module;
• Read the article in canvas, “Diet Protein Quality and
Malnutrition in Africa” Br. J Ntrn. 108:869,2012
• Review the few background slides in this slide deck
• Respond to the questions in this slide deck via a word
document (or PDF) using full sentences.
• Submit via canvas.
Background: reminder of protein’s functions
 Background continued: Dietary Reference Intakes

• 16% of the weight of protein is nitrogen

• Therefore, nitrogen x 6.25 is the equation
used to convert from nitrogen content to
protein content;
• Also, note that carbohydrate and fats do not
contain nitrogen, only protein does;
• WHO protein recommendations are stated as
“nitrogen”, while in the US it’s as “protein”
 ..Two important key concepts….
Modern Nutrition in Health & Disease, 11 th edition

• 1- Dietary proteins that are eaten do NOT directly

become body proteins( ie, become muscle, etc)…
– Instead, dietary proteins consumed SUPPLY THE AMINO
ACIDS which are used for SYNTHESIS and the many
numerous other functions of protein in the body;

• 2- The human body does NOT store protein or

amino acids, so we do need a continual source. By
contrast, we do have the ability to store
carbohydrates and fats.
 Key concepts: factors dictating protein properly being used
to fulfill physiologic protein functions:
Modern Nutrition in Health and Disease, 11 th Edition

• When calorie and carbohydrate intake is sufficient,

then amino acids are used appropriately to meet the
various functions of protein;

• Factors that most influence the use of amino acids

for body fuel or energy as contrasted to properly
being used for the various protein functions include:
– Being in an energy deficit state
– Insufficient daily dietary carbohydrate
 Protein (or nitrogen) balance Modern Nutrition in Health & Disease, 11 th edition

Difference between rates of protein synthesis (PS) + breakdown (PB).

The goal during adulthood, (non-pregnant or body building) is balance

Positive Net Balance

+ PS > PB = retaining protein +
Needed for: growth, pregnancy,
recovery; *PS=retaining protein
(or nitrogen) in new tissue

Negative Net Balance

- PB > PS = protein loss -
In malnutrition, illness, injury
*increased breakdown to meet ↑
energy needs
 Evaluation of Protein Quality
• Two important aspects of evaluating protein quality
– Amino acid profile (compared to “ideal” pattern)
– Digestibility of the protein
• Plant proteins are often contained within cell walls that are resistant to human digestion,
limiting digestibility
• Some legumes have anti-nutritional factors such as trypsin that also limit digestibility

Source True Digestibility, %

Egg 97
Milk / cheese 95
Meat / fish 94
Soy flour 86
Whole wheat 85
Corn, whole 87
Oatmeal 86
Beans 78
American mixed diet 96

Abbreviations: FAO, Food and Agriculture Organization; WHO, World Health Organization.
Institute of Medicine. Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Fiber, Protein, and Amino
Acids. Washington, DC: National Academies Press, 2005, p. 683-689. 8
Report of the Joint FAO/WHO Expert Consultation. Protein quality evaluation. FAO Food and Nutrition Paper No 51. 1991.
 Protein Digestibility Corrected Amino Acid Score

• Protein digestibility corrected amino acid score (PDCAAS) is

the current “gold” standard by FAO/WHO for assessing
protein qualitymg of limiting AA in
1 g test protein
PDCAAS (%) True fecal digestibility (DF; %)
mg of same AA in
1 g of reference or
“ideal” protein

– DF = (NI – NFΔ) / NI where

• NI = nitrogen intake (g protein/6.25)
• NFΔ = fecal nitrogen on a diet containing the protein minus fecal nitrogen
on a protein-free diet (corrects for endogenous nitrogen)
• Complete proteins can often have PDCAAS values of ≥ 1.00
– Standard practice is to truncate values exceeding 1.00 to simply
Abbreviations:1.00
FAO, Food and agriculture Organization; WHO, world Health Organization.
Institute of Medicine. Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Fiber, protein, and Amino
Acids. Washington, DC: National Academies Press, 2005, p. 683-689. 9
Schaafsma G. J Nutr. 2000;130(7):1865S-1867S.
 Example of PDCAAS Calculation
• Identify the limiting AA (LAA) in a protein/ called the Amino Acid Score
mg / g Protein
Whole Wheat FNB/IOM
Amino Acid Flour Standard Ratio

Histidine 22 18 1.22
Isoleucine 40 25 1.6
Leucine 63 55 1.15
Lysine 26 51 0.51 (LAA)
Met + Cys 35 25 1.4
Phe + Tyr 81 47 1.72
Threonine 27 27 1.00
Tryptophan 11 7 1.57
Valine 43 32 1.34
FNB, Food
Institute and Nutrition
of Medicine. Board;
Dietary IOM, Institute
Reference of Medicine.
Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Fiber, protein, and Amino Acids.
10
Washington, DC: National Academies Press, 2005, p. 686-689.
 Example of PDCAAS Calculation (Cont’d)
• PDCAAS of whole wheat = ratio for lysine (LAA) x digestibility
– 0.51 × 0.85 = 0.433
– Therefore, whole wheat is an incomplete protein
and not suitable as a sole protein source in the
diet

• For the percent daily value (% DV) of protein on food labels, the
total protein content is first corrected using PDCAAS before a % DV
value is listed
– % DV = amount of nutrient in 1 serving (corrected) ⁄ DV for nutrient (50 g for
protein in adults)

US Food and Drug Administration. Food Labeling Guide Section 7. October 2009. Available at:
http://www.fda.gov/Food/GuidanceComplianceRegulatoryInformation/GuidanceDocuments/FoodLabelingNutrition/FoodLabelingGuide/ucm06 11
4894.htm.
Accessed July 20, 2011.
 PDCAAS of Protein Sources
Protein Source PDCAAS
Egg 1.0

Milk 1.0

Beef 0.92

Soy protein 1.0

Wheat 0.42

Whey protein 1.0

Casein 1.0

Peanuts 0.52

Black beans 0.75

Hoffman JR and Falvo MJ. J Sports Sci Med. 2004;3:118–130. 12

Schaafsma G. J Nutr. 2000;130(7):1865S-1867S.
 Protein quality and Malnutrition
Schonfeldt, 2012

In Africa, the population has an annual household income

that is lowest of all nations. In low income countries,
consumption of sufficient high quality protein remains a
high priority issue. Low income African countries generally
will have 3% of their total calorie intake from animal meats,
11% from root and tubers, 6% from beans and nuts and the
rest from cereal. Typically food intake consists of a white
maize porridge, brown bread, tea with milk and sugar.
About 16% of children are underweight and another 20%
have stunted growth.
 Protein quality and malnutrition
background continued

Many variables place additional demands on the body’s

requirement for nitrogen and hence, amino acids/protein.
Some of these factors include calorie deficit, infections, high
disease burden, and time of linear growth. WHO, (The
World Health Organization), recommends increasing daily
protein by 10% for each day of illness and another 10% per
day for an energy deficit*. The adult recommendation from
WHO is a daily intake of 105 mg nitrogen/ per kilogram of
body weight/day.
*Note: the term ‘energy deficit’ means that the individual
has metabolic needs for a certain amount of total daily
calories, but their dietary intake is less than these needs.
 Malnutrition and protein quality,
background continued
It is also known that to maintain nitrogen balance at a
lower intake level, (0.57g/kg), than WHO recommends, a 9-
20% HIGHER level of TOTAL CALORIC INTAKE is necessary.
When there are reductions in total caloric intake by 20%,
(from calorie recommendation levels), this energy deficit
will increase nitrogen requirement by ~ 50% .

Note: reminder: when an individual is in an energy deficit,

any protein consumed will be first used as an energy
source, rather than meeting protein functional needs. This
is the basis for needing increased amounts of total calories
and nitrogen.
Nitrogen balance means that protein consumed is equal to
protein lost, so the individual is in a state of nitrogen
balance. In healthy adults, the goal is to be in nitrogen
balance.
Data from 116 countries demonstrate that usable protein (vs total protein intake)
is a better indicator of protein inadequacy risk.
Pro availability independently (& negatively)is associated w. stunting
(p ≤ .001) Br. J. Nutr. 108:S77, 2012
• Thus, protein QUALITY not just quantity is a
significant factor in health outcomes globally.
 Are you a valuable member of an international health
care team? Can you answer these questions?

• You are on a global health mission acting as a

team member who is an expert in nutrition.
 Answer these questions:

• A: If African countries typically consume ~ 3% of their total

calorie intake from animal protein sources, why is this a
concern?
• B: What does the term, “usable” protein mean?
• C: What factors determine protein quality?
• D: How does the WHO recommendation for 105 milligrams
of nitrogen per kilogram of body weight compare to the DRI
recommendation of 0.8grams of protein per kilogram of
body weight?
• E. Show how you calculated your response to D above.
 Questions continued…

Question F background: you are told that two different

mixtures of various plant proteins (cereals such as maize,
ground nuts, & vegetables such as cassava) are being
considered as a supplemental protein provision for adults
who present to the ship for health care (global health
access via ship docking in various African ports).
As the nutrition expert, you are then asked to determine
which of the two protein supplements would provide the
highest quality protein for this very high
nutritional risk population.
 Question F continued

• F: protein A contains an equal amount of wheat and

corn, as the highest percentages of plant protein;
• Protein B contains an equal amount of corn and
beans, as the highest percentages of plant protein.
• How can you use this information to make this
decision?
• Explain the process of how you are deciding among
the two choices;
• Which of the two options would you select?
 Are you a valuable member of this health care
team?
• G: Final question: Aside from this assignment, the protein
module focused on the health benefits associated with
consumption of plant proteins. Yet, now in this assignment
we are highlighting the concerns with plant protein as the
main source of dietary protein. Why is this the case? What’s
the rationale for this difference? Explain the differences in
point of view regarding plant protein.