Critical Reviews in Food Science and Nutrition

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Protein, lysine and vitamin D: critical role in

muscle and bone health

Renuka Aggarwal & Kiran Bains

To cite this article: Renuka Aggarwal & Kiran Bains (2020): Protein, lysine and vitamin D:
critical role in muscle and bone health , Critical Reviews in Food Science and Nutrition, DOI:
10.1080/10408398.2020.1855101

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Published online: 08 Dec 2020.

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CRITICAL REVIEWS IN FOOD SCIENCE AND NUTRITION
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Protein, lysine and vitamin D: critical role in muscle and bone health
Renuka Aggarwal and Kiran Bains
Department of Food and Nutrition, Punjab Agricultural University, Ludhiana, India

ABSTRACT KEYWORDS
Optimum body composition in terms of higher muscle and bone mass is crucial for balancing Bone mass; lysine; muscle
metabolic activities for sustainability of healthy human life. Individuals with lesser muscle mass mass; protein
respond poorly to stressed states such as traumatic injury, sepsis and advanced cancers. Most
common diseases like obesity, heart disease, cancer and diabetes can be prevented by muscle
mass modification. The nutrients like protein, lysine, calcium and vitamin D play a critical role in
the maintenance of muscle mass and bone health. Poor dietary protein quality owing to high
amounts of cereals and little animal foods have a marked negative impact on health in resource-
limited settings. Lysine intake in developing countries is low mainly due to lesser food intake, con-
sumption of cereals as staple diet and processing loss of lysine. Furthermore, lysine intakes have
been shown to be marginal in low socio-economic groups which are of even greater concern.
Cereal-based diets and cereal-based food subsidy programs offer low quality proteins and pose a
risk of quality protein deficiency. Diets lacking in vitamin D contribute to vitamin D deficiency
which is prevalent in epidemic proportions in large part of the world. Cereal-based vegetarian
diets are responsible for lesser bioaccessibility of calcium as well. For obtaining optimal health,
optimal muscle mass should be maintained at a younger age, which can be achieved by improv-
ing nutritional quality of diets. Dietary and medicinal supplementation of lysine, calcium and vita-
min D may improve the body composition of young adult women in the form of proportionally
more muscle mass, bone mass and lesser fat mass, which in turn, may prove helpful in improving
general well-being, physical fitness as well as preventing metabolic diseases in develop-
ing countries.

Introduction The sufficient grain production in the country led to the

initiation of various programs which could provide energy
India is a land of agriculture. It is the most important eco-
and protein in sufficient quantities to the population so as
nomic sector that provides one-third of the country’s gross
to combat malnutrition. These programs had much focus on
domestic product and has provided employment to nearly
providing required quantities of diet to the population
two-third of its population but the country continued to suf-
ignoring the quality of protein to fulfill the requirement of
fer a lot from food insecurity. In 1960s, population in devel-
oped nations outstripped food production, but India and all essential amino acids. Inspite of various programs which
other developing nations faced famine and lack of food are working in the country since many years, the number of
availability. Indian agriculture was largely dependent on rain malnourished individual’s in the country is rising. Many
and lack of good varieties always led to more inputs but other developing nations are also facing similar burden of
lesser yield and money. This situation increased number of malnutrition. The cereals offer poor quality proteins and
poor persons in the society and contributed to the problems raise a risk for quality protein deficiency. It has been found
of food insecurity and malnutrition. Massive shipments of that 4–26% population of various age groups belonging to
imported grain were the only means by which the continent rural or urban sectors in India, is at risk of quality protein
was averting famine. At that time, Dr. Swaminathan and Dr. deficiency (Minocha, Thomas, and Kurpad 2017).
Norman Borlaug worked to develop wheat varieties that For a healthy human, protein quality and quantity is vital
would yield higher levels of grain as well as develop stalk to maintain optimum muscle mass which in turn is respon-
structures strong enough to support the increased biomass. sible to keep various metabolic activities in balance for sus-
The scientists created agricultural awareness among the tainability of healthy human life. Muscles are the principal
farmers and provided practical experience of farming in reservoir of amino acids and play an important role in pro-
field. This step transformed India from a “food deficient” to tein metabolism of the body. They provide hepatic gluco-
food sufficient nation, raising the total crop yield of wheat neogenic precursors during the absence of gut amino acid
from 12 million tons to 23 million tons in four crop seasons absorption and help in the maintenance of protein synthesis
ended India’s reliance on grain imports (Quinn 2015). in vital bodily tissues and organs. As a result of changed

CONTACT Renuka Aggarwal renukaaggarwal@[Link] Department of Food and Nutrition, Punjab Agricultural University, Ludhiana 141004, Punjab, India.
ß 2020 Taylor & Francis Group, LLC
2 R. AGGARWAL AND K. BAINS

muscle metabolism, chronic diseases and many pathological function gets improved when the amino acids are taken in
conditions can be prevented (Wolfe 2006). Muscles play a larger amounts (Scognamiglio et al. 2004). The larger pro-
significant role in obesity. Resting energy expenditure is sig- tein intake than recommendations improve the metabolic
nificantly affected by muscle protein turnover which is function of muscles as more amino acids enhance mitochon-
stimulated as a result of substantially maintained muscle drial protein synthesis required for substrate metabolism as
mass (Paddon et al. 2004). Fat oxidation is the main source well as myofibrillar proteins synthesis (Bohe et al. 2003).
of energy for muscle protein turnover leading to maintained During the deficiency of specific amino acids, mammalian
energy balance, and thus, helps to prevent obesity target of rapamycin complex 1 (mTORC1) perceives it as
(Rasmussen and Wolfe 1999). amino acid deficiency, and therefore, suppresses cellular
The proportional reduction of muscles represents higher growth and protein and lipid synthesis (Laplante and
percentage of fat mass leading to higher amounts of plasma Sabatini 2012). Therefore, a diet should be rich in quality
free fatty acids (FFA). Greater amounts of plasma FFA is protein which provides all the indispensible amino acids
linked to insulin resistance and inhibits glucose oxidation (IAA) required for the metabolic function of the muscles.
and limit glucose uptake in the muscles. Therefore, insulin These amino acids cannot be produced in the body in the
resistance is found to be associated with triacylglycerol sufficient amounts and must be provided in the diet.
deposition in muscles (Goodpaster et al. 2003). Muscles also The IAAs include lysine, histidine, isoleucine, leucine,
possess a strong link with osteoporosis. Bone strength and valine, threonine, phenylalanine, methionine and trypto-
mass are increased through modeling and remodeling of phan. Intake of IAA stimulates the synthesis of muscle pro-
bone and the mechanical force on bone is the pre-requisite teins in the same way as it is stimulated by a combination
of these processes. Muscle contractions, body weight and of IAA and other dispensable amino acids (DAAs). When a
weight-bearing exercises are the major sources of mechanical person ingests IAA alone, for the synthesis of new protein,
force on bones (Frost 1997). In relation to the adult bone, it the DAAs that are required by the body can be synthesized
has been found that dietary proteins influence factor IGF-1 efficiently from reutilization of endogenous DAAs. The
which has a positive effect on bone formation and skeletal acute response of protein synthesis and breakdown and dose
development and plays a critical role similar to that of cal- of ingested IAAs are closely related to each other. During
cium and vitamin D in the prevention of osteoporosis and the low dietary doses of IAAs, the stimulation of muscle
maintaining bone health (Schurch et al. 1998). and synthesis of whole-body protein is linearly related to the
It has been found that at the age of 40 years, muscle mass increased availability of IAAs. When the dose of IAA is
degeneration begins at a rate of 8% per decade, and at the high, the body reaches at a plateaus of synthetic response,
age of 70 years, this loss increases to 15% per decade. There but there is continuously a gain in net protein balance, i.e.
are many reasons like age-related disease effects, decrease in synthesis minus breakdown, which ultimately subdues the
hormonal activity and motor unit remodeling for the decline protein breakdown. Therefore, a close and linear relation-
in muscle mass which lead to a decrease in the rate of pro- ship exists between the amounts of IAA in a single meal
tein synthesis as the age increases. The rate of protein syn- and between the net gains of body protein. Over the time,
thesis decreases by 38% in middle age (50 y) while it the effect of the intake of higher amounts of IAA on net
decreases to 55% with advanced age (70 y) as compared to gain of body protein reach a plateau as the protein break-
individuals of younger age, i.e. 20 y (Flakoll et al. 2004). down can be suppressed upto a certain extent. The point at
Along with this, it is also likely that poor-quality protein which body reaches a plateau in achieving net gain of body
intake in early life has a negative outcome in later life and is protein depends on a many factors, which includes total cal-
associated with sarcopenia. Sarcopenia is a loss of skeletal oric intake, the level of physical activity and genetic propen-
muscle mass and function that occurs with aging and lead sity for increasing muscle size (Wolfe et al. 2016). When an
to the development of frailty, an increased likelihood of falls increased amount of IAAs are taken at the plateau stage,
and impairment of the ability to perform activities of daily there is a higher synthesis of protein and the protein mass
living (Evans 1995). of the body is maintained with an increased rate of protein
Protein intake in the diet directly affects muscle mass as synthesis and a decreased rate of protein breakdown as com-
higher amounts of dietary protein leads to greater availabil- pared to the stage when there is lower intake of IAA. An
ity of plasma amino acids resulting in an increased protein increased rate of muscle protein turnover due to stimulated
synthesis (Motil et al. 1981). Synthesis of muscle protein is protein synthesis will and improve the muscle quality (Fitts,
stimulated in a dose-dependent way by the amino acids Ramatowski, and Peters 2007).
absorbed as a result of the digestion of proteins (Paddon Protein and amino acids increase muscle mass and apart
et al. 2004; Carroll et al. 2005). Myofibrillar proteins that are from muscle synthesis, also play a vital role in bone health,
older gets replaced with better functioning and new proteins body composition management, satiety, glucose homeostasis,
due to higher muscle protein turnover. It has been found gastrointestinal functions, cell signaling and bacterial flora of
that increased availability of amino acids in young healthy the intestine. Lysine is the first amino acid lacking in cereal-
adults who have been confined to bed and had no physical pulse diets, and therefore, may affect the protein quality of
activity showed an improvement in their muscle mass and the diets. Lysine performs several functions in the body.
strength (Paddon et al. 2004). It has been found that in free- Lysine is changed to acetyl CoA which is a crucial compo-
living elderly individuals, muscle strength and physical nent in energy production and metabolism of carbohydrates.
 CRITICAL REVIEWS IN FOOD SCIENCE AND NUTRITION 3

Lysine acts as the precursor of carnitine which supports the global level the quantity and quality of proteins should be
transportation of long chain fatty acids into the mitochon- sufficient and the diet must provide a balanced supply of
dria for the production of energy for various metabolic essential amino acids (Ritchie, Reay, and Higgins 2018).
functions. Transformation of lysine results in the biogenesis Lysine intake in developing nations is low mainly due to
of elastin and collagen. Lysine also plays a key role in the lesser food intake, consumption of cereals as staple diet and
maintenance of healthy bones by reducing the amount of processing loss of lysine. Furthermore, negligible lysine
urinary calcium and increasing its absorption. L-Lysine along intakes in low socio-economic group Indians need attention
with L-Arginine stimulate bone-forming cells activity and as they are much lower than the daily recommended lysine
increases collagen production. Lysine can help to contribute intake of 45 mg/g protein for healthy adults (FAO 2013). In
an increased bone strength, therefore, it may be associated developing countries like India, where dietary supply of
with protection against osteoporosis. It is further suggested essential amino acids is less, it is pertinent to correctly
that lysine is an anti-catabolic compound which enhances monitor the relationship between dietary requirements and
absorption of calcium in the intestine and also provide the supply of “available amino acids” as the deficiency of later is
renal protection for absorbed calcium. This combined effect likely to restrict the protein metabolism (Rowan et al. 1994).
may contribute to positive calcium balance and suggests Along with poor quality protein, Indian vegetarian diets lack
potential usefulness of lysine for both preventive and thera- in vitamin D. In Indian subcontinent, 70–100% of the gen-
peutic interventions in osteoporosis (Civitelli et al. 1992). It eral population is suffering from the deficiency of vitamin D
has the ability to induce strong inflammatory and immune (Ritu and Gupta 2014). Vitamin D plays a major role in cal-
responses, has role in augmented healing of all types of cium and phosphorous homeostasis and skeletal-musculo
wounds (both acute and chronic) and plays important role health and is needed for the muscle contraction, nerve con-
in inducing extensive angiogenic responses (Datta, Bhinge, duction, bone mineralization and general functioning in all
and Chandran 2001). cells of the body (Holick 2006). Vitamin D deficiency prob-
Vitamin D plays a major role in calcium and phosphor- ably plays a key role in higher prevalence of osteoporosis,
ous homeostasis and skeletal-musculo health and is needed
diabetes, cancer, cardiovascular diseases and many infec-
for the muscle contraction, nerve conduction, bone mineral-
tions. The research studies suggest that inadequacy of vita-
ization and general functioning in all cells of the body
min D can lead to sarcopenia in adults due to loss of
(Holick 2006). Vitamin D deficiency probably plays a key
muscle strength and muscle mass.
role in higher prevalence of osteoporosis, diabetes, cancer,
The dietary quality of cereal-based diets is under surveil-
cardio-vascular diseases and many infections. The research
lance as these are deficient in nutrients critical for maintain-
studies suggest that inadequacy of vitamin D can lead to sar-
ing optimum body composition. From the Indian viewpoint,
copenia in adults due to loss of muscle strength and
cereals contribute toward major part of protein intake in
muscle mass.
India. Almost 50–60% of protein intake in urban and rural
The clinical implications of calcium deficiency including
sectors is through cereals. Pulses provide 10% and 11% of
rickets, poor bone mass accrual as well as abnormal fetal
protein intake, while milk and other dairy products contrib-
programming during pregnancy, poor peak bone mass due
to poor accrual in childhood and adolescence, postmeno- ute 10% and 12% in rural and urban Indian diets, respect-
pausal osteoporosis and osteoporosis of the elderly were ively (NSSO 2014). The nutritional quality of pulses is
reported. Serum calcium is maintained within a narrow nor- affected due to the anti-nutrient content of some legumes
mal range, chiefly by resorption from the skeleton and alter- and pulses and increasing cost of legumes is another factor
ation of urinary calcium loss and absorption from gut. limiting its consumption. Conversely, production of milk
Absorption is dependent on vitamin D sufficiency, presence has been increased due to increased number of co-opera-
of calcium binders in diet such as phosphate, oxalate and tives. The available quantity of milk has doubled over the
phytate, age group and physiological state. A reappraisal of years but the availability of pulses has almost halved since
dietary calcium recommendations is necessary for develop- 1950–1951 in India.
ing nations as daily calcium intake both the reality and the The amino acids and lysine present in milk proteins are
recommendations are far lower than the Western data extremely digestible (Rutherfurd and Moughan 2005). Fat-
(Bhatia 2008). free fluid milk influences greater gain in muscle mass and
In populations having limited resources, more consump- considerable losses in fat mass (Josse et al. 2010).
tion of poor quality protein cereals and lesser amount of Furthermore, reductions in serum PTH and an increase in
animal foods give low quality dietary protein that has a serum 25 hydroxy vitamin D levels in milk was significantly
negative effect on muscle mass and ultimately health. Diets related to increased dietary calcium intakes and this may
in India are mainly cereal and pulse based and are rich in possess positive effect on bone turnover. Similarly, eggs are
anti-nutritional factors and insoluble fiber. These factors an inexpensive source of essential micronutrients and an
affect the protein digestibility (57–75%) and it is very low excellent source of high-quality protein (Miranda et al.
when compared with protein-based foods of North America, 2015). Consumption of omnivorous diets with a higher pro-
i.e. 88–94% (Gilani, Cockell, and Sepehr 2005). Cereals are tein intake achieved by consuming more eggs and dairy
limiting in lysine while sulfur containing amino acids are foods were effective to significantly increase the lean body
limiting in pulses. To meet the nutritional demands at the mass as reported by Iglay et al. (2009). Daily supply of
4 R. AGGARWAL AND K. BAINS

adequate dietary sources of vital nutrients hold significance had a %BF of 39%, which corresponded to a BMI of 29 for
in maintaining muscle and bone health. SA black women. Central fat mass was lower in black SA
than in European SA women. In NZ, Pacific women had the
highest total appendicular skeletal muscle mass (ASMM)
Body composition, bone health and dietary pattern and lowest central fat mass, whereas, Asian Indian women
among ethnic groups had the lowest ASMM and bone mineral content while had
Asian Indian phenotypes have high body fat with relatively highest central fat mass. The relationship between %BF and
less body mass index (BMI), less lean body mass and BMI varied with ethnicity and may be due to differences in
marked abdominal obesity. Multivariate analysis suggested muscularity and central fatness. Use of universal waist cut-
that the association between lean mass and fat mass was points or BMI may not be appropriate for comparison of
attributed to hereditary, dietary factors and physical activity obesity prevalent among differing ethnic groups, as these do
level (Visser et al. 2002). Schutz, Kyle, and Pichard (2002) not provide a consistent reflection of fat distribution and
studied healthy subjects from large Caucasian group and adiposity across ethnic groups. Bose et al. (2008) studied
determined the reference values of fat mass index (FMI) and body composition of two tribal populations of Keonjhar,
fat-free mass index (FFMI), as a function of age and gender Orissa, India. A total of 600 Savar (300 men and 300
and to develop percentile distribution for these two parame- women) and 409 (226 men and 183 women) Bathudi adults
ters. A total of 5635 apparently healthy adults from 24 to were studied. Both the tribes had similar height and there
98 y of age belonging to Caucasian population in were no significant ethnic differences in mean age in both
Switzerland (2986 men and 2649 women) participated in the sexes. Bathudis had lower mean values (except for FFM and
study. The median FFMI (18–34 y) were 15.4 kg/m2 in FFMI in men) of all anthropometric and body composition
young females and 18.9 kg/m2 in young males. A modest variables compared to Savars in both sexes.
increase in females and no difference with age in males was Yang et al. (2010) assessed the skeletal health status and
observed. The median FMI was 5.5 kg/m2 in females and relationship between bone mineral density and nutrient
4.0 kg/m2 in males. From young to elderly age categories, intake, estrogen level, menstrual status and other factors in
FMI progressively rose by an average of 62% in females and Chinese adolescent dancers. Seventy seven healthy controls
55% in males as compared to an increase in BMI of 19% and sixty dancers were measured for estrogen level, bone
and 9%, respectively. The study concluded that reference density and body composition. Nutrient intake, physical
intervals for FMI and FFMI could be of practical value for activity and menstrual status was assessed. The dancers
the clinical evaluation of a deficit in fat-free mass (FFM) under study had a significantly lower percentage of body fat
with or without excess fat mass (sarcopenic obesity) for a (25 vs. 34), lean BMI (18.3 kg/m2 vs. 21.7 kg/m2) and later
given age category, complementing the classical concept of age at menarche (14.0 y vs. 13.0 y). Estrogen level, daily cal-
BMI in a more qualitative manner. orie and fat intake in them were also lower than in the con-
Bakker et al. (2003) conducted a study to analyze the lon- trols. Nande, Hussain, and Vali (2009) conducted a study on
gitudinal relationship between body composition compo- housewives of 19 to 70 years of age belonging to minority
nents (total body weight, standing height, BMI, waist community in Maharastra, India and derived a direct posi-
circumference, hip circumference, waist to hip ratio, sum of tive correlation between BMR and BMI. The study showed
four skin folds, fat mass and FFM and lumbar bone mineral very strong positive relationship with FFM in overweight
density (LBMD) and lumbar bone mineral content (LBMC) and obese subjects while a medium positive relationships
in young adults over a 10-y period among 225 men and 241 was found with BF content. Both FM and FFM were signifi-
women at 27, 32 and/or 36 y of age. Total body weight, cant contributors to BMR. BMR related negatively with age
standing height and BMI also showed a significant positive and the age related decline in BMR was due to a reduction
univariate relationship with LBMD and LBMC in both sexes in FFM.
and fat mass only with female LBMD. There was 4–27% of The percent body fat of Indian children is significantly
the variation in bone mineral over this 10-y period as FFM higher than white UK children while their BMI, skin-fold
can be interpreted as a proxy for skeletal muscle mass. It thickness and waist circumference were significantly lower
was concluded that there is importance of muscle contrac- than their UK counterparts. Indian children had higher fast-
tions on bone to increase bone strength in young adults. ing glucose and insulin and were found to be more insulin
Rush et al. (2007) investigated body composition differen- resistant (Lakshmi et al. 2012). The study concluded that the
ces among five ethnic groups for the percent body fat (%BF) “thin–fat” phenotype observed in Indian children is also
and relationship between BMI. The sample comprised of apparent in pre-pubertal Indian children who have greater
721 healthy women of 18–60 years of age (BMI: adiposity than white UK children despite significantly lower
17.4–54.0 kg/m2) from South Africa (SA, 201 black, 94 BMIs. Indian children are more insulin resistant than white
European) and New Zealand (NZ, 173 European, 76 Maori, UK children even after adjustment for adiposity. Kumar
84 Pacific, 93 Asian Indian). Regression analysis revealed et al. (2013) studied 371 adults (60.6% males) having a
that for a BMI of 30 kg/m2 in NZ Europeans, equivalent to mean age of 58.2 ± 16.6 years. Out of all the subjects, 5.4%
43% body fat, the corresponding BMIs for Asian Indian were East Asians, 24.8% South Asians, 29.4% African/Afro-
women, Pacific and NZ Maori were 26, 36 and 34 kg/m2, Caribbean and 38.5% Caucasoid. The diabetes was found in
respectively. At a BMI of 30 kg/m2, SA European women 29.1% of the subjects. The measurements of body
 CRITICAL REVIEWS IN FOOD SCIENCE AND NUTRITION 5

composition parameters showed that the muscle mass was with aging and further the phenomenon is attenuated
reduced while body fat was greater among South Asian dia- in women.
betic women than others. BMI and percentage of body fat of Eight studies were identified to explore dietary patterns and
Indian and German children and adolescents showed that relationship with diet-related non-communicable diseases
German children were taller, whereas, Indians showed (NCD) in India by Green et al. (2016). It was observed that most
higher values of BMI and percent body fat. Indian children of the populations were vegetarians with a preponderance of
had significantly higher percent of body fat between cereals, pulses, fruits and vegetables. The dietary patterns
10–15 years in boys and 8–16 years in girls as observed included high-sugar and high-fat foods as well as more of meat
(Jenewa et al. 2014). and its products. The dietary patterns varied largely between dif-
Marwaha et al. (2014) assessed lean muscle mass (LMM) ferent regions and the evidences showed a change in dietary pat-
in 1045 healthy Indian women. Mean appendicular lean terns over the time but there was no evidence showing difference
mass increased from the second decade to reach maximum in dietary patterns based on age and sex. The populations con-
in the fourth decade. Post-menopausal females with lesser suming high fat diets were at a greater risk of having higher BMI
LMM were significantly older, leaner and had lower bone and the populations consuming diets high in snacks and sweets
mineral density (BMD). Lean mass was negatively correlated were associated with more risk of diabetes as compared to the
with age and positively with BMI and BMD at all sites. Peak traditional diets rich in pulses and rice.
muscle mass among Indian females is achieved in the fourth The leading indicator of bone health among 190 partici-
decade and they have lower total and regional lean mass pants in the age category of 18–80 years was identified by
than other ethnic groups. In a study on 152 sedentary adult Tomlinson et al. (2019). Bone mineral density (BMD) and its
Indian women, a gradual increase in anthropometric and content (BMC) were assessed in thoracic (upper and lower),
body composition parameters such as weight, waist circum- appendicular and lumbar pelvic areas by dual energy X-ray
ference, hip circumference, BMI, fat mass and visceral fat absorptiometry. The diets were assessed using three day food
rating and a decrease in lean body mass with the advance- diary. The multiplex luminometry was used to assess endo-
ment of age was reported by Kaur et al. (2012). It was rec- crine profile while Baecke questionnaire was used to assess the
ommended that a diet with higher protein and lesser fat physical activity among the subjects. Fat Mass Index (FMI)
combined with exercise can help in sustaining optimum was related with 14 outcome measures and adiposity only
body composition. Singh et al. (2015) analyzed the variation modulated nine out of 22 BMD and BMC related outcome
in anthropometric dimensions and body composition measures while obesity which was assessed using BMI classifi-
parameters of working women employees of different Indian cation had positively affected 20 out of 22 BMD and BMC
geographical zones and observed that all anthropometric related outcome measures. BMD was also found to be associ-
parameters and body composition were significantly ated with protein intake. The BMI, sport-based physical activ-
(p < .001) different but fat free mass did not differ signifi- ity and daily energy intake were positively related with 7 out
cantly. The study concluded that diet, environmental condi- of 10 BMD sites with age while percent body fat was shown to
tions and living style of different regions can influence the be negative indicator of bone characteristics. Hence, BMI is a
anthropometry and body composition of women. good indicator of bone characteristics and high percent body
Malik et al. (2016) conducted a study on 140 Indian stu- fat must also be the focus of osteoporosis risk with ageing.
dents from Delhi, India who were in the age group High BMI in combination with moderate to vigorous activity
17–21 years and measured their body parameters as indica- supplemented with an ideal diet (quantity and quality) are
tive of their general health. Their BMI, total body fat, vis- identified as positive regulators of bone heath.
ceral fat, subcutaneous fat and skeletal muscle were recorded The girls in the age group of 11- and 12-year old from a
and analyzed. The sample population was primarily healthy peri-urban area in South Africa exceeded the boys of same
and consisted majorly of female participants, i.e. 57.1%. A age in BMI and body composition, i.e. body fat mass and
larger population of females (17.5%) was found to be over- lean fat mass has been reported by Fourie, Gericke, and
weight or obese according to BMI when compared with Kruger (2019). BMD and BMC were found to be nonsignifi-
males (10%). A strong and significant positive correlation cantly higher in girls as compared to the boys. The study
was obtained between BMI and visceral fat deposits, total reported 25(OH)D3 values lower than the reference range
body fat and subcutaneous fat of subjects under study. values. The results on dietary intake showed that the chil-
However, a negative correlation was obtained for BMI and dren had a sufficient intake of macronutrients, but vitamin
skeletal muscle of the individuals. Other body composition D calcium and phosphate was deficient in the diets. The
parameters like visceral fat had been found to be good study stressed a concern for vitamin D and calcium intake
markers of predisposition of the individual to various meta- among the children. The study observed no significant rela-
bolic disorders like coronary heart disease, diabetes mellitus, tionships or differences in the vitamin D status and bone
pulmonary problems and dyslipidemia. High subcutaneous measurements between the girls and boys.
fat levels, however, had been correlated with insulin resist-
ance. In a study by He et al. (2018), the body composition
Protein and lysine content of diets
was evaluated to investigate age and sex-related differences
in 3451 healthy Chinese subjects. The results revealed that Leinonen et al. (2019) compared different plant-based pro-
there is a decrease in FFM and increase in percent body fat tein sources (including cereals and pulses) and the protein
6 R. AGGARWAL AND K. BAINS

intake which were determined by the limiting amino acids among undernourished children suffering from intestinal
and found that to fulfill the minimum amount of lysine parasite infestations decreased from 42.8 mg/kg/day to
from cereals, the required total protein intake should be 35.5 mg/kg/day after providing successful anti parasitic treat-
higher than the daily recommended intake. So, taking cere- ment. The study suggested that intestinal parasitic infest-
als as the main source of lysine will lead to excess of daily ation increased the lysine requirement by 20% and the
energy intake, and deficient of lysine and supplementing the requirement of lysine in undernourished children was found
diet with other food items which are rich in nutrients that to be similar to that of well-nourished children.
are not available from cereals will be difficult. A negative Cereal-based Indian diets provide 60% of the protein and
correlation exists between the proportion of the protein and the protein is low in quality and digestibility as reported by
lysine supply obtained from cereals because of two reasons. Swaminathan, Vaz, and Kurpad (2012). The data of the
First, in low income countries with an overall limited pro- communities belonging to slums, tribes and rural Indian
tein supply, the low cost protein sources like cereals are the population doing sedentary work showed that the protein
only alternative. Second, cereals have low concentrations of intake particularly from cereals is about 1 g/kg/day and tribal
lysine and depending upon it for protein intake would make and rural groups appear to have an inadequate protein qual-
it very difficult to attain the recommended daily intake of ity with respect to their protein intake. It is assumed that
lysine. In consequence, in countries with very high percent- this sedentary rural population is at risk of not meeting their
age of cereal-based protein contribution, the average per protein requirements. The risk of deficiency is higher in the
person lysine intake is proceeding toward the limit of lysine populations with relatively low BMI. Hence, in rural India,
deficiency. In these countries, there is a great possibility that the burden of improving the quality of protein intake exists
a greater part of the population especially the growing chil- and the quality of the diet indicates a challenge that should
dren are taking diet that does not supply enough lysine be met. Minocha, Thomas, and Kurpad (2017) reported that
(Moya 2016). the Indian population belonging to different age groups and
Out of the total consumption of protein throughout the residing in urban or rural sector is at risk of quality protein
world, 60% is dependent on plant-based protein while ani- deficiency. The consumption of high-quality protein foods
mal protein contributes to only 40% of the total protein like milk and pulses can help in alleviating these risks. Also,
intake. (Boland et al. 2013; FAOSTAT 2018). Therefore, the the cereal-based food subsidy policies should move their
quality protein intake largely depends on the animal-based focus toward distribution of quality foods to the population.
lysine. Moreover, the ongoing, total worldwide production Ghosh, Suri, and Uauy (2012) reported that 50% women,
of lysine from land animals is of a similar extent to the total 30% men and 15% children in Ghana were at risk of lysine
demand of lysine from the global population. inadequacy. It was suggested that for improving the nutri-
The staple diets in most of the developing countries tional status of populations in developing countries, lysine
include cereals as well as pulses. Cereals are limiting in could be a useful nutritional intervention. Further, a study
lysine while pulses lack in sulfur amino acids. During food was conducted to evaluate the protein quality and nutri-
preparation, the Maillard-type reactions occur resulting in tional content of cereal-legume blends of Ghana for comple-
loss of available lysine manifesting the problem of lysine mentary foods. The protein quality of nine different cereal-
deficiency especially among cereals. Therefore, estimating legume combinations was evaluated using protein digestibil-
the quantity of digestible essential amino acids, especially ity corrected amino acid score (PDCAAS). It was found that
lysine, is essential. True ileal digestibility of most amino cereal-legume blends made with cowpeas or peanut were
acids including reactive and total lysine were determined for low in quality protein. Moreover, the locally available ingre-
eleven foods and ten food ingredients commonly consumed dients when used for preparing traditional cereal-legume
in India (Rutherfurd, Bains, and Moughan 2012). Available blends did not meet the complementary food recommenda-
(digestible reactive) lysine content ranged from 1.8 to 12.7 g/ tions for energy, quality protein and fat. In all blends, lysine
100 g and 1.9–15.4 g/100 g among the prepared foods and was the most limiting amino acid (PDCAAS 0.50 to 0.82).
ingredients, respectively. True ileal amino acid digestibility Further, addition of lysine increased utilizable protein by 1%
varied widely between prepared foods and the ingredients to 10% in soybean blends, 35% to 40% in peanut blends and
for each amino acid (on average 60–92%) and across amino 14% to 24% in cowpea blends (Suri, Debrah, and
acids within each ingredient and prepared food (overall Ghosh 2014).
digestibility 31–96%). Amino acid digestibility was low for Etzel (2004) reported that bioactive components in dairy
majority of the prepared foods and ingredients and therefore products such as branched-chain amino acids in whey pro-
digestibility should be considered when estimating the qual- tein might be responsible for the positive effects on muscles.
ity of protein for poor quality foods. Considering the daily Hoppe et al. (2004) recommended that along with quantity,
energy intakes of Indian population, it is assumed that lysine the source of protein also has regulatory effect on body
is limiting for all adults in most of the Indian diets. growth as milk protein is strongly related with an increase
A mean lysine requirement of 30 mg/kg/day for healthy in height in comparison to vegetable protein or meat. It has
Indian adults, which is the same amount that was proposed an important role in factors such as serum insulin-like
previously for Western populations on the basis of measure- growth factor-I (sIGF-I) which is responsible for regulating
ments by an indicator amino acid balance technique was growth in height. It plays a significant role in regulation of
purposed by Kurpad et al. (2001). The requirement of lysine fat distribution and reduction in fat mass. The diets rich in
 CRITICAL REVIEWS IN FOOD SCIENCE AND NUTRITION 7

calcium increase fat metabolism and prevent fat gain, belonging to both sexes suffer from vitamin D deficiency.
thereby greatly stimulating the process of losing fat from the Recent data from Delhi and Lucknow on vitamin D status
body. The calcium provided from dairy foods exerts an even among pregnant women in all three trimesters, revealed
greater effect on body weight and fat loss. The dairy foods high prevalence (74% to 98%) of hypovitaminosis D
has the capability to increase FFM and decrease body fat [25(OH)D < 20 ng/dL], with mean values varying from 8.7
even without calorie restriction Zemel et al. (2004). to 14 ng/mL (Sachan et al. 2005).
In developing countries like India, due to widely prac- In another case, Harinarayan et al. (2007) studied the 25-
ticed vegetarianism, people consume lesser amounts of dairy hydroxy vitamin D [25(OH)D], parathyroid hormone, serum
and animal products (Richardson 1990). Phillips et al. calcium levels and dietary habits among Indian rural and
(2003) suggested that any improved nitrogen retention urban populations. The daily dietary calcium intake of both
observed with milk compared with soy consumption during the populations was low in comparison to the recommended
a resistance training protocol may reflect differences in the dietary allowances. Dietary calcium and phosphorous intakes
amino acid profile during delivery to peripheral tissues. were significantly higher in urban than rural adults. The
Rutherfurd and Moughan (2005) determined true ileal higher dietary phytate-to-calcium ratio was found in subjects
digestible reactive lysine, true ileal reactive lysine digestibility from rural areas than the urban area subjects. Similarly,
and reactive lysine contents in a variety of processed milk among the rural subjects, the 25(OH)D concentrations were
products. The growing rats were fed with semi-synthetic higher than the urban subjects. In the rural subjects,
diets including chromic oxide as an indigestible marker and 25(OH)D-deficient (20 ng/mL), insufficient (20–30 ng/mL)
having milk products as the only source of protein. The true and sufficient (30 ng/mL) levels were reported in 70%, 29%
ileal reactive lysine digestibility was highest in the UHT and 1% of the women and 44%, 39.5% and 16.5% of the
milk (100%) but it was found to be high (>91%) in all the men while among the urban subjects, the corresponding val-
milk products tested while the lowest value was found in the ues were 75%, 19% and 6% in women and 62%, 26% and
infant formulae (91% to 93%). The mean digestible total 12% in men, respectively. The study showed that lower
lysine content was significantly different from the available 25(OH)D concentrations and dietary calcium intakes were
lysine content for most of the products examined. They con- associated with deleterious effects on bone mineral
cluded that milk proteins are highly digestible source of homeostasis.
amino acids and lysine. The prevalence of biochemical hypovitaminosis D was
McGregor and Poppitt (2013) found that during energy- observed in 90.8% of healthy school girls of 6–18 years of
restricted weight loss, milk protein has the capability of age while clinical vitamin D deficiency was noted in 11.5%.
decreasing adiposity and developing changes in body com- A higher prevalence of vitamin D deficiency, i.e. 74–96%
position in terms of increase in lean body mass which may among evidently healthy Indians has also been reported by
indirectly improve metabolic health. Similarly, Bagatini et al. Marwaha et al. (2009). The prevalence of vitamin D levels
(2014) suggested that among elderly women of 80–92 years below 5 ng/mL was in 4.2%; 5–l0 ng/mL was in 25.2%;
of age having mean dairy intake of 2.8 servings/day, a posi- 10–20 ng/mL was in 55.4% and above 20 ng/mL was in
tive association exists between their dairy intake, muscle 15.1% of the studied group. This study showed that despite
mass and appendicular bone mineralization. adequate sun exposure and outdoor activities, 85% of the
healthy Indian adult men could not achieve normal serum
25 (OH)D levels.
Calcium and vitamin D deficiency and their
Hervas et al. (2018) studied the relationship of bone stiff-
consequences
ness index (SI) with dietary intake, physical fitness, physical
The clinical inferences of calcium deficiency including poor activity (PA) and body composition among young university
bone mass accrual as well as abnormal fetal programming students (18–21 years). The vigorous to moderate physical
during pregnancy, rickets, poor peak bone mass due to poor activity was found to be the major predictor of SI. Among
accrual in childhood and adolescence, postmenopausal males, the SI was very closely related with vigorous PA and
osteoporosis and elderly osteoporosis were reported. Serum among females it was associated with the number of steps/
calcium was found within a narrow normal range, mainly day. Calcium intake was the only nutritional parameter that
by alteration of urinary calcium loss, resorption from the had a positive relationship with SI. The study found that
skeleton and absorption from gut. Absorption of calcium is bone and muscle interrelate with PA and identified the pre-
dependent on physiological state, age, vitamin D sufficiency, dictors of bone status in both males and females. Therefore,
presence of calcium binders in diet like phytates, phosphates it is pertinent to identify the modifiable factors and maxi-
and oxalates. Therefore, there is a need to reconsider the mizing peak bone mass at an early age for planning an
dietary recommendations of calcium for Indians as daily cal- effective intervention program for prevention of
cium intake both the recommendations and reality are far- osteoporosis.
away lower than the Western data (Bhatia 2008). Hayek et al. (2018) studied the association between vita-
The prevalence of inadequate levels 25(OH)D in post- min D status and percent body fat among 344 Lebanese
menopausal women was high and especially those with adults, aged between 20 and 74 years (50% Male). The over-
osteoporosis and a high history of fracture (Gaugris 2005). weight and obesity was found among more than half of the
In India, among healthy population, 74% to 96% individuals participants and the average serum vitamin D levels were
8 R. AGGARWAL AND K. BAINS

found to be 28.2 ± 13.9 ng/mL among the subjects. Out of all osteocalcin and decrease in serum carboxy-terminal collagen
the participants, 68.3% had 25(OH)D
20 ng/mL while crosslinks (CTX) may positively affect bone turnover in the
37.5% of population had 25(OH)D
30 ng/mL. The results women consuming milk. The study highlighted that milk is
showed that participants with a higher waist circumference an effective drink to support favorable body composition,
(WC) (p ¼ .012), higher percent body fat (PBF) (p < .005) strength and bone changes in women with resistance train-
had low vitamin D status as compared to the sufficient ing. Josse et al. (2011) further observed an improved com-
group, whereas BMI did not differ by vitamin D status. position of weight lost among the subjects following exercise
Logistic regression analysis indicated that a 1% increase in intervention with more intake of dairy foods and dietary
body fat increases the odds of having 25(OH)D  30 ng/mL protein and restricted intake of dietary energy as compared
by 8% while controlling for BMI and other confounders to those who consumed diets lower in protein and lower or
(p ¼ .019). The study emphasized the need for regular devoid of dairy foods. The findings suggested that greater
screening of vitamin D status particularly in those individu- intake of protein with significant intake from dairy foods,
als who are at risk with high PBF and WC, have low vita- moderate restriction in energy intake and combined resist-
min D intake and who work indoors and supplementation ance and aerobic training can result in favorable body com-
of vitamin D can be effective treatment of low levels. position, strength and fitness changes that are not
represented by simple methods of body weight or BMI.
These findings highlighted that consumption of low-fat dairy
Supplementation of lysine, calcium and vitamin D
foods should be promoted so as to ensure sufficient intake
for muscle and bone health
of calcium in previously deficient populations and also for
A favorable relationship has been observed between con- adequate supply of high-quality protein that can help in lean
sumption of dairy food and adiposity, weight gain preven- mass retention and fat loss during energy restriction.
tion, weight loss and a decrease in metabolic syndrome risk The risk assessment of osteoporosis in pre- and post-
factors and incidence of insulin resistance among many menopausal women was studied by Chowdhary (2012). A
population surveys and observational studies as reported by lot of difference was observed in the intake of milk and
Caan (2007). Other effects of dairy and calcium foods that milk products in pre and post-menopausal group. Nutrients
could be contributing to a higher fat loss include a decrease like protein (r ¼ 0.312) and calcium (r ¼ 0.318) were posi-
in fat absorption, an increase in excretion of fecal fat, ther- tively correlated with bone mineral density (BMD) along
mic effect of food and fat oxidation (Lorenzen et al. 2007). with zinc, vitamin A and energy. Positive association was
A study of 2375 male subjects above 20 years of age sug- also observed with total dietary fiber intake and BMD
gested that taking a pint of milk daily in diet or equivalent (r ¼ 0.257), excess weight, high BMI, more hip and waist cir-
dairy products can reduce the risk of metabolic syndrome to cumference. Conversely, fat mass, visceral fat and degree of
fifty percent (Elwood, Pickering, and Fehily 2007). The most obesity were negatively correlated to BMD. Intake of cal-
obvious method of prevention is undoubtedly to reduce the cium and minimum half an hour exposure to morning sun-
amount of carbohydrates, specifically fast digesting starches light is must to improve bone health.
and sugars. Milk proteins are a highly digestible source of Egg has been considered as an excellent food component
amino acids and lysine. Wilkinson et al. (2007) suggested since ancient times. Hida et al. (2012) suggested that con-
that in men, milk adequately supports loss in fat mass and sumption of protein supplement in the form of egg white
gain in muscle mass. Westerterp et al. (2009) recommended for 12 weeks among female athletes in Japan resulted in
that dietary strategy to promote adipose fat loss is the intake changes in protein metabolites as compared to the carbohy-
of dairy proteins which have been shown to increase skeletal drate supplement. The study recommended that longer
muscle mass through stimulation of muscle protein synthe- intervention or higher protein intakes may be needed to
sis. The epidemiological evidence also shows that with the observe the effects of these changes in protein metabolites
consumption of dairy foods the prevalence of metabolic dis- on measures of body composition or strength. Six months
orders can be decreased because milk protein can decrease of egg supplementation among children aged 6–9 years
the prevalence of individual metabolic risk factors such as receiving two eggs had a significantly greater increase in
mild hyperglycemia, dyslipidaemia and hypertension. In height and weight compared to no eggs or one egg groups
comparison to isoenergetic carbohydrate drink, consumption was observed by Baum, Miller, and Gaines (2017).
of fat-free fluid milk (500 mL) immediately after and 1 h of A study was conducted on 88 families in China, where
resistance exercise for 12 weeks resulted in substantial gain half of the families received wheat flour fortified with 3 g of
in skeletal muscle mass and loss of fat mass with increased lysine per kilogram for three months and the other half
strength in some exercises among young women (Josse et al. were given wheat flour without any fortification. The results
2010). An increase in serum 25[OH]D levels were also showed that children consuming wheat flour fortified with
found among women consuming one liter of milk. lysine had significantly greater gain in their heights and
However, despite the vitamin D intake being 180% above weights while no effect was found on their hemoglobin val-
the current dietary recommended intakes, all of the subjects ues. The adult men and women receiving lysine also showed
still remained below sufficiency post-intervention. Reduction higher values for their pre-albumin level. These results indi-
in serum PTH related to increased dietary calcium intakes cated that families eating wheat-based diet can significantly
was also observed and this along with an increase in improve nutritional status of their members by consuming
 CRITICAL REVIEWS IN FOOD SCIENCE AND NUTRITION 9

lysine fortified wheat flour (Zhao et al. 2004). In another results indicated that animal’s performance, including food
similar study, 40 families received lysine fortified wheat flour intake, body weight and food efficiency was higher in the
while another 40 families got wheat flour without fortifica- HFL groups as compared to the WT group. Also, the appar-
tion. Wheat was considered as a main source of protein pro- ent protein digestibility, lysine availability and protein effi-
viding 59% of the protein for men, 65% for women and ciency ratio increased in HFL diets than the WT diets.
58% for children. The results showed a significant increase Hence, feeding of lysine-biofortified rice showed improve-
in height, weight, transferrin and hemoglobin levels of the ment in food efficiency, growth performance and lysine
families receiving lysine fortified wheat flour. These results availability in growing rats.
further confirmed that lysine fortification of wheat flour can Elwakeel et al. (2019) conducted a study on growing rab-
help to significantly improve sensitive indicators of nutri- bits to find out the effect of vitamin D3 (VD3) on utilization
tional status (Hussain et al. 2004) of lysine. The researcher conducted the study for 5 weeks
Two clinical studies were conducted by Civitelli et al. and used various levels lysine (5.5, 6 and 6.5 g/kg dry mat-
(1992) to determine the effect of lysine on calcium absorp- ter; DM) and vitamin D (0, 500 and 1000 IU). The results
tion. In the first study, 3 g of calcium as CaCl2 along with showed that average daily gain (ADG) and final body weight
400 mg of lysine was given to ten women with osteoporosis. (FBW) were significantly (p < .01) affected by lysine. The
The women without osteoporosis or osteopenia comprised study concluded that lysine utilization did not improve with
the control group and were given calcium as CaCl2 (3 g) vitamin D3, but lysine increased N intake, retained N, the
and placebo. The collection of blood and urine samples was ADG and the FBW in growing rabbits.
done before treatment and every hour for 3 h following Funderburk et al. (2018) studied body composition, diet-
treatment. An increase in serum calcium levels and urinary ary intake of vitamin D and calcium, serum levels of
excretion of calcium was observed in both the groups after 25(OH) vitamin D3 among 36 females and males. The study
the treatment. The study found that the subjects taking reported 25(OH)D deficiency among 22% of the participants
lysine along with calcium excreted significantly lesser while 33% subjects were 25(OH)D insufficient. Sixteen per-
amounts of urinary calcium as compared to the other group cent subjects consumed adequate vitamin D while only 5%
suggesting that lysine may prove helpful in suppressing cal- consumed adequate calcium. One male and eight females
cium excretion in healthy individuals. In the second study, had below average DXA assessments for bone health. Serum
800 mg oral preparation of three different amino acids 25(OH)D levels was significantly correlated with vitamin D
namely L-lysine, L-tryptophan and L-valine was randomly intake (s ¼ 0.29, p < .01). While an inverse relationship
given to 45 women with osteoporosis as a daily supplement between 25(OH)D and weight (r ¼ 0.45, p < .05) was
for three days to find its effect on intestinal calcium absorp- found among females. Thirty one percent of participants
tion. It was found that there was a significant increase in had 25(OH)D levels insufficient or deficient and had higher
calcium absorption as compared to other groups whose waist circumference in comparison to the reference. The
value remained unchanged. The studies suggested that lysine study reported that most of the participants consumed inad-
supplementation, after an oral calcium load may facilitate equate amounts of calcium and vitamin D and had a high
intestinal calcium absorption and decrease urinary excretion rate of 25(OH)D insufficiency and deficiency. The study
of calcium. concluded that normalizing serum 25(OH)D either through
The nutrient combination of b-hydroxy-b-methylbuty- supplements or food has the potential to positively impact
rate, arginine and lysine (HMB/ARG/LYS) was tested in many parameters of an individual’s health including bone
non-exercising elderly subjects by Fuller et al. (2011). The health, visceral adiposity, weight and waist circumference.
study suggested that the muscle mass of the subjects Heuvel and Steijns (2018) reported that among the
increased with HMB/ARG/LYS combination alone regardless Chinese girls and Caucasians, with the daily Ca intake lower
of their vitamin D status, however, accompanying strength than 750 mg, plain dairy products or those fortified with
increased only when subjects also had serum 25(OH)D3 lev- vitamin D and/or Ca the total body bone mineral content
els (
30 ng/mL), thus, demonstrating a synergy between the (BMC) improved by 45–50 g over one year period. Bone
supplementation and vitamin D. Therefore, in elderly popu- mineral density (BMD) increased by 0.7–1.8% with Ca forti-
lations and others having insufficient vitamin D levels, sup- fied dairy products over two years period. Therefore, dairy
plementation with both HMB-containing supplement and products can be an effective source for improving BMC or
vitamin D may prove helpful in increasing muscle mass and BMD among the various population groups.
also improving muscle strength and function. An improve-
ment of muscle growth of monogastric animals such as pigs
Conclusion
via dietary lysine supply was observed which may be due to
a greater increase in protein synthesis rather than a decrease This review recognizes many issues related to the optimal
in protein degradation (Liao, Wang, and Regmi 2015). body composition that require further research for clarifica-
Yang et al. (2017) conducted a feeding study on rats for tion. Primary need is to maintain a healthy body compos-
70 days to examine the nutritive value of two transgenic ition in terms of more muscle and bone mass. There is a
lines of rice having high concentration of free lysine (HFL) large variation in the body composition parameters among
in comparison to their wild type (WT) or the WT rice sup- persons belonging to different ethnic groups. Poor dietary
plemented with different concentrations of L-lysine. The protein quality owing to high amounts of cereals and little
10 R. AGGARWAL AND K. BAINS

animal foods has a marked negative impact on body com- postmenopausal weight gain. Archives of Internal Medicine 167 (9):
position in resource-limited settings and majority of the 893–902. doi: 10.1001/archinte.167.9.893.
Carroll, C. C., J. D. Fluckey, R. H. Williams, D. H. Sullivan, and T. A.
populations. Protein and amino acids apart from muscle
Trappe. 2005. Human soleus and vastus lateralis muscle protein
synthesis also play a complex role in regulation of body metabolism with an amino acid infusion. American Journal of
composition, bone health, glucose homeostasis, satiety, cell Physiology-Endrocrinolgy and Metabolism 288:479–85.
signaling, gastrointestinal function and bacterial flora. Chowdhary, D. 2012. Nutritional and lifestyle factors for the risk
Cereal-based diets and cereal-based food subsidy programs assessment of osteoporosis in pre and post menopausal women.
offer low quality proteins and less bioaccessible calcium and MSc thesis, Punjab Agricultural University, Ludhiana, India.
Civitelli, R., D. T. Villareal, D. Agnusdei, P. Nardi, L. V. Avioli, and C.
pose a risk of quality protein deficiency. Improving the qual- Gennari. 1992. Dietary L-lysine and calcium metabolism in humans.
ity of diets through dietary or medicinal supplementation is Nutrients 8:400–5.
an effective approach to achieve optimum muscle and bone Datta, D., A. Bhinge, and V. Chandran. 2001. Lysine: Is it worth more.
health. The population groups where there is relatively low Cytotechnology 36 (1–3):3–32. doi: 10.1023/A:1014097121364.
supply of foods rich in protein, lysine, calcium and vitamin Elwakeel, E. A., A. E. Khalek, A. E. Hady, M. G. Ahmed, and O. A.
D, the food fortification and/or targeted nutrition supple- Hassan. 2019. Effect of vitamin D3 supplementation on lysine util-
ization in growing rabbits. Animal Feed Science and Technology 254:
mentation policies must be implemented to reduce the bur- 114221. doi: 10.1016/[Link].2019.114221.
den of nutrient deficiency-related conditions. The review Elwood, P. C., J. E. Pickering, and A. M. Fehily. 2007. Milk and dairy
emphasizes the need to shift the objectives of various poli- consumption, diabetes and the metabolic syndrome: The Caerphilly
cies and programs providing subsidized foods from energy prospective study. Journal of Epidemiology and Community Health
sufficiency to a more nutrient quality sufficiency of which 61 (8):695–8. doi: 10.1136/jech.2006.053157.
Etzel, M. R. 2004. Manufacture and use of dairy protein fractions.
quality protein should be an integral part. The population
Journal of Nutrition 134:996–1002.
groups where there is relatively low supply of foods rich in Evans, W. J. 1995. What is sacopenia? The Journals of Gerontology
vitamin D and inadequate exposure to natural ultraviolet B Series A: Biological Sciences and Medical Sciences 50A (Special):5–8.
radiation from sunlight, the food fortification and/or tar- doi: 10.1093/gerona/50A.Special_Issue.5.
geted vitamin D supplementation policies must be imple- FAO. 2013. Dietary protein quality evaluation in human nutrition.
mented to reduce the burden of vitamin D deficiency- Report of an FAO Expert Consultation. Food and Nutrition Paper 92.
FAOSTAT. 2018. Food and Agriculture Data. The Food and
related conditions. A regular screening of serum vitamin D Agriculture Organization of the United Nations (FAO). Accessed
levels and bone mineral density among vulnerable sections November 19, 2018. [Link] org/faostat/en/.
must be carried out periodically. Fitts, R. H., J. G. Ramatowski, and J. R. Peters. 2007. The deleterious
effects of bed rest on human skeletal muscle fibers are exacerbated
by hypercortisolemia and ameliorated by dietary supplementation.
References American Journal of physiology- Cell Physiology 293:313–20.
Flakoll, P., S. Rick, B. Shawn, L. Deanna, C. Christopher, and N.
Bagatini, S. R., K. Zhu, J. R. Lewis, and R. L. Prince. 2014. Dairy food Steven. 2004. Effect of hydroxy-methylbutyrate, arginine, and lysine
intake, peripheral bone structure, and muscle mass in elderly ambu- supplementation on strength, functionality, body composition, and
latory women. Journal of Bone and Mineral Research 29 (7): protein metabolism in elderly women. Nutrition 20 (5):445–51. doi:
1691–700. doi: 10.1002/jbmr.2181.
10.1016/[Link].2004.01.009.
Bakker, I., J. W. R. Twisk, W. Van Mechelen, and H. C. G. Kemper.
Fourie, M., G. J. Gericke, and M. C. Kruger. 2019. Body composition
2003. Fat-free body mass is the most important body composition
and intake of nutrients associated with bone metabolism in young
determinant of 10-yr longitudinal development of lumbar bone in
adolescents in a peri-urban setting. South African Journal of Clinical
adult men and women. The Journal of Clinical Endocrinology and
Nutrition 32 (4):99–106. doi: 10.1080/16070658.2018.1487614.
Metabolism 88 (6):2607–13. doi: 10.1210/jc.2002-021538.
Frost, H. M. 1997. On our age-related bone loss: Insights from a new
Baum, J. I., J. D. Miller, and B. L. Gaines. 2017. The effect of egg sup-
paradigm. Journal of Bone and Mineral Research 12 (10):1539. doi:
plementation on growth parameters in children participating in a
10.1359/jbmr.1997.12.10.1539.
school feeding program in rural Uganda: A pilot study. Food &
Fuller, J. C., S. Baier, P. Flakoll, L. Steven, D. V. M. Nissen, N. Naji,
Nutrition Research 61 (1):1330097. doi: 10.1080/16546628.2017.
1330097. and J. A. Rathmacher. 2011. Vitamin D status affects strength gains
Bhatia, V. 2008. Dietary calcium intake - a critical reappraisal. The in older adults supplemented with a combination of b-hydroxy-b-
Indian Journal of Medical Research 127 (3):269–73. methylbutyrate, arginine, and lysine: A cohort study. Journal of
Bohe, J., A. Low, R. R. Wolfe, and M. J. Rennie. 2003. Human muscle Parenteral and Enteral Nutrition 35 (6):757–62. doi: 10.1177/
protein synthesis is modulated by extracellular but not intracellular 0148607111413903.
amino acid availability: A dose response study. The Journal of Funderburk, L., M. Peterson, N. Shah, M. Morgan, and P. Grandjean.
Physiology 552 (1):315–24. doi: 10.1113/jphysiol.2003.050674. 2018. Serum vitamin D and body composition in adults undergoing
Boland, M. J., A. N. Rae, J. M. Vereijken, M. P. M. Meuwissen, fitness assessments: A correlation study. Public Library of Science 13:
A. R. H. Fischer, M. A. J. S. van Boekel, S. M. Rutherfurd, H. e0197903.
Gruppen, P. J. Moughan, and W. H. Hendriks. 2013. The future Gaugris, S., R. P. Heaney, S. Boonen, H. Kurth, J. D. Bentkover, and
supply of animal derived protein for human consumption. Trends in S. S. Sen. 2005. Vitamin D inadequacy among post-menopausal
Food Science & Technology 29 (1):62–73. doi: 10.1016/[Link].2012.07. women: A systematic review. QJM: An International Journal of
002. Medicine 98 (9):667–76. doi: 10.1093/qjmed/hci096.
Bose, K., S. Bisai, F. Chakraborty, A. Khatun, and H. Bauri. 2008. Body Ghosh, S., D. Suri, and R. Uauy. 2012. Assessment of protein adequacy
composition of two tribal populations of Keonjhar, Orissa, India: A in developing countries: Quality matters. British Journal of Nutrition
comparison. International Journal of Biological Anthropology 1 (2): 108 (S2):S77–S87. doi: 10.1017/S0007114512002577.
1–4. Gilani, G. S., K. A. Cockell, and E. Sepehr. 2005. Effects of antinutri-
Caan, B., M. Neuhouser, A. Aragaki, C. B. Lewis, R. Jackson, M. S. tional factors on protein digestibility and amino availability in foods.
Leboff, K. L. Margolis, L. Powell, G. Uwaifo, E. Whitlock, et al. Journal of AOAC International 88 (3):967–87. doi: 10.1093/jaoac/88.
2007. Calcium plus vitamin D supplementation and the risk of 3.967.
 CRITICAL REVIEWS IN FOOD SCIENCE AND NUTRITION 11

Goodpaster, B. H., S. Krishnaswami, H. Resnick, D. E. Kelley, C. Kumar, S., M. Khosravi, A. Massart, M. Potluri, and A. Davenport.
Haggerty, T. B. Harris, A. V. Schwartz, S. Kritchevsky, and A. B. 2013. The effects of racial differences on body composition and total
Newman. 2003. Association between regional adipose tissue distribu- body water measured by multifrequency bioelectrical impedance
tion and both type 2 diabetes and impaired glucose tolerance in eld- analysis influence delivered Kt/V dialysis dosing. Nephron Clinical
erly men and women. Diabetes Care 26 (2):372–79. doi: 10.2337/ Practice 124 (1–2):60–6. doi: 10.1159/000355009.
diacare.26.2.372. Kurpad, A. V., T. Raj, A. E. Khoury, L. Beaumier, R. Kuriyan, A.
Green, R., J. Milner, J. Joy, M. Edward, S. Agrawal, and A. D. Srivatsa, S. Borgonha, A. Selvaraj, M. Regan, and V. R. Young. 2001.
Dangour. 2016. Dietary patterns in India: A systematic review. The Lysine requirements of healthy adult Indian subjects, measured by
British Journal of Nutrition 116 (1):142–48. doi: 10.1017/ an indicator amino acid balance technique. The American Journal of
S0007114516001598. Clinical Nutrition 73 (5):900–07. doi: 10.1093/ajcn/73.5.900.
Harinarayan, C. V., T. Ramalakshmi, U. V. Prasad, D. Sudhakar, P. V. Lakshmi, S., B. Metcalf, C. Joglekar, C. S. Yajnik, C. H. Fall, and T. J.
L. N. Srinivasarao, K. V. S. Sarma, and E. G. T. Kumar. 2007. High Wilkin. 2012. Differences in body composition and metabolic status
prevalence of low dietary calcium, high phytate consumption and between white UK and Asian Indian children. Pediatric Obesity 7
vitamin D deficiency in healthy south Indians. The American (5):347–54. doi: 10.1111/j.2047-6310.2012.00063.x.
Journal of Clinical Nutrition 85 (4):1062–67. doi: 10.1093/ajcn/85.4. Laplante, M., and D. M. Sabatini. 2012. mTOR signaling in growth
1062. control and disease. Cell 149 (2):274–93. doi: 10.1016/[Link].2012.03.
Hayek, S. A., J. M. B. Mosleh, R. Ghadieh, and J. E. H. Fares. 2018. 017.
Vitamin D status and body composition: A cross-sectional study Leinonen, I., P. P. M. Iannetta, R. M. Rees, W. Russell, C. Watson, and
among employees at a private university in Lebanon. BioMed A. P. Barnes. 2019. Lysine supply is a critical factor in achieving sus-
Central Nutrition 4:31–8. tainable global protein economy. Frontiers in Sustainable Food
He, X., L. Zishuai, X. Tang, Z. Lijun, W. Li, H. Yongjun, J. Tianbo, Systems 3 (27):1–11. doi: 10.3389/fsufs.2019.00027
and Y. Dongya. 2018. Age- and sex-related differences in body com- Liao, S. F., S. Wang, and N. Regmi. 2015. Lysine nutrition in swine
position in healthy subjects aged 18 to 82 years. Medicine 97:25–9. and the related monogastric animals: Muscle protein biosynthesis
Hervas, G., F. R. Litago, J. Irazusta, A. F. Atutxa, A. Belen, A. and beyond. Springerplus 4:147–58. doi: 10.1186/s40064-015-0927-5.
Berm udez, and I. Zarrazquin. 2018. Physical activity, physical fitness, Lorenzen, J. K., S. Nielsen, J. J. Holst, I. Tetens, J. F. Rehfeld, and A.
body composition, and nutrition are associated with bone status in Astrup. 2007. Effect of dairy calcium or supplementary calcium
university students. Nutrients 10:61–70. intake on postprandial fat metabolism, appetite, and subsequent
Heuvel, V. D., and J. M. Steijns. 2018. Dairy products and bone health: energy intake. The American Journal of Clinical Nutrition 85 (3):
How strong is the scientific evidence? Nutrition Research Review 31 678–87. doi: 10.1093/ajcn/85.3.678.
Malik, D., J. Thakur, J. Aggarwal, A. Dua, S. Nijhawan, A. Kumar, K.
(2):1–[Link]: 10.1017/S095442241800001.
Kaur, H. Aggarwal, D. Mehta, H. Verma, et al. 2016. Quetelet’s
Hida, A., Y. Hasegawa, Y. Mekata, M. Usuda, Y. Masuda, H. Kawano,
index and body fat percentage assessment in indian undergraduate
and Y. Kawano. 2012. Effects of egg white protein supplementation
students. The Delhi University Journal of Undergraduate Research
on muscle strength and serum free amino acid concentrations.
and Innovation 2:56–69.
Nutrients 4 (10):1504–17. doi: 10.3390/nu4101504.
Marwaha, R. K., M. K. Garg, K. Bhadra, A. Mithal, and N. Tandon.
Holick, M. F. 2006. High prevalence of vitamin D inadequacy and
2014. Assessment of lean (muscle) mass and its distribution by dual
implications for health. Mayo Clinic Proceedings 81 (3):353–73. doi:
energy X-ray absorptiometry in healthy Indian female. Archives of
10.4065/81.3.353.
Osteoporosis 9 (1):186. doi: 10.1007/s11657-014-0186-z.
Hoppe, C., T. R. Udam, L. Lauritzen, C. Molgaard, A. Juul, and K. F.
Marwaha, R. K., N. Tandon, C. Shivaprasad, R. Kanwar, K. Mani, R.
Michaelsen. 2004. Animal protein intake, serum insulin-like growth
Aggarwal, K. Bhadra, S. Singh, B. Sharma, and R. P. Tripathi. 2009.
factor I, and growth in healthy 2.5-y-old Danish children. The
Peak bone mineral density of physically active healthy Indian men
American Journal of Clinical Nutrition 80 (2):447–52. doi: 10.1093/ with adequate nutrition and no known current constraints to bone
ajcn/80.2.447. mineralization. Journal of Clinical Densitometry 12 (3):314–21. doi:
Hussain, T., S. Abbas, M. A. Khan, and N. S. Scrimshaw. 2004. Lysine 10.1016/[Link].2009.05.004.
fortification of wheat flour improves selected indices of the nutri- McGregor, R. A., and S. D. Poppitt. 2013. Milk protein for improved
tional status of predominantly cereal-eating families in Pakistan. metabolic health: A review of the evidence. Nutrition & Metabolism
Food and Nutrition Bulletin 25 (2):114–22. doi: 10.1177/ 10 (1):46. doi: 10.1186/1743-7075-10-46.
156482650402500202. Minocha, S., T. Thomas, and A. V. Kurpad. 2017. Dietary protein and
Iglay, H. B., J. W. Apolzan, D. E. Gerrard, J. K. Eash, J. C. Anderson, the health-nutrition-agriculture connection in India. The Journal of
and W. W. Campbell. 2009. Moderately increased protein intake Nutrition 147 (7):1243–50.
predominately from egg sources does not influence whole body, Miranda, J. M., X. Anton, C. R. Valbuena, P. R. Saavedra, J. A.
regional, or muscle composition responses to resistance training in Rodriguez, A. Lamas, C. M. Franco, and A. Cepeda. 2015. Egg and
older people. The Journal of Nutrition, Health and Aging 13 (2): egg-derived foods: Effects on human health and use as functional
108–14. doi: 10.1007/s12603-009-0016-y. foods. Nutrients 7 (1):706–29. doi: 10.3390/nu7010706.
Jenewa, S. J., P. Elliott, H. Kesteloot, R. Nichols, G. Claeys, A. R. Dyer, Motil, K. J., D. E. Matthews, D. M. Bier, J. F. Burke, H. N. Munro, and
and R. Stamler. 2014. Inverse relation of dietary protein markers V. R. Young. 1981. Whole-body leucine and lysine metabolism:
with blood pressure. Journal of Nutrition 134:968–73. Response to dietary protein intake in young men. American Journal
Josse, A. R., S. A. Atkinson, M. A. Tarnopolsky, and S. M. Phillips. of Physiology-Endrocrinolgy and Metabolism 240:712–21.
2011. Increased consumption of dairy foods and protein during diet Moya, M. 2016. Lysine genetically enriched cereals for improving nutri-
and exercise induced weight loss promotes fat mass loss and lean tion in children under 5years in low- and middle- income countries.
mass gain in overweight and obese premenopausal women. The Journal of Nutritional Health & Food Engineering 5 (2):583–86. doi:
Journal of Nutrition 141 (9):1626–34. doi: 10.3945/jn.111.141028. 10.15406/jnhfe.2016.05.00164.
Josse, A. R., J. E. Tang, M. A. Tarnopolsky, and S. M. Phillips. 2010. Nande, P., M. Hussain, and S. Vali. 2009. Influence of obesity on body
Body composition and strength changes in women with milk and measurements and composition in adult women belonging to
resistance exercise. Medicine & Science in Sports & Exercise 42: minority community. Indian Journal of Nutrition and Dietetics 47:
1122–30. 137–51.
Kaur, G., K. Bains, H. Kaur, and A. Kaur. 2012. Assessment of changes NSSO. 2014. Nutritional Intake in India 2011-12. NSS 68th Round.
in anthropometry and body composition with progression of age Kolkata: National Sample Survey Organization Office. Ministry of
among occupationally sedentary women. International Journal of Statistics and Programme Implementation, Government of India
Nutrition and Health Sciences 3:13–18. 2011–12.
12 R. AGGARWAL AND K. BAINS

Paddon, J. D., M. M. Sheffield, X. J. Zhang, E. Volpi, S. E. Wolf, A. Singh, I., R. Shweta, V. L. Robert, and M. Dhurjati. 2015. Workstation
Aarsland, A. A. Ferrando, and R. R. Wolfe. 2004. Amino acid inges- related anthropometric and body composition parameters of Indian
tion improves muscle protein synthesis in the young and elderly. women of different geographical regions. The Journal of Krishna
American Journal of Physiology-Endrocrinolgy and Metabolism 286: Institute of Medical Sciences University 4:38–44.
321–28. Suri, D. J., K. T. Debrah, and S. A. Ghosh. 2014. Optimization of the
Phillips, S. M., L. G. Bandini, H. Cyr, D. S. Colclough, E. Naumova, nutrient content and protein quality of cereal-legume blends for use
and A. Must. 2003. Dairy food consumption and body weight and as complementary foods in Ghana. Food and Nutrition Bulletin 35
fatness studied longitudinally over the adolescent period. (3):372–81. doi: 10.1177/156482651403500309.
International Journal of Obesity and Obesity 9:1106–13. doi: 10.1038/ Swaminathan, S., M. Vaz, and A. V. Kurpad. 2012. Protein intakes in
[Link].0802370. India. British Journal of Nutrition 108 (S2):S50–S58. doi: 10.1017/
Quinn, K. M. 2015. M. S. Swaminathan – scientist, hunger fighter, S0007114512002413.
World Food Prize Laureate. Current Science 3:417–29. Tomlinson, D. J., R. M. Erskine, C. I. Morse, and G. L. Onambele.
Rasmussen, B., and R. R. Wolfe. 1999. Regulation of fatty acid oxida- 2019. Body fat percentage, body mass index, fat mass index and the
tion in skeletal muscle. Annual Review of Nutrition 19:463–84. doi: ageing bone: Their singular and combined roles linked to. Physical
10.1146/[Link].19.1.463. Activity and Diet. Nutrients 11 (195): 1–23. doi: 10.3390/nu11010195
Richardson, D. P. 1990. Food fortification. The Proceedings of the Visser, M., S. B. Kritchevsky, B. H. Goodpaster, A. B. Newman, M.
Nutrition Society 49 (1):39–50. doi: 10.1079/pns19900007. Nevitt, E. Stamm, and T. B. Harris. 2002. Leg muscle mass and
Ritchie, H., D. S. Reay, and P. Higgins. 2018. Beyond calories: A holis- composition in relation to lower extremity performance in men and
tic assessment of the global food system. Frontiers in Sustainable women aged 70 to 79 years: The health, aging and body compos-
Food Systems 2:57. doi: 10.3389/fsufs.2018.00057. ition study. Journal of the American Geriatrics Society 50 (5):
Ritu, G., and A. Gupta. 2014. Vitamin D deficiency in India: 897–904. doi: 10.1046/j.1532-5415.2002.50217.x.
Prevalence, causalities and interventions. Nutrients 6:729–75. Westerterp, P. M. S., A. Nieuwenhuizen, D. Tome, S. Soenen, and
Rowan, A. M., P. J. Moughan, M. N. Wilson, K. Maher, and J. C. K. R. Westerterp. 2009. Dietary protein, weight loss, and weight
Tasman. 1994. Comparison of the ileal and faecal digestibility of maintenance. Annual Review of Nutrition 29:21–41. doi: 10.1146/
dietary amino acids in adult humans and evaluation of the pig as a
annurev-nutr-080508-141056.
model animal for digestion studies in man. British Journal of
Wilkinson, S. B., M. A. Tarnopolsky, M. J. Macdonald, J. R.
Nutrition 71 (1):29–42. doi: 10.1079/BJN19940108.
Macdonald, D. Armstrong, and S. M. Phillips. 2007. Consumption
Rush, E. C., J. H. Goedecke, C. Jennings, L. Micklesfield, L. Dugas,
of fluid skim milk promotes greater muscle protein accretion after
E. V. Lambert, and L. D. Plank. 2007. BMI, fat and muscle differen-
resistance exercise than does consumption of an isonitrogenous and
ces in urban women of five ethnicities from two countries.
isoenergetic soy-protein beverage. The American Journal of Clinical
International Journal of Obesity 31 (8):1232–39. doi: 10.1038/[Link].
Nutrition 85 (4):1031–40. doi: 10.1093/ajcn/85.4.1031.
0803576.
Wolfe, R. R. 2006. The underappreciated role of muscle in health and
Rutherfurd, S. M., K. Bains, and P. J. Moughan. 2012. Available lysine
disease. The American Journal of Clinical Nutrition 84 (3):475–82.
and digestible amino acid contents of proteinaceous foods of India.
British Journal of Nutrition 108 (S2):S59–S68. doi: 10.1017/ doi: 10.1093/ajcn/84.3.475.
S0007114512002280. Wolfe, R. R., R. R. Shane, Y. Kim, and P. J. Moughan. 2016. Protein
Rutherfurd, S. M., and P. J. Moughan. 2005. Digestible reactive lysine quality as determined by the digestible indispensable amino acid
in selected milk-based products. Journal of Dairy Science 88 (1): score: Evaluation of factors underlying the calculation. Nutrition
40–48. doi: 10.3168/jds.S0022-0302(05)72660-6. Reviews 74 (9):584–99. doi: 10.1093/nutrit/nuw022.
Sachan, A., R. Gupta, V. Das, A. Agarwal, P. K. Awasthi, and V. Yang, L. C., Y. Lan, J. Hu, Y. H. Yang, Q. Zhang, Z. W. Huang, and
Bhatia. 2005. High prevalence of vitamin D deficiency among preg- J. H. Piao. 2010. Relatively high bone mineral density in Chinese
nant women and their newborns in northern India. The American adolescent dancers despite lower energy intake and menstrual dis-
Journal of Clinical Nutrition 81 (5):1060–64. doi: 10.1093/ajcn/81.5. order. Biomedical and Environmental Sciences 23 (2):130–36. doi: 10.
1060. 1016/S0895-3988(10)60042-6.
Schurch, M. A., R. Rizzoli, D. Slosman, L. Vadas, P. Vergnaud, and Yang, Q.-Q., P. K. Suen, C.-Q. Zhang, W. S. Mak, M.-H. Gu, Q.-Q.
J. P. Bonjour. 1998. Protein supplements increase serum insulin-like Liu, and S. S.-M. Sun. 2017. Improved growth performance, food
growth factor-I levels and attenuate proximal femur bone loss in efficiency, and lysine availability in growing rats fed with lysine-bio-
patients with recent hip fracture. A randomized, double-blind, pla- fortified rice. Scientific Reports 7 (1):1389–400. doi: 10.1038/s41598-
cebo-controlled trial. Annals of Internal Medicine 128 (10):801–09. 017-01555-0.
doi: 10.7326/0003-4819-128-10-199805150-00002. Zemel, M. B., W. Thompson, A. Milstead, K. Morris, and P. Campbell.
Schutz, Y., U. U. G. Kyle, and C. Pichard. 2002. Fat-free mass index 2004. Dietary calcium and dairy products accelerate weight and fat
and fat mass index percentiles in Caucasians aged 18-98 y. loss during energy restriction in obese adults. Obesity Research 12
International Journal of Obesity and Related Metabolic Disorders 26 (4):582–90. doi: 10.1038/oby.2004.67.
(7):953–60. doi: 10.1038/[Link].0802037. Zhao, W., F. Zhai, D. Zhang, Y. An, Y. Liu, Y. He, K. Ge, and N. S.
Scognamiglio, R., A. Avogaro, C. Negut, R. Piccolotto, S. V. Scrimshaw. 2004. Lysine-fortified wheat flour improves the nutri-
Kreutzenberg, and A. Tiengo. 2004. The effects of oral amino acid tional and immunological status of wheat-eating families in northern
intake on ambulatory capacity in elderly subjects. Aging Clinical and China. Food and Nutrition Bulletin 25 (2):123–29. doi: 10.1177/
Experimental Research 16 (6):443–47. doi: 10.1007/BF03327399. 156482650402500203.