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Zhao ZF, Li BY, He Q, Hao JY, Zhang KS, Zhang B, Hu W, Feng HT, Szeto IMY, Chen YM, Zhang GX, Tang XY. Impact of dairy supplementation on bone acquisition in children's limbs: a 12-month cluster-randomized controlled trial and meta-analysis. Arch Osteoporos 2024; 19:65. [PMID: 39043915 DOI: 10.1007/s11657-024-01422-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Accepted: 07/13/2024] [Indexed: 07/25/2024]
Abstract
The impact of milk on bone health in rural preschoolers is under-researched. This study, through a clinical trial and a meta-analysis, finds that milk supplementation enhances forearm and calcaneus bone acquisition in children, supporting the benefits of daily milk consumption. PURPOSE This study evaluated the impact of dairy supplementation on bone acquisition in children's limbs through a cluster-randomized controlled trial and a meta-analysis. METHODS The trial involved 315 children (4-6 year) from Northwest China, randomized to receive either 390 ml of milk daily (n = 215) or 20-30 g of bread (n = 100) over 12 months. We primarily assessed bone mineral density (BMD) and content (BMC) changes at the limbs, alongside bone-related biomarkers, measured at baseline, the 6th and 12th months. The meta-analysis aggregated BMD or BMC changes in the forearm/legs/calcaneus from published randomized trials involving children aged 3-18 years supplemented with dairy foods (vs. control group). RESULTS Of 278 completed the trial, intention-to-treat analysis revealed significant increases in BMD (4.05% and 7.31%) and BMC (4.69% and 7.34%) in the left forearm at the 6th and 12th months in the milk group compared to controls (P < 0.001). The calcaneus showed notable improvements in BMD (2.01%) and BMC (1.87%) at 6 months but not at 12 months. Additionally, milk supplementation was associated with beneficial changes in bone resorption markers, parathyroid hormone (- 12.70%), insulin-like growth factor 1 (6.69%), and the calcium-to-phosphorus ratio (2.22%) (all P < 0.05). The meta-analysis, encompassing 894 children, indicated that dairy supplementation significantly increased BMD (SMD, 0.629; 95%CI: 0.275, 0.983) and BMC (SMD, 0.616; 95%CI: 0.380, 0.851) (P < 0.05) in the arms, but not in the legs (P > 0.05). CONCLUSION Milk supplementation significantly improves bone health in children's forearms, underscoring its potential as a strategic dietary intervention for bone development. Trial registration NCT05074836.
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Affiliation(s)
- Zi-Fu Zhao
- Inner Mongolia Yili Industrial Group Co., Ltd., Hohhot, China
- Inner Mongolia Dairy Technology Research Institute Co. Ltd., Hohhot, China
| | - Bang-Yan Li
- Department of Epidemiology, School of Public Health, Sun Yat-Sen University, Guangzhou, China
| | - Qin He
- Institute of Nutrition and Food Hygiene, School of Public Health, Lanzhou University, Lanzhou, Gansu Province, China
| | - Jing-Yu Hao
- Inner Mongolia Yili Industrial Group Co., Ltd., Hohhot, China
- Inner Mongolia Dairy Technology Research Institute Co. Ltd., Hohhot, China
| | - Kai-Shuai Zhang
- Inner Mongolia Yili Industrial Group Co., Ltd., Hohhot, China
| | - Bo Zhang
- Inner Mongolia Yili Industrial Group Co., Ltd., Hohhot, China
| | - Wei Hu
- Department of Epidemiology, School of Public Health, Sun Yat-Sen University, Guangzhou, China
| | - Hao-Tian Feng
- Inner Mongolia Yili Industrial Group Co., Ltd., Hohhot, China
- Inner Mongolia Dairy Technology Research Institute Co. Ltd., Hohhot, China
| | - Ignatius Man-Yau Szeto
- Inner Mongolia Yili Industrial Group Co., Ltd., Hohhot, China
- Inner Mongolia Dairy Technology Research Institute Co. Ltd., Hohhot, China
| | - Yu-Ming Chen
- Department of Epidemiology, School of Public Health, Sun Yat-Sen University, Guangzhou, China.
| | - Ge-Xiang Zhang
- Institute of Nutrition and Food Hygiene, School of Public Health, Lanzhou University, Lanzhou, Gansu Province, China.
| | - Xin-Yi Tang
- Department of Pediatrics, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China.
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Ayling K, Li R, Muhardi L, Melse-Boonstra A, Sun Y, Chen W, Kudla U. Systematic Literature Review of the Nutrient Status, Intake, and Diet Quality of Chinese Children across Different Age Groups. Nutrients 2023; 15:1536. [PMID: 36986271 PMCID: PMC10057142 DOI: 10.3390/nu15061536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 02/23/2023] [Accepted: 03/15/2023] [Indexed: 03/30/2023] Open
Abstract
There is a lack of comprehensive reports on nutrient deficiencies and dietary intake among various age groups of children in China. The objective of this review is to provide an overview of the nutrient status, intake, and diet adequacy of Chinese children (0-18 years old). PubMed and Scopus were searched for literature published between January 2010 and July 2022. A systematic review approach with a quality assessment was performed to analyze 2986 identified articles in English and Chinese. Eighty-three articles were included in the analysis. In younger children, anemia and iron and Vitamin A deficiencies remain severe public health problems, despite high Vitamin A and adequate iron intake. In older children, a high prevalence of selenium; Vitamin A and D deficiencies; and inadequate intakes of Vitamins A, D, B, C, selenium, and calcium were reported. Intakes of dairy, soybeans, fruits, and vegetables were below recommended levels. High intakes of iodine, total and saturated fat, and sodium and low dietary diversity scores were also reported. As nutritional concerns vary with age and region, future nutrition interventions should be tailored accordingly.
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Affiliation(s)
- Katie Ayling
- Friesland Campina, 3818 LA Amersfoort, The Netherlands;
| | - Rongrong Li
- Department of Clinical Nutrition, Peking Union Medical College Hospital (PUMCH), Beijing 100730, China
| | | | - Alida Melse-Boonstra
- Division of Human Nutrition and Health, Wageningen University & Research, 6703 HE Wageningen, The Netherlands
| | - Ye Sun
- Friesland Campina Development Centre AMEA, Singapore 118261, Singapore
| | - Wei Chen
- Department of Clinical Nutrition, Peking Union Medical College Hospital (PUMCH), Beijing 100730, China
| | - Urszula Kudla
- Friesland Campina, 3818 LA Amersfoort, The Netherlands;
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Pan D, Qing MF, Ma DH, Wei J, Wang Z, Cai LY, Xu H, Zhou Y, Chen QM. Detection of the peripheral blood antigens and clinical value in recurrent aphthous ulcer: A cross-section study. J Dent Sci 2023; 18:304-309. [PMID: 36643277 PMCID: PMC9831785 DOI: 10.1016/j.jds.2022.05.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 05/21/2022] [Indexed: 01/18/2023] Open
Abstract
Abstract Background/purpose Recurrent aphthous ulcer (RAU) is one of the most common diseases of oral mucosa, which is generally believed to be related to immunity, though the etiology is still unclear. It is suspected that allergies are directly related to RAU. So we sought to explore the relationship between hypersensitivity and RAU. Materials and methods 40 RAU patients who were in ulceration period and 40 people who were in good health were selected from Jan 2016 to Feb 2017, matched in age and sex. The peripheral blood antigens of 40 RAU patients and 40 healthy people was tested, and serum specific IgE (sIgE) with 6 groups of antigens and total IgE (tIgE) analysis was performed to identify IgE-mediated allergic reaction possibly affecting RAU. We then investigated the food intolerance and IgG levels to discover the correlation between non-IgE mediated allergic reaction and RAU. Results The positive cases and rate of sIgE in RAU group was higher than that of control, but the difference was not statistically significant (P>0.05). Positive grade of animal fur scraps (EX1), house dust mixed (HX2) and the serum tIgE concentration of the RAU group were significantly higher than the control group (P<0.05).The number of food intolerance in RAU group was significantly higher than that in control group (P<0.05). Conclusion Our findings suggested certain correlation between RAU and anaphylaxis. Daily contact allergens and food intolerance may be one of the causes of RAU. Moreover, this provides reference value for clinical diagnosis and treatment.
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Affiliation(s)
- Dan Pan
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Chinese Academy of Medical Sciences Research Unit of Oral Carcinogenesis and Management, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, China
| | - Mao-feng Qing
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Chinese Academy of Medical Sciences Research Unit of Oral Carcinogenesis and Management, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, China
| | - Dan-hua Ma
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Chinese Academy of Medical Sciences Research Unit of Oral Carcinogenesis and Management, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, China
| | - Jiao Wei
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Chinese Academy of Medical Sciences Research Unit of Oral Carcinogenesis and Management, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, China,Department of Oral Mucosal Diseases, State Key Laboratory of Military Stomatology and National Clinical Research Center for Oral Disease and Shaanxi Key Laboratory of Stomatology, School of Stomatology, The Fourth Military University, Xi'an, Shanxi, China
| | - Zhen Wang
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Chinese Academy of Medical Sciences Research Unit of Oral Carcinogenesis and Management, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, China
| | - Lu-yao Cai
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Chinese Academy of Medical Sciences Research Unit of Oral Carcinogenesis and Management, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, China
| | - Hao Xu
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Chinese Academy of Medical Sciences Research Unit of Oral Carcinogenesis and Management, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, China,Corresponding author. State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Chinese Academy of Medical Sciences Research Unit of Oral Carcinogenesis and Management, West China Hospital of Stomatology, Sichuan University, No. 14, Sec 3 Renminnan Road, Chengdu, Sichuan, 610041, China.
| | - Yu Zhou
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Chinese Academy of Medical Sciences Research Unit of Oral Carcinogenesis and Management, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, China,Corresponding author. State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Chinese Academy of Medical Sciences Research Unit of Oral Carcinogenesis and Management, West China Hospital of Stomatology, Sichuan University, No. 14, Sec 3 Renminnan Road, Chengdu, Sichuan, 610041, China.
| | - Qian-ming Chen
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Chinese Academy of Medical Sciences Research Unit of Oral Carcinogenesis and Management, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, China
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Ding Y, Han F, Xie Z, Li G, Zhuang Y, Yin J, Fu M, You J, Wang Z. Dairy fortification as a good option for dietary nutrition status improvement of 676 preschool children in China: A simulation study based on a cross-sectional diet survey (2018-2019). Front Nutr 2022; 9:1081495. [PMID: 36570132 PMCID: PMC9773072 DOI: 10.3389/fnut.2022.1081495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 11/24/2022] [Indexed: 12/14/2022] Open
Abstract
Background Chinese children are deficient in several essential nutrients due to poor dietary choices. Dairy products are a source of many under-consumed nutrients, but preschool children in China consume dairy products significantly less than the recommended level. Methods From the cross-sectional dietary intake survey of infants and young children aged 0-6 years in China (2018-2019), preschool children (age: 3-6 years) (n = 676) were selected. The four-day dietary data (including 2 working days and 2 weekends) collected through an online diary with reference to the food atlas were used for analysis and simulation. In scenario 1, individual intake of liquid milk equivalents was substituted at a corresponding volume by soymilk, cow's milk, or formulated milk powder for preschool children (FMP-PSC). In scenario 2, the amount of cow's milk or FMP-PSC increased to ensure each child's dairy intake reached the recommended amount (350 g/day). In both scenarios, the simulated nutrient intakes and nutritional inadequacy or surplus were compared to the survey's actual baseline data. Results It was suggested suggested that replacing dairy foods with FMP-PSC at matching volume is better than replacing them with soymilk or cow's milk to increase the intake of DHA, calcium, iron, zinc, iodine, vitamin A, vitamin B1, vitamin B3, vitamin B12, vitamin C and vitamin D. Moreover, our results suggested that adding FMP-PSC to bring each child's dairy intake to the recommended amount can bring the intakes of dietary fiber, DHA, calcium, iron, zinc, iodine, vitamin A, vitamin B1, vitamin B3, vitamin B9, vitamin B12, vitamin C and vitamin D more in line with the recommendations when compared with cow's milk. Conclusion Accurate nutrition information should be provided to the parents of preschool children so as to guide their scientific consumption of dairy products and the usage and addition of fortified dairy products can be encouraged as needed.
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Affiliation(s)
- Ye Ding
- Department of Maternal, Child and Adolescent Health, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Fei Han
- Danone Open Science Research Center for Life-Transforming Nutrition, Shanghai, China
| | - Zhencheng Xie
- Department of Maternal, Child and Adolescent Health, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Genyuan Li
- Department of Maternal, Child and Adolescent Health, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Yiding Zhuang
- Department of Maternal, Child and Adolescent Health, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Jia Yin
- Department of Maternal, Child and Adolescent Health, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Mingxian Fu
- Department of Maternal, Child and Adolescent Health, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Jialu You
- Danone Open Science Research Center for Life-Transforming Nutrition, Shanghai, China
| | - Zhixu Wang
- Department of Maternal, Child and Adolescent Health, School of Public Health, Nanjing Medical University, Nanjing, China,*Correspondence: Zhixu Wang,
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Lenighan YM, Tassy M, Nogueira-de-Almeida CA, Offord EA, Mak TN. Milk beverages can reduce nutrient inadequacy among Brazilian pre-school children: a dietary modelling study. BMC Nutr 2022; 8:121. [PMID: 36316737 PMCID: PMC9623914 DOI: 10.1186/s40795-022-00620-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Accepted: 10/13/2022] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Previous studies found high prevalence of inadequate intakes of vitamins E, D and K, calcium and potassium among Brazilian pre-school children, with suboptimal consumption of dairy products. Dietary modelling was applied to determine the theoretical impact of improving dairy products consumption on nutrient adequacy in 4-5-year-old Brazilian children. METHODS Adherence to the dairy recommendation of two servings/day was calculated using data from the Brazil Kids Nutrition and Health Study (KNHS) (n = 228). Two modelling scenarios were applied to test the impact on nutrient intakes of (1) adding one or two servings of a frequently consumed cow's milk or a widely available fortified alternative: pre-school children milk (PCM), and of (2) substituting the current milk consumed by PCM. Mean nutrient intakes and percentage of children adhering to the nutrient recommendations were determined at baseline and after applying modelling scenarios. RESULTS Seventy-six percent (n = 174) of children did not meet the recommended daily two servings of dairy products, 56% had less than one serving of dairy products on the day of recall. The mean consumption of whole milk (fortified and unfortified) was 147 g/d, yoghurt 114 g/d and cheese 34 g/d. The addition of one serving of cow's milk demonstrated a 17% reduction in calcium inadequacy, 18% reduction in vitamin A and 3% reduction in zinc inadequacy. Adding one serving of PCM further reduced calcium inadequacy from 87 to 41%, vitamin E from 81 to 37%, and zinc inadequacy by 10%. Replacing the child's current milk with a PCM resulted in further reduction of micronutrient inadequacies, including calcium, vitamin D and vitamin E. CONCLUSIONS Dairy products consumption in pre-school children should be encouraged to reduce nutrient inadequacies. In particular, consumption of PCM would help to reduce calcium, vitamin D and vitamin E inadequacy, nutrients of concern in this population.
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Affiliation(s)
- Yvonne M. Lenighan
- grid.419905.00000 0001 0066 4948Department of Nutrition Sciences, Nestlé Institute of Health Sciences, Nestlé Research, Société des Produits Nestlé S.A., Vers-chez-les-Blanc, 1000 Lausanne, Switzerland
| | - Marie Tassy
- grid.419905.00000 0001 0066 4948Department of Nutrition Sciences, Nestlé Institute of Health Sciences, Nestlé Research, Société des Produits Nestlé S.A., Vers-chez-les-Blanc, 1000 Lausanne, Switzerland
| | | | - Elizabeth A. Offord
- grid.419905.00000 0001 0066 4948Department of Nutrition Sciences, Nestlé Institute of Health Sciences, Nestlé Research, Société des Produits Nestlé S.A., Vers-chez-les-Blanc, 1000 Lausanne, Switzerland
| | - Tsz Ning Mak
- grid.419905.00000 0001 0066 4948Department of Nutrition Sciences, Nestlé Institute of Health Sciences, Nestlé Research, Société des Produits Nestlé S.A., Vers-chez-les-Blanc, 1000 Lausanne, Switzerland
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Mak TN, Angeles-Agdeppa I, Tassy M, Capanzana MV, Offord EA. The Nutritional Impact of Milk Beverages in Reducing Nutrient Inadequacy among Children Aged One to Five Years in the Philippines: A Dietary Modelling Study. Nutrients 2020; 12:E3330. [PMID: 33138121 PMCID: PMC7692769 DOI: 10.3390/nu12113330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 10/20/2020] [Accepted: 10/22/2020] [Indexed: 11/16/2022] Open
Abstract
Around half of Filipino children are not consuming any dairy products on a given day, which has shown to be associated with increased risk of inadequate nutrient intakes. The current study applies dietary modelling to assess the nutritional impact of meeting dairy recommendations in reducing nutrient inadequacy in children aged one to five years in the Philippines. Dietary intake data of Filipino children aged one to five years (n = 3864) were analyzed from the 8th National Nutrition Survey 2013. Children who did not meet national dairy recommendations were identified. Two scenarios were applied, based on two types of commonly consumed milk products by the survey participants. In scenario one, one serving of powdered milk was added to the diet of these children. In scenario two, one serving of a young children milk (YCM) or preschool children milk (PCM) was added to the diet of children aged one to two years and three to five years, respectively. Mean nutrient intakes and percentages of children with inadequate intakes were estimated before and after applying modelling scenarios. Scenario one demonstrated improvement in calcium, phosphorus, sodium, vitamin A and riboflavin intakes, while in scenario two, further improvement of intakes of a wider range of nutrients including iron, selenium, zinc, magnesium, potassium, vitamins C, D, E, thiamin, niacin, vitamins B6, and B12 was observed. In both scenarios, if all children would meet their dairy recommendations, theoretical reductions in population nutrient inadequacy would be observed for all micronutrients, for example, only 20% of children aged one to two years would be inadequate in vitamin A instead of the current 60%, iron inadequacy would see a 5% reduction, and approximately 10% reduction for calcium and 20% reduction for folate. The present study is the first to apply dietary modelling to assess the theoretical impact of meeting dairy recommendations on nutrient inadequacy in children in the Philippines. Dairy consumption should be encouraged as part of the strategy to reduce nutrient inadequacies. Calcium, iron, vitamins D, E, and folate are of concern in the Philippines as the level of inadequacies are extremely high in early years, YCM and PCM can help increase the intake of these nutrients.
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Affiliation(s)
- Tsz-Ning Mak
- Nestlé Institute of Health Sciences, Nestlé Research, Route du Jorat 57, 1000 Lausanne, Switzerland; (M.T.); (E.A.O.)
| | - Imelda Angeles-Agdeppa
- Department of Science and Technology-Food and Nutrition Research Institute, Taguig City 1631, Philippines; (I.A.-A.); (M.V.C.)
| | - Marie Tassy
- Nestlé Institute of Health Sciences, Nestlé Research, Route du Jorat 57, 1000 Lausanne, Switzerland; (M.T.); (E.A.O.)
| | - Mario V. Capanzana
- Department of Science and Technology-Food and Nutrition Research Institute, Taguig City 1631, Philippines; (I.A.-A.); (M.V.C.)
| | - Elizabeth A. Offord
- Nestlé Institute of Health Sciences, Nestlé Research, Route du Jorat 57, 1000 Lausanne, Switzerland; (M.T.); (E.A.O.)
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Community-based interventions to increase dairy intake in healthy populations: a systematic review. Public Health Rev 2020; 41:18. [PMID: 32774990 PMCID: PMC7401205 DOI: 10.1186/s40985-020-00135-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 06/18/2020] [Indexed: 12/03/2022] Open
Abstract
Background Considering the low frequency of dairy intake in the population, interventions aiming to increase its consumption can be a priority for any health system. Objective This study aims to summarize community-based interventions for improving dairy consumption and their effectiveness to help policy-makers in designing coherent public health strategies. Methods This study was conducted in 2019, using PubMed/MEDLINE, Scopus, EMBASE, Cochrane Library, Web of Science, ProQuest, and Google Scholar. Two independent reviewers selected the eligible studies, and the outcomes of interest were extracted. The quality of eligible studies was assessed using the Joanna Briggs Institute Critical Appraisal Checklist for randomized controlled trials and quasi-experimental studies. Results Out of 521 initially identified articles, 25 studies were included. Interventions reported in 19 studies were effective in increasing dairy consumption. Interventions in high-income countries were more effective than those in middle- and low-income countries. Interventions in health centers and supermarkets were more effective than the community and school-level interventions. Interventions in supermarkets and adolescents as target groups were more effective than children, middle-aged people, and the elderly. Also, educational interventions and changing buying/selling pattern were more effective than multiple interventions. Interventions longer than 24 and 48 weeks were more effective than shorter interventions. Conclusion Three policy options including educational interventions, multiple interventions, and changing the purchase pattern are suggested. It seems that applying all of the interventions together can be more effective. Also, long-term and well-designed future studies in different settings are recommended to confirm these results.
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