Nutrition folly #2: The world protein gap
- “Kwashiorkor is the most serious and widespread nutritional disorder known to medical and nutritional science.” (WHO/FAO, Kwashiorkor in Africa)
- “In many parts of the world the majority of children suffered some protein deficiency.” (Waterlow et al, 1960)
- “Every doctor, nutritionist or political leader concerned with the problem of world hunger has now concluded that the problem is one of protein malnutrition.” (Gounelle de Pontanel, 1972)
FACT: “The assumption that kwashiorkor was the world’s most common manifestation of severe malnutrition in children was largely based on 1952 survey results from parts of Africa where kwashiorkor was common. This limited survey was assumed to be typical of the whole world but that was certainly not the case in Asia for example where most of the world’s malnourished children were then located.” (Dr Geoffrey P Webb).
“The Great Protein Fiasco” is what this is now known as. Unless you’re of a certain vintage, you won’t be aware of this very embarrassing chapter in the history of nutrition. But, it’s worth remembering because you can hear its echoes in today’s dietary dogmas. I read Professor Donald McLaren’s Dogma Disputed: The Great Protein Fiasco 1974 as a young PhD student and learned early in my career the importance of heeding the lessons of the past.
The “protein gap” story begins in the 1930s, a time when scientists were making exciting discoveries about vitamins, minerals, amino acids and fatty acids and their critical roles in nutrition and health. In 1933, Dr Cicely Williams who was working in Africa in the Gold Coast (present day Ghana) published an article in Archives of Diseases in Childhood that described a deficiency disease caused by an unknown amino acid or protein deficiency that became known as kwashiorkor. She reported characteristic signs in the hair, skin and body that distinguished it from wasting from a deficiency of calories.
From the 1950s, experts working for WHO and FAO (organisations formed after the Second World War) decided that kwashiorkor was the “most serious and widespread nutritional disorder known to medical and nutritional science”. The United Nations Expert Committee on Nutrition of FAO/WHO convened the Protein Advisory Group in 1955, hoping to convince the UN that there was an impending protein crisis. Politicians and scientists were vocal on the importance of the issue.
Protein malnutrition became the definition and the cure was skim milk. Meanwhile, millions of other children suffered a “mere” wasting disease called marasmus that resulted from overall deficiency of calories rather than protein. However, many children had degrees of both kwashiorkor and marasmus and by the early 1960s, they were merged under the term protein-energy malnutrition. However, in practice, McLaren reminds us the emphasis was the protein gap and the need for more and better quality protein. FAO announced “the No 1 problem for national agricultural departments is the production of protein foods of good quality”.
The global food industry response was immediate. Novel sources of protein, such as fish meal and algal products, gluten and textured vegetable proteins (that were made to taste and look like meat) were formulated and sold or donated by high income countries to poorer developing countries. In the US, they produced corn-soy-milk and wheat-soy blends. Guatamala’s Incaparina became famous around the world and the Australian milk biscuit was born.
Some scientists were sceptics, but few were willing to ruin their academic reputations. They were afraid to say anything for fear of having their credibility questioned and financial support cut off. McLaren was brave, speaking out on the lack of scientific evidence to support the consensus opinion. His attempts to argue the case at meetings were deleted from reports he says.
But as McLaren points out, scientists bear a responsibility to ensure that both sides of the story are considered carefully because in this case the welfare of undernourished children was at stake. While it is common to see a cost-benefit analysis, a cost-detriment analysis was also needed. The negative aspects of a focus on the wrong target included the lack of progress that would have been made with better use of the same human and financial resources. The protein case was built on general ignorance of food composition and erroneous generalisations made from limited survey data from parts of Africa that was assumed to be typical of the whole world. It wasn’t.
So where do we stand today? In most instances, childhood malnutrition is the result of an energy deficit (not enough food) rather than a protein gap. If a child gets enough food, they will nearly always get an adequate amount of protein with a balanced pattern of amino acids. We also know that dietary factors are of secondary importance in childhood malnutrition – the primary causes are poverty, ignorance, poor housing, poor hygiene and lack of family planning.
When it comes to protein, nutrition scientists are still wondering what levels of protein intake are harmful and what the ideal ratio of plant to animal proteins is. In high income countries, most people eat more protein than is strictly needed, yet many scientists believe that more is better because protein is satiating and reduces the chance of excessive calorie intake.
As for child health pioneer Dr Cicely Williams, she played no part in the protein gap fiasco that followed her early findings. Indeed, on her 80th birthday she said she had been obliged to spend the last 20 years of her life trying to debunk kwashiorkor. She went on to lead an extraordinary life and her achievements are many.
Professor Jennie Brand-Miller (AM, PhD, FAIFST, FNSA, MAICD) is an internationally recognised authority on carbohydrates and the glycemic index with over 250 scientific publications. She holds a Personal Chair in Human Nutrition in the Boden Institute of Obesity, Nutrition, Exercise and Eating Disorders and Charles Perkins Centre at the University of Sydney. She is the co-author of many books for the consumer on the glycemic index and health.