Food and Chemical Toxicology 49 (2011) 668–672
Contents lists available at ScienceDirect
Food and Chemical Toxicology
journal homepage: www.elsevier.com/locate/foodchemtox
Grass Pea and Neurolathyrism: Farmers’ perception on its consumption
and protective measure in North Shewa, Ethiopia
Anteneh Girma a,⇑, Beneberu Tefera a, Legesse Dadi b
a
b
Debreberhan Agricultural Research Center, P.O. Box 112 D/Berhan, Ethiopia
Catholic Relief Society Ethiopia, P.O. Box 6592 Addis Ababa, Ethiopia
a r t i c l e
i n f o
Article history:
Available online 17 September 2010
Keywords:
Ethiopia
Grass pea
Farmers’ perception
Processing methods
a b s t r a c t
Neurolathyrism in Ethiopia is caused by food dependency on grass pea (Lathyrus sativus L.). In the study
area, a large proportion of the farmers are growing grass pea since it can withstand harsh environments.
Socio-economic factors (poverty; lack of money to buy other food legumes) and environmental problems
(such as water logging and frost hazards) influence consumption of grass pea. Most of the respondents have
the idea that some chemical contained in grass pea causes a health problem. Different processing and preparation methods are used to prepare grass pea into different food forms. The major processing methods
include washing and soaking, as the farmers apply these methods mainly because they assume that the
chemical that causes lathyrism, scientifically known as b-ODAP (b-N-oxalyl-L-a,b-diaminopropionic acid)
is reduced through washing and soaking. The farmers adopt different strategies to avoid the problem of
lathyrism such as avoiding consumption of grass pea in the form that they suspect to cause the problem,
blending/mixing with other crops, applying different processing/detoxification methods. Since grass pea is
consumed with a fear of lathyrism, future research should concentrate either on developing grass pea varieties with safe level of b-ODAP content or improving the traditional/indigenous processing methods.
Ó 2010 Elsevier Ltd. All rights reserved.
1. Introduction
Grass pea (Lathyrus sativus L.) is a drought tolerant food legume
that is produced and consumed in developing countries of Asia like
Bangladesh, India, and part of Africa such as Ethiopia, that are susceptible to drought (Stodolak and Starzynska, 2008; Barceloux,
2008). In Ethiopia, because of its better tolerance to adverse environmental conditions, especially drought and water-logging, than
other legumes; grass pea is a staple food during famines, crop failures and in cases of extreme poverty as well as in times of food crisis. It is a low-input crop mostly planted on marginal land where it
sustains on residual moisture (Dadi et al., 2003). These agronomic
properties make it the cheapest pulse available in Bangladesh and
Ethiopia during times of drought and food insecurity. It is often
considered as lifesaver crop (Lambein et al., 2008) or as insurance
crop (Campbell, 1997).
Grass pea is a cheap source of protein for human and animal consumption (Campbell, 1997; Urga et al., 2005). The protein content of
grass pea seeds collected from 15 major production areas of Ethiopia was 27–32% (Urga et al., 2005), which is higher than the average
percentage of protein content (21–25%) in other legume seeds
(Monsoor and Yusuf, 2002). However, uninterrupted consumption
of an exclusive diet of grass pea can give rise to the crippling neurol⇑ Corresponding author. Tel.: +251911118736.
E-mail address: antegirma@yahoo.com (A. Girma).
0278-6915/$ - see front matter Ó 2010 Elsevier Ltd. All rights reserved.
doi:10.1016/j.fct.2010.08.040
athyrism, irreversible spastic paraparesis of the lower limbs (Fikre
et al., 2009). While earlier researchers considered that neurolathrrism might be caused by the deficiency of an essential factor
(Ressler, 1962 cited in Lambein et al., 2008), the discovery of a
neuro-excitatory amino acid b-ODAP (b-N-oxalyl-L-a,b-diaminopropionic acid) by Rao in 1964, has changed the attention to focus
on the elimination of this neurotoxin from the plant (Lambein
et al., 2008).
Multitudes of professionals have made efforts to eliminate or
reduce the level of this small molecule from the seeds of grass
pea. Breeders were working to select varieties with zero or low
b-ODAP content. Agronomists were researching on different agronomic practices (sowing date and zinc application) to reduce the
b-ODAP content. Toxicologists were trying to determine a threshold of toxicity. Biotechnologists are trying to exploit the new biotechnology for eliminating the toxicity. But, the plant scientist
could not succeed in eliminating b-ODAP and toxicologists could
not determine a threshold of toxicity. Only recently, epidemiology
discovered a link with illiteracy, poverty and young age as risk
factors for neurolathyrism and fermentation of the seeds or consumption together with cereals, onions and ginger as protective
factors (Getahun et al., 2003, 2005; Dadi et al., 2003; Yigzaw
et al., 2001; Stodolak and Starzynska, 2008; Lambein, 2009). Hence,
documentation of location specific farmers’ indigenous knowledge
and processing methods are important to standardize the processing methods towards reducing the grass pea toxicity.
A. Girma et al. / Food and Chemical Toxicology 49 (2011) 668–672
The purpose of this research was to understand indigenous
community knowledge about grass pea toxicity and related attitudes towards its consumption and to assess the traditional methods of processing and preparation and their effect on toxicity levels
and nutrient level of grass pea in a location where grass pea is produced in large amounts but where the incidence of neurolathyrism
is minimal.
2. Methodology
This study was undertaken in April 2001 in Moretina Juru, the
district that is known for its high grass pea production in Ethiopia.
The district has a total of 662.7 km2 with a total population of
91,900 (47,597 males and 43,303 females) at an annual growth
rate of 1.7% (CSA, 2008). The majority of the populations are of
the Amharic ethnic group and they share similar culture, tradition
and religion (Ethiopia Orthodox Church). Crop production is the
dominant activity and the main means of live in the district. The
cropping system and livestock play an important role in the farming system. Crop and livestock production are highly integrated.
Livestock provides draft power and manure for crop production
while crop provides feeds and crop residues for the livestock
sub-system. The dominant soils are vertisols characterized by
water logging (Hailu and Chilot, 1989).
In the study, a cross-sectional survey was designed to lead the
data collection and analysis. A combination of probability random
sampling and non-probability sampling method has been used. A
multistage sampling method was used to identify sample farmers.
First, the district was selected purposively based on the status of
grass pea production in the zone. Second, from the selected district,
two grass pea producing kebeles (Administrative unit) were selected. Third, respondent farmers from the two kebeles were identified using a systematic random sampling procedure. Sample size
was determined based on the project time and resource availability
and accordingly a total sample size for the study was 100 grass pea
producing households. For this purpose, the member list of the
kebeles was used.
Information referring to household characteristics, grass pea
production practices, processing and consumption, and institutional support services were collected using a structured questionnaire. In the study area, basically it is the responsibility of women
to undertake home based food processing and preparation activities. Therefore, information relating to grass pea processing, preparation and consumption was collected from women while
information referring to grass pea production was collected from
the head of household (man or female) who makes production related decisions. Moreover, information on farmers’ indigenous
knowledge about grass pea toxicity and related attitudes towards
its consumption were collected from both women and men. The
Questionnaire was pre-tested and modified accordingly. Female
and male enumerators have been recruited from among the secondary school graduates to conduct the interview. The researchers
have informed the enumerators on the purpose of the survey and
trained in the techniques of interviewing. Secondary data on production were collected from CSA, district and zonal Agricultural
departments. For this purpose, guidelines have been collected
and used. Simple descriptive statistical tools were used to analyze
survey data. Computer software, Statistical Package for Social Sciences (SPSS), version 10 was used to analyze the data.
3. Results
The average farm size was 1.81 ha per household with standard
deviation of 0.69 ha. Of this area 1.62 ha was under crop cultivation. In the study areas, small amounts of land around the home-
669
stead were set aside for grazing and only a single farmer has left
his 0.25 ha land under fallow and this reflects the population pressure on land. Farmers use their land mainly for crop cultivation.
The principal cereal crops grown in the study area are bread wheat
and teff (Eragrostis tef). The major food legumes grown are grass
pea, lentil, chickpea and faba bean. Farmers allocated almost a
quarter of a hectare to grass pea production.
In the study district, 83% of farmers are growing grass pea. They
have great interest in growing grass pea because of its performance under harsh environment and its nutritional value. The
other reason for growing grass pea production is attributed to its
minimum inputs and management requirements. Farmers in the
study areas have on average 20 years experience in grass pea farming. They cultivate grass pea for consumption, soil fertility maintenance, cash income, and for livestock feed where 27%, 22%, 28%
and 23% of the respondents cultivate grass pea for consumption,
selling, soil fertility maintenance and animal feed purposes,
respectively.
Grass pea area accounts for 44.4% of the total area allocated to
pulse production in 2000/2001. Available secondary information
on grass pea indicates that grass area shows an increasing trend
during the period from 1995/96 to 2000/2001 (WoARD, 2001). In
the study area 57% of the sample farmers reported no change in
allocation of area to grass pea. About 16% of the farmers reported
increasing trend in grass pea area. Grass pea is substituting preferred crops such as faba been, chickpea and lentils. As a result,
grass pea’s value in the market has increased over the past years.
The reason they gave for increase in grass pea was that grass pea
does not require intensive management and make little competition for labor with other crops, because planting and harvesting
of grass pea is usually done after all operations for other crops
are completed.
In the study areas, among the legumes grass pea, lentil, chickpea and faba bean were widely produced in 2000/2001. The proportion of farmers growing grass pea was much higher than the
proportion of farmers growing other legumes in the same years.
Farmers consider yield, soil fertility, flood and drainage condition
in deciding where to grow grass pea. Grass pea is capable of growing in all types of land (fertile, less fertile, flooded and logged) but
most farmers grow grass pea on fertile land. In Moretina Jiru district about 55% of the sample farmers grew grass pea on fertile land
to get higher yield. It is also grown on less fertile land previously
used for cereals to maintain fertility through crop rotation. It appears that in this district soil fertility maintenance is one of the
important factors for production of grass pea. It is considered as
soil fertility restorer and quite a number of farmers include grass
pea in their crop rotation sequences. Just like other legumes grass
pea is cultivated without application of inputs such as fertilizer,
improved seed and pesticides. Because of the fact that grass pea
is planted late in the season on residual moisture, there would
not be sufficient moisture for the development of aphids. Improved
varieties of grass pea are not available and all the farmers grow local cultivars.
Grass pea is a good source of protein and energy and different
food types/dishes are prepared from grass pea. In the area, the
grass pea preparations consumed include boiled whole seeds (nifro), roasted whole seed (kollo), the traditional sauce (shiro wot
and kik wot), and Local drink (Areke). Grass pea is most widely used
in the form of ‘shiro’ whereby 100% of the respondents consumed it
at least once a day throughout the year (Table 1).
Socio-economics and technical factors influence consumption
of food prepared from grass pea. According to the survey results,
91% of respondents know the potential health hazards of grass
pea consumption. 39.0% of the respondents consume food containing grass pea mainly because of poverty and 61% because of shortage of other legumes.
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A. Girma et al. / Food and Chemical Toxicology 49 (2011) 668–672
Table 1
Household grass pea utilization in different forms in Moretina Jiru District, Ethiopia.
Source: Own survey 2001.
Grass pea
utilization
Number of
respondents
Frequency % of
the respondents
Nifro
Kolo
Shiro
Kik
Areke
25
30
98
21
6
25.51
30.61
100.00
21.43
6.12
Table 3
Farmers’ Perception of grass pea toxicity and method to process grass pea in Moretina
Jiru. Source: Own survey 2001.
Number of
respondents
Frequency % of
the respondents
Know toxicity of grass pea
88
89.8
Method to reduce toxicity
Washing frequency
Mixing with other crop
Toasting, soaking
Washing, toasting
41
53
2
29
31.00
40.00
2.00
22.00
Table 2
Farmers’ preference for grass pea consumption as compared with other pulses in
Moretina Jiru. Source: Own survey 2001.
Farmers’
preference/rank
Number of
respondents
Frequency % of
the respondents
First
Second
Third
Fourth
Fifth
4
11
15
26
37
4.3
11.8
16.1
28.0
39.8
Farmers prefer to consume faba been, field pea, chickpea or lentils rather than consuming grass pea. In terms of preference farmers ranked grass pea as least preferred legumes (Table 2). Despite
their preferences farmers widely consume grass pea mainly because production of preferred legumes has decreased due to the
threat of insect pests, water logging and frost hazards. The preferred legumes are in short supply and hence expensive on the
market as compared to grass pea. Poverty is widespread in the
study area and most farmers cannot afford to consume preferred
legumes such as faba been, chickpea and lentil. Grass pea performs
better under moisture stress and water logging conditions, and
better withstands pests as compared to other food legumes. Because of this farmers expanded its production and widely consume
it.
Different processing and preparation methods are used to prepare grass pea in these forms. Grass pea is mainly processed into
splits and fine flour at home using stone hand mills. Whether it
is ground into fine flour or splits, grass pea is usually lightly toasted
to ease the process of de-husking. Women usually perform the processing at home. Males are rarely involved in grass pea processing
activities. Some of the conventional processing methods for legumes are more rigorously applied in case of grass pea. For instance grass pea grain and/or splits are more frequently washed
or soaked for 3–4 h. When grass pea is consumed in nifro (boiled
grain) forms, relatively minimum processing is involved.
Sample farmers were asked about the relation between grass
pea and lathyrism. Most of them do know that lathyrism is caused
by grass pea. Most of the farmers in the study area know grass pea
contains toxic compound, which affects human health (Table 3).
Although many farmers know the effect of grass pea on health,
many of them do not know whether the onset and severity of lathyrism had a direct relationship to the amount and the length of
period of grass pea consumption.
The processing and preparation methods of grass pea vary
depending on the forms in which it is consumed. Table 4 presents
different methods of grass pea processing and preparations. The
most common methods of grass pea processing methods by food
types are highlighted as follows.
Nifro: Depending on the processes involved, there are two common methods in which grass pea seeds are processed and prepared
into Nifro. The difference between the two methods mainly fall on
the type of grass pea seeds added to the water. In the first case,
only cleaned seeds are used while in the other method the grass
Table 4
Grass pea processing and preparation into different types of food in Moretina Jiru,
Ethiopia. Source: Own survey 2001.
Description
Number of
respondents
Frequency % of
the respondents
Nifro
Clean-soak-boil
Clean-wash-boil
Clean-boil
Clean-slight toast -boil
2
1
28
18
4.0
2.0
57.0
37.0
Kolo
Clean-slight boil-toast
55
100.00
Kita
Clean-split-wash-grind
Clean-grind
Clean-dry-grind
Clean-wash-dry-grind
2
47
2
1
4.0
90.0
4.0
2.0
9
1
19.6
2.0
2
4.0
5
12.0
7
17.0
1
16
2.0
39.0
61
67.03
29
31.87
1
1.09
Kik
Clean-split-clean-wash-dry-kik-boil
Clean-slight roast-split-clean-soakwash-dry-kik-boil
Soak-wash-roast-split-clean-washdry-kik-boil
Clean-soak-dry-split-clean-washdry-kik-boil
Wash-dry-split-clean-wash-drykik-boil
Clean-split-soak-clean-kik-boil
Clean-roast- split-clean-washdry-kik-boil
Shiro
Clean-roast-split-clean-washdry-shiro
Clean-Wash-roast-split-cleanwash-shiro
Clean-roast- split-soak-cleanwash-dry-shiro
pea seeds are briefly roasted before added to the water. Then, enough water is added and the grain is cooked until tender. In both
cases it is common to mix grass pea with wheat or sorghum and
boil the mixture.
Kolo: For preparation of kolo grass pea seeds are briefly boiled
for a few minutes in a metal pan. This practice is mainly done to
soak grass pea seeds and for cleaning purpose. Finally the grass
pea seeds are toasted on clay or in a metal pan. Grass pea kolo is
mixed with similarly prepared wheat, chickpea or sunflower before
consumption.
Kik: There are three common methods of processing grass pea
into kik.
In the first case, clean grass pea is toasted on a clay or metal
pan. The toasted grass pea is then processed into large splits using
stone mill and husks removed by winnowing. The splits are
washed and sun dried and finally used for making kik wot. The second method differs from the first in that toasting of grass pea seeds
A. Girma et al. / Food and Chemical Toxicology 49 (2011) 668–672
is performed before making grass pea splits using stone hand mill.
Despite this, the removing processing and preparation operation
are similar to the first method. The third method, entails soaking
and washing before making splits. The soaked and washed grass
pea seeds are set in the sun for drying. Once the grass pea grain
is dried, women grind it to make splits. The grass pea splits are
usually washed and sun dried. Dried splits arte used for kik
preparation.
Shiro: There are two common methods to prepare grass pea into
shiro.
The first method involves toasting cleaned grass pea seed on a
clay or metal pan. The toasted grass pea is ground to make grass
pea splits and the husks are removed. The splits are washed and
sun dried. Finally the splits are mixed with spices and ground into
shiro flour. In the second method washing is done before toasting.
The toasted grass pea is ground to make splits. After grinding into
splits the husks are removed by winnowing. The splits are washed
and sun dried. Finally the splits are mixed with spices and ground
into shiro flour. Shiro is made from grass pea alone or from mixtures of grass pea and other legumes such as faba bean, field pea
and chickpea.
4. Discussion
Grass pea is produced in the study area where 83% of the
respondents grow grass pea occupying 44% of the total area under
legumes. It is grown in all administrative zones in Ethiopia. It occupies 10.08% of the total area under legumes and ranks fifth in area
among the legumes. Annual grass pea production accounts for
10.29% of the food legumes (CSA, 2009). The average annual
growth rate of grass pea’s area and production was consistently
positive at a rate of 4.29% and 7.23%, respectively (Teklewold and
Leggese, 2006).
Gras pea is consumed in different forms in the study area,
which include boiled whole seeds (nifro), roasted whole seed (kollo), the traditional sauce (shiro wot and kik wot), and Local drink
(Areke) where 25.1%, 30.6%, 100%, 21.4% and 6.12% of the respondents consumed, respectively. In addition, earlier studies in the
country reported the utilization of grass pea seed comprising Eshet
(unripe green), Kitta (bread) and Injera (pancake) (Getahun et al.,
2005).
There are slight variations among farmers within the study area
in terms of methods of processing and of the sequence that is followed in processing grass pea. Some farmers either wash or soak
the seeds before preparation into the preferred form. Hours of
soaking and frequency of washing varies between households.
Washing is widely practiced by the farmers irrespective of the
forms in which grass pea is processed or consumed. Grass pea
splits used for making shiro is washed 3–4 times. Grass pea’s grain
or splits or both may be soaked for shiro making. On average grass
pea for shiro is soaked for less than an hour. The average soaking
for kik preparation is 1.27 h. Cold water is commonly used for
washing and soaking grass pea. The main reason for washing and
soaking grass pea is to remove dust and to reduce the toxic compound found in grass pea. Some farmers also do washing and soaking to avoid unpleasant flavour and make it tender. Toasting is
done to facilitate de-husking and for ease of grinding. Boiling of
grass pea is mainly done to make the grain tender and palatable.
Farmers clearly know that repeated washing and soaking reduces
the toxic compound and improves flavour of grass pea dishes.
However, they do not realize the effects of soaking and repeated
washing in reducing nutritive value of the grass pea dishes by
removing water soluble vitamins and micronutrients.
Despite their knowledge of the potential effect of grass pea on
health, most of the consumers consume grass pea for economic
671
reasons. Most of the households in rural areas are poor and cannot
afford to buy other more preferred legumes. Therefore, they have
no other option than consuming grass pea produced on their
own farm. Teklewold and Leggese (2006) indicated that lathyrism
significantly affected poor household who had greater household
food insecurity, owned fewer assets (such as land and livestock)
and had lower income. Poor households will continue to depend
on grass pea as a source of protein for years to come. Farmers apply
the following strategies to reduce the b-ODAP contents of grass pea
and thereby minimize the health hazard when grass pea is
consumed:
(i) Avoid consumption of grass pea: some farmers wish to refrain
from consumption of grass pea. But this is not a viable
option for most of the households in view of widespread
poverty in rural areas.
(ii) Blending/mixing with other crops: some farmers believe that
blending grass pea with other legumes or cereals reduce
the health risk that could occur following excessive consumption of grass pea. Farmers mix grass pea with other
legumes in one to one ratio. They mix grass pea with other
legumes to reduce the intake of the toxic compound and
thereby reduce the health risk associated with grass pea
consumption. The farmers’ strategy seems to be supported
by detailed earlier studies on lathyrism victims in a prisoner
of war camp where it the relative safety was reported of
diets containing sufficient cereals mixed with grass pea
(Lambein et al., 2001). Similarly, this strategy is also recommended by Getahun et al. (2005), after an attempt to associate the type of grass pea preparation with the risk of
neurolaythrism where mixing grass pea with more than
one- third of cereals reduced the risk of paralysis as observed
in Ethiopia. While reduction of the intake of b-ODAP occurs
whether the grass pea is mixed with other legumes or with
cereals, only the addition of cereals will improve the amino
acid balance of the diets, especially the content of sulphur
containing amino acids methionine and cysteine. The importance of this for the etiology of neurolathyrism is extensively
discussed by other authors in this issue.
(iii) Processing(detoxification): farmers basically use different processing methods to reduce the toxic compound found in
grass pea. The processing methods practiced by the farmers
involve heating, washing and/or soaking. b-ODAP being
water-soluble, the indigenous processing methods, which
involve heating and treating with water, reduce the toxic
compound (TekleHaimanot et al., 2005). The conventional
processing methods are more rigorously applied on grass
pea grain than on other legumes. Farmers in the study areas
frequently wash grass pea to make it safe for consumption.
Moreover, farmers think that lathyrism is caused by exposure to vapour coming out during grass pea cooking or when
harvesting on a cloudy day. They assumed that exposure to
vapour and water used for cooking (boiling) grass pea is dangerous. Therefore, they drain boiling water and dispose of it
in a place where people and animals would not step on it.
This is done because they assume that draining the water
washes away the toxic compound. Most of the farmers in
the study area believe that consuming grass pea kita or porridge with milk, butter or oil is more toxic and dangerous for
health. Research findings confirmed that b-ODAP found in
grass pea is water-soluble (Srivastava and Khokhar, 1996;
Girma et al., 1997) and this indicates that treating with
water and heat reduces the toxic content. Similarly, fermentation of grass pea reduced b-ODAP level in grass pea on the
average by 82% for high toxin variety and by up to 97% for
the low toxin variety (Yigzaw et al., 2001).
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A. Girma et al. / Food and Chemical Toxicology 49 (2011) 668–672
(iv) Variety selection: Farmers wish to have varieties with no or
safe level of b-ODAP, but there is no variety with no or safe
b-ODAP content at present. The research efforts of the then
Ethiopian Agriculture Research Organization (EARO) have
released the first low neurotoxin variety of grass pea in
2005, which was considered safe for human consumption.
At the time of release, the new variety called ‘Wasie’ had
low neurotoxin content (0.08%, compared with 0.4% in the
local check) and was recommended to reduce the number
of lathyrism cases for Ethiopia grass pea growing areas
(ICARDA, 2005). However, the large scale production of grass
pea at farmers’ fields in Ethiopia could not repeat the low
level of b-ODAP (Personal communication, Pulses section
of Debrezeit Agriculture Research Center, 2009). This observation is supported by earlier studies documenting that
environmental factors such as drought, zinc deficiency, iron
oversupply and the presence of heavy metals in the soil can
considerably increase the level of b-ODAP in the seeds
grown in farmers’ fields as compared to more optimal experimental fields (Campbell, 1997).
5. Conclusions
Grass pea grows under adverse environmental conditions and is
equally nutritive compared to other more preferred legumes. As
evidenced by this study, grass pea occupies large land area and is
grown and consumed by many farmers following long processing
methods. Therefore, in addition to breeding endeavour aimed at
developing free or safe b-ODAP level; there is need for research focused on developing simple detoxification techniques and popularising them as part of agricultural extension programs. Thus future
research should concentrate on improving the processing methods
such as soaking methods and time, washing and frequency of
washing, heating and time of heating.
In the meantime, research should develop varieties with save
level of b-ODAP. The development of grass pea varieties with
acceptable level of b-ODAP and yield would have positive impact
in reducing costs of food processing and preparation by reducing
the time of soaking and cooking. It also saves protein, vitamins
and other nutrients due to rigorous processing usually done for
reducing the toxic effect of grass pea. It will also reduce the incidence of lathyrism and increases labour availability on farm.
Therefore, concrete efforts should be made by the national and
international agricultural research systems to generate grass pea
varieties with safe level of b-ODAP. to provide a safe and healthy
food for the consumers.
Because grass pea is deficient is some essential sulphur containing amino acids, it can be a healthy part of the diet only in combination with foodstuffs providing sufficient supply of these amino
acids such as cereals (wheat, teff, maize) sesame or onions and ginger. Considering this, grass pea can be a precious commodity and
an important source of dietary protein.
Conflict of Interest
The authors declare that there are no conflicts of interest.
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