Energy and macronutrient intakes in Jordan: a population study

Jordan has never conducted a nutrition survey to determine nutrient and energy intakes. The current study aimed to describe the energy and macronutrient consumed by the Jordanian population. A cross-sectional food consumption study was conducted, including a sample of Jordanians using two non-consecutive 24-h dietary recalls (24-h DR) between October 2021 and March 2022. A total of 2145 males and females aged 8 to 85 years old living in households were studied. The average of two 24-h DRs for each individual was converted into energy and nutrient intakes. After measuring weight, height, and waist circumference, the body mass index (BMI) and waist-to-height ratio (WHtR) were calculated. The percentage of under-reporters was higher in women than men (58.2% vs. 45.9%). Adults and older adult women had the highest prevalence of obesity (29.6%), while adults and older adult men had the highest prevalence of overweight (41.4%). There is a significant increase in energy intake in children, boys, and all adults, compared to the recommended calories. The mean energy percentage (E %) of total fat was 38%, exceeding the upper limit of the Acceptable Macronutrient Distribution Range (AMDR). At the same time, the mean daily dietary fiber intake fell below the recommended levels (ranging from 13.5 g in children to 19.5 g in older adults). The study population consumes more fat and less fiber than the recommended levels. Actions must be taken across all age groups to correct the deviation of energy and macronutrient intakes from the recommended dietary allowances.

Inclusion criteria.All the people aged eight years and older residing in the selected private households consented to participate.The participants were divided into four age groups (8-12, 13-19, 20-64, and 65 years and older).

Exclusion criteria.
Children under eight in the chosen households and pregnant or lactating female subjects were excluded from the study.
Ethical approval.Individuals who agreed to participate in the survey received detailed information about the objectives; parents were asked for oral approval for their children to participate.No incentive money was offered for taking part in the survey.The Institutional Board Review (IRB) committee at The Hashemite University reviewed and approved the survey protocol (No.7/13/2020/2021).After receiving oral permission from the head of the household, one of the participant's parents signed an informed consent form for children and adolescents, and data collection began in the presence of parents during the first visit.Informed consent was obtained from the other participants of the household.Informed consent was obtained from all subjects and/or their legal guardian(s).
Data were collected by a trained interviewer who has a nutrition background.Each chosen household was only visited once.During the visit, the participants completed a face-to-face questionnaire on sociodemographic data, general health data, and intake of dietary supplements.Weight, height, and waist circumference were measured.Two non-consecutive 24-h DR was also conducted, the first of which was a face-to-face interview, while the second 24-h DR was collected via telephone.
Dietary assessment.Two non-consecutive 24-h DR obtained dietary intake for all age groups (weekday and weekend).The days of reporting were randomly selected, but participants were able to change them according to their availability for the interview.For children, the 24-h DR was administered in the presence of one of the parents.Participants were asked to recall and state all foods and beverages, including their quantity, preparation method, and most commonly consumed food brand names, from midnight to midnight the previous day.Various portion estimating aids, such as household measurement items and food models, were used; additionally, a well-known idea about the quantity was created by using a colored food atlas containing over one hundred foods and composite recipes consisting of photos of various foods and meals commonly consumed in Jordanian diets-a series of at least four photographs depicting portion sizes for each food item.To calculate the average dietary intake of energy and macronutrients.The consumed food items are linked to the following databases: ESHA's Food Processor®, Nutrition Analysis Software (version 11:0; ESHA Research), Composition of Local Jordanian Food Dishes 16 , and Lebanon Food Composition Data: Traditional Dishes, Arabic Sweets, and Market Foods 17 were used to analyze the food intake of the two recalls.The average total energy and macronutrient intake for all age groups was calculated.
Anthropometry.Anthropometric measurements, including height, weight, and waist circumference, were performed in all age groups according to standards by a trained nutritionist.Height was measured to the nearest centimeter, with participants in a standing position with light clothing and barefoot, using a portable wall stadiometer.Body weight was measured to the nearest tenth of a kilogram in the same conditions using a digital scale (Microlife WS 50.Widnau.Switzerland).Waist circumference was measured using an anthropometric tape at the level of the narrowest point between the lower costal border and the iliac crest 18 .Body mass index (BMI)(kg/ m 2 ) was calculated from the height and weight measurements according to Quetelet's formula 18 : BMI = weight (kg)/height (m 2 ) for adults.The Body Mass Index-for-Age Z-Score (BAZ) was calculated for children and adolescents.For the association of BMI-for-age with overweight and obesity, values > + 1 SD represent overweight, Ethical approval and consent to participate.The study was conducted according to the guidelines of the Declaration of Helsinki.The Institutional Board Review (IRB) committee at The Hashemite University reviewed and approved the survey protocol (No.7/13/2020/2021).

General characteristics of JPFCS.
A total of 2145 individuals participated in this study, of whom 954 (44.1%) were males, and 1200 (55.9%) were females; their general characteristics are presented in Table 1.Most of the study population were adults; aged 20-64 years (66.6%) and geographically distributed in the central governates in Jordan (62.1%).Nutritional supplements were consumed by approximately 21% of the subjects studied, with Vitamin D supplements having the highest contribution, and the mean family size was 4.5 people in the studied sample.Moreover, nearly half of the sample (49.8%) reported having a household income of less than 500 Jordanian dinars (JOD).
In the baseline data of our study, both genders were found to be almost similarly distributed in all other characteristics except dietary supplement use, which was shown to be used by females more frequently than males (28.6% vs. 11.1%)(Table 1).
The anthropometric assessment of the JPFCS study population is shown in Table 2.A significant (p = < 0.001) difference in overweight and obesity status relative to gender.Males were more likely to be overweight than females (42.1% vs. 28.9%,respectively) among adults ,and females were more likely to be obese for the age mentioned earlier than males (29.7% vs. 20.7%,respectively).Moreover, there was a significant (p = 0.012) difference in overweight and obesity status among older adults based on gender.Males were more likely to be overweight than females (44.0% vs. 28.6%,respectively), and females were more likely to be obese than males for the same age (53.1% vs. 24.0%,respectively)..On the other hand, males across all of the JPFCS age groups had larger percentages of abnormal ratios in terms of WHtR compared to females in the same age group.Furthermore, the adults category had the greatest abnormal WHtR (66.3% for males and 58.4% for females), which was statistically significant (p = 0.002), while the ratio was abnormal in less than 30% of males and around 23% of females in both other age categories.

Descriptive analysis of the EI misreporting among the JPFCS study population. As shown in
Table 3, 52.8% of JPFCS participants underreported their EI, while only 2.2% overreported; female participants tend to have a higher proportion of EI reporting (58.2%) than males (45.9%), which was significantly different (p = < 0.001).As the JPFCS study population was stratified according to gender and age, both genders tend to under-report their EI and become less reliable when reporting it.
Vol:.( 1234567890  www.nature.com/scientificreports/Although males during adolescence and early adulthood years have the same proportion of being UnR (47.8%), adult females tend to have a higher proportion of being UnR (61%) when compared to UnR adolescent female girls (54.4%).Additionally, older adult males and females have the highest EI reporting percentage (60% and 70.8%, respectively) compared to other age categories.Interestingly, none of the females aged 65 years and older in the JPFCS study population OvR had their EI, and only one male (2%) reported it (Table 3).
Energy and macronutrient intakes among the JPFCS study population.Among the study population, 47.2% were among the plausible EI group.Those 'participants' dietary intakes were included in the analysis to produce our JPFCS nutritional assessment.Table 4 presents the mean daily energy and macronutrient intake consumed by the selected study population.Male adults consumed a higher average amount of energy (2907.5 kcal), followed by adolescent boys (2758.6 kcal) and 'males' older adults (2513.5 kcal).While adolescent girls' mean daily EI is the highest (2220.9kcal), followed by adult females (2209.3kcal), female in older adults age has an average EI of (2039.1 kcal).With a p-value of 0.05, both genders have a significantly higher average of EI (2757.7 kcal vs. 2614.5kcal for males and 2161.7 kcal vs. 2096.6kcal for females) than EE, as shown in Fig. 1, which also displays differences in total daily EE and EI across all age groups.In contrast, the average daily EI of children boys and adult males is significantly higher than their average EE (Fig. 1a and c; p-value < 0.05), only the average daily EI of adult females is significantly higher than their average EE (p-value = 0.045) (Fig. 1c).
On the other hand, female older adults consumed a higher protein intake (15.9%), followed by male adults (15.8%) and male older adults (15.0%).All age/gender groups' intakes of protein and carbohydrates were within the typical ranges for a balanced diet (45-51% and 13-16%, respectively), while all participants (rather than age group or gender) had a higher tendency to consume a higher percentage of fat exceeded the daily recommendation (36-42%).Regardless of gender, it was apparent that low fiber intake was consumed by children, adolescents, adults, and older adults (14.5 g, 17.5 g, 16.3 g, 19.0 g, and 20.0 g, respectively).Furthermore, the average beverage consumption was the highest among older adult males (3080 ml) and the lowest among children girls (1570 ml) (Table 4).

Discussion
Individual nutrition surveys for examining food consumption patterns and their relationship to population-level energy, macronutrient, and micronutrient intakes have gained recognition worldwide; however, studies investigating food consumption based on individual nutrition surveys are lacking in the Eastern Mediterranean Region.The current study describes Jordanian children, adolescents, adults, and older adults' energy and macronutrient intakes.To the best of our knowledge, this is the first population-based study that estimates energy, macronutrient, fiber, and beverage intakes among Jordanians and in this region.
The general population's use of dietary supplements has been extensively studied.In the current study, 20.9% of participants (11.1% of males and 28.6% of females) used at least one dietary supplement, and the most commonly used supplements were Vitamin D, multivitamins, and omega 3, respectively.One possible explanation for why vitamin D is the most frequently used supplement is that in Jordan, the prevalence of vitamin D deficiency among males was 54% and 78.5% among females 26 .In another study, multivitamins were reported to be the most commonly used dietary supplements among Jordanian adults, followed by vitamin D and C 27 .
Energy intake is one of two components of energy balance; positive energy balance occurs when EI exceeds EE, which usually results in weight gain, defined as being overweight or obese.Using BMI as an anthropometric index for determining obesity, the current study found that approximately 60% of adults and older adults were overweight or obese, while 37% of children and adolescents were overweight or obese.www.nature.com/scientificreports/Many Jordanian studies reported the prevalence of overweight and obesity across all age groups except for EI.According to a multipurpose national household survey, approximately three-quarters of men and women aged 18-90 were overweight or obese 5 .In a nationwide, cross-sectional study of children aged 6-17 years conducted in 2015, the overall prevalence of overweight and obesity was 17.3% and 15.7%, respectively 28 .The findings of the current study were consistent with previously published studies.Using WHtR as another measure to define obesity, 46% of men and 54% of women were determined to be obese, which was consistent with Ajlouni et al. 5 , who reported that 60.4% of men and 75.6% of women were obese.Even though a cutoff of ≥ 0.5 is widely accepted as a universal level for obesity in children (aged ≥ 6 years) and adults 21 , the WHtR has not been studied extensively in Jordanian children and adolescents.Al Hourani and Alkhatib (2022) reported that 12.2% of children aged 10-14 years in a sample of 793 from the Amman subdistrict had abnormal WHtR 29 .
Energy intake has been extensively studied globally on various age groups using assessment methods with small or national sample sizes.Underreporting is still a problem that should be addressed in surveys designed to estimate EI; in our study, we estimated that 52% of the population was UnR.In the Belgian national food consumption survey on the population aged 15 years and older, 20% of the respondents were UnR 30 .Lundblad et al., 2019 reported a similar proportion in a population-based sample of Norwegians aged 40 to 99 years 1 .Also, similar results were reported in the Australian national nutrition and physical activity survey, though 28.6% of the respondents considered UnR using the Goldberg method, it was 44.5% using the predicted total EE method 31 .In the German national nutrition survey II, the proportion of UnR is 23% for the diet history interviews, 22% for the weighed food records, and 16% for the 24-h DR 32 .Malaysian adult nutrition surveys in 2003 and 2014 reported that the UnR of EI was 53.6% and 61%, respectively 33 .
The proportion of UnR varies widely; this can be attributed to various factors such as dietary assessment methods, female gender, increased age, and obesity 32 .The current study's findings correlate to these factors associated with UnR; furthermore, the first study used a 24-h DR to assess EI in a large population of different age groups, with a large proportion of females.
The current study found a significant increase in EI versus EE in both genders across the entire population, with a significant increase in EI observed in particular among male children and adult males and females.energy consumption in Brazil 48 .Further analysis of the current study data on beverage consumption is required to categorize it into different types, such as water, tea/coffee, sugary soft drinks, and others.The current study's findings can, at least partly, explain the role of dietary factors in the increased prevalence of overweight across all age groups and the progression of chronic non-communicable diseases in Jordan.Furthermore, this study was conducted following the COVID-19 pandemic and its effects on food habits and nutrient intake.The study's dietary profile can help support initiatives to lower the prevalence of obesity and diabetes mellitus.

Conclusion
Our findings provided important insights into the dietary patterns of the Jordanian population, revealing some nutrient deficiencies as well as excessive nutrient intake.It is also necessary to reduce fat consumption while increasing fiber consumption.More efforts are needed to improve the diets of older children and adolescents.It will also be necessary to monitor its progression.
Future research is required in a variety of areas, such as dietary habits for age groups that are at risk, like pregnant women and young children, the connection between energy and macronutrient intakes and obesity across all age groups, but particularly in children and adolescents, and the need to conduct regular surveys of food consumption to track changes over time.

Strength and limitations.
The current study has several strengths: first, it is noteworthy that this is the first population-based study designed to estimate dietary consumption in Jordan.Second, a large population sample of 2145 people aged 8 to 85 years old was recruited; third, rather than self-reporting, participants' heights, body weights, and waist circumference were measured, resulting in much more accurate assessments of BMI and WHtR.; The study has some limitations that should be considered: the fact that some of the participants were under reporters is a general limitation of all dietary assessment methods, including the current study.Data on physical activity were not obtained.Because the study was cross-sectional, establishing causality between the variables studied was difficult.Another potential limitation is that no biological samples, such as blood or urine, were collected, and no blood pressure was measured.

Figure 1 .
Figure 1.Differences in total daily energy expenditure and energy intake across all age groups: (a) for children, (b) for adolescents, (c) for adults, and (d) for older adults.*< 0.05; **< 0.01.

Table 1 .
Characteristics of the population sample stratified by gender.

Table 2 .
Anthropometric assessment of the population sample stratified by age and gender.Data are presented as numbers and percent within parenthesis: n (%).WHtR, Waist-to-height ratio.Significant values are in bold.

Table 4 .
Mean daily intakes of energy (kilocalories) and macronutrients (grams and percentage contribution to total energy intake) of participants according to age group.Data are presented as means ± SD. *p < 0.05; ***p < 0.001.