{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,14]],"date-time":"2026-09-14T13:06:44Z","timestamp":1789391204245,"version":"build-2803163510"},"reference-count":113,"publisher":"MDPI AG","issue":"18","license":[{"start":{"date-parts":[[2026,9,14]],"date-time":"2026-09-14T00:00:00Z","timestamp":1789344000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/100000002","name":"U.S. National Institutes of Health","doi-asserted-by":"publisher","award":["1K01HL171461-03"],"award-info":[{"award-number":["1K01HL171461-03"]}],"id":[{"id":"10.13039\/100000002","id-type":"DOI","asserted-by":"publisher"}]},{"award":["1K01HL171461-03"],"award-info":[{"award-number":["1K01HL171461-03"]}],"id":[{"id":"https:\/\/ror.org\/01cwqze88","id-type":"ROR","asserted-by":"publisher"}]},{"name":"ARM-President\u2019s Early Investigator Award","award":["87293"],"award-info":[{"award-number":["87293"]}]},{"award":["87293"],"award-info":[{"award-number":["87293"]}],"id":[{"id":"https:\/\/ror.org\/016tfm930","id-type":"ROR","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Nutrients"],"abstract":"<jats:p>Background\/Objectives: Nutrient deficiencies associated with progression from obesity to metabolic dysfunction are poorly characterized. Using electronic health records (TriNetX Research Network), we evaluated the association between key nutritional deficiencies and metabolic outcomes among patients with obesity. Methods: Deficiencies assessed included protein\u2013energy malnutrition, deficiencies in vitamin D, calcium, magnesium, and vitamin B12, and prior underweight status. Outcomes included severe obesity, prediabetes, type 2 diabetes, metabolic syndrome, metabolic dysfunction-associated steatotic liver disease (MASLD), and metabolic dysfunction-associated steatohepatitis (MASH). After matching propensity scores, cohorts with the double burden of malnutrition (DBM) were compared with a reference cohort of patients with obesity but no history of nutritional deficiencies. Results: The most prevalent types of DBM were vitamin D deficiency (10.6%), protein deficiency (8.9%) and calcium deficiency (7.5%). Incidence rates of obesity and all types of DBM increased from 2023 to 2025. Although middle-aged White and Black\/African American patients represented the largest demographic groups, adults aged &gt;70 years exhibited higher incidence rates of protein, calcium, magnesium, and B12 deficiencies. Vitamin D deficiency (median hazard ratio [HR] 3.09; IQR 2.32\u20135.66), vitamin B12 deficiency (median HR 2.49; IQR 2.16\u20136.08), and prior underweight (median HR 2.23; IQR 1.76\u20133.98) were associated with the highest burden of metabolic diseases. Conclusions: These findings underscore the interplay between nutritional deficiencies and metabolic disease risk in obesity and support targeted interventions for populations affected by DBM, especially older adults, and in the context of racial and socioeconomic disparities.<\/jats:p>","DOI":"10.3390\/nu18183005","type":"journal-article","created":{"date-parts":[[2026,9,14]],"date-time":"2026-09-14T12:09:51Z","timestamp":1789387791000},"page":"3005","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Enhanced Metabolic Risks in Patients with Obesity and Nutritional Deficiencies in the U.S.: A TriNetX Study"],"prefix":"10.3390","volume":"18","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-8014-6330","authenticated-orcid":false,"given":"Elvia Y.","family":"Osorio","sequence":"first","affiliation":[{"name":"Department of Internal Medicine, Division of Infectious Diseases, University of Texas Medical Branch, Galveston, TX 77555, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Zbigniew","family":"Gugala","sequence":"additional","affiliation":[{"name":"Department of Orthopedic Surgery and Rehabilitation, University of Texas Medical Branch, Galveston, TX 77555, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Peter C.","family":"Melby","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine, Division of Infectious Diseases, University of Texas Medical Branch, Galveston, TX 77555, USA"},{"name":"Department of Microbiology and Immunology, University of Texas Medical Branch, Galveston, TX 77555, USA"},{"name":"Center for Tropical Diseases, Institute for Human Infection and Immunity, University of Texas Medical Branch, Galveston, TX 77555, USA"},{"name":"Department of Pharmacology and Toxicology, University of Texas Medical Branch, Galveston, TX 77555, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Monique R.","family":"Ferguson","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine, Division of Infectious Diseases, University of Texas Medical Branch, Galveston, TX 77555, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3881-737X","authenticated-orcid":false,"given":"Kamil","family":"Khanipov","sequence":"additional","affiliation":[{"name":"Department of Pharmacology and Toxicology, University of Texas Medical Branch, Galveston, TX 77555, USA"},{"name":"The Institute for Translational Sciences, University of Texas Medical Branch, Galveston, TX 77555, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,9,14]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","unstructured":"Akombi, B.J., Chitekwe, S., Sahle, B.W., and Renzaho, A.M.N. (2019). Estimating the Double Burden of Malnutrition among 595,975 Children in 65 Low- and Middle-Income Countries: A Meta-Analysis of Demographic and Health Surveys. Int. J. Environ. Res. Public Health, 16.","DOI":"10.3390\/ijerph16162886"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"65","DOI":"10.1016\/S0140-6736(19)32497-3","article-title":"Dynamics of the double burden of malnutrition and the changing nutrition reality","volume":"395","author":"Popkin","year":"2020","journal-title":"Lancet"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"100466","DOI":"10.1016\/j.gfs.2020.100466","article-title":"The Processed food revolution in African food systems and the Double Burden of Malnutrition","volume":"28","author":"Reardon","year":"2021","journal-title":"Glob. Food Secur."},{"key":"ref_4","unstructured":"NCD Risk Factor Collaboration (NCD-RisC) (2024). Worldwide trends in underweight and obesity from 1990 to 2022: A pooled analysis of 3663 population-representative studies with 222 million children, adolescents, and adults. Lancet, 403, 1027\u20131050."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"998","DOI":"10.1016\/S0140-6736(24)00051-5","article-title":"Double burden of underweight and obesity: Insights from new global evidence","volume":"403","author":"Tumas","year":"2024","journal-title":"Lancet"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"156523","DOI":"10.1016\/j.metabol.2026.156523","article-title":"Increasing prevalence of obesity among US adults from 1999 to 2023, data from the US National Health and Nutrition Examination Survey (NHANES)","volume":"177","author":"Muntner","year":"2026","journal-title":"Metab.-Clin. Exp."},{"key":"ref_7","unstructured":"CDC (2025). Obesity, Adult Obesity Prevalence Maps."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"126","DOI":"10.1080\/07315724.2014.901196","article-title":"Comparison of prevalence of inadequate nutrient intake based on body weight status of adults in the United States: An analysis of NHANES 2001\u20132008","volume":"34","author":"Agarwal","year":"2015","journal-title":"J. Am. Coll. Nutr."},{"key":"ref_9","first-page":"e55062","article-title":"Nutritional Deficiencies Before and After Bariatric Surgery in Low- and High-Income Countries: Prevention and Treatment","volume":"16","author":"Kamal","year":"2024","journal-title":"Cureus"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"595","DOI":"10.1007\/BF00400248","article-title":"Type 2 (non-insulin-dependent) diabetes mellitus: The thrifty phenotype hypothesis","volume":"35","author":"Hales","year":"1992","journal-title":"Diabetologia"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"2400","DOI":"10.2337\/db10-0385","article-title":"Exposure to the Chinese famine in early life and the risk of hyperglycemia and type 2 diabetes in adulthood","volume":"59","author":"Li","year":"2010","journal-title":"Diabetes"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"237","DOI":"10.1146\/annurev-publhealth-031210-101230","article-title":"Prenatal famine and adult health","volume":"32","author":"Lumey","year":"2011","journal-title":"Annu. Rev. Public Health"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"787","DOI":"10.1016\/S2213-8587(15)00279-X","article-title":"Association between type 2 diabetes and prenatal exposure to the Ukraine famine of 1932\u20131933: A retrospective cohort study","volume":"3","author":"Lumey","year":"2015","journal-title":"Lancet Diabetes Endocrinol."},{"key":"ref_14","doi-asserted-by":"crossref","unstructured":"Taeubert, M.J., Kuipers, T.B., Zhou, J., Li, C., Wang, S., Wang, T., Tobi, E.W., Belsky, D.W., and Lumey, L.H. (2024). Adults prenatally exposed to the Dutch Famine exhibit a metabolic signature associated with a broad spectrum of common diseases. BMC Med., 22.","DOI":"10.1186\/s12916-024-03529-2"},{"key":"ref_15","doi-asserted-by":"crossref","unstructured":"Elegbeleye, J.A., Fayemi, O.E., Agbemavor, W.S.K., Krishnamoorthy, S., Adebowale, O.J., Adeyanju, A.A., Mkhabela, B., and Bamidele, O.P. (2025). Beyond Calories: Addressing Micronutrient Deficiencies in the World\u2019s Most Vulnerable Communities\u2014A Review. Nutrients, 17.","DOI":"10.3390\/nu17243960"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"850","DOI":"10.1016\/j.ajcnut.2023.12.019","article-title":"Food Insecurity, Neighborhood Food Environment, and Health Disparities: State of the Science, Research Gaps and Opportunities","volume":"119","author":"Brown","year":"2024","journal-title":"Am. J. Clin. Nutr."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"1257","DOI":"10.3945\/jn.115.226654","article-title":"Urbanicity Gradients Are Associated with the Household- and Individual-Level Double Burden of Malnutrition in Sub-Saharan Africa","volume":"146","author":"Jones","year":"2016","journal-title":"J. Nutr."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"e13366","DOI":"10.1111\/obr.13366","article-title":"The nutrition transition to a stage of high obesity and noncommunicable disease prevalence dominated by ultra-processed foods is not inevitable","volume":"23","author":"Popkin","year":"2022","journal-title":"Obes. Rev."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"27","DOI":"10.7570\/jomes24045","article-title":"Ultra-Processed Food Consumption and Obesity: A Narrative Review of Their Association and Potential Mechanisms","volume":"34","author":"Shim","year":"2025","journal-title":"J. Obes. Metab. Syndr."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"307","DOI":"10.1007\/s11154-020-09578-1","article-title":"Double burden of malnutrition in persons with obesity","volume":"21","author":"Barazzoni","year":"2020","journal-title":"Rev. Endocr. Metab. Disord."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"51","DOI":"10.4161\/derm.24494","article-title":"Sunlight and Vitamin D: A global perspective for health","volume":"5","author":"Wacker","year":"2013","journal-title":"Dermato-Endocrinol."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"327","DOI":"10.1038\/nature10213","article-title":"Human nutrition, the gut microbiome and the immune system","volume":"474","author":"Kau","year":"2011","journal-title":"Nature"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"218","DOI":"10.1007\/s00253-025-13570-7","article-title":"Bidirectional interactions between circadian rhythms and the gut microbiome","volume":"109","author":"Bautista","year":"2025","journal-title":"Appl. Microbiol. Biotechnol."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"2564","DOI":"10.1210\/jc.2016-3591","article-title":"Impaired Release of Vitamin D in Dysfunctional Adipose Tissue: New Cues on Vitamin D Supplementation in Obesity","volume":"102","author":"Sabovic","year":"2017","journal-title":"J. Clin. Endocrinol. Metab."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"690","DOI":"10.1093\/ajcn\/72.3.690","article-title":"Decreased bioavailability of vitamin D in obesity","volume":"72","author":"Wortsman","year":"2000","journal-title":"Am. J. Clin. Nutr."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"e1590","DOI":"10.1016\/S2214-109X(24)00276-6","article-title":"Global estimation of dietary micronutrient inadequacies: A modelling analysis","volume":"12","author":"Passarelli","year":"2024","journal-title":"Lancet Glob. Health"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"2133","DOI":"10.1038\/s41591-024-03165-6","article-title":"Western diets and chronic diseases","volume":"30","author":"Adolph","year":"2024","journal-title":"Nat. Med."},{"key":"ref_28","first-page":"103472","article-title":"The Malnutrition of Obesity: Micronutrient Deficiencies That Promote Diabetes","volume":"2012","author":"Via","year":"2012","journal-title":"Int. Sch. Res. Not."},{"key":"ref_29","doi-asserted-by":"crossref","unstructured":"Dhalla, N.S., Tappia, P.S., and Elimban, V. (2026). Micronutrient Deficiencies, Oxidative Stress, and Inflammation in Cardiometabolic Pathologies: Three Is a Crowd. Functional Biochemistry of Micronutrients, Springer Nature.","DOI":"10.1007\/978-3-032-14441-6"},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"20220224","DOI":"10.1098\/rstb.2022.0224","article-title":"Natural selection and human adiposity: Crafty genotype, thrifty phenotype","volume":"378","author":"Wells","year":"2023","journal-title":"Philos. Trans. R. Soc. B Biol. Sci."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"e12981","DOI":"10.1111\/obr.12981","article-title":"Foetal and childhood exposure to famine and the risks of cardiometabolic conditions in adulthood: A systematic review and meta-analysis of observational studies","volume":"21","author":"Hidayat","year":"2020","journal-title":"Obes. Rev."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"e816","DOI":"10.1016\/S2214-109X(18)30308-5","article-title":"Early life nutritional supplements and later metabolic disease","volume":"6","author":"Prentice","year":"2018","journal-title":"Lancet Glob. Health"},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"1025","DOI":"10.2337\/dc17-2336","article-title":"Obesity Progression Between Young Adulthood Midlife Incident Diabetes: ARetrospective Cohort Study of, U.S. Adults","volume":"41","author":"Stokes","year":"2018","journal-title":"Diabetes Care"},{"key":"ref_34","unstructured":"Everitt, B.S. (2006). The Cambridge Dictionary of Statistics, Cambridge University Press."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"1338","DOI":"10.1001\/jama.2018.13467","article-title":"Association of Clinical and Social Factors with Excess Hypertension Risk in Black Compared with White US Adults","volume":"320","author":"Howard","year":"2018","journal-title":"JAMA"},{"key":"ref_36","doi-asserted-by":"crossref","unstructured":"Martini, D., Godos, J., Bonaccio, M., Vitaglione, P., and Grosso, G. (2021). Ultra-Processed Foods and Nutritional Dietary Profile: A Meta-Analysis of Nationally Representative Samples. Nutrients, 13.","DOI":"10.3390\/nu13103390"},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"e13146","DOI":"10.1111\/obr.13146","article-title":"Ultraprocessed food and chronic noncommunicable diseases: A systematic review and meta-analysis of 43 observational studies","volume":"22","author":"Lane","year":"2021","journal-title":"Obes. Rev."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"283","DOI":"10.1017\/S0029665121000902","article-title":"The global challenge of hidden hunger: Perspectives from the field","volume":"80","author":"Lowe","year":"2021","journal-title":"Proc. Nutr. Soc."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"88","DOI":"10.1186\/s12937-026-01340-8","article-title":"Link between ultra-processed foods and drinks intake, gut microbiota and inflammation: An exploratory analysis in adult volunteers","volume":"25","author":"Autuori","year":"2026","journal-title":"Nutr. J."},{"key":"ref_40","doi-asserted-by":"crossref","unstructured":"Kannan, K., and Vimalkumar, K. (2021). A Review of Human Exposure to Microplastics and Insights Into Microplastics as Obesogens. Front. Endocrinol., 12.","DOI":"10.3389\/fendo.2021.724989"},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"449","DOI":"10.1016\/S2213-8587(26)00074-4","article-title":"Implications of microplastics as emerging endocrine disruptors","volume":"14","author":"Bornstein","year":"2026","journal-title":"Lancet Diabetes Endocrinol."},{"key":"ref_42","doi-asserted-by":"crossref","unstructured":"Hales, L.J., Coleman-Jensen, A., United States Department of Agriculture, and Economic Research Service (2024). Household Food Insecurity Across Race and Ethnicity in the United States, 2016-21, Economic Research Service.","DOI":"10.32747\/2024.9460433.ers"},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"183","DOI":"10.1111\/obr.12131","article-title":"Protein leverage and energy intake","volume":"15","author":"Gosby","year":"2014","journal-title":"Obes. Rev."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"1225","DOI":"10.1002\/oby.22531","article-title":"Protein Leverage: Theoretical Foundations and Ten Points of Clarification","volume":"27","author":"Raubenheimer","year":"2019","journal-title":"Obesity"},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"672","DOI":"10.1038\/s41574-025-01143-7","article-title":"The role of ultra-processed food in obesity","volume":"21","author":"Juul","year":"2025","journal-title":"Nat. Rev. Endocrinol."},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"214","DOI":"10.1007\/s13679-024-00569-w","article-title":"Ultra-Processed Food Addiction: A Research Update","volume":"13","author":"LaFata","year":"2024","journal-title":"Curr. Obes. Rep."},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"13","DOI":"10.1038\/s44324-025-00056-3","article-title":"Ultra-processed food consumption affects structural integrity of feeding-related brain regions independent of and via adiposity","volume":"3","author":"Morys","year":"2025","journal-title":"npj Metab. Health Dis."},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"283","DOI":"10.1017\/S0029665120000166","article-title":"Emotional eating and obesity in adults: The role of depression, sleep and genes","volume":"79","author":"Konttinen","year":"2020","journal-title":"Proc. Nutr. Soc."},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"e075354","DOI":"10.1136\/bmj-2023-075354","article-title":"Social; clinical, and policy implications of ultra-processed food addiction","volume":"383","author":"Gearhardt","year":"2023","journal-title":"BMJ"},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"e158451","DOI":"10.1172\/JCI158451","article-title":"Metabolic changes in aging humans: Current evidence and therapeutic strategies","volume":"132","author":"Palmer","year":"2022","journal-title":"J. Clin. Investig."},{"key":"ref_51","doi-asserted-by":"crossref","unstructured":"Karvonen-Gutierrez, C., and Kim, C. (2016). Association of Mid-Life Changes in Body Size, Body Composition and Obesity Status with the Menopausal Transition. Healthcare, 4.","DOI":"10.3390\/healthcare4030042"},{"key":"ref_52","doi-asserted-by":"crossref","first-page":"e941394","DOI":"10.12659\/MSM.941394","article-title":"The Impact of Visceral Adiposity on Testosterone Levels in American Adult Men: A Cross-Sectional Analysis","volume":"29","author":"Su","year":"2023","journal-title":"Med. Sci. Monit."},{"key":"ref_53","doi-asserted-by":"crossref","first-page":"1028","DOI":"10.1079\/PHN2005794","article-title":"Energy requirements and aging","volume":"8","author":"Roberts","year":"2005","journal-title":"Public Health Nutr."},{"key":"ref_54","doi-asserted-by":"crossref","first-page":"758","DOI":"10.5534\/wjmh.250126","article-title":"Sex and Gender Differences in Obesity: Biological, Sociocultural, and Clinical Perspectives","volume":"43","author":"Kim","year":"2025","journal-title":"World J. Mens. Health"},{"key":"ref_55","doi-asserted-by":"crossref","unstructured":"Yu, Y., Li, H., Hu, N.-X., Wu, X.-H., Huang, X.-Y., Lin, H.-T., Yu, K.-L., and Li, J.-L. (2024). Global burden and health inequality of nutritional deficiencies from 1990 to 2019. Front. Nutr., 11.","DOI":"10.3389\/fnut.2024.1470713"},{"key":"ref_56","doi-asserted-by":"crossref","first-page":"1059","DOI":"10.1093\/ajcn\/nqab113","article-title":"Association of food insecurity with dietary intakes and nutritional biomarkers among US children, National Health and Nutrition Examination Survey (NHANES) 2011\u20132016","volume":"114","author":"Jun","year":"2021","journal-title":"Am. J. Clin. Nutr."},{"key":"ref_57","doi-asserted-by":"crossref","first-page":"146","DOI":"10.1007\/s10522-025-10289-w","article-title":"Aging influences protein digestion, absorption and amino acid metabolism","volume":"26","author":"Qiu","year":"2025","journal-title":"Biogerontology"},{"key":"ref_58","doi-asserted-by":"crossref","first-page":"1359S","DOI":"10.1093\/jn\/131.4.1359S","article-title":"Factors in Aging that Effect the Bioavailability of Nutrients","volume":"131","author":"Russell","year":"2001","journal-title":"J. Nutr."},{"key":"ref_59","doi-asserted-by":"crossref","first-page":"435","DOI":"10.1093\/ndt\/gfae204","article-title":"Biology of calcium homeostasis regulation in intestine and kidney","volume":"40","author":"Deluque","year":"2025","journal-title":"Nephrol. Dial. Transplant."},{"key":"ref_60","doi-asserted-by":"crossref","first-page":"305","DOI":"10.1007\/s40653-019-00282-0","article-title":"Malnutrition and Medical Neglect","volume":"13","author":"Burford","year":"2020","journal-title":"J. Child. Adolesc. Trauma"},{"key":"ref_61","doi-asserted-by":"crossref","first-page":"e2501889","DOI":"10.1002\/advs.202501889","article-title":"The Molecular Basis of Amino Acids Sensing","volume":"12","author":"Jiang","year":"2025","journal-title":"Adv. Sci."},{"key":"ref_62","doi-asserted-by":"crossref","first-page":"130","DOI":"10.12997\/jla.2021.10.2.130","article-title":"The Role of Vitamin D in Adipose Tissue Biology: Adipocyte Differentiation, Energy Metabolism, and Inflammation","volume":"10","author":"Park","year":"2021","journal-title":"J. Lipid Atheroscler."},{"key":"ref_63","doi-asserted-by":"crossref","unstructured":"Ghosh, J., and Chattopadhyay, D. (2026). Immunometabolic control of cytokine production by micronutrients in health, aging, and inflammation. Front. Immunol., 17.","DOI":"10.3389\/fimmu.2026.1781797"},{"key":"ref_64","doi-asserted-by":"crossref","unstructured":"Finta, H., Avram, C., Buicu, C.-F., Ceana, D.-E., Moldovan, I., and Ruta, F. (2026). Micronutrient Status, Health Implications, and Assessment Aproaches in Older Adults: A Narrative Review of Recent Studies. Life, 16.","DOI":"10.3390\/life16040570"},{"key":"ref_65","unstructured":"United States Census Bureau (2026, June 01). American Community Survey 1-Year Estimates. Census Reporter Profile Page for West South Central Division, Available online: http:\/\/censusreporter.org\/profiles\/03000US7-west-south-central-division\/."},{"key":"ref_66","doi-asserted-by":"crossref","unstructured":"Judd, S.E., Letter, A.J., Shikany, J.M., Roth, D.L., and Newby, P.K. (2015). Dietary Patterns Derived Using Exploratory and Confirmatory Factor Analysis are Stable and Generalizable Across Race, Region, and Gender Subgroups in the REGARDS Study. Front. Nutr., 1.","DOI":"10.3389\/fnut.2014.00029"},{"key":"ref_67","doi-asserted-by":"crossref","first-page":"1904","DOI":"10.1017\/S0007114521000696","article-title":"Correlates of a southern diet pattern in a national cohort study of blacks and whites: The REasons for Geographic and Racial Differences in Stroke (REGARDS) study","volume":"126","author":"Couch","year":"2021","journal-title":"Br. J. Nutr."},{"key":"ref_68","doi-asserted-by":"crossref","first-page":"74","DOI":"10.1016\/j.amepre.2008.09.025","article-title":"Neighborhood environments: Disparities in access to healthy foods in the U.S","volume":"36","author":"Larson","year":"2009","journal-title":"Am. J. Prev. Med."},{"key":"ref_69","doi-asserted-by":"crossref","first-page":"1345","DOI":"10.1017\/S1368980018000101","article-title":"Barriers to fruit and vegetable consumption among farmers\u2019 market incentive programme users in Illinois, USA","volume":"21","author":"Singleton","year":"2018","journal-title":"Public Health Nutr."},{"key":"ref_70","unstructured":"Hewison, M., Bouillon, R., Giovannucci, E., Goltzman, D., Meyer, M., and Welsh, J. (2024). Chapter 56\u2014Determinants of vitamin D levels from sun exposure: A global perspective. Feldman and Pike\u2019s Vitamin D, Academic Press. [5th ed.]."},{"key":"ref_71","doi-asserted-by":"crossref","first-page":"74","DOI":"10.1016\/S0140-6736(82)90214-8","article-title":"Increased skin pigment reduces the capacity of skin to synthesise vitamin D3","volume":"1","author":"Clemens","year":"1982","journal-title":"Lancet"},{"key":"ref_72","doi-asserted-by":"crossref","first-page":"E813","DOI":"10.1152\/ajpendo.00310.2025","article-title":"Undernutrition-related diabetes in mice is linked to early undernutrition","volume":"330","author":"Osorio","year":"2026","journal-title":"Am. J. Physiol. Endocrinol. Metab."},{"key":"ref_73","doi-asserted-by":"crossref","first-page":"128","DOI":"10.1017\/S0954422418000239","article-title":"Interplay between early-life malnutrition, epigenetic modulation of the immune function and liver diseases","volume":"32","author":"Campisano","year":"2019","journal-title":"Nutr. Res. Rev."},{"key":"ref_74","doi-asserted-by":"crossref","first-page":"2153","DOI":"10.1210\/jc.2005-2778","article-title":"Early Development of Adiposity and Insulin Resistance after Catch-Up Weight Gain in Small-for-Gestational-Age Children","volume":"91","author":"Ong","year":"2006","journal-title":"J. Clin. Endocrinol. Metab."},{"key":"ref_75","doi-asserted-by":"crossref","unstructured":"Ansai, N., Fryar, C.D., and Afful, J. (2026). Health E-Stat 119: Prevalence of Underweight Among Children, Adolescents, and Adults: United States, 1960-1962 Through August 2021-August 2023. NCHS Health E-Stats, 1\u22125.","DOI":"10.15620\/cdc\/174643"},{"key":"ref_76","doi-asserted-by":"crossref","unstructured":"Price, A.A., Williams, J.A., Doetsch, H.E., Spees, C.K., and Taylor, C.A. (2020). Utilization of Current Diagnostic Indicators to Characterize Pediatric Undernutrition among US Children. Nutrients, 12.","DOI":"10.3390\/nu12051409"},{"key":"ref_77","unstructured":"The Annie E. Cassie Foundation (2025). Total Population by Child and Adult Populations in United States. 2015\u20132024, The Annie E. Casey Foundation, Kids Count Data Center."},{"key":"ref_78","doi-asserted-by":"crossref","first-page":"358","DOI":"10.1097\/PSY.0000000000001193","article-title":"A Gene-Acculturation Study of Obesity Among US Hispanic\/Latinos: The Hispanic Community Health Study\/Study of Latinos","volume":"85","author":"McArdle","year":"2023","journal-title":"Psychosom. Med."},{"key":"ref_79","doi-asserted-by":"crossref","first-page":"50","DOI":"10.4278\/ajhp.140128-QUAN-49","article-title":"The Role of Physical Activity and Sedentary Behaviors in Explaining the Association Between Acculturation and Obesity Among Mexican-American Adults","volume":"30","author":"Murillo","year":"2015","journal-title":"Am. J. Health Promot."},{"key":"ref_80","unstructured":"U.S. Department of Health and Human Services, Office of Minority Health (2026, June 01). Obesity and Hispanic\/Latino Americans, Available online: https:\/\/minorityhealth.hhs.gov\/obesity-and-hispanicslatinos."},{"key":"ref_81","doi-asserted-by":"crossref","first-page":"190","DOI":"10.1016\/j.advnut.2022.12.001","article-title":"The Determinants of Food Insecurity Among Hispanic\/Latinx Households with Young Children: A Narrative Review","volume":"14","author":"Varela","year":"2023","journal-title":"Adv. Nutr."},{"key":"ref_82","unstructured":"Feeding America National Organization (2023). Food Insecurity among the Overall Population in the United States. Map the Meal Gap, Feeding America National Organization."},{"key":"ref_83","doi-asserted-by":"crossref","first-page":"2419","DOI":"10.1001\/jama.2018.7270","article-title":"Differences in Obesity Prevalence by Demographic Characteristics and Urbanization Level Among Adults in the United States, 2013\u20132016","volume":"319","author":"Hales","year":"2018","journal-title":"JAMA"},{"key":"ref_84","doi-asserted-by":"crossref","unstructured":"Nuako, A., Liu, J., Pham, G., Smock, N., James, A., Baker, T., Bierut, L., Colditz, G., and Chen, L.-S. (2022). Quantifying rural disparity in healthcare utilization in the United States: Analysis of a large midwestern healthcare system. PLoS ONE, 17.","DOI":"10.1371\/journal.pone.0263718"},{"key":"ref_85","doi-asserted-by":"crossref","first-page":"377","DOI":"10.1080\/20009666.2019.1681056","article-title":"A resident-led project to improve documentation of overweight and obesity in a primary care clinic","volume":"9","author":"Vitale","year":"2019","journal-title":"J. Community Hosp. Intern. Med. Perspect."},{"key":"ref_86","doi-asserted-by":"crossref","first-page":"S156","DOI":"10.3122\/jabfm.2023.230454R1","article-title":"Food Insecurity Is Associated with Vitamin B12 Deficiency: The All of Us Database","volume":"37","author":"Parente","year":"2024","journal-title":"J. Am. Board. Fam. Med."},{"key":"ref_87","doi-asserted-by":"crossref","first-page":"585","DOI":"10.4239\/wjd.v14.i5.585","article-title":"Association between metformin and vitamin B12 deficiency in patients with type 2 diabetes","volume":"14","author":"Sayedali","year":"2023","journal-title":"World J. Diabetes"},{"key":"ref_88","doi-asserted-by":"crossref","first-page":"107968","DOI":"10.1016\/j.amepre.2025.107968","article-title":"Racial and Ethnic Disparities in Alcohol Consumption and Mortality in the U.S","volume":"69","author":"Naimi","year":"2025","journal-title":"Am. J. Prev. Med."},{"key":"ref_89","doi-asserted-by":"crossref","unstructured":"Obeid, R., Heil, S.G., Verhoeven, M.M.A., van den Heuvel, E.G.H.M., de Groot, L.C.P.G.M., and Eussen, S.J.P.M. (2019). Vitamin B12 Intake From Animal Foods, Biomarkers, and Health Aspects. Front. Nutr., 6.","DOI":"10.3389\/fnut.2019.00093"},{"key":"ref_90","doi-asserted-by":"crossref","unstructured":"Argano, C., Mirarchi, L., Amodeo, S., Orlando, V., Torres, A., and Corrao, S. (2023). The Role of Vitamin D and Its Molecular Bases in Insulin Resistance, Diabetes, Metabolic Syndrome, and Cardiovascular Disease: State of the Art. Int. J. Mol. Sci., 24.","DOI":"10.20944\/preprints202309.0595.v1"},{"key":"ref_91","doi-asserted-by":"crossref","first-page":"e2250621","DOI":"10.1001\/jamanetworkopen.2022.50621","article-title":"Folate, Vitamin B6, and Vitamin B12 Status in Association with Metabolic Syndrome Incidence","volume":"6","author":"Zhu","year":"2023","journal-title":"JAMA Netw. Open"},{"key":"ref_92","first-page":"E36","article-title":"The Influence of Metabolic Syndrome in Predicting Mortality Risk Among US Adults: Importance of Metabolic Syndrome Even in Adults with Normal Weight","volume":"17","author":"Shi","year":"2020","journal-title":"CDC Prev. Chronic Dis."},{"key":"ref_93","doi-asserted-by":"crossref","first-page":"100393","DOI":"10.1016\/j.jnha.2024.100393","article-title":"Protein source associated with risk of metabolic syndrome in adults with low and adequate protein intake: A prospective cohort study of middle-aged and older adults","volume":"28","author":"Lyu","year":"2024","journal-title":"J. Nutr. Health Aging"},{"key":"ref_94","doi-asserted-by":"crossref","first-page":"e2324","DOI":"10.1210\/clinem\/dgae075","article-title":"Magnesium Depletion Score and Metabolic Syndrome in US Adults: Analysis of NHANES 2003 to 2018","volume":"109","author":"Wang","year":"2024","journal-title":"J. Clin. Endocrinol. Metab."},{"key":"ref_95","doi-asserted-by":"crossref","first-page":"e13850","DOI":"10.1111\/obr.13850","article-title":"Dietary calcium intake in relation to metabolic syndrome in adults: A systematic review and dose\u2013response meta-analysis of epidemiological studies with GRADE assessment","volume":"26","author":"Nematbakhsh","year":"2025","journal-title":"Obes. Rev."},{"key":"ref_96","doi-asserted-by":"crossref","first-page":"2055","DOI":"10.1017\/S1368980019000247","article-title":"Dietary calcium intake and the risk of metabolic syndrome: Evidence from observational studies","volume":"22","author":"Cheng","year":"2019","journal-title":"Public Health Nutr."},{"key":"ref_97","doi-asserted-by":"crossref","first-page":"e00499-20","DOI":"10.1128\/mSystems.00499-20","article-title":"Dietary Intervention Reverses Fatty Liver and Altered Gut Microbiota during Early-Life Undernutrition","volume":"5","author":"Bauer","year":"2020","journal-title":"mSystems"},{"key":"ref_98","doi-asserted-by":"crossref","first-page":"e43","DOI":"10.1017\/jns.2026.10114","article-title":"Dietary fish oil improves intestinal barrier function and intestinal microbiota composition and reduces systemic inflammation in a mouse model of moderate acute malnutrition","volume":"15","author":"Patterson","year":"2026","journal-title":"J. Nutr. Sci."},{"key":"ref_99","doi-asserted-by":"crossref","first-page":"269","DOI":"10.4240\/wjgs.v12.i6.269","article-title":"Role of micronutrients in staging of nonalcoholic fatty liver disease: A retrospective cross-sectional study","volume":"12","author":"Bertol","year":"2020","journal-title":"World J. Gastrointest. Surg."},{"key":"ref_100","doi-asserted-by":"crossref","unstructured":"Fu, L., Wang, Y., and Hu, Y.-Q. (2023). Bi-directional causal effect between vitamin B12 and non-alcoholic fatty liver disease: Inferring from large population data. Front. Nutr., 10.","DOI":"10.3389\/fnut.2023.1015046"},{"key":"ref_101","doi-asserted-by":"crossref","unstructured":"Aureli, A., Recupero, R., Mariani, M., Manco, M., Carlomagno, F., Bocchini, S., Nicodemo, M., Marchili, M.R., Cianfarani, S., and Cappa, M. (2023). Low Levels of Serum Total Vitamin B12 Are Associated with Worse Metabolic Phenotype in a Large Population of Children, Adolescents and Young Adults, from Underweight to Severe Obesity. Int. J. Mol. Sci., 24.","DOI":"10.3390\/ijms242316588"},{"key":"ref_102","doi-asserted-by":"crossref","unstructured":"Lee, Y.J., Wang, M.Y., Lin, M.C., and Lin, P.T. (2016). Associations between Vitamin B-12 Status and Oxidative Stress and Inflammation in Diabetic Vegetarians and Omnivores. Nutrients, 8.","DOI":"10.3390\/nu8030118"},{"key":"ref_103","doi-asserted-by":"crossref","unstructured":"Vaccaro, J.A., Qasem, A., and Naser, S.A. (2023). Folate and Vitamin B12 Deficiency Exacerbate Inflammation during Mycobacterium avium paratuberculosis (MAP) Infection. Nutrients, 15.","DOI":"10.3390\/nu15020261"},{"key":"ref_104","doi-asserted-by":"crossref","unstructured":"Liu, Y., Qian, K., Shi, X., Jing, Y., He, H., Li, Y., Li, D., and Wang, S. (2024). Synergistic Effects of Nutrients on Musculoskeletal Health in Gerontology: Understanding the Combined Impact of Macronutrients and Micronutrients. Nutrients, 16.","DOI":"10.3390\/nu16111640"},{"key":"ref_105","doi-asserted-by":"crossref","unstructured":"Oma\u00f1a-Guzm\u00e1n, I., Kammar-Garc\u00eda, A., Gutierrez-Robledo, L.M., and Rosas-Carrasco, O. (2024). Undernutrition risk and obesity increase the risk of osteosarcopenia in Mexican adults aged 50 and over: A prospective cohort study. Front. Nutr., 11.","DOI":"10.3389\/fnut.2024.1499453"},{"key":"ref_106","doi-asserted-by":"crossref","first-page":"733.e1","DOI":"10.1016\/j.jamda.2017.02.023","article-title":"Osteosarcopenic Obesity: Prevalence and Relation with Frailty and Physical Performance in Middle-Aged and Older Women","volume":"18","author":"Szlejf","year":"2017","journal-title":"J. Am. Med. Dir. Assoc."},{"key":"ref_107","doi-asserted-by":"crossref","unstructured":"Armandi, A., Rosso, C., Caviglia, G.P., Ribaldone, D.G., and Bugianesi, E. (2021). The Impact of Dysmetabolic Sarcopenia Among Insulin Sensitive Tissues: A Narrative Review. Front. Endocrinol., 12.","DOI":"10.3389\/fendo.2021.716533"},{"key":"ref_108","doi-asserted-by":"crossref","first-page":"e243604","DOI":"10.1001\/jamanetworkopen.2024.3604","article-title":"Sarcopenia and Sarcopenic Obesity and Mortality Among Older People","volume":"7","author":"Benz","year":"2024","journal-title":"JAMA Netw. Open"},{"key":"ref_109","doi-asserted-by":"crossref","unstructured":"Long, Y., Zhao, H., Sun, D., Wen, Y., and Yu, Y. (2026). Association between osteosarcopenia and frailty in older adults: A systematic review and meta-analysis. BMC Geriatr., 26.","DOI":"10.1186\/s12877-026-06976-z"},{"key":"ref_110","doi-asserted-by":"crossref","first-page":"221","DOI":"10.1016\/S2213-8587(24)00316-4","article-title":"Definition and diagnostic criteria of clinical obesity","volume":"13","author":"Rubino","year":"2025","journal-title":"Lancet Diabetes Endocrinol."},{"key":"ref_111","doi-asserted-by":"crossref","first-page":"1092","DOI":"10.1182\/blood-2023-173737","article-title":"Symptomatic Iron Deficiency without Anemia: An Underrecognized Phenomenon","volume":"142","author":"Sevgi","year":"2023","journal-title":"Blood"},{"key":"ref_112","doi-asserted-by":"crossref","first-page":"101299","DOI":"10.1016\/j.eclinm.2022.101299","article-title":"Global; regional, and national burdens of common micronutrient deficiencies from 1990 to 2019: A secondary trend analysis based on the Global Burden of Disease 2019 study","volume":"44","author":"Han","year":"2022","journal-title":"eClinicalMedicine"},{"key":"ref_113","doi-asserted-by":"crossref","first-page":"857","DOI":"10.1093\/ajcn\/nqy110","article-title":"Fortifying food with folic acid to prevent neural tube defects: Are we now where we ought to be?","volume":"107","author":"Molloy","year":"2018","journal-title":"Am. J. Clin. Nutr."}],"container-title":["Nutrients"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2072-6643\/18\/18\/3005\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,9,14]],"date-time":"2026-09-14T12:36:17Z","timestamp":1789389377000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2072-6643\/18\/18\/3005"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,9,14]]},"references-count":113,"journal-issue":{"issue":"18","published-online":{"date-parts":[[2026,9]]}},"alternative-id":["nu18183005"],"URL":"https:\/\/doi.org\/10.3390\/nu18183005","relation":{},"ISSN":["2072-6643"],"issn-type":[{"value":"2072-6643","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,9,14]]}}}