International Journal of Public Health

, Volume 64, Issue 6, pp 873–885 | Cite as

Fueling an epidemic of non-communicable disease in the Balkans: a nutritional survey of Bosnian adults

  • Selma GicevicEmail author
  • Audrey J. Gaskins
  • Teresa T. Fung
  • Bernard Rosner
  • Edin Sabanovic
  • Mirjana Gurinovic
  • Agnes Kadvan
  • Emir Kremic
  • Walter Willett
Original article



Dietary surveys are essential for guiding national efforts to reduce the burden of non-communicable disease, but individual-level dietary data are lacking in many low- and middle-income countries. We aimed to estimate the prevalence of inadequate and excessive intakes of specific nutrients in Bosnia and Herzegovina.


A dietary survey among 853 adults using two 24-h recalls.


The majority of men (73%) and women (66%) were overweight/obese, and > 50% of participants had elevated blood pressure. Low intakes of N-3 polyunsaturated fatty acids, specifically α-linolenic acid (men: 94.4 mg/day among, women: 96.6 mg/day) and DHA + EPA (men: 18.2 mg/day, women: 16.0 mg/day), low fiber intake (women: 21.5 g/day), and high sodium (men: 3244 mg/day, women: 2291 mg/) and saturated fatty acids intakes (men: 29.2 g/day) were reported. There was also a suggestion of low intakes of vitamins A, B6, C and D (in both sexes), and of riboflavin, folate, B12 and calcium (in women).


Our findings provide initial evidence on the Bosnian population’s dietary habits and identify aspects that need attention. As the survey evolves into a continuing surveillance system, it will allow evaluation of dietary changes over time.


Diet survey Nutrition assessment Nutrient intake Low- and middle-income countries SFA PUFA Usual nutrient intakes 



This study was funded by the Department of Nutrition, Harvard T.H. Chan School of Public Health and the Institute for Statistics of the Federation on Bosnia and Herzegovina.

Compliance with ethical standards

Conflict of interest

Selma Gicevic declares that she has no conflict of interest. Audrey J. Gaskins declares that she has no conflict of interest. Teresa T. Fung declares that she has no conflict of interest. Bernard Rosner declares that he has no conflict of interest. Edin Sabanovic declares that he has no conflict of interest. Mirjana Gurinovic declares that she has no conflict of interest. Agnes Kadvan declares that she has no conflict of interest. Emir Kremic declares that he has no conflict of interest. Walter Willett declares that he has no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Supplementary material

38_2019_1222_MOESM1_ESM.docx (72 kb)
Supplementary material 1 (DOCX 71 kb)


  1. Azais-Braesco V, Sluik D, Maillot M, Kok F, Moreno LA (2017) A review of total and added sugar intakes and dietary sources in Europe. Nutr J 16:6CrossRefGoogle Scholar
  2. Barr SI, Murphy SP, Poos MI (2002) Interpreting and using the dietary references intakes in dietary assessment of individuals and groups. J Am Diet Assoc 102:780–788CrossRefGoogle Scholar
  3. Beaton GH, Milner J, Corey P, McGuire V, Cousins M, Stewart E (1979) Sources of variance in 24-hour dietary recall data: implications for nutrition study design and interpretation. Am J Clin Nutr 32:2546–2559CrossRefGoogle Scholar
  4. BHAS (2015) Household Budget Survey in Bosnia and Herzegovina: report. The Agency for Statistics of Bosnia and Herzegovina, SarajevoGoogle Scholar
  5. Blanton CA, Moshfegh AJ, Baer DJ, Kretsch MJ (2006) The USDA automated multiple-pass method accurately estimates group total energy and nutrient intake. J Nutr 136:2594–2599CrossRefGoogle Scholar
  6. EFSA (2017) Dietary reference values for nutrients: summary report. EFSA supporting publication 2017Google Scholar
  7. EFSA Panel on Dietetic Products Nutrition, and Allergies (NDA) (2010) Scientific opinion on principles for deriving and applying Dietary Reference Values. EFSA J 8:1458Google Scholar
  8. Ezzati M, Riboli E (2013) Behavioral and dietary risk factors for noncommunicable diseases. N Engl J Med 369:954–964CrossRefGoogle Scholar
  9. FAO (2014) ICN2-second international conference on nutrition. Accessed Sept 2018
  10. Flint AJ, Rexrode KM, Hu FB, Glynn Caspard RJ, Manson H, Body JE et al (2010) Body mass index, waist circumference, and risk of coronary heart disease: a prospective study among men and women. Obes Res Clin Pract 4:e171–e181CrossRefGoogle Scholar
  11. FMHFBIH/IPHFBIH (2012) Federation of Bosnia and Herzegovina Adult Population Health Status Study. Federal Ministry of Health/Institute for Public Health of the Federation of Bosnia and Herzegovina, SarajevoGoogle Scholar
  12. Forouzanfar MH, Alexander L, Anderson HR, Bachman VF, Biryukov S, Brauer M et al (2015) Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks in 188 countries, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 386:2287–2323CrossRefGoogle Scholar
  13. Gurinovic M, Milesevic J, Novakovic R, Kadvan A, Djekic-Ivankovic M, Satalic Z et al (2016a) Improving nutrition surveillance and public health research in Central and Eastern Europe/Balkan Countries using the Balkan Food Platform and dietary tools. Food Chem 193:173–180. CrossRefGoogle Scholar
  14. Gurinovic M, Milesevic J, Kadvan A, Nikolic M, Zekovic M, Djekic-Ivankovic M et al (2016b) Development, features and application of DIET ASSESS and PLAN (DAP) software in supporting public health nutrition research in Central Eastern European Countries (CEEC). Food Chem 238:186–194. CrossRefGoogle Scholar
  15. Huybrechts I, Aglago EK, Mullee A, De Keyzer W, Leclercq C, Allemand P et al (2017) Global comparison of national individual food consumption surveys as a basis for health research and integration in national health surveillance programmes. Proc Nutr Soc 76:549–567CrossRefGoogle Scholar
  16. IOM (2001) Appendix I iron intakes and estimated percentile of the distribution of iron requirements from the continuing survey of food intakes by individuals (CSFII), 1994–1996. In: Dietary reference intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, and Zinc. The National Academies Press, Washington D.C,
  17. IOM (2003a) E adjustment of observed intake data to estimate the distribution of usual intakes in a group. In: Dietary reference intakes: applications in dietary planning. National Academies Press (US), Washington, D.C.Google Scholar
  18. IOM (2003b) Dietary reference intakes: applications in dietary planning. National Academies Press, Washington, D.C.Google Scholar
  19. Lachat C, Otchere S, Roberfroid D, Abdulai A, Seret FM, Milesevic J et al (2013) Diet and physical activity for the prevention of noncommunicable diseases in low- and middle-income countries: a systematic policy review. PLoS Med 10(6):e1001465. CrossRefGoogle Scholar
  20. Marazzi G, Iellamo F, Volterrani M, Lombardo M, Pelliccia F, Righi D et al (2012) Comparison of Microlife BP A200 plus and Omron M6 blood pressure monitors to detect atrial fibrillation in hypertensive patients. Adv Ther 29:64–70CrossRefGoogle Scholar
  21. Mensink RP, Zock PL, Kester AD, Katan MB (2003) Effects of dietary fatty acids and carbohydrates on the ratio of serum total to HDL cholesterol and on serum lipids and apolipoproteins: a meta-analysis of 60 controlled trials. Am J Clin Nutr 77:1146–1155CrossRefGoogle Scholar
  22. Micha R, Khatibzadeh S, Shi P, Fahimi S, Lim S, Andrews KG et al (2014) Global, regional, and national consumption levels of dietary fats and oils in 1990 and 2010: a systematic analysis including 266 country-specific nutrition surveys. BMJ 348:g2272CrossRefGoogle Scholar
  23. Moshfegh AJ, Rhodes DG, Baer DJ, Murayi T, Clemens JC, Rumpler WV et al (2008) The US Department of Agriculture Automated Multiple-Pass Method reduces bias in the collection of energy intakes. Am J Clin Nutr 88:324–332CrossRefGoogle Scholar
  24. Moshfegh A, Goldman J, Ahuja J, Rhodes D, LaComb R (2009) What we eat in America, NHANES 2005–2006: usual nutrient intakes from food and water compared to 1997 dietary reference intakes for vitamin D, calcium, phosphorus, and magnesium. US Department of Agriculture, Agricultural Research ServiceGoogle Scholar
  25. Murray CJ, Lopez AD (2013) Measuring the global burden of disease. N Engl J Med 369:448–457CrossRefGoogle Scholar
  26. Nikolic M, Milesevic J, Zekovic M, Gurinovic M, Glibetic M (2018) The development and validation of food atlas for portion size estimation in the Balkan region. Front Nutr. Google Scholar
  27. Petrova S, Dimitrov P, Willett WC, Campos H (2011) The global availability of n-3 fatty acids. Public Health Nutr 14:1157–1164CrossRefGoogle Scholar
  28. Pietrzik K (ed) (2012) Modern lifestyles, lower energy intake and micronutrient status. Springer, BerlinGoogle Scholar
  29. Popkin BM (2004) The nutrition transition: an overview of world patterns of change. Nutr Rev 62:S140–S143CrossRefGoogle Scholar
  30. Powles J, Fahimi S, Micha R, Khatibzadeh S, Shi P, Ezzati M et al (2013) Global, regional and national sodium intakes in 1990 and 2010: a systematic analysis of 24 h urinary sodium excretion and dietary surveys worldwide. BMJ Open 3:e003733CrossRefGoogle Scholar
  31. Rippin HL, Hutchinson J, Jewell J, Breda JJ, Cade JE (2017) Adult nutrient intakes from current national dietary surveys of European Populations. Nutrients. Google Scholar
  32. Rosner B (1983) Percentage points for a generalized ESD many-outlier procedure. Technometrics 25:165–172CrossRefGoogle Scholar
  33. Rosner B (2011) Multisample reference. In: Seibert D (ed) Fundamentals of biostatistics, 7th edn. Brooks/Cole, Boston, p 566Google Scholar
  34. Sacks FM, Svetkey LP, Vollmer WM, Appel LJ, Bray GA, Harsha D, DASH-Sodium Collaborative Research Group et al (2001) Effects on blood pressure of reduced dietary sodium and the Dietary Approaches to Stop Hypertension (DASH) diet. N Engl J Med 344:3–10CrossRefGoogle Scholar
  35. Topouchian J, Agnoletti D, Blacher J, Youssef A, Chahine MN, Ibanez I (2014) Validation of four devices: Omron M6 Comfort, Omron HEM-7420, Withings BP-800, and Polygreen KP-7670 for home blood pressure measurement according to the European Society of Hypertension International Protocol. Vasc Health Risk Manag 10:33–44Google Scholar
  36. UNIEAGS (2014) A world that counts: mobilising the data revolution for sustainable development. Independent Expert Advisory Group SecretariatGoogle Scholar
  37. USHHS and USDA (2015) 2015–2020 Dietary Guidelines for Americans. U.S. Department of Health and Human Services and U.S. Department of AgricultureGoogle Scholar
  38. WHO (2008) Waist circumference and waist–hip ratio: report of a WHO expert consultation. World Health Organization, GenevaGoogle Scholar
  39. WHO (2010) Global recommendations on physical activity for health. World Health Organization, GenevaGoogle Scholar
  40. WHO (2012) Guideline: sodium intake for adults and children. World Health Organization, GenevaGoogle Scholar
  41. WHO (2014) European Food and Nutrition Action Plan 2015–2020. World Health Organization, CoppenhagenGoogle Scholar
  42. WHO (2015a) Bosnia and Herzegovina: WHO statistical profile 2012. WHO, GenevaGoogle Scholar
  43. WHO (2015b) Guideline: Sugars intake for adults and children. World Health Organization, GenevaGoogle Scholar
  44. WHO/FAO (2002) Diet, nutrition and the prevention of chronic diseases: report of a joint WHO/FAO expert consultation. World Health Organization/Food and Agriculture Organization, GenevaGoogle Scholar
  45. Willett WC (2012a) Nutritional epidemiology, 3rd edn. Oxford University Press, New YorkCrossRefGoogle Scholar
  46. Willett WC (2012b) Dietary fats and coronary heart disease. J Intern Med 272:13–24CrossRefGoogle Scholar
  47. ZJZFBIH (2012) Health population survey in the Federation of Bosnia and Herzegovina. Public Health Institute FBiH, SarajevoGoogle Scholar

Copyright information

© Swiss School of Public Health (SSPH+) 2019

Authors and Affiliations

  1. 1.Department of NutritionHarvard T.H. Chan School of Public HealthBostonUSA
  2. 2.Channing Division of Network Medicine, Department of MedicineBrigham and Women’s HospitalBostonUSA
  3. 3.Department of NutritionSimmons UniversityBostonUSA
  4. 4.Department of BiostatisticsHarvard T.H. Chan School of Public HealthBostonUSA
  5. 5.Agency for Statistics of Bosnia and HerzegovinaSarajevoBosnia and Herzegovina
  6. 6.Centre of Research Excellence in Nutrition and Metabolism, Institute for Medical ResearchUniversity of BelgradeBelgradeSerbia
  7. 7.Capacity Development Network in Nutrition in Central and Eastern EuropeCAPNUTRABelgradeSerbia
  8. 8.Institute for Statistics of the Federation of Bosnia and HerzegovinaSarajevoBosnia and Herzegovina
  9. 9.Department of EpidemiologyHarvard T.H. Chan School of Public HealthBostonUSA

Personalised recommendations