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Actual macronutrient composition of the Mediterranean diet and its association with adiposity and inflammation: a cross-sectional real-life study
(Springer Science and Business Media LLC, 2025-11-11)
Claudia Vetrani
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Evelyn Frias-Toral
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Annamaria Di Martino
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Federica Cantelli
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Chiara Graziadio
Background and objectives The Mediterranean diet (MD) relies on a specific food consumption pattern that has been given pleiotropic effects on human health. However, even foods typically considered beneficial within the MD framework may vary in macronutrient composition, potentially leading to imbalanced or unhealthy dietary profiles despite overall adherence. To date, no study has evaluated the total energy intake and percentage macronutrient composition in a cohort of adult individuals stratified by their adherence to MD. We aimed to investigate the total energy intake and macronutrient composition among individuals stratified by adherence to MD, and its association with indices of adiposity and inflammation. Methods A cross-sectional study was conducted in 1342 volunteers. Participants underwent clinical examination (anthropometry, body composition, and high-sensitivity C-reactive protein assessment), and nutritional data collection, including adherence to MD (PREDIMED questionnaire) and habitual diet composition (7-day food records). The associations between PREDIMED score, macronutrient composition, and clinical outcomes were explored by Pearson’s correlation. Linear regression analysis was used to assess the macronutrient that best predicted adherence to MD. Results Participants with high adherence to MD (H-MD) presented lower intake of carbohydrate, while higher protein and fat amounts than individuals with medium (M-HD) or low (L-MD) adherence to MD. The H-MD group showed lower adiposity (body mass index, waist circumference, and fat mass) and C-reactive protein concentrations than individuals in the M-MD and L-MD groups p < 0.001 for all comparisons). Linear regression analysis showed low carbohydrate intake as the best predictor of high PREDIMED score (β: -0.875; p < 0.001). Conclusion H-MD is characterised by lower carbohydrate, higher protein and fat intakes than those usually reported in nutritional recommendations. This profile was significantly associated with lower adiposity and inflammation. A low carbohydrate amount was the best predictor of H-MD, suggesting that dietary carbohydrate should be on the lower side of the recommended range.
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Timing matters: lipid intake and its influence on menopausal-related symptoms
(Springer Science and Business Media LLC, 2025-08-18)
Ludovica Verde
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Luigi Barrea
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Evelyn Frias-Toral
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Raynier Zambrano-Villacres
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SIMANCAS RACINES, DANIEL ALEJANDRO
Background Menopause contributes to central obesity and increases cardiovascular risk in women. Diet influences both menopausal symptoms and cardiovascular health, but the impact of chrononutrition, namely food timing, is not well understood. This cross-sectional study investigated whether the timing of food intake affected menopausal symptoms in 100 postmenopausal women with overweight or obesity. Methods Anthropometric and clinical parameters, and lifestyle habits were assessed. Menopausal symptoms were evaluated using the Menopause Rating Scale (MRS). Nutritional assessment utilized 7-day food records. Food intake was divided into morning intake (meals from breakfast to lunch) and evening intake (meals from afternoon snacks to dinner). Results The mean MRS score was 22.7 ± 7.8, showing a high prevalence of symptoms in the study population. Postmenopausal women under the median of morning energy intake showed a significantly a higher score for heart discomfort (p = 0.045), while those under the median of morning intake of lipids showed significantly higher scores for heart discomfort and lower scores for bladder problems (p = 0.013 and p = 0.040, respectively). Postmenopausal women above the median evening intake of lipids showed a significantly higher score for heart discomfort (p = 0.007). The heart discomfort score correlated negatively and positively with the morning (r = -0.210, p = 0.034) and evening (r = 0.210, p = 0.034) intakes of lipids, respectively, even after correction for confounding factors (r = -0.219 and r = 0.219, p = 0.028 for both). Conclusion Consuming most of the energy and lipids later in the day was linked to higher prevalence of menopausal symptoms in postmenopausal women with overweight or obesity. This eating pattern may potentially have adverse effects on the cardiovascular health of these women. Therefore, adopting chrononutrition behaviors, particularly favoring an earlier intake of energy and lipids, could prove beneficial as an additional measure in the nutritional therapy for postmenopausal women dealing with overweight or obesity.
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Beyond dietary therapy: addressing weight stigma awareness in medical students
(Springer Science and Business Media LLC, 2025-08-22)
Giuseppe Annunziata
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Giordano Bruno Zonzini
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Evelyn Frias-Toral
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Raynier Zambrano-Villacres
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Alexander Bertuccioli
Background The growing prevalence of obesity worldwide has drawn increased attention to the issue of weight stigma. Discriminatory attitudes related to body weight are evident across various settings, including those that should ideally offer support to individuals with obesity, such as schools and sports facilities. This research aimed to examine weight-related stigma among university students enrolled in healthcare-related academic programs. Methods To measure weight stigma, researchers administered the Italian version of the Attitude Toward Obese Persons (I-ATOP) questionnaire to 201 students from the University of Urbino (Italy) and the University of Malaga (Spain). The analysis explored variations in stigma levels based on gender, BMI classification, nationality, Italian regional location, level of academic education, medical history, and lifestyle factors. Results The participant pool was predominantly female (58.2%) and Spanish (66.7%), with an average age of 22.86 ± 3.08 years and a mean BMI of 22.80 ± 3.25 kg/m, placing most respondents in the normal weight range. Nearly half (47.8%) demonstrated a low degree of stigmatising attitudes. Within the sample, significantly lower stigma levels were reported among female and Spanish students (> = 0.001 and > = 0.011, respectively), as well as among those without a history of eating disorders (> = 0.017) and those who engaged in physical activity (> = 0.029). Additionally, stigma showed a notable decline in relation to higher educational attainment ConclusionThis pilot study reveals the presence of weight stigma even within healthcare education settings, where future health professionals are being trained. These findings underscore the urgent need for comprehensive educational strategies aimed at fostering inclusive and nonjudgmental attitudes toward individuals with obesity. Importantly, the assessment and management of weight stigma should extend beyond nutritional therapy alone, recognizing its psychological, social, and structural dimensions. Integrating this broader perspective into healthcare curricula is thus essential to improve the quality of care for individuals living with one of the most prevalent and complex chronic conditions.
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Differential impact of coffee quantity and sweetening on body composition parameters and inflammation
(Frontiers Media SA, 2025-09-17)
Giuseppe Annunziata
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Evelyn Frias-Toral
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Francesco Campa
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Maria Antonieta Touriz Bonifaz
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Ludovica Verde
Background: Coffee is the most consumed and popular beverage worldwide. The health benefits of its regular, moderate consumption are well known, and include antioxidant and anti-inflammatory effects, as well as metabolic effects, reducing the risk of obesity and related diseases. The available literature, however, provides no information about the effect of coffee consumption on body composition (BC) and inflammation. The present cross-sectional observational study aims to investigate the effect of coffee consumption on BC and inflammation-related parameters, as well as the possible impact of adding sugar and the frequency of consumption. Coffee consumption habits, preference for adding sugar and frequency of daily consumption were assessed in 2,556 adults (1,080 men and 1,476 women). BC was assessed using Bioelectrical Impedance Analysis (BIA), whilst high-sensitivity C-reactive protein (hs-CRP) levels were monitored for inflammatory status. Results: A total of 1,855 subjects (680 men and 1,175 women) were included in the statistical analysis. Compared to non-consumers, coffee consumers showed lower body mass index (BMI), waist girth (WG), and hs-CRP levels, and higher skeletal muscle mass (SMM), appendicular SMM (ASMM), phase angle (PhA), and standardised PhA (SPA) (p< 0.001 for all). The same trend was observed for unsweetened coffee consumers compared to subjects consuming sweetened coffee. With increasing coffee consumption, BMI, WG, and hs-CRP generally decreased, whilst SMM and ASMM showed a bell-shaped trend with peak values in those consuming 2–3 cups per day. Similarly, PhA and SPA values were highest among moderate coffee consumers. Conclusion: These findings suggest that moderate coffee consumption, particularly unsweetened coffee, is associated with more favourable body composition and inflammatory profiles. Given the observational design, causality cannot be established. Nevertheless, the results may inform dietary guidance aimed at supporting muscle maintenance and mitigating obesity-related metabolic risk.
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Weight loss, changes in body composition and inflammatory status after a very low-energy ketogenic therapy (VLEKT): does gender matter?
(Springer Science and Business Media LLC, 2024-10-19)
Giovanna Muscogiuri
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Ludovica Verde
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Evelyn Frias-Toral
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REYTOR GONZÁLEZ, CLAUDIA MARÍA
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Giuseppe Annunziata
Background: Considering differences in body composition and inflammatory status between sexes, as well as recent recommendations advocating for personalized dietary approaches, this study aimed to explore how sex influences weight loss, changes in body composition, and inflammatory status in subjects with grade I and II obesity undergoing a 45-day of the Very Low-Energy Ketogenic Therapy (VLEKT). Methods: Participants (21 premenopausal females and 21 males), included in the study adhered to the 45-day of the VLEKT and underwent assessments of anthropometric parameters (weight, height, body mass index—BMI –, and waist circumference), body composition via bioelectrical impedance analysis, and inflammatory status measured by high sensitivity C-reactive protein (hs-CRP) levels at baseline and post-intervention. Results: At baseline, premenopausal females and males did not differ in BMI (p = 0.100) and hs-CRP levels (p = 0.948). Males demonstrated overall larger benefits than premenopausal females from the VLEKT in terms of weight loss (Δ% = − 11.63 ± 1.76 vs − 8.95 ± 1.65 kg, p < 0.001), fat mass (Δ% = − 30.84 ± 12.00 vs -21.36 ± 4.65 kg, p = 0.002), and hs-CRP levels (Δ% = − 41.42 ± 21.35 vs − 22.38 ± 17.30 mg/L, p = 0.003). Of interest, in males phase angle values are statistically improved compared to female (Δ% = 17.11 ± 9.00 vs 7.05 ± 3.30°, p < 0.001). Conclusion: These findings underscore the importance of considering sex-specific responses in personalized obesity treatment strategies, particularly dietary interventions like VLEKTs. Graphical Abstract: (Figure presented.)
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Use of phase angle as an indicator of overtraining in sport and physical training
(Springer Science and Business Media LLC, 2024-11-29)
Giuseppe Annunziata
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Antonio Paoli
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Evelyn Frias-Toral
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Stellario Marra
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Francesco Campa
The use of bioelectrical impedance analysis (BIA) is now well established in healthcare as an essential support tool for patient management in various clinical settings. Its use in sports is rapidly expanding due to the valuable insights it offers, helping to better structure athletes’ diets and training programs, thereby optimizing their performance. In the context of sport, however, there is a consensus regarding the importance of proper interpretation of BIA-derived data, which cannot be limited to mere estimation of body composition. In this sense, therefore, the evaluation and interpretation of raw bioelectrical parameters, including resistance, reactance, and phase angle (PhA) is of relevant importance. The assessment of PhA is particularly significant in the context of sports, as it is closely linked to key factors such as muscle mass, strength, and overall muscle quality. However, the existing relationship between PhA and systemic, and loco-regional inflammation, which, in a broader sense, is the rationale behind its use for assessing and monitoring localised muscle damage. Thus, the importance of PhA monitoring during training becomes evident, as it plays a crucial role in assessing and potentially identifying functional impairments, such as overtraining syndrome, as well as muscle injury and related changes in fluid distribution, at an early stage. The aim of this review is to provide the scientific basis necessary to consider the use of whole-body PhA as an indicator of overtraining.
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Adherence to the Mediterranean diet as a possible additional tool to be used for screening the metabolically unhealthy obesity (MUO) phenotype
(Springer Science and Business Media LLC, 2023-09-28)
Luigi Barrea
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Ludovica Verde
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SIMANCAS RACINES, DANIEL ALEJANDRO
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ZAMBRANO ESPINOSA, ANA KARINA
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Evelyn Frias-Toral
<jats:title>Abstract</jats:title><jats:sec> <jats:title>Background</jats:title> <jats:p>The terms metabolically healthy obesity (MHO) and metabolically unhealthy obesity (MUO) categorize subjects with obesity based on the presence or absence of cardio-metabolic risk factors. Detecting MUO phenotype is crucial due to the high risk of cardio-metabolic complications, requiring tailored and intensive follow-up. However, diagnosing MUO is time-consuming and costly. Thus, we aimed to investigate the role of Mediterranean diet (MD) in determining MHO/MUO phenotypes and whether adherence to MD could serve as an additional screening tool for MUO phenotype.</jats:p> </jats:sec><jats:sec> <jats:title>Methods</jats:title> <jats:p>The study population of this cross-sectional observational study consisted of 275 subjects with obesity. We assessed their lifestyle habits (physical activity and smoking habits), anthropometric measurements (weight, height, waist circumference, body mass index), blood pressure, metabolic parameters, inflammatory marker (high sensitivity C reactive protein levels), adherence to MD (by <jats:italic>PREvención con DIetaMEDiterránea</jats:italic> (PREDIMED) questionnaire), and MHO/MUO phenotypes.</jats:p> </jats:sec><jats:sec> <jats:title>Results</jats:title> <jats:p>The study included 275 individuals with obesity (256F/19M; 34.0 ± 10.5 years; BMI 38.3 ± 5.95 kg/m<jats:sup>2</jats:sup>). Among them, 114 (41.5%) exhibited MHO phenotype, while 161 (58.5%) had MUO phenotype. MHO phenotype exhibited favorable anthropometric and cardio-metabolic profiles, characterized by lower waist circumference (p < 0.001), BMI (p < 0.001), insulin resistance (p < 0.001), blood pressure (p < 0.001), inflammation (p < 0.001), and lipid levels (p < 0.001) compared to MUO phenotype. Notably, we found that MHO phenotype had higher adherence to MD (p < 0.001) and consumed more extra virgin olive oil (EVOO) (p < 0.001), vegetables (p < 0.001), fruits (p < 0.001), legumes (p = 0.001), fish (p < 0.001), wine (p = 0.008), and nuts (p = 0.001), while reporting lower intake of red/processed meats (p < 0.001), butter, cream, margarine (p = 0.008), soda drinks (p = 0.006), and commercial sweets (p = 0.002) compared to MUO phenotype. Adherence to MD (p < 0.001) and EVOO (p = 0.015) intake were identified as influential factors in determining the presence of MUO/MHO phenotypes. Furthermore, a PREDIMED score < 5 proved to be the most sensitive and specific cut-point value for predicting the presence of MUO phenotype (p < 0.001).</jats:p> </jats:sec><jats:sec> <jats:title>Conclusion</jats:title> <jats:p>High adherence to MD was associated with MHO phenotype. Moreover, we suggest that a specific cut-off of the PREDIMED score could be an indicator to discriminate patients with MUO/MHO phenotypes and therefore help in identifying patients at higher cardiovascular risk who will require specific dietary intervention.</jats:p> </jats:sec>
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Very low-calorie ketogenic diet (VLCKD): a therapeutic nutritional tool for acne?
(Springer Science and Business Media LLC, 2024-03-31)
Ludovica Verde
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Evelyn Frias-Toral
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Sara Cacciapuoti
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SIMANCAS RACINES, DANIEL ALEJANDRO
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Matteo Megna
Background: Acne, a chronic inflammatory disease impacting the pilosebaceous unit, is influenced significantly by inflammation and oxidative stress, and is commonly associated with obesity. Similarly, obesity is also associated with increased inflammation and oxidation. The role of diet in acne remains inconclusive, but the very low-calorie ketogenic diet (VLCKD), known for weight loss and generating anti-inflammatory ketone bodies, presents promising potential. Despite this, the effects of VLCKD on acne remain underexplored. This study aimed to investigate the efficacy of a 45-day active phase of VLCKD in reducing the clinical severity of acne in young women with treatment-naïve moderate acne and grade I obesity. Methods: Thirty-one women with treatment-naïve moderate acne, grade I obesity (BMI 30.03–34.65 kg/m2), aged 18–30 years, meeting inclusion/exclusion criteria, and consenting to adhere to VLCKD were recruited. Baseline and post-intervention assessments included anthropometric measurements, body composition, phase angle (PhA), trimethylamine N-oxide (TMAO) levels, and reactive oxygen metabolite derivatives (dROMs) as markers of inflammation, dysbiosis, and oxidative stress, respectively. A comprehensive dermatological examination, incorporating the Global Acne Grading System (GAGS) and the Dermatology Life Quality Index (DLQI), was conducted for all women. Results: VLCKD resulted in general improvements in anthropometric and body composition parameters. Significantly, there were significant reductions in both the GAGS score (Δ%: − 31.46 ± 9.53, p < 0.001) and the DLQI score (Δ%: − 45.44 ± 24.02, p < 0.001) after the intervention. These improvements coincided with significant decreases in TMAO (p < 0.001) and dROMs (p < 0.001) levels and a significant increase in PhA (Δ%: + 8.60 ± 7.40, p < 0.001). Changes in the GAGS score positively correlated with changes in dROMs (p < 0.001) and negatively with PhA (p < 0.001) even after adjusting for Δ% FM. Changes in the DLQI score positively correlated with changes in dROMs (p < 0.001) and negatively with PhA (p < 0.001) even after adjustment for Δ% FM. Conclusion: Given the side effects of drugs used for acne, there is an increasing need for safe, tolerable, and low-cost treatments that can be used for acne disease. The 45-day active phase of VLCKD demonstrated notable improvements in acne severity, and these improvements seemed to be attributable to the known antioxidant and anti-inflammatory effects of VLCKD.

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