The increasing burden of obesity worldwide, along with its array of associated diseases, is one of the greatest global health challenges of our time. Consequently, considerable resources are used in trying to reduce obesity rates and mitigating its consequences upon health. However, overweight people and obesity are still increasing, and so is the associated morbidity, despite these efforts [1
]. Nutritional management is the most employed type of intervention involved in weight reduction for people with obesity, alone or in combination with other interventions such as exercise and motivational counseling or other behavioral interventions [4
]. While the role of macronutrients is well established and described in obesity-related nutritional management, there are limited and contradicting data regarding the management of micronutrient requirements during these interventions in both children and adults [5
]. Although the importance of micronutrient adequacy is well recognized in obesity prevention and management [7
], there is also limited information regarding the management of micronutrients in healthcare systems from developing countries.
In Romania, the prevalence of obesity, reported by recent published studies, varies largely between 9.1% and 34.70% [8
], however these data are less reliable, as previously discussed [9
Equally important, the Romanian healthcare system does not have a clear policy regarding the involvement of licensed nutritionists/dieticians in addition to the medical services offered to patients with obesity, and in many cases the health care system does not cover the expenses encumbered for employing dieticians along with the doctors in designing life-style interventions that are aimed to decrease body weight. As a consequence, patients with obesity, especially in outpatient settings, often do not receive structured advice from their health care providers about how to implement healthy dietary habits, or no dietary advice is offered at all. Hospitalized patients may receive adequate nutritional advice from hospital-associated dieticians, however there is no clear policy regarding follow-up once a patient leaves the hospital. In all such cases, the burden of designing and implementing healthy dietary habits remains almost completely on the patient’s shoulders, as the choice of further involving a registered dietician is made by a minority of patients who can afford the associated expenses.
This study aimed to characterize the adequacy of macro- and micro-nutrients consumed by adults with obesity that were, at the time of assessment, under medical supervision by a qualified healthcare provider for obesity-associated diseases. The tested hypothesis was that, in the absence of proper nutritional assessment for intakes and of structured dietary advice and follow-up throughout the period when subjects attempt to lose weight, it is unlikely that adequate nutritional intakes would be reached at the levels of recommended dietary allowances (RDAs), per either United States Department of Agriculture (USDA) [11
] or European Food Safety Authority (EFSA) [12
This study examined the daily dietary intakes for more than 30 nutrients in both male and female adults from Western Romania with obesity, who at the time of the assessment were under medical supervision, all having metabolic disorders or cardiovascular diseases. The study further assessed the prevalence of reaching adequate intakes for micronutrients and macronutrient adequacy and distribution as a source of energy, using both USDA and EFSA criteria.
One of the main findings was that the intake of micronutrients, according to both criteria, was below recommendations for the vast majority of obese adults. Because the participants were, at the time of our investigation, under medical supervision, we decided not to exclude any subject due to low/high estimated energy intake (mean energy intake in the lowest 5% range was 653.8 ± 105.4 kcal and in the highest 5% range was 3371.2 ± 840.9 kcal). It is important to note that for all participants, there was no long-term structured dietary advice given by licensed dieticians/nutritionists, nor follow-up plans intended to re-assess recommendations, and that the food intakes were, in general, a result of advice given by doctors, without specifics, or a result of voluntary decisions taken by the participants in an attempt to lower their body weight. It is worth mentioning that in Romania, the profession of a nutritionist or dietician has been acknowledged since 2015 [20
], however Methodological Norms for the Application of the Law have been published only very recently, in 2019 [21
Using the USDA criteria, the adequacy of intake for less than 5% of participants was observed for vitamin D, fluoride, choline, vitamin E, potassium, linoleic acid, and alfa linolenic acid in both genders, and for magnesium in females. When EFSA criteria were applied, the adequacy of intake for less than 5% of participants was noted for vitamin D, vitamin E, and fluoride in both genders, for alpha-linolenic acid in males, and for choline, potassium, and fiber in females.
Conversely, the highest percentages of subjects reaching the recommended intakes were for thiamine (ranging from 45.75% to 99.06% across gender or criteria stratification), iron (from 26.42% to 86.80%), and selenium (ranging from 35.38% to 86.80% across gender of criteria stratification). It is also important to note that for most nutrients, there were significant differences in the prevalence of reaching the recommended intakes between males and females (Table 6
The estimated micronutrient intakes, as well as the prevalence of reaching the recommended values, are in line with previously published studies and point to the fact that obesity is associated not only with well-known associated diseases, but also with important and numerous micronutrient deficiencies, and in different settings (whether under supervised dietary interventions or not) [4
]. However, this is the first study, to the best of our knowledge, that assessed micronutrient intakes in people with obesity who were under medical supervision and that, at best, may have received recommendations mainly focused on the macronutrient content of food, but with no implemented follow-up plans.
This study also indicated a misbalance in macronutrient energy sources, with varying intakes of energy from fat and carbohydrates (Table 4
and Table 5
). While the recommended intake range of energy from fat was reached by 61.8% of subjects in the first quartile for energy intakes, only 23.5% of participants had an adequate value of energy from fat in the highest quartile, with no differences between men and women. These data also suggested that higher energy intakes were associated with increased consumption of fats.
The analysis of dietary fatty acid types revealed that 7.1% ± 2.4 from energy came from PUFAs and 12.7% ± 3.9% came from SFAs. These results are consistent with previous reports on fat and fatty acid intakes in European countries and worldwide. These indicated that in most countries, SFA intakes were higher than recommended, with intakes ranging from 8.9% to 15.5% E for SFA, while PUFA intakes were often below the optimal intakes, ranging from 3.9% to 11.3% E [26
]. In an epidemiological review (26) in the general population, Romania was placed in the top 3 nations for SFAs intake. Globally, the estimated worldwide average intake of SFAs was 9.4% of energy intake (% E), with a 95% confidence interval between 9.2% E and 9.5% E. The same review found that globally, omega-6 polyunsaturated fat mean intake was 5.9% E, and mean intake of seafood omega-3 fats was 163 mg/day, while plant omega-3 consumption was 1371 mg/day.
Health problems arise not only from the low intakes of PUFA, but also from an inadequate ratio of LA/ALA. High omega-6/omega-3 ratios were previously associated with weight gain and mood and cognition disorders such as neurological and psychiatric disorders, including depression, anxiety, schizophrenia, and attention deficit hyperactivity disorder, in animal and human studies [29
Sodium intake below the upper limit set by USDA was reached by only 10.6% of males and by 40.1% of females, and when using EFSA criteria, only 2.1% of males and 13.21% of females had lower intakes than the upper limit. Taking into account that when using sodium biomarkers usually an underestimation is detected, these results might be underestimating the real intake for this population [31
]. In a previous report, the average sodium intake in Eastern Europe was 11.1 g salt (NaCl) per day [32
This study has several limitations that need consideration. The dietary intakes were self-reported and underreporting of intakes (recall bias) is a common limitation of 24 h dietary recalls [33
]. Since the study was cross-sectional, it did not infer causal relationships with current diagnostics.
Another limitation is that the accuracy of nutrient intake estimates was limited by the variability in both natural and processed foods as well as in laboratory analyses of food samples, which are in the databases used by Nutritio for nutrient retrieval. This study did not use biomarkers and therefore no methodological validation was possible. The data presented cannot be considered representative for all individuals with obesity, but could be, at best, representative only for those who decided to lose weight in the absence of professional, long-term dietary advice and supervision. Therefore, for people with obesity who are either under professional nutritional advice or who do not limit their calorie intake in order to lose weight, one cannot make inferences regarding the adequacy of micronutrient intakes.