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Choi JH, Lulu C, Park SJ, Lee HJ. Adherence to the nutritional recommendations according to diabetes status in Korean adults: a cross-sectional study. BMC Public Health 2024; 24:2647. [PMID: 39334162 PMCID: PMC11438389 DOI: 10.1186/s12889-024-20058-y] [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: 10/16/2023] [Accepted: 09/12/2024] [Indexed: 09/30/2024] Open
Abstract
BACKGROUND Nutritional therapy plays a crucial role in diabetes management. Assessing adherence to nutritional recommendations is critical for evaluating whether the current status of nutrition education is appropriate. This study aimed to evaluate adherence to nutritional recommendations according to diabetes status using data from the Korean National Health and Nutrition Examination Survey from 2016 to 2019. METHODS A total of 2,793 participants (55.4% male) were evaluated regarding their adherence to nutritional recommendations. The "aware" group comprised people who had been clinically diagnosed by a physician. The "treated" group comprised people receiving anti-diabetic medications. The "control" group comprised people who achieved an HbA1c level < 6.5%. The "educated" group comprised people who had received nutrition education or counseling at various locations. RESULTS Among the 1,918 individuals in the "aware" group, only 243 (8.7%) had received nutrition education. Adherence to nutritional recommendations was generally low, with people with diabetes showing slightly higher adherence to total energy intake (59.6% vs. 55.3%) and total sugar intake (88.0% vs. 84.5%) than people without diabetes. However, adherence to total carbohydrate intake was poor in both the treated and educated groups (34.3% and 26.0%, respectively) compared to the untreated and non-educated groups (44.4% and 36.0%, respectively). CONCLUSIONS These findings indicate inadequate nutritional management for people with diabetes in Korea. Nutrition education should be effectively strengthened to achieve nutritional goals.
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Affiliation(s)
- Jong Han Choi
- Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Chen Lulu
- Department of Food and Nutrition, College of Bionanotechnology, Gachon University, 1342 Seongnamdaero, Sujeong-gu, Gyeonggi-do, 13120, Seongnam-si, Republic of Korea
| | - Seon-Joo Park
- Department of Food and Nutrition, College of Bionanotechnology, Gachon University, 1342 Seongnamdaero, Sujeong-gu, Gyeonggi-do, 13120, Seongnam-si, Republic of Korea.
- Institute for Aging and Clinical Nutrition Research, Gachon University, Seongnam-si, Republic of Korea.
| | - Hae-Jeung Lee
- Department of Food and Nutrition, College of Bionanotechnology, Gachon University, 1342 Seongnamdaero, Sujeong-gu, Gyeonggi-do, 13120, Seongnam-si, Republic of Korea.
- Institute for Aging and Clinical Nutrition Research, Gachon University, Seongnam-si, Republic of Korea.
- Department of Health Sciences and Technology, GAIHST, Gachon University, Seongnam-si, Republic of Korea.
- Gachon Biomedical Convergence Institute, Gachon University Gil Medical Center, Seongnam-si, Republic of Korea.
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Pasquale A, Raffaele D, Gerardo C, Marisa C, Silvestre P, Valentina G, Umberto DF, Michele M, Stefano P, Mariarosaria DL, Vincenzo G. 3-Day food record: efficacy in patients with type 2 diabetes mellitus. J Basic Clin Physiol Pharmacol 2023; 34:767-771. [PMID: 37702297 DOI: 10.1515/jbcpp-2023-0202] [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: 08/21/2023] [Accepted: 08/28/2023] [Indexed: 09/14/2023]
Abstract
OBJECTIVES This study aimed to assess the efficacy of the 3-day food records in monitoring and enhancing dietary habits among patients with type 2 diabetes mellitus. METHODS A total of 49 patients with type 2 diabetes mellitus were enrolled, with 38 completing the study. Participants were instructed to record their food intake over 3 consecutive days every 2 months. Key anthropometric and glycometabolic parameters, including body weight, abdominal circumference, glycated hemoglobin, and fasting blood sugar, were evaluated at baseline and after 6 months. RESULTS The introduction of the 3-day food records led to significant improvements in body weight, abdominal circumference, glycated hemoglobin, and fasting blood sugar. Additionally, there was a notable increase in the percentage of patients adhering to the LARN nutritional recommendations, especially concerning the intake of carbohydrates, simple sugars, proteins, fiber, and water. However, adherence to lipid and saturated fat recommendations remained a challenge. CONCLUSIONS The 3-day food records emerges as a valuable tool in the dietary management of patients with type 2 diabetes mellitus. By facilitating real-time monitoring and feedback, it holds promise in enhancing patient adherence to nutritional guidelines, thereby improving key health outcomes.
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Affiliation(s)
| | | | | | | | | | | | - De Fortuna Umberto
- Department of Translational Medical Sciences, University Federico II, Naples, Italy
| | - Modestino Michele
- Department of Translational Medical Sciences, University Federico II, Naples, Italy
| | - Palermi Stefano
- Public Health Department, University of Naples Federico II, Naples, Italy
| | - De Luca Mariarosaria
- Department of Translational Medical Sciences, University Federico II, Naples, Italy
| | - Guardasole Vincenzo
- Department of Translational Medical Sciences, University Federico II, Naples, Italy
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Phillips LA, Mullan BA. Ramifications of behavioural complexity for habit conceptualisation, promotion, and measurement. Health Psychol Rev 2023; 17:402-415. [PMID: 35382707 DOI: 10.1080/17437199.2022.2060849] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 03/28/2022] [Indexed: 11/04/2022]
Abstract
Behavioural theories, predictions, and interventions should be relevant to complex, real-world health behaviours and conditions. Habit theory and habit formation interventions show promise for predicting and promoting, respectively, longer-term behaviour change and maintenance than has been attained with theories and interventions focused only on deliberative behavioural factors. However, the concept of habit has largely been treated as uniform across different types of behaviours. In this conceptual review, we contend that the definitional aspects of habit differ at a conceptual level for simple versus more complex behaviours, with ramifications for prediction, promotion, and measurement of habits. Specifically, habits are defined as direct context-response associations learned through repeatedly rewarded responding - but what is meant by 'response' and 'reward' depends upon the complexity of the behaviour. We review literature that suggests (1) responses in complex habits have separable and substitutable components (vs a single and static, unitary component) and (2) rewards for complex habits are necessarily continued and intrinsic (vs temporary and extrinsic, respectively). We discuss some empirical and theoretical questions raised by these issues around behavioural complexity and habit. Lastly, we outline the ramifications of these issues for habit measurement (habit strength and habit formation) via self-report and objective measures.
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Self-Reported Dietary Management Behaviors and Dietary Intake among Chinese Adults with Diabetes: A Population-Based Study. Nutrients 2022; 14:nu14235178. [PMID: 36501208 PMCID: PMC9740534 DOI: 10.3390/nu14235178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 11/25/2022] [Accepted: 12/02/2022] [Indexed: 12/12/2022] Open
Abstract
Few studies have analyzed the implementation of dietary management in Chinese adults with diabetes. Thus, we assessed and compared dietary intake and diet quality between diabetic patients with and without dietary management behaviors (DPDM vs. NDPDM), and evaluated the adherence to dietary guidelines in both groups of patients. The data were obtained from the 2002, 2010-2013, and 2015 China National Nutrition Survey. A total of 69,583, 67,177, and 96,631 subjects participated in the 2002, 2010-2013, and 2015 survey rounds, respectively. The dietary intake data were measured using 3-day 24 h dietary recalls and weighed records of household condiments. The China Healthy Diet Index (CHDI) was used to evaluate diet quality. The study included 6229 patients with diabetes, of which 78% had dietary management behaviors. The diabetic patients with dietary management behaviors showed higher percentages of energy from high-quality carbohydrates, animal protein, saturated fatty acids, and unsaturated fatty acids and lower percentages from low-quality carbohydrates and plant protein than NDPDM. The diabetic patients with dietary management behaviors also had lower intakes of cereals and tubers and higher intakes of vegetables than NDPDM. The total CHDI score of DPDM was higher than NDPDM (56.3 ± 12.7 vs. 54.1 ± 12.3). The proportion of DPDM meeting the recommended intake for different food items ranged from 3.3% to 42.8% and from 3.0% to 39.2% in NDPDM. The diabetic patients with dietary management behaviors showed better adherence to dietary guidelines and higher diet quality scores than NDPDM, while the overall adherence was poor in both groups of patients. Our findings suggested that measures are needed to promote and refine dietary management behaviors, which can help to improve disease management in diabetic patients.
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Sińska BI, Dłużniak-Gołaska K, Jaworski M, Panczyk M, Duda-Zalewska A, Traczyk I, Religioni U, Kucharska A. Undertaking Healthy Nutrition Behaviors by Patients with Type 1 Diabetes as an Important Element of Self-Care. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:13173. [PMID: 36293753 PMCID: PMC9602576 DOI: 10.3390/ijerph192013173] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 09/29/2022] [Accepted: 10/03/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Self-control/self-care means the active participation of a diabetic patient in therapy. It involves making numerous decisions and undertaking actions independently. The primary activities under the patient's control include adherence to medication regimens and maintenance of a health-promoting lifestyle, especially a healthy diet. However, the sense of responsibility for one's own health, i.e., high sense of responsibility (HSR), is an important element in the treatment of diabetes and in undertaking pro-health behaviors. The study aimed at analyzing adherence to dietary recommendations in the context of HSR in patients with type 1 diabetes. METHODS The cross-sectional study was conducted on a group of 394 adults. The assessment of adherence to dietary recommendations was performed with the present authors' Diabetes Dietary Guidelines Adherence Index (DDGA Index). The measurement of HSR was performed with the standardized Sense of Responsibility for Health Scale (HSRS). The assessment of the multifactorial influence of independent variables on the DDGA Index, including the "responsibility for health" variable, was conducted with the use of a linear regression model. RESULTS The mean DDGA value was 18.68 (SD = 3.97). The patients significantly more often avoided unhealthy products than included recommended products into the diet at a required frequency. A positive correlation was demonstrated between HSR and adherence to dietary recommendations (βstd. = 0.43, p < 0.001). CONCLUSIONS The sense of responsibility for one's health plays a main role in adherence to dietary recommendations in diabetes. Our study showed that a higher sense of responsibility for health was associated with a higher level of adherence to dietary recommendations. Patients with a high sense of responsibility for one's health will be more involved in the therapeutic process, including adherence to dietary recommendations. Therefore, all education actions should comprise not only dietary knowledge transfer and shaping appropriate skills, but they should also strengthen the sense of responsibility for one's health.
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Affiliation(s)
- Beata Irena Sińska
- Department of Human Nutrition, Faculty of Health Sciences, Medical University of Warsaw, 27 Erazma Ciołka Street, 01-445 Warsaw, Poland
| | - Karolina Dłużniak-Gołaska
- Pediatric Clinical Hospital—University Clinical Center, Medical University of Warsaw, 63A Żwirki I Wigury Street, 02-091 Warsaw, Poland
| | - Mariusz Jaworski
- Department of Education and Research in Health Sciences, Faculty of Health Sciences, Medical University of Warsaw, 14/16 Litewska Street, 00-575 Warsaw, Poland
| | - Mariusz Panczyk
- Department of Education and Research in Health Sciences, Faculty of Health Sciences, Medical University of Warsaw, 14/16 Litewska Street, 00-575 Warsaw, Poland
| | - Aneta Duda-Zalewska
- Department of Public Health, Faculty of Health Sciences, Medical University of Warsaw, Jana Nielubowicza Street 5, Blok F, 02-097 Warsaw, Poland
| | - Iwona Traczyk
- Department of Human Nutrition, Faculty of Health Sciences, Medical University of Warsaw, 27 Erazma Ciołka Street, 01-445 Warsaw, Poland
| | - Urszula Religioni
- School of Public Health, Centre of Postgraduate Medical Education of Warsaw, Kleczewska 61/63, 01-826 Warsaw, Poland
| | - Alicja Kucharska
- Department of Human Nutrition, Faculty of Health Sciences, Medical University of Warsaw, 27 Erazma Ciołka Street, 01-445 Warsaw, Poland
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Zhang Y, Han H, Chu L. Effectiveness of restricted diet with a plate in patients with type 2 diabetes: A randomized controlled trial. Prim Care Diabetes 2022; 16:368-374. [PMID: 35331663 DOI: 10.1016/j.pcd.2022.03.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 03/07/2022] [Accepted: 03/11/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND In view of the complexity of dietary and nutritional education for most patients with type 2 diabetes mellitus (T2DM), a simplified approach called the "restricted diet with a plate" or "plate model" is recommended. PURPOSE To evaluate whether the plate model can effectively improve glycemic control and cardiovascular risk markers in type 2 diabetes mellitus (T2DM), while reducing the time devoted to education and avoiding weight gain. METHODS The study was a randomized, multicenter, controlled study, conducted between October 2018 and October 2019, among patients with T2DM living in Nanjing. The study included 419 participants who were randomly divided into a plate group and a counting group. The plate model included three components: a low-literacy, color leaflet containing the explanation and composition of the plate model, health education, and medical visits. Patients in the counting group received health education, group medical visits, and a paper booklet containing traditional carbohydrate counting education. Primary outcomes were glycemic control and weight. RESULTS Participants in the plate model reduced HbA1c by 0.7% in the first three months, and reduced to a greater extent at six months (1.44%), but this was not sustained, and HbA1c increased slightly over the following six months. Fasting plasma glucose (FPG) and 2-h postprandial glucose (2hPG) values were significantly reduced at the endpoint in the plate model (9.25 ± 1.72% vs. 7.44 ± 0.88%, P = 0.008; 12.07 ± 2.94 vs. 8.35 ± 1.99%; P = 0.004); however, the 2hPG values decreased most significantly. Total cholesterol (TC) and low-density lipoprotein cholesterol (LDL-C) levels decreased significantly in the plate group, which occurred at six months and lasted for 12 months. In the first three months, the average weight loss in the plate group was 1.2 kg/month (95% CI 0.92-1.48), and in the fourth to twelfth months, the average weight gain was 0.21 kg/month (95% CI 0.08-0.34). There was significant difference in education time between the groups (17.3 ± 4.42 vs. 38.6 ± 12.63; P < 0.001). CONCLUSIONS The plate model is at least as effective as the counting model over the short term for glycemic control and perhaps even better for weight and lipid control. Plate model has the potential to improve education of those with low health literacy by reducing reading demands.
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Affiliation(s)
- Yongwen Zhang
- Department of Endocrinology, Nanjing Integrated Traditional Chinese and Western Medicine Hospital Affiliated with Nanjing University of Chinese Medicine, Nanjing 210014, China.
| | - Huanhuan Han
- Department of Endocrinology, Nanjing Integrated Traditional Chinese and Western Medicine Hospital Affiliated with Nanjing University of Chinese Medicine, Nanjing 210014, China.
| | - Lanfang Chu
- Department of Integrated Traditional Chinese and Western Medicine, East Region Military Command General Hospital, Nanjing 210012, China.
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Grammatikopoulou MG, Goulis DG. Medical Nutrition Therapy in Diabetes Mellitus: New Insights to an Old Problem. Nutrients 2022; 14:698. [PMID: 35277056 PMCID: PMC8838997 DOI: 10.3390/nu14030698] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 02/02/2022] [Indexed: 02/01/2023] Open
Abstract
The management of all types of diabetes mellitus (DM) has transformed during the past decade [...].
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Affiliation(s)
- Maria G. Grammatikopoulou
- Department of Nutritional Sciences and Dietetics, Faculty of Health Sciences, Alexander Campus, International Hellenic University, GR-57400 Thessaloniki, Greece;
- Unit of Reproductive Endocrinology, 1st Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, Papageorgiou General Hospital, GR-56429 Thessaloniki, Greece
| | - Dimitrios G. Goulis
- Unit of Reproductive Endocrinology, 1st Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, Papageorgiou General Hospital, GR-56429 Thessaloniki, Greece
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Dobrow L, Estrada I, Burkholder-Cooley N, Miklavcic J. Potential Effectiveness of Registered Dietitian Nutritionists in Healthy Behavior Interventions for Managing Type 2 Diabetes in Older Adults: A Systematic Review. Front Nutr 2022; 8:737410. [PMID: 35141261 PMCID: PMC8819057 DOI: 10.3389/fnut.2021.737410] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 12/03/2021] [Indexed: 11/13/2022] Open
Abstract
Purpose A systematic review was conducted to assess how the involvement of a registered dietitian nutritionist (RDN) in healthy behavior interventions (HBIs) potentially affects outcomes in older adults with type 2 diabetes (T2D). Methods Literature was searched for primary research published between 2016 and 2020 on HBI involving a RDN affecting outcomes in older adults with T2D. Evaluations of hemoglobin A1c (HbA1c), blood glucose, blood pressure, cholesterol, anthropometry, body composition, medication usage, healthcare cost, and self-efficacy and/or adherence to healthy behaviors outcomes were selected for inclusion. All the literature included were summarized, evaluated for certainty of evidence criteria, and assessed for bias. Results A total of 12 studies were included for assessment. Involvement of a RDN in HBI was shown to reduce HbA1c, fasting blood glucose, low-density lipoprotein (LDL) cholesterol, and blood pressure and improve lean body mass, body mass index (BMI), and self-efficacy in populations of older adults with T2D. Compared to older adults with T2D receiving HBI involving RDNs, patients receiving usual care may incur higher healthcare costs or longer hospital stays. There was a high certainty of evidence for a RDN involvement in HBI with regard to reduction in HbA1c. There was a moderate certainty of evidence for a RDN involvement in HBI with regard to favorable changes in weight or body composition and cardiometabolic health outcomes. Statistically significant improvements in outcomes were usually sustained in follow-up after conclusion of HBI. Conclusion RDNs may play an integral role in HBIs resulting in improved glycemic control, weight management, cardiovascular outcomes, and presumably comorbidity management. RDNs are important facilitators of diet education and nutrition assessment, which are essential in T2D management and should, therefore, be considered for routine inclusion in interprofessional teams for improved outcomes in older adults with T2D.
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Affiliation(s)
- Laurel Dobrow
- Schmid College of Science and Technology, Chapman University, Orange, CA, United States
| | - Isabella Estrada
- Schmid College of Science and Technology, Chapman University, Orange, CA, United States
| | | | - John Miklavcic
- Schmid College of Science and Technology, Chapman University, Orange, CA, United States
- School of Pharmacy, Chapman University, Irvine, CA, United States
- *Correspondence: John Miklavcic
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Grammatikopoulou MG, Gkiouras K, Polychronidou G, Kaparounaki C, Gkouskou KK, Magkos F, Donini LM, Eliopoulos AG, Goulis DG. Obsessed with Healthy Eating: A Systematic Review of Observational Studies Assessing Orthorexia Nervosa in Patients with Diabetes Mellitus. Nutrients 2021; 13:3823. [PMID: 34836080 PMCID: PMC8622186 DOI: 10.3390/nu13113823] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 10/20/2021] [Accepted: 10/24/2021] [Indexed: 12/12/2022] Open
Abstract
Orthorexia nervosa (ON) is an unspecified feeding or eating disorder (USFED) characterized by an exaggerated, unhealthy obsession with healthy eating. Τypical eating disorders (EDs) and USFEDs are common among patients with diabetes mellitus (DM), which complicates metabolic control and disease outcomes. The present systematic review summarizes the evidence on the prevalence of ON symptomatology among patients with DM. PubMed, Web of Science, Scopus, and grey literature were searched, and relevant observational studies were screened using the Rayyan software. The quality of the studies was assessed using the appraisal tool for cross-sectional studies (AXIS) and the Newcastle-Ottawa scale (NOS). Out of 4642 studies, 6 fulfilled the predefined criteria and were included in the qualitative synthesis. Most studies relied on the ORTO-15 or its adaptations to identify ON among patients with DM. No apparent sex or age differences exist regarding the prevalence of ON symptoms. None of the studies compared the prevalence of ON in patients with type 1 and type 2 DM. Most of the research was of average to good methodological quality. In conclusion, patients with DM often exhibit ON tendencies, although research is still limited regarding the etiology or mechanistic drivers behind ON and the characteristics of patients with a dual ON-DM diagnosis.
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Affiliation(s)
- Maria G. Grammatikopoulou
- Department of Nutritional Sciences & Dietetics, Faculty of Health Sciences, Alexander Campus, International Hellenic University, GR-57400 Thessaloniki, Greece;
- Unit of Reproductive Endocrinology, 1st Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, Papageorgiou General Hospital, GR-56429 Thessaloniki, Greece
| | - Konstantinos Gkiouras
- Medical School, Faculty of Health Sciences, University Campus, Aristotle University of Thessaloniki, GR-54124 Thessaloniki, Greece; (K.G.); (G.P.); (C.K.)
| | - Georgia Polychronidou
- Medical School, Faculty of Health Sciences, University Campus, Aristotle University of Thessaloniki, GR-54124 Thessaloniki, Greece; (K.G.); (G.P.); (C.K.)
| | - Chrysi Kaparounaki
- Medical School, Faculty of Health Sciences, University Campus, Aristotle University of Thessaloniki, GR-54124 Thessaloniki, Greece; (K.G.); (G.P.); (C.K.)
| | - Kalliopi K. Gkouskou
- Laboratory of Biology, School of Medicine, National and Kapodistrian University of Athens, GR-11527 Athens, Greece; (K.K.G.); (A.G.E.)
- Embiodiagnostics Biology Research Company, GR-71305 Heraklion, Greece
| | - Faidon Magkos
- Department of Nutrition, Exercise and Sports, Faculty of Science, University of Copenhagen, 1958 Frederiksberg, Denmark;
| | - Lorenzo Maria Donini
- Department of Experimental Medicine-Medical Pathophysiology, Food Science and Endocrinology Section, Sapienza University of Rome, 00185 Rome, Italy;
| | - Aristides G. Eliopoulos
- Laboratory of Biology, School of Medicine, National and Kapodistrian University of Athens, GR-11527 Athens, Greece; (K.K.G.); (A.G.E.)
- Biomedical Research Foundation of the Academy of Athens, GR-11527 Athens, Greece
- Center for New Biotechnologies and Precision Medicine, School of Medicine, National and Kapodistrian University of Athens, GR-11527 Athens, Greece
| | - Dimitrios G. Goulis
- Unit of Reproductive Endocrinology, 1st Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, Papageorgiou General Hospital, GR-56429 Thessaloniki, Greece
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