The WHO/FAO/UNU (2007) report examines dietary protein and amino acid requirements for all age groups, protein requirements during pregnancy, lactation and catch-up growth in children, the implications of these requirements for developing countries and protein quality evaluation. Requirements were defined as the minimum dietary intake which satisfies the metabolic demand and achieves nitrogen equilibrium and maintenance of the body protein mass, plus the needs for growth in children and pregnancy and lactation in healthy women. Insufficient evidence was identified to enable recommendations for specific health outcomes. A meta analysis of nitrogen balance studies identifies protein requirements for adults 10 % higher than previous values with no influence of gender or age, consistent with a subsequently published comprehensive study. A new factorial model for infants and children, validated on the basis of the adequacy of breast milk protein intakes and involving a lower maintenance requirement value, no provision for saltatory growth and new estimates of protein deposition identifies lower protein requirements than in previous reports. Higher values for adult amino acid requirements, derived from a re-evaluation of nitrogen balance studies and new stable isotope studies, identify some cereal-based diets as being inadequate for lysine. The main outstanding issues relate to the biological implausibility of the very low efficiencies of protein utilisation used in the factorial models for protein requirements for all population groups especially pregnancy when requirements may be overestimated. Also considerable uncertainty remains about the design and interpretation of most of the studies used to identify amino acid requirement values.

During the past 25 years a significant amount of research has been conducted to determine amino acid requirements in humans. This is primarily due to advancements in the application of stable isotopes to examine amino acid requirements. The indicator amino acid oxidation (IAAO) method has emerged as a robust and minimally invasive technique to identify requirements. The IAAO method is based on the concept that when one indispensable dietary amino acid (IDAA) is deficient for protein synthesis, then the excess of all other IDAA, including the indicator amino acid, will be oxidized. With increasing intakes of the limiting amino acid, IAAO will decrease, reflecting increasing incorporation into protein. Once the requirement for the limiting amino acid is met there will be no further change in the indicator oxidation. The IAAO method has been systematically applied to determine most IDAA requirements in adults. The estimates are comparable to the values obtained using the more elaborate 24h-indicator amino acid oxidation and balance (24h-IAAO/IAAB) model. Due to its non-invasive nature the IAAO method has also been used to determine requirements for amino acids in neonates, children and in disease. The IAAO model has recently been applied to determine total protein requirements in humans. The IAAO method is rapid, reliable and has been used to determine amino acid requirements in different species, across the life cycle and in disease. The recent application of IAAO to determine protein requirements in humans is novel and has significant implications for dietary protein intake recommendations globally.

The 1985 FAO/WHO/UNU protein report defined reference amino acid patterns for infants based on breast milk and for preschool children, schoolchildren and adults from age specific estimates of dietary indispensible amino acid requirements divided by the safe protein requirement for each age group. This report argued that the protein quality of a diet should be estimated from its digestibility adjusted by its amino acid score calculated from its limiting amino acid in comparison with the reference amino acid pattern. Subsequently a joint FAO/WHO expert consultation on protein quality evaluation (1991) endorsed this protein digestibility-corrected score approach. However it rejected the adult scoring pattern identified in the 1985 report arguing that the amino acid values for this pattern were too low. As an interim measure it suggested that the scoring pattern for preschool children should be used for all age groups apart from infants. The recent WHO/FAO/UNU (2007) report endorsed the 1985 report in recommending the amino acid content of breast milk as the best estimate of infant amino acid requirements. However it was only able to identify reliable requirement values for adults and adopted a factorial approach to derivation of age-related scoring patterns. This utilized the adult pattern for maintenance, and the pattern of human tissue protein for growth. Thus scoring patterns were derived for children aged 0·5, 1–2, 3–10, 11–14, 15–18 years and for adults. The total dietary amino acid requirements calculated for these age groups were divided by the mean protein requirement to give the scoring pattern which should be used to adjust digestible intakes to identify the available protein in specific diets. However because the adult values were determined in subjects at protein intakes much higher than the mean minimum protein requirement, i.e. at 1 g/kg/d rather than 0·66 g/kg/d, the pattern is likely to include higher values than the minimum requirement and should therefore be referenced against the safe allowance.

The factorial approach is used to measure the dietary indispensable amino acid (IAA) requirements in children, although recent measurements based on the indicator amino acid oxidation (IAAO) method have begun to generate more direct evidence. Difficulties with the factorial method are that it depends on accurate estimates of the maintenance protein requirement, as well as of protein deposition during growth. Also, a value for the efficiency of utilizing dietary protein for deposition has to be selected, based on published Nitrogen (N) balance studies. In the recent 2007 WHO/FAO/UNU report, the amino acid requirement pattern for infants was taken to be similar to the amino acid composition of breast milk. For pre-school and older children, the factorial method gave values for the scoring pattern of protein that were fairly close to the earlier 1985 WHO/FAO/UNU report for children, since growth progressively became a smaller component of the factorial calculation as age progressed. However, given that there are several assumptions in the derivation of factorial estimates, direct experimental measurements of the amino acid requirement are desirable. The IAAO method, as it is non-invasive, as made it possible to measure the IAA requirements in children. Over the last decade, some of the IAA requirements have been determined by using the IAAO method in healthy school age children; however, the data on IAA requirements in developing country populations are still being conducted. In the elderly, there are not enough data to make a separate recommendation for IAA requirements from that of adults.

Indian diets derive almost 60 % of their protein from cereals with relatively low digestibility and quality. There have been several surveys of diets and protein intakes in India by the National Nutrition Monitoring Board (NNMB) over the last 25 years, in urban and rural, as well as in slum dwellers and tribal populations. Data of disadvantaged populations from slums, tribals and sedentary rural Indian populations show that the protein intake (mainly from cereals) is about 1 gm/kg/day. However, the protein intake looks less promising in terms of the protein digestibility corrected amino acid score (PDCAAS), using lysine as the first limiting amino acid, where all populations, particularly rural and tribal, appear to have an inadequate quality to their protein intake. The protein: energy (PE) ratio is a measure of dietary quality, and has been used in the 2007 WHO/FAO/UNU report to define reference requirement values with which the adequacy of diets can be evaluated in terms of a protein quality corrected PE ratio. It is likely that about one third of this sedentary rural population is at risk of not meeting their requirements. These levels of risk of deficiency are in a population with relatively low BMI populations, whose diets are also inadequate in fruits and vegetables. Therefore, while the burden of enhancing the quality of protein intake in rural India exists, the quality of the diet, in general, represents a challenge that must be met.

Cereals and legumes are staple foods in India and are limiting in lysine and sulphur amino acids, respectively. Available lysine loss, due to Maillard-type reactions that may occur during food preparation, exacerbates the problem of lysine deficiency particularly in cereals. Consequently, determining the contents of digestible essential amino acids, particularly lysine, is important. True ileal digestibilities of most amino acids (including total and reactive lysine) were determined for ten food ingredients and eleven foods commonly consumed in India. Semi-synthetic diets each containing either an ingredient or the prepared food as the sole protein source were formulated to contain 100 g kg− 1 protein (75 g kg− 1 for rice-based diets) and fed to growing rats. Titanium dioxide was included as an indigestible marker. Digesta were collected and the amino acid content (including reactive lysine) of diets and ileal digesta determined. Available (digestible reactive) lysine content ranged from 1·9–15·4 g kg− 1 and 1·8–12·7 g kg− 1 across the ingredients and prepared foods respectively. True ileal amino acid digestibility varied widely both across ingredients and prepared foods for each amino acid (on average 60–92 %) and across amino acids within each ingredient and prepared food (overall digestibility 31–96 %). Amino acid digestibility was low for many of the ingredients and prepared foods and consequently digestibility must be considered when assessing the protein quality of poorer quality foods. Given commonly encountered daily energy intakes for members of the Indian population, it is estimated that lysine is limiting for adults in many Indian diets.

The WHO (2007) Technical Report on protein and amino acid requirements in human nutrition states that the best estimate for a population average requirement is 105 mg nitrogen/kg body weight per day, or 0·66 g protein/kg body weight per day. In many developing countries protein intake falls significantly short of these values. Apart from protein quantity, protein quality including bioavailability and digestibility, from different food sources, are currently on the global agenda. The 1st International Symposium on Dietary Protein for Human Health held in Auckland, in March 2011, and the consecutive Food and Agricultural Organization of the United Nations (FAO) Expert Consultation on Dietary Protein Quality, both highlighted the importance of assessing the quality of protein from different food sources through determination of amino acid content. Throughout the developed world, animal products and cereals are the two most important sources of protein; in developing countries this order is reversed. In low income countries only 3 % of total dietary energy, as an indicator of diet composition, is derived from meat and offal, 11 % from roots and tubers and 6 % from pulses, nuts and oilseeds. The remainder of the dietary energy is mainly derived from cereal-based staple food. Although the production of livestock has increased in developing countries, the consumption of protein in these countries with people consuming the most limited amounts of protein are continually decreasing. Undernutrition, including insufficient consumption of protein, remains a persistent problem in the developing world, and although many diets within these developing countries are deficient in the quantity of protein compared to recommendations, the quality of the protein also strongly comes into focus.

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.

The determination of whether increased dietary protein can positively affect health outcomes is hindered by the absence of prospective, randomized trials directly addressing this issue in which all pertinent variables are controlled. Consequently, we can only address the question deductively by considering the support for the rationale underlying the notion of a beneficial effect of increased dietary protein intake. With regard to health outcomes, we have focused on older individuals. Muscle mass and function are progressively lost with aging, so that by the age of 60 many individuals have reached a threshold where function begins to be affected. An association between reduced muscle mass and strength and unfavourable health outcomes is more likely to be revealed in individuals who have significant decrements in muscle mass and strength. In this article support for the rationale underlying the notion of a beneficial effect of increased dietary protein intake is considered. Dietary protein intake, and the resulting increased availability of plasma amino acids, stimulates muscle protein synthesis. If all other variables are controlled, increased muscle protein synthesis leads to improved muscle mass, strength and function over time. Increased muscle mass, strength and function are related to improved health outcomes in older individuals. Since adverse effects of reasonable increases in protein intake above the recommended dietary allowance (RDA) of 0·8 g protein/kg/day have not been reported, it is reasonable to conclude that the optimal protein intake for an older individual is greater than the RDA.

Recent advances in elucidating the mechanisms that control body protein synthesis and degradation both expand and complicate our understanding of how these processes are regulated. This review presents an introduction to the multiple regulatory systems involved, emphasizing the number of potential controls. These include gene transcription, gene activation or suppression, activation or suppression of mRNA translation and activation or suppression of signaling pathways. The complexity of these interacting controls presents a challenge to our understanding of the overall coordinated regulation of protein synthesis and degradation and its response to any particular stimulus. Specific examples are used to illustrate regulatory mechanisms, including the ways in which protein metabolism is regulated by the amino acid leucine. In addition to regulation associated with gene expression and post-translational control, the expanding field of epigenetics adds another layer of complexity, including trans-generational responses to nutrient intake, highlighting the potential for long-term impact of nutritional experience on the metabolism of subsequent generations.

Obesity is a serious health problem because of its co-morbidities. The solution, implying weight loss and long-term weight maintenance, is conditional on: (i) sustained satiety despite negative energy balance, (ii) sustained basal energy expenditure despite BW loss due to (iii) a sparing of fat-free mass (FFM), being the main determinant of basal energy expenditure. Dietary protein has been shown to assist with meeting these conditions, since amino acids act on the relevant metabolic targets. This review deals with the effects of different protein diets during BW loss and BW maintenance thereafter. Potential risks of a high protein diet are dealt with. The required daily intake is 0·8–1·2 g/kg BW, implying sustaining the original absolute protein intake and carbohydrate and fat restriction during an energy-restricted diet. The intake of 1·2 g/kg BW is beneficial to body composition and improves blood pressure. A too low absolute protein content of the diet contributes to the risk of BW regain. The success of the so-called ‘low carb’ diet that is usually high in protein can be attributed to the relatively high-protein content per se and not to the relatively lower carbohydrate content. Metabolic syndrome parameters restore, mainly due to BW loss. With the indicated dosage, no kidney problems have been shown in healthy individuals. In conclusion, dietary protein contributes to the treatment of obesity and the metabolic syndrome, by acting on the relevant metabolic targets of satiety and energy expenditure in negative energy balance, thereby preventing a weight cycling effect.

For an adult in N balance, apart from small amounts of amino acids required for the synthesis of neurotransmitters, hormones, etc, an amount of amino acids almost equal to that absorbed from the diet can be considered to be “surplus” in that it will be catabolized. The higher diet-induced thermogenesis from protein than from carbohydrate or fat has generally been assumed to be due to increased protein synthesis, which is ATP expensive. To this must be added the ATP cost of protein catabolism through the ubiquitin-proteasome pathway. Amino acid catabolism will add to thermogenesis. Deamination results in net ATP formation except when serine and threonine deaminases are used, but there is the energy cost of synthesizing glutamine in extra-hepatic tissues. The synthesis of urea has a net cost of only 1·5 × ATP when the ATP yield from fumarate metabolism is offset against the ATP cost of the urea cycle, but this offset is thermogenic. In fasting and on a low carbohydrate diet as much of the amino acid carbon as possible will be used for gluconeogenesis – an ATP-expensive, and hence thermogenic, process. Complete oxidation of most amino acid carbon skeletons also involves a number of thermogenic steps in which ATP (or GTP) or reduced coenzymes are utilized. There are no such thermogenic steps in the metabolism of pyruvate, acetyl CoA or acetoacetate, but for amino acids that are metabolized by way of the citric acid cycle intermediates there is thermogenesis ranging from 1 up to 7 × ATP equivalent per mol.

Red meat intake has been frequently associated with the development of coronary artery disease and type 2 diabetes but vegetable protein has been associated with protection from these diseases. Whether this is related to the protein per se or to the increased polyunsaturated fat or higher fibre levels associated with more vegetarian diets is not clear.

High protein diets are associated with greater satiety and in some studies are associated with greater weight loss compared with high carbohydrate diets especially in an ad libitum design. These diets also lower plasma triglyceride and blood pressure and sometimes spare lean mass. There appear to be no harmful effects of high protein diets on bone density or renal function in weight loss studies.

Studies examining the health benefits of high-protein diets typical of most affluent and many developing countries are not consistent. Prospective epidemiological studies relating dietary protein to clinical and metabolic endpoints suggest increased weight gain and increased risk of diabetes amongst those with a high protein intake and an increased risk of cancer with high intakes of red meat, but lower blood pressure and possibly a reduced risk of heart disease with higher protein intakes. The potential for high-protein diets to confer greater benefit than other diets has been examined using ad libitum and energy restricted diets. Of greatest interest have been the comparisons between high-protein and high-carbohydrate diets. Many trials have reported greater weight loss especially in the context of ad libitum diets over the short-to medium-term, sparing of lean body mass, lowering of triglyceride levels, improved HDL: total cholesterol ratio and improved glycaemic control. Limited data regarding insulin sensitivity are less consistent. A major difficulty in interpreting the results of these studies is that carbohydrate quality has not been taken into account. Furthermore, longer term comparisons of weight reducing diets differing in macronutrient composition have reported similar outcomes, suggesting that compliance is a more important consideration. Nevertheless dietary patterns with high-protein intakes are appropriate for weight reduction and weight maintenance and may be useful for those who have high triglyceride levels and other features of the metabolic syndrome.

In a variety of chronic and acute disease states, alterations in protein synthesis, breakdown and protein turnover rates occur that are related to the loss of body protein and skeletal muscle wasting. A key observation is the stimulation of protein breakdown in muscle and the stimulation of protein synthesis in the splanchnic area; mainly liver. An altered splanchnic extraction of amino acids as well as an anabolic resistance to dietary protein, related to stress, disuse and aging play a key role in the pathogenesis of muscle wasting in these conditions. To overcome these factors, specific dietary protein and amino acid diets have been introduced. The main focus of these diets is the quantity and quality of dietary proteins and whether a balanced mixture or solely dietary essential amino acids are required with or without higher intake levels of specific amino acids. Specifically in cancer patients, stimulated muscle protein synthesis has been obtained by increasing the amount of protein in a meal and by providing additional leucine. Also in other chronic diseases such as chronic obstructive pulmonary disease and cystic fibrosis, meals with specific dietary proteins and specific combinations of dietary essential amino acids are able to stimulate anabolism. In acute diseases, a special role for the amino acid arginine and its precursor citrulline as anabolic drivers has been observed. Thus, there is growing evidence that modifying the dietary amino acid composition of a meal will positively influence the net balance between muscle protein synthesis and breakdown, leading to muscle protein anabolism in a variety of chronic and acute disease states. Specific amino acids with anabolic potential are leucine, arginine and citrulline.

In addition to supplying essential nutrients, some food proteins can confer additional health benefits beyond nutrition. The presence of bioactive proteins and peptides in different foods is a factor not currently taken into consideration when assessing the dietary quality of food proteins. The range of described physiological benefits attributed to bioactive proteins and peptides is diverse. Multiple factors can potentially impact on the ability of a bioactive peptide or protein to elicit an effect. Although some food proteins act directly in their intact form to elicit their effects, generally it is peptides derived from digestion, hydrolysis or fermentation that are of most interest. The levels of bioactive peptides generated must be sufficient to elicit a response, but should not be so high as to be unsafe, thus causing negative effects. In addition, some peptides cause systemic effects and therefore must be absorbed, again in sufficient amounts to elicit their action. Many studies to date have been carried out in vitro; therefore it is important that further trials are conducted in vivo to assess efficacy, dose response and safety of the peptides, particularly if health related claims are to be made. Therefore, methods must be developed and standardised that enable the measurement of health benefits and also the level of bioactive peptides which are absorbed into the bloodstream. Once standardised, such methods may provide a new perspective and an additional mechanism for analysing protein quality which is currently not encompassed by the use of the protein digestibility-corrected amino acid score (PDCAAS).

Dietary guidelines from a variety of sources are generally congruent that an adequate dietary protein intake for persons over the age of 19 is between 0·8–0·9 g protein/kg body weight/d. According to the US/Canadian Dietary Reference Intakes, the RDA for protein of 0·8 g protein/kg/d is “…the average daily intake level that is sufficient to meet the nutrient requirement of nearly all [~98 %]… healthy individuals…” The panel also states that “…no additional dietary protein is suggested for healthy adults undertaking resistance or endurance exercise.” These recommendations are in contrast to recommendations from the US and Canadian Dietetic Association: “Protein recommendations for endurance and strength trained athletes range from 1·2 to 1·7 g/kg/d.” The disparity between those setting dietary protein requirements and those who might be considered to be making practical recommendations for athletes is substantial. This may reflect a situation where an adaptive advantage of protein intakes higher than recommended protein requirements exists. That population protein requirements are still based on nitrogen balance may also be a point of contention since achieving balanced nitrogen intake and excretion likely means little to an athlete who has the primary goal of exercise performance. The goal of the present review is to critically analyse evidence from both acute and chronic dietary protein-based studies in which athletic performance, or correlates thereof, have been measured. An attempt will be made to distinguish between protein requirements set by data from nitrogen balance studies, and a potential adaptive ‘advantage’ for athletes of dietary protein in excess of the RDA.

The subject of protein quality assessment of foods and diets was addressed at the Codex Committee on Vegetable Proteins (1982–1989), FAO/WHO (1989, 2001) and WHO/FAO (2002) expert reviews. These international developments are summarized in this manuscript. In 1989, a Joint FAO/WHO Expert Consultation on Protein Quality Evaluation reviewed knowledge of protein quality assessment of foods, and specifically evaluated amino acid score corrected for protein digestibility, the method recommended by the Codex Committee on Vegetable Proteins. The report of the Consultation published in 1991 concluded that the Protein Digestibility-corrected Amino Acid Score (PDCAAS) method was the most suitable approach for routine evaluation of protein quality for humans. The Consultation recognized that the amino acid scoring pattern proposed by FAO/WHO/UNU (1985) for preschool children was at that time the most suitable pattern for calculating PDCAAS for all ages except infants in which case the amino acid composition of human milk was recommended to be the basis of the scoring pattern. The rat balance method was considered as the most suitable practical method for predicting protein digestibility by humans. Since its adoption by FAO/WHO (1991), the PDCAAS method has been criticised for a number of reasons. The FAO/WHO (2001) Working Group on analytical issues related to protein quality assessed the validity of criticisms of the PDCAAS method. While recognizing a distinct regulatory use of protein quality data, the Working Group recommended that the PDCAAS method may be inappropriate for the routine prediction of protein quality of novel and sole source foods which contain high levels of anti nutritional factors; and that for regulatory purposes, the method should be revised to permit values of >100 for high quality proteins. In evaluating the recommendations of the Working Group, the WHO/FAO (2002) Expert Consultation on Protein and Amino Acid Requirements endorsed the PDCAAS method with minor modifications to the calculation method but also raised several issues. These included the calculation of scoring patterns; prediction of amino acid digestibility by faecal and ileal methods; reduced bioavailability of lysine in processed proteins; truncation of the amino acid score and consequent PDCAAS value; protein digestibility as a first limiting factor in determining the overall available dietary nitrogen; and the calculation of amino acid score for a dietary protein mixture. These concerns were considered particularly important in relation to the regulatory aspects of protein quality of foods, and their resolution was urgently recommended through a new separate expert review.

In 1989 the Joint FAO/WHO Expert Consultation on Protein Quality Evaluation recommended the use of the Protein Digestibility Corrected Amino Acid Score (PDCAAS) method for evaluating protein quality. In calculating PDCAAS, the limiting amino acid score (i.e., ratio of first limiting amino acid in a gram of target food to that in a reference protein or requirement) is multiplied by protein digestibility. The PDCAAS method has now been in use for 20 years. Research emerging during this time has provided useful data on various aspects of protein quality evaluation that has made a review of the current methods used in assessing protein quality necessary. This paper provides an overview of the use of the PDCAAS method as compared to other methods and addresses some of the key challenges that remain in regards to protein quality evaluation. Furthermore, specific factors influencing protein quality including the effects of processing conditions and preparation methods are presented. Protein quality evaluation methods and recommended protein intakes currently used in different countries vis-à-vis the WHO/FAO/UNU standards are further provided. As foods are frequently consumed in complement with other foods, the significance of the PDCAAS of single protein sources may not be evident, thus, protein quality of some key food groups and challenges surrounding the calculation of the amino acid score for dietary protein mixtures are further discussed. As results from new research emerge, recommendations may need to be updated or revised to maintain relevance of methods used in calculating protein quality.