Developed and validated food frequency questionnaires in Iran: A systematic literature review
Samaneh Sadat Ayoubi1, Zahra Yaghoubi2, Naseh Pahlavani3, Elena Philippou4, Mahsa MalekAhmadi1, Habibollah Esmaily5, Golnaz Ranjbar1, Maryam Amini6, Mohsen Nematy1, Abdolreza Norouzy1
1 Department of Nutrition, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
2 Department of Community Oral Health, School of Dentistry, Mashhad University of Medical Sciences, Mashhad, Iran
3 Cellular and Molecular Research Center, Research Institute for Health Development, Kurdistan University of Medical Sciences, Sanandaj, Iran
4 Department of Life and Health Sciences and Engineering, University of Nicosia, Nicosia, Cyprus
5 Social Determinants of Health Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
6 Department of Nutrition Research, National Nutrition and Food Technology Research Institute, Tehran, Iran
|Date of Submission||04-Jul-2020|
|Date of Decision||15-Sep-2020|
|Date of Acceptance||03-Feb-2021|
|Date of Web Publication||31-Jul-2021|
Dr. Abdolreza Norouzy
Department of Nutrition, School of Medicine, Mashhad University of Medical Sciences, Paradise Daneshgah, Azadi Square, Mashhad
Dr. Zahra Yaghoubi
Department of Community Oral Health, School of Dentistry, Mashhad University of Medical Sciences, Paradise Daneshgah, Azadi Square, Mashhad
Source of Support: None, Conflict of Interest: None
Background: Food frequency questionnaires (FFQs) are inexpensive, easy to administer, and practical tools for dietary assessment in epidemiological studies. Several studies have investigated the validity and reproducibility of FFQs for the Iranian population. This systematic review aimed to assess the developed and validated FFQs for use in the Iranian population and compare their features and the validation studies in this regard. Materials and Methods: A comprehensive search was conducted in ISI Web of Knowledge, PubMed, Scopus, and Iranian databases without time constraints to retrieve the relevant English and non-English publications. Studies would be included if they were focused on the design and validation of FFQs in Iran. Results: In total, 782 articles were found, 22 of which met the eligibility criteria and evaluated 18 FFQs. Validation studies had been conducted on 18 out of 20 FFQs. The median of the correlation coefficients for the comparison of the FFQ intakes and the dietary reference method by nutrients varied within the range of 0.19–0.65, indicating reasonable validity. The median of the correlation coefficients for the comparison of two FFQs by nutrients was 0.28–0.85, showing appropriate reproducibility. However, low validity was observed in some nutrients and food groups, such as egg, legumes, iron, folate, and α-tocopherol. In seven studies, biomarkers were used for the assessment of nutrient intake using an FFQ with the median correlation coefficient of −0.07–0.42. In addition, the quality of methodology was evaluated in the FFQ validation studies, with 18 out of 20 studies reporting good and excellent quality. Conclusion: Although the FFQs used to assess the dietary intake of the Iranian population have different features, they have acceptable validity and reproducibility. Nevertheless, some food groups and nutrients have poor validity and must be considered attentively.
Keywords: Food frequency questionnaires, Iran, reproducibility, systematic review, validity
|How to cite this article:|
Ayoubi SS, Yaghoubi Z, Pahlavani N, Philippou E, MalekAhmadi M, Esmaily H, Ranjbar G, Amini M, Nematy M, Norouzy A. Developed and validated food frequency questionnaires in Iran: A systematic literature review. J Res Med Sci 2021;26:50
|How to cite this URL:|
Ayoubi SS, Yaghoubi Z, Pahlavani N, Philippou E, MalekAhmadi M, Esmaily H, Ranjbar G, Amini M, Nematy M, Norouzy A. Developed and validated food frequency questionnaires in Iran: A systematic literature review. J Res Med Sci [serial online] 2021 [cited 2022 May 17];26:50. Available from: https://www.jmsjournal.net/text.asp?2021/26/1/50/322873
| Introduction|| |
Dietary intake assessment is a complex task and a significant challenge in epidemiological research. The assessment of dietary intake is fundamental in the study of the interrelations between diets and diseases. Most epidemiological studies use food frequency questionnaires (FFQ) to estimate dietary intakes or evaluate specific dietary patterns and nutrients since these tools are relatively inexpensive and easier to administer and analyze in large sample sizes compared to other dietary intake assessment methods, such as food records. FFQs typically assess the dietary intake within the past year and comprise a list of commonly consumed foods with some possible options regarding the frequency of their consumption (e.g., once a day, once a week, once a month). In FFQs, portion size is either standard or selected from the provided portion size images. Other methods of dietary assessment are 24-h recalls, weighted food records, and diet histories.
Currently, no “gold standard” methods are available for dietary intake assessment or the measurement of the intake of specific foods or nutrients. The available methods have specific strengths and limitations and heavily rely on the participants' willingness to cooperate. An FFQ is used to assess the habitual intakes of a population over time and is also expected to rank individuals based on their nutrient intakes. On the other hand, food records or recalls only assess certain days or weeks, and although they are more accurate, they may not fully represent the usual dietary intakes. Moreover, since diet in general but also types of foods consumed vary in different populations, it is imperative to use population-specific FFQs.
In Iran, various FFQs have been designed and validated to evaluate the dietary intake of various age groups in the population based on food records, dietary recalls, or biochemical markers.,, This systematic review aimed to evaluate the FFQs that have been specifically designed to assess the dietary intake of the Iranian population and compare their features and the validation studies in this regard. Our findings could be practical for designing new FFQs and performing validation studies on the Iranian population.
| Materials and Methods|| |
This systematic review was conducted based on the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, with the specification of the methods before commencing the literature search. A systematic search for the relevant articles regarding Iranian FFQs was performed up to July 2020 in databases such as ISI Web of Knowledge, PubMed, Scopus, and Iranian SID database using various keywords, including “food frequency questionnaire” OR “FFQ” OR “diet history questionnaire” in combination with “validity” and “Iran.” After eliminating duplicate references, the eligibility assessment of the identified studies was carried out independently by two investigators (S. S. A. and Z. Y.).
The eligibility criteria were as follows: (1) study design (design, validation, and reproducibility assessment of FFQs); (2) study participants (all types of study participants included with any age, both patients and healthy participants); (3) type of dietary assessment tool (FFQ and diet history); (4) comparable with questionnaires (dietary reference methods such as food records and recalls), biomarkers, and expert opinion; and (5) English and Persian articles published until July 2020. Review studies were excluded.
Data extraction from eligible studies
The extracted data from the retrieved articles included the aim of the questionnaire design in terms of variable measurement, number of food items, items on frequency and portion size, method of questionnaire design (experience based/data based), reference methods of the validation studies (e.g., dietary reference methods, biomarkers, expert panel), number of the participants, gender and age of the participants, method of questionnaire administration, dietary assessment method in the validation studies (dietary recall or food record), duration of the dietary reference method (record/recall), food group/nutrients, blood biomarkers, urine biomarkers, statistical methods in the FFQ validation studies (e.g., correlation coefficients [high or low validity]), energy adjustment, de-attenuation (adjustment for within-person variation of food intake on different days), reproducibility of food groups/nutrients, and interval between the two administrations of the FFQs in the reproducibility studies.
The methodology quality of the selected studies was scored by two reviewers who used the previously applied scores as adapted from the study by Serra-Majem et al.; the highest score was seven (highest quality), and the lowest score was zero (lowest quality). The scores were assigned based on various components, including the samples and sample size (maximum score: 1), type of statistics (score 3), administration method (score 0.5), food grouping details (score 1), frequency scale, and portion size (score: 1), and consideration of seasonality (score: 0.5). The quality of each study was scored as poor (scores ≤2), acceptable (scores 2.5≤–<3.5), good (scores 3.5≤–<5), and excellent (scores 5≤).
The four main methods used in the validation studies were as follows:
- FFQ data were compared with the actual intake calculated by another dietary reference method (food records/24-h recalls)
- FFQ data were compared with blood and urine biomarkers, hair, and body tissues
- Factors could be calculated based on the FFQ data and compared with the factors of the dietary reference method,,
- The validity of the FFQ items could be calculated by an expert panel, and based on their feedback regarding the essentiality of an item, the content validity ratio would be calculated. In addition, the content validity index would be calculated based on expert opinion regarding the correlation between the aim of the questionnaire design with an item.
FFQ reproducibility could be assessed by the comparison of the data of two FFQ administrations and the calculation of factors such as the correlation coefficients, intraclass correlation, and Cronbach's alpha. In the selected studies, the median of the correlation coefficients between dietary reference methods and FFQs were summarized to assess validity; if two or more correlation coefficients were observed in one study, their median would be used. Notably, the intraclass correlations were summarized in similar manners.
| Results|| |
As depicted in [Figure 1], 782 studies were identified. After the initial review of the titles and abstracts, 760 articles were excluded, and 22 studies that met the eligibility criteria were selected for further analysis [Figure 1].
Initially, we reviewed the features of the Iranian FFQs, including the aim of the design, methods of developing the FFQ, number of the food items and frequency questions, and portion size calculation. In the next step, the features of the FFQ validation studies were evaluated, including the sample size, sample population, method of FFQ administration, methods of FFQ validation, statistical approaches in the validation studies, quality of the FFQ validation methodology, and FFQ reproducibility assessments.
Food frequency questionnaires features
[Table 1] shows the features of the included FFQs. In total, 20 FFQs were identified, which had been developed in Iran.,,,,,,,,,,,,,,,,,,,,, In four articles,,,, the validation studies were focused on the same two FFQs. Notably, 18 FFQs were validated in 20 studies.
|Table 1: Characteristics of food frequency questionnaires designed and validated in Iran (sorted by the number of included food items)|
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Aim of food frequency questionnaires design
Eight FFQs were developed to assess specific nutrients, including the folate intake in breast cancer patients,, iron and Vitamins A and C intake in the women of the reproductive age, calcium intake among students, sodium intake in the general population, antioxidant intake among the elderly, and gluten intake in patients with ulcerative colitis. Furthermore, one FFQ was used to assess fruit and vegetable intake, and another FFQ evaluated the foods contributing to cardiovascular diseases. Finally, 12 FFQs were developed to assess the intake of various nutrient and food groups comprehensively.,,,,,,,,,,,,
Methods of food frequency questionnaires development
The methods of FFQ development were categorized as experience based and data based. In the first approach, experienced dietitians or epidemiologists selected food items from food composition tables. The selected food items had to be popular and have considerable nutrient contents with varied consumption by the general population. The experience-based approach was used in four FFQs.,,, In the second approach, food items were selected based on the data of other dietary reference methods, such as food records and dietary recalls.,,,,,,,,,,,,, The data-based approach was classified into three subcategories, as follows:
- Six FFQs were modified based on a previous version of the questionnaires, which were shortened to select the food items of target nutrients,,,,,
- Four FFQs were the culturally adapted versions of the validated FFQs used in other countries,,,,,
- In six FFQs, food items were selected based on food records or 24-h recalls of the previous studies conducted in Iran.,,,,, The selected food items defined the intake percentage of target nutrients.
Notably, the method of FFQ development was not mentioned in three articles.,,
Number of food items and frequency questions
In the reviewed studies, the number of the selected food items was within the range of 40–189 (mean: 109.4, median: 130.5). The assessment of the frequency of food intake was performed using open-ended questions, and the respondents marked their intake as daily, weekly, monthly, yearly, or never in 14 FFQs.,,,,,,,,,,,,,,, In five FFQs, the response categories of food intake frequency was listed with nine or 10 options,,,,, while the data collection method for the food intake frequency was not mentioned in one study.
Data on portion size had been collected in 16 FFQs.,,,,,,,,,,,,,,,,, In one FFQ, portion size was measured based on the recall portion size of the previous studies conducted in the same location, while in another FFQ, the portion size was determined based on the previously established weight of measures. On the other hand, the portion size was not assessed in two FFQs,, while eight studies used images to assist participants in the description of portion size.,,,,,,,
Food frequency questionnaires validation studies
The sample size of the validation studies was within the range of 30–498 (mean: 189.6, median: 152).
In 11 studies (57.8%), the participants were selected from the general population.,,,,,,,,,, The other studies were performed on patients with ulcerative colitis, women of the reproductive age, students, pregnant women, the elderly,, females aged 18–45 years, and women with recently diagnosed breast cancer.,
Food frequency questionnaires administration method
In 17 studies, questionnaires were completed by interviewers,,,,,,,,,,,,,,,,, while three studies applied self-administered questionnaires.,, The administration method was not reported in the validation studies of two FFQs.,
Food frequency questionnaires validation methods
The FFQ validation studies are presented in [Table 2]. Accordingly, four methods were applied to validate FFQs.
|Table 2: Summary of food frequency questionnaire validity and reproducibility studies in Iran (studies sorted by the number of included food items)|
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Food frequency questionnaires validation based on dietary reference methods
In 14 studies, FFQs were validated based on dietary reference methods, including food records and 24-h recalls. In addition, three FFQs were validated based on food records within the range of 18–24 days,,, eight studies used 24-h recalls for 2–24 days,,,,,,,,,, and three studies used both methods.,,
To validate FFQs, seven studies assessed various food groups,,,,,,, eight studies assessed nutrient intakes,,,,,,,, and three studies assessed both parameters.,, In the mentioned studies, Pearson's correlation coefficients were calculated to compare the food groups and nutrient intakes using the dietary reference methods (record/recall) and the collected data using FFQs,,,,,,,,,,,,, [Table 3] and [Table 4] show the correlation coefficients (r) used for the comparison of the FFQ data with the dietary reference methods for food groups and nutrient intakes, respectively.
|Table 3: Correlation coefficients between food frequency questionnaire data and crude data of dietary reference methods (food groups)|
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|Table 4: Correlation coefficients between food frequency questionnaire data and crude data of dietary reference methods (nutrients)|
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According to the findings, the validity of food group consumption was high (median of correlation coefficient of FFQs ≥0.60) for tea and coffee and fruits and refined grains, while it was moderate (median of correlation coefficient: 0.40–0.59) for solid fats, plant protein, whole grains, dairies, vegetables, soft drinks, nuts, sugar, fast foods, salty snacks, plant protein, beverages, poultry, potato, leafy vegetables, and liquid foods, fair (median of correlation coefficient: 0.30–0.39) for vegetable oils, hydrogenated vegetable oils, meat, honey and jam, grains, fruits and vegetables, pickle, and fish, and poor (median of correlation coefficient: <0.3) for egg, legumes, and sweets.
High validity was only observed for sucrose (median of correlation coefficient ≥0.60), while for most nutrients, the median correlation coefficient was within the range of 0.40–0.59, indicating moderate validity. Fair validity (correlation coefficient: 0.30–0.39) was reported for iron, Vitamin C, Vitamin B2, niacin, fiber, polyunsaturated fatty acids (PUFAs), manganese, zinc, sodium, lactose, and trans fatty acids. Poor validity (median of correlation coefficients of FFQs <0.3) was observed for potassium, Vitamin A, Vitamin E, Vitamin B6, Vitamin B12, α-tocopherol, folate, copper, and fructose. Among fatty acids, validity was highest for saturated fatty acids, followed by monounsaturated fatty acids and PUFAs.
Food frequency questionnaires validation based on biomarkers
According to the current review, eight studies used biomarkers as the reference method,,,,,,,, including five studies that used blood biomarkers,,,, and three studies that employed blood and urine biomarkers.,, Moreover, two studies used biomarkers as a single reference method,, and six studies used biomarkers along with a dietary reference method for this purpose.,,,,, [Table 5] shows the correlation coefficients for the comparison of the FFQ data and biomarkers.
|Table 5: Correlation coefficients between food frequency questionnaire data and biomarkers|
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According to the findings, the blood biomarkers that were used in more than one study were retinol,,,,,, α-tocopherol,,, Vitamin C,, and β-carotene.,,, In addition, cholesterol was measured in two studies, while the correlation was reported in only one study. The common urinary biomarkers included the 24-h protein excretion (r median: −0.0675).,, and potassium excretion (r median: 0.423)., In most of the reviewed studies, the median correlation coefficients between the FFQs and biomarkers were within the range of 0.30–0.39, indicating fair validity for Vitamin C, cholesterol, folate, 24-h urine nitrogen, and β-carotene. The highest consistency between the FFQs and biomarkers was observed with urinary potassium (r median: 0.423), which indicated moderate validity. On the other hand, poor validity (r < 0.30) was denoted with retinol, protein, α-tocopherol, Vitamin A, cobalamin, and pyridoxal-5-phosphate.
According to the current review, three studies used factor analysis to identify the dietary patterns in FFQs and assess their validity. In this approach, the correlations between the factors of the FFQ and dietary reference methods were calculated as well.,,
In one study, an expert panel calculated the content validity ratio and content validity index in order to the assess validity of FFQs.
Statistical approaches in the validation process
In 16 studies, correlation coefficients were used to compare the FFQ data by a dietary reference method,,,,,,,,,,,,,,,, while three studies used the Bland-Altman plot in addition to correlation coefficients.,, In one study, the triad method was employed, which is a three-way comparison of the FFQ with detailed measures of dietary intake, such as a dietary record and biochemical measure., The content validity index was also used for this purpose in one research. Three studies identified dietary patterns using factor analysis to assess the validity of dietary patterns.,,
Methodology quality of food frequency questionnaires validation studies
In this literature review, the selected studies were scored against a validation study methodology tool. Correspondingly, two studies had acceptable quality,, eight studies had good quality, and 10 studies were considered to have excellent quality.
Assessment of food frequency questionnaires reproducibility
The reproducibility of FFQs was evaluated in 14 studies,,,,,,,,,,,,, [Table 2]. With the exception of one study, the other studies had measured FFQ reproducibility twice. The median time interval between the FFQ administrations was 3 months, ranging from 2 weeks to 14 months. Reproducibility was assessed by intraclass correlation coefficients between two FFQs that were administered in most of the studies in this regard,,,,,,,,,,,,,, while the Cronbach's alpha was calculated in one study only. The intraclass correlations between the FFQs were within the range of 0.28 (total sugar) to 0.85 (chloride), with 0.67 calculated as the median for nutrients. As for food groups, the intraclass correlations ranged from 0.30 (beverages) to 0.83 (tea and coffee), 0.85 (sugar), and 0.85 (fish), with the median of 0.65 showing moderate reproducibility. The reported Cronbach's alpha was 0.79 to show acceptable reproducibility.
| Discussion|| |
This systematic review was a comprehensive study of the FFQs developed to assess the dietary intakes of the Iranian population. In total, 20 FFQs have been developed so far, 18 of which have been the subject of validation studies. According to our findings, the most commonly used validation method was comparison with another dietary reference method. Correlation coefficients were also used in almost all the validation studies. According to the obtained results, the median correlation coefficient for nutrients between various FFQs and dietary reference methods was 0.39, which is similar to the FFQ applied in Japan, while lower than western countries, where the correlation coefficients have been reported to be within the range of 0.60–0.70. The lower correlation coefficient between FFQs and dietary reference methods in Iran could be due to the complexity of the Iranian diet since it is a combination of traditional dishes, western dishes, fast foods, and local foods. Another source of complexity arises as traditional foods may be similar in terms of description or nomenclature, while the recipes may vary. Moreover, fast foods are most commonly consumed by some populations (e.g., young adults), and local foods are mainly consumed by some ethnicities only and may not be incorporated into the developed questionnaires in this regard.
With regard to validity, the current systematic review revealed that the correlation coefficients between the FFQs and dietary reference methods varied in terms of food groups, which could be due to the differences in the number and clarity of the food items, portion sizes, and interpersonal variability. Food groups such as tea and coffee, refined grains, and fruits could be assessed with high validity, which may be attributed to their frequent consumption and the fact that they could be easily remembered by the individual. In the reviewed studies, dairy products had moderate validity, which may be due to their frequent consumption and inclusion of sufficient items with detailed questions in the questionnaires. There seems to be better consistency between FFQs and other dietary assessment methods in terms of the foods that are consumed frequently (e.g., rice, bread, vegetables, sugar, soft drinks, and fast food) rather than seasonally compared to the foods that are consumed less frequently. According to our findings, the median of the correlation coefficients for nuts was 0.445, which indicated moderate validity probably due to the high interpersonal variability in nut consumption. On the other hand, solid fats had moderate validity (median of correlation coefficients: 0.5), which animal fats had lower validity (median of correlation coefficients: 0.3), which could be due to the presence of hydrogenated vegetable oils in solid fats. Compared to the other studies in this regard, the consistency between FFQs and reference methods was slightly lower in Iran in terms of total fats (0.51 vs. 0.44), Vitamin C (0.50 vs. 0.0.34), Vitamin A (0.37 vs. 0.19), calcium (0.56 vs. 0.42), and iron (0.47 vs. 0.35).
According to the current systematic review, the validation of 70% of FFQs was based on another dietary reference method, which compares well to the study conducted by Cade et al., in which the value was reported to be 75%. Among Iranian validation studies, 40% have been performed based on biomarkers, which are considered to be a “gold standard” method. This rate is higher compared to the reported values in the studies conducted in other countries, in which the validation of only 19% of FFQs has been based on biomarkers. The more frequent use of biomarkers in Iran may be attributed to the lack of national food composition tables, which in turn leads to the preference of biomarker-based validation studies. Nevertheless, the use of biomarkers has some limitations since not only these factors are influenced by diet but also by the degree of absorption and metabolism. Therefore, the correlation between biomarkers and questionnaires is expected to be less significant than the correlation between questionnaires and dietary reference methods. As it was predicted, our findings showed a nonsignificant correlation between biomarkers and nutrient intake, and the correlation coefficients were within the range of −0.07–0.42.
In the reviewed articles, the expected intraclass correlation for the reproducibility of functional FFQs was within the range of 0.5–0.7, which indicated acceptable reproducibility. Commonly consumed food groups (e.g., tea and coffee) were observed to have higher correlation coefficients. Notably, the seasonal variation in the food intakes, which affected reproducibility, was investigated in only few studies,,,,,,, and the lack of this item may cause false reproducibility due to systematic error.
In the current review, the methodology quality of the validation studies was considered acceptable in 90% of the reviewed articles, which is higher than the value reported in a similar study (59%) and regarded as an advantage of Iranian validation studies. Furthermore, most of the questionnaires (90%) were administered through face-to-face interviews, which shows the superiority of this method for the Iranian population. It is expected that the questionnaires administered through interviewers have higher correlations owing to the guidance of the interviewer. In the self-administered questionnaire used by Nouri et al., the correlation coefficients of nutrients were lower than the interviewer-administered questionnaires. In the review of the foreign validation studies conducted by Cade et al., 67% of the questionnaires were interviewer-administered and resulted in higher correlation coefficients for some nutrients. Although interview administration and the immediate assessment of the responses is an advantage, the costs of the recruitment and training of interviewers may be disadvantageous.
According to the current review, the mean food items in the FFQs was 109.4, which is higher than the findings of the worldwide systematic review study by Cade et al.; the value was estimated at 88 in the mentioned research. The discrepancy could be due to the complexity of the Iranian diet. The mean sample size of the FFQ validation studies was 189.6 (range: 30–498), while the mean sample size of international FFQ validation studies has been estimated at 255 (range: 6–3750). Nevertheless, it seems that a larger sample size has no significant impact on the correlation coefficients in validation studies.
Strengths and limitations
This systematic review aimed to assess the features and validation studies of Iranian FFQs. The quality of the reviewed studies was scored to better judgment in the generalizability of study results. The major limitation of this review was the heterogeneity of the reported data in the reviewed studies. Although adjustment for energy intake and within-person variation (de-attenuation) would make the data more accurate, we used crude correlation coefficients since adjustment was not performed in all the studies.
| Conclusion|| |
According to the results of this systematic review, the FFQs in Iran may be representative of the regular Iranian diet and have acceptable validity and reproducibility despite the variations in their features. Furthermore, the validation studies had acceptable quality. The FFQs also had some limitations; for instance, they had low validity for some food groups and nutrients, such as egg, legumes, sweets, potassium, Vitamin E, Vitamin A, Vitamin B6, Vitamin B12, α-tocopherol, folate, copper, and fructose. Therefore, Iranian FFQs may not be applicable in some cases, and FFQ validity must be assessed for the intended items before the selection of the questionnaire.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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