{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,7]],"date-time":"2026-10-07T13:53:56Z","timestamp":1791381236103,"version":"4.3.3"},"reference-count":35,"publisher":"Springer Science and Business Media LLC","issue":"8","license":[{"start":{"date-parts":[[2026,10,7]],"date-time":"2026-10-07T00:00:00Z","timestamp":1791331200000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"},{"start":{"date-parts":[[2026,10,7]],"date-time":"2026-10-07T00:00:00Z","timestamp":1791331200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"funder":[{"DOI":"10.13039\/501100001691","name":"Japan Society for the Promotion of Science","doi-asserted-by":"publisher","award":["24K02873"],"award-info":[{"award-number":["24K02873"]}],"id":[{"id":"10.13039\/501100001691","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/501100001691","name":"Japan Society for the Promotion of Science","doi-asserted-by":"publisher","award":["24240091"],"award-info":[{"award-number":["24240091"]}],"id":[{"id":"10.13039\/501100001691","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/501100001691","name":"Japan Society for the Promotion of Science","doi-asserted-by":"publisher","award":["15H05363"],"award-info":[{"award-number":["15H05363"]}],"id":[{"id":"10.13039\/501100001691","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["Eur J Nutr"],"published-print":{"date-parts":[[2026,12]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Purpose<\/jats:title>\n                    <jats:p>Diet influences frailty, and protein intake has been a prime focus of prevention. However, frailty remains prevalent, even among older adults with relatively high protein intake, suggesting the influence of remaining energy distribution between carbohydrates and fats. We investigated the association between the carbohydrate-to-fat energy ratio (CFr) and comprehensive frailty in older Japanese adults and whether this association differed by protein intake.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>Cross-sectional baseline data from 5679 community-dwelling adults aged \u2265 65\u00a0years in the Kyoto\u2013Kameoka Study were analyzed. Diet was assessed using a validated 46-item food-frequency questionnaire. Percent energy from carbohydrates, fats, and protein was calculated. CFr was defined as the ratio of percent energy from carbohydrates to that from fat. Frailty was defined as a Kihon Checklist score \u2265 7. Multivariable logistic regression estimated odds ratios (ORs) and 95% confidence intervals (CIs) for frailty across CFr quartiles, adjusting for sociodemographic, lifestyle, and health-related factors. Restricted cubic splines assessed dose\u2013response associations overall and within sex-specific tertiles of protein intake.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      Among the 5679 participants, 1705 (30.0%) had comprehensive frailty. Compared with the lowest CFr quartile, the adjusted ORs were 1.12 (95% CI, 0.92\u20131.36) for Q2, 1.44 (1.18\u20131.76) for Q3, and 1.92 (1.55\u20132.38) for Q4 (\n                      <jats:italic>P<\/jats:italic>\n                      for trend &lt;\u20090.001). Positive associations were also observed across sex-specific protein-intake tertiles, with no evidence of effect modification by protein intake.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>A higher CFr is associated with a higher prevalence of comprehensive frailty in older Japanese adults, with broadly similar associations across protein-intake levels.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1007\/s00394-026-04099-0","type":"journal-article","created":{"date-parts":[[2026,10,7]],"date-time":"2026-10-07T13:11:10Z","timestamp":1791378670000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Carbohydrate-to-fat ratio is positively associated with comprehensive frailty across protein-intake levels in older adults"],"prefix":"10.1007","volume":"65","author":[{"given":"Hinako","family":"Nanri","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tsukasa","family":"Yoshida","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Eiichi","family":"Yoshimura","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jun","family":"Kunisawa","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hiroyuki","family":"Fujita","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Misaka","family":"Kimura","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yosuke","family":"Yamada","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,10,7]]},"reference":[{"issue":"6","key":"4099_CR1","doi-asserted-by":"publisher","first-page":"1069","DOI":"10.1111\/j.1532-5415.2005.53312.x","volume":"53","author":"K Rockwood","year":"2005","unstructured":"Rockwood K (2005) Frailty and its definition: a worthy challenge. J Am Geriatr Soc 53(6):1069\u20131070. https:\/\/doi.org\/10.1111\/j.1532-5415.2005.53312.x","journal-title":"J Am Geriatr Soc"},{"issue":"9868","key":"4099_CR2","doi-asserted-by":"publisher","first-page":"752","DOI":"10.1016\/S0140-6736(12)62167-9","volume":"381","author":"A Clegg","year":"2013","unstructured":"Clegg A, Young J, Iliffe S et al (2013) Frailty in elderly people. Lancet 381(9868):752\u2013762. https:\/\/doi.org\/10.1016\/S0140-6736(12)62167-9","journal-title":"Lancet"},{"issue":"1","key":"4099_CR3","doi-asserted-by":"publisher","DOI":"10.1186\/s12877-017-0496-2","volume":"17","author":"L Lorenzo-Lopez","year":"2017","unstructured":"Lorenzo-Lopez L, Maseda A, de Labra C et al (2017) Nutritional determinants of frailty in older adults: a systematic review. BMC Geriatr 17(1):108. https:\/\/doi.org\/10.1186\/s12877-017-0496-2","journal-title":"BMC Geriatr"},{"key":"4099_CR4","doi-asserted-by":"publisher","DOI":"10.1093\/nutrit\/nuaa104","author":"R Tagawa","year":"2020","unstructured":"Tagawa R, Watanabe D, Ito K et al (2020) Dose-response relationship between protein intake and muscle mass increase: a systematic review and meta-analysis of randomized controlled trials. Nutr Rev. https:\/\/doi.org\/10.1093\/nutrit\/nuaa104","journal-title":"Nutr Rev"},{"key":"4099_CR5","doi-asserted-by":"publisher","DOI":"10.3390\/nu12102915","author":"HJ Coelho-Junior","year":"2020","unstructured":"Coelho-Junior HJ, Marzetti E, Picca A et al (2020) Protein intake and frailty: a matter of quantity, quality, and timing. Nutrients. https:\/\/doi.org\/10.3390\/nu12102915","journal-title":"Nutrients"},{"issue":"1","key":"4099_CR6","doi-asserted-by":"publisher","first-page":"29","DOI":"10.1186\/s12937-017-0250-9","volume":"16","author":"S Kobayashi","year":"2017","unstructured":"Kobayashi S, Suga H, Sasaki S et al (2017) Diet with a combination of high protein and high total antioxidant capacity is strongly associated with low prevalence of frailty among old Japanese women: a multicenter cross-sectional study. Nutr J 16(1):29. https:\/\/doi.org\/10.1186\/s12937-017-0250-9","journal-title":"Nutr J"},{"issue":"9","key":"4099_CR7","doi-asserted-by":"publisher","first-page":"801","DOI":"10.1016\/j.jamda.2018.04.005","volume":"19","author":"H Nanri","year":"2018","unstructured":"Nanri H, Yamada Y, Yoshida T et al (2018) Sex difference in the association between protein intake and frailty: assessed using the Kihon checklist indexes among older adults. J Am Med Dir Assoc 19(9):801\u2013805. https:\/\/doi.org\/10.1016\/j.jamda.2018.04.005","journal-title":"J Am Med Dir Assoc"},{"issue":"2","key":"4099_CR8","doi-asserted-by":"publisher","first-page":"161","DOI":"10.1007\/s12603-022-1740-9","volume":"26","author":"H Nanri","year":"2022","unstructured":"Nanri H, Watanabe D, Yoshida T et al (2022) Adequate protein intake on comprehensive frailty in older adults: Kyoto-Kameoka study. J Nutr Health Aging 26(2):161\u2013168. https:\/\/doi.org\/10.1007\/s12603-022-1740-9","journal-title":"J Nutr Health Aging"},{"issue":"1","key":"4099_CR9","doi-asserted-by":"publisher","first-page":"180","DOI":"10.1093\/ajcn\/nqaa044","volume":"112","author":"HR Lieberman","year":"2020","unstructured":"Lieberman HR, Fulgoni VL, Agarwal S et al (2020) Protein intake is more stable than carbohydrate or fat intake across various US demographic groups and international populations. Am J Clin Nutr 112(1):180\u2013186. https:\/\/doi.org\/10.1093\/ajcn\/nqaa044","journal-title":"Am J Clin Nutr"},{"issue":"2","key":"4099_CR10","doi-asserted-by":"publisher","first-page":"129","DOI":"10.1123\/ijsnem.16.2.129","volume":"16","author":"S Bilsborough","year":"2006","unstructured":"Bilsborough S, Mann N (2006) A review of issues of dietary protein intake in humans. Int J Sport Nutr Exerc Metab 16(2):129\u2013152. https:\/\/doi.org\/10.1123\/ijsnem.16.2.129","journal-title":"Int J Sport Nutr Exerc Metab"},{"issue":"12","key":"4099_CR11","doi-asserted-by":"publisher","first-page":"1898","DOI":"10.1017\/S0007114521002609","volume":"127","author":"D Ashtary-Larky","year":"2022","unstructured":"Ashtary-Larky D, Bagheri R, Bavi H et al (2022) Ketogenic diets, physical activity and body composition: a review. Br J Nutr 127(12):1898\u20131920. https:\/\/doi.org\/10.1017\/S0007114521002609","journal-title":"Br J Nutr"},{"issue":"10107","key":"4099_CR12","doi-asserted-by":"publisher","first-page":"2050","DOI":"10.1016\/S0140-6736(17)32252-3","volume":"390","author":"M Dehghan","year":"2017","unstructured":"Dehghan M, Mente A, Zhang X et al (2017) Associations of fats and carbohydrate intake with cardiovascular disease and mortality in 18 countries from five continents (PURE): a prospective cohort study. Lancet 390(10107):2050\u20132062. https:\/\/doi.org\/10.1016\/S0140-6736(17)32252-3","journal-title":"Lancet"},{"key":"4099_CR13","unstructured":"U.S. Department of Agriculture ARS. What We Eat in America (WWEIA), NHANES 2017\u20132018: Table 5. Percentages of Energy from Protein, Carbohydrate, Fat, and Alcohol Washington, DCn.d. Accessed on 16 Sept 2025"},{"key":"4099_CR14","unstructured":"Ministry of Health, Labour and Welfare. Report of the National Health and Nutrition Survey, Japan, 2023. Tokyo, Japan, 2025."},{"issue":"10","key":"4099_CR15","doi-asserted-by":"publisher","first-page":"1329","DOI":"10.1093\/gerona\/glw033","volume":"71","author":"H Sandoval-Insausti","year":"2016","unstructured":"Sandoval-Insausti H, Perez-Tasigchana RF, Lopez-Garcia E et al (2016) Macronutrients intake and incident frailty in older adults: a prospective cohort study. J Gerontol A Biol Sci Med Sci 71(10):1329\u20131334. https:\/\/doi.org\/10.1093\/gerona\/glw033","journal-title":"J Gerontol A Biol Sci Med Sci"},{"issue":"7","key":"4099_CR16","doi-asserted-by":"publisher","first-page":"2919","DOI":"10.1007\/s00394-019-02131-0","volume":"59","author":"E Verspoor","year":"2020","unstructured":"Verspoor E, Voortman T, van Rooij FJA et al (2020) Macronutrient intake and frailty: the Rotterdam study. Eur J Nutr 59(7):2919\u20132928. https:\/\/doi.org\/10.1007\/s00394-019-02131-0","journal-title":"Eur J Nutr"},{"key":"4099_CR17","doi-asserted-by":"publisher","DOI":"10.3390\/nu14235072","author":"T Tanaka","year":"2022","unstructured":"Tanaka T, Kafyra M, Jin Y et al (2022) Quality specific associations of carbohydrate consumption and frailty index. Nutrients. https:\/\/doi.org\/10.3390\/nu14235072","journal-title":"Nutrients"},{"issue":"7","key":"4099_CR18","doi-asserted-by":"publisher","first-page":"478","DOI":"10.1111\/ggi.14597","volume":"23","author":"N Yang","year":"2023","unstructured":"Yang N, Lee Y, Kim MK et al (2023) Macronutrients intake and physical frailty in Korean older adults: a cohort-based cross-sectional study. Geriatr Gerontol Int 23(7):478\u2013485. https:\/\/doi.org\/10.1111\/ggi.14597","journal-title":"Geriatr Gerontol Int"},{"issue":"6","key":"4099_CR19","doi-asserted-by":"publisher","DOI":"10.1016\/j.cdnut.2023.100096","volume":"7","author":"J Norgren","year":"2023","unstructured":"Norgren J, Sindi S, Sandebring-Matton A et al (2023) The dietary carbohydrate\/fat-ratio and cognitive performance: panel analyses in older adults at risk for dementia. Curr Dev Nutr 7(6):100096. https:\/\/doi.org\/10.1016\/j.cdnut.2023.100096","journal-title":"Curr Dev Nutr"},{"issue":"8","key":"4099_CR20","doi-asserted-by":"publisher","first-page":"733 e7","DOI":"10.1016\/j.jamda.2017.02.022","volume":"18","author":"Y Yamada","year":"2017","unstructured":"Yamada Y, Nanri H, Watanabe Y et al (2017) Prevalence of frailty assessed by Fried and Kihon checklist indexes in a prospective cohort study: design and demographics of the Kyoto-Kameoka longitudinal study. J Am Med Dir Assoc 18(8):733 e7-833. https:\/\/doi.org\/10.1016\/j.jamda.2017.02.022","journal-title":"J Am Med Dir Assoc"},{"issue":"2","key":"4099_CR21","doi-asserted-by":"publisher","first-page":"77","DOI":"10.1080\/11026480600568720","volume":"50","author":"CTY Goto","year":"2006","unstructured":"Goto C, Tokudome Y, Imaeda N, Takekuma K, Kuriki K, Igarashi F, Ikeda M, Tokudome S (2006) Validation study of fatty acid consumption assessed with a short food frequency questionnaire against plasma concentration in middle-aged Japanese people. Scand J Food Nutr 50(2):77\u201382","journal-title":"Scand J Food Nutr"},{"issue":"3","key":"4099_CR22","doi-asserted-by":"publisher","first-page":"100","DOI":"10.2188\/jea.17.100","volume":"17","author":"N Imaeda","year":"2007","unstructured":"Imaeda N, Goto C, Tokudome Y et al (2007) Reproducibility of a short food frequency questionnaire for Japanese general population. J Epidemiol 17(3):100\u2013107","journal-title":"J Epidemiol"},{"issue":"1","key":"4099_CR23","first-page":"40","volume":"5","author":"S Tokudome","year":"2004","unstructured":"Tokudome S, Goto C, Imaeda N et al (2004) Development of a data-based short food frequency questionnaire for assessing nutrient intake by middle-aged Japanese. Asian Pac J Cancer Prev 5(1):40\u201343","journal-title":"Asian Pac J Cancer Prev"},{"issue":"4","key":"4099_CR24","doi-asserted-by":"publisher","first-page":"135","DOI":"10.2188\/jea.15.135","volume":"15","author":"Y Tokudome","year":"2005","unstructured":"Tokudome Y, Goto C, Imaeda N et al (2005) Relative validity of a short food frequency questionnaire for assessing nutrient intake versus three-day weighed diet records in middle-aged Japanese. J Epidemiol 15(4):135\u2013145","journal-title":"J Epidemiol"},{"issue":"3","key":"4099_CR25","doi-asserted-by":"publisher","first-page":"688","DOI":"10.3390\/nu11030688","volume":"11","author":"D Watanabe","year":"2019","unstructured":"Watanabe D, Nanri H, Yoshida T et al (2019) Validation of energy and nutrition intake in Japanese elderly individuals estimated based on a short food frequency questionnaire compared against a 7-day dietary record: the Kyoto-Kameoka study. Nutrients 11(3):688","journal-title":"Nutrients"},{"key":"4099_CR26","unstructured":"Science and Technology Agency of Japan. Standard Tables of Food Composition in Japan, 5th rev. ed.; JPB, Ministry of Finance: Tokyo, Japan, 2001."},{"key":"4099_CR27","doi-asserted-by":"publisher","DOI":"10.1186\/s40001-026-04126-0","author":"W Zhu","year":"2026","unstructured":"Zhu W, Chen Q, Li D et al (2026) Low-carbohydrate, high-fat diet is inversely associated with the triglyceride-glucose index: evidence from NHANES 1999\u20132018. Eur J Med Res. https:\/\/doi.org\/10.1186\/s40001-026-04126-0","journal-title":"Eur J Med Res"},{"issue":"4","key":"4099_CR28","doi-asserted-by":"publisher","first-page":"518","DOI":"10.1111\/ggi.12397","volume":"15","author":"H Arai","year":"2015","unstructured":"Arai H, Satake S (2015) English translation of the Kihon Checklist. Geriatr Gerontol Int 15(4):518\u2013519. https:\/\/doi.org\/10.1111\/ggi.12397","journal-title":"Geriatr Gerontol Int"},{"issue":"3","key":"4099_CR29","doi-asserted-by":"publisher","first-page":"515","DOI":"10.1111\/ggi.12892","volume":"17","author":"A Maseda","year":"2017","unstructured":"Maseda A, Lorenzo-Lopez L, Lopez-Lopez R et al (2017) Spanish translation of the Kihon Checklist (frailty index). Geriatr Gerontol Int 17(3):515\u2013517. https:\/\/doi.org\/10.1111\/ggi.12892","journal-title":"Geriatr Gerontol Int"},{"issue":"6","key":"4099_CR30","doi-asserted-by":"publisher","first-page":"709","DOI":"10.1111\/ggi.12543","volume":"16","author":"S Satake","year":"2016","unstructured":"Satake S, Senda K, Hong YJ et al (2016) Validity of the Kihon Checklist for assessing frailty status. Geriatr Gerontol Int 16(6):709\u2013715. https:\/\/doi.org\/10.1111\/ggi.12543","journal-title":"Geriatr Gerontol Int"},{"issue":"1","key":"4099_CR31","doi-asserted-by":"publisher","DOI":"10.1186\/s12877-022-03177-2","volume":"22","author":"D Watanabe","year":"2022","unstructured":"Watanabe D, Yoshida T, Watanabe Y et al (2022) Validation of the Kihon Checklist and the frailty screening index for frailty defined by the phenotype model in older Japanese adults. BMC Geriatr 22(1):478. https:\/\/doi.org\/10.1186\/s12877-022-03177-2","journal-title":"BMC Geriatr"},{"key":"4099_CR32","doi-asserted-by":"publisher","DOI":"10.3390\/nu10091334","author":"HJ Coelho-J\u00fanior","year":"2018","unstructured":"Coelho-J\u00fanior HJ, Rodrigues B, Uchida M et al (2018) Low protein intake is associated with frailty in older adults: a systematic review and meta-analysis of observational studies. Nutrients. https:\/\/doi.org\/10.3390\/nu10091334","journal-title":"Nutrients"},{"issue":"3","key":"4099_CR33","doi-asserted-by":"publisher","first-page":"e1","DOI":"10.1161\/CIR.0000000000000510","volume":"136","author":"FM Sacks","year":"2017","unstructured":"Sacks FM, Lichtenstein AH, Wu JHY et al (2017) Dietary fats and cardiovascular disease: a presidential advisory from the American Heart Association. Circulation 136(3):e1\u2013e23. https:\/\/doi.org\/10.1161\/CIR.0000000000000510","journal-title":"Circulation"},{"key":"4099_CR34","doi-asserted-by":"publisher","first-page":"e7492","DOI":"10.1136\/bmj.e7492","volume":"346","author":"L Te Morenga","year":"2012","unstructured":"Te Morenga L, Mallard S, Mann J (2013 ) Dietary sugars and body weight: systematic review and meta-analyses of randomised controlled trials and cohort studies. BMJ 346:e7492. https:\/\/doi.org\/10.1136\/bmj.e7492","journal-title":"BMJ"},{"issue":"10170","key":"4099_CR35","doi-asserted-by":"publisher","first-page":"434","DOI":"10.1016\/S0140-6736(18)31809-9","volume":"393","author":"A Reynolds","year":"2019","unstructured":"Reynolds A, Mann J, Cummings J et al (2019) Carbohydrate quality and human health: a series of systematic reviews and meta-analyses. Lancet 393(10170):434\u2013445. https:\/\/doi.org\/10.1016\/S0140-6736(18)31809-9","journal-title":"Lancet"}],"container-title":["European Journal of Nutrition"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1007\/s00394-026-04099-0.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/article\/10.1007\/s00394-026-04099-0","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1007\/s00394-026-04099-0.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,10,7]],"date-time":"2026-10-07T13:11:13Z","timestamp":1791378673000},"score":1,"resource":{"primary":{"URL":"https:\/\/link.springer.com\/10.1007\/s00394-026-04099-0"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,10,7]]},"references-count":35,"journal-issue":{"issue":"8","published-print":{"date-parts":[[2026,12]]}},"alternative-id":["4099"],"URL":"https:\/\/doi.org\/10.1007\/s00394-026-04099-0","relation":{},"ISSN":["1436-6207","1436-6215"],"issn-type":[{"value":"1436-6207","type":"print"},{"value":"1436-6215","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,10,7]]},"assertion":[{"value":"20 January 2026","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"18 August 2026","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"7 October 2026","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"The authors declare that they have no conflict of interest.","order":1,"name":"Ethics","label":"Conflict of interest","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"The Needs in the Sphere of Daily Life Survey and Health and Nutritional Survey were administered via postal questionnaires, and informed consent was obtained from those who returned the completed forms. The study was approved by the Ethics Committees of Kyoto University of Advanced Science (No. 24M20) and the National Institute of Biomedical Innovation, Health and Nutrition (2025-035).","order":2,"name":"Ethics","label":"Ethical approval","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"Informed consent was obtained from all participants through the return of completed questionnaires.","order":3,"name":"Ethics","label":"Consent to participate","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"Not applicable.","order":4,"name":"Ethics","label":"Consent for publication","group":{"name":"EthicsHeading","label":"Declarations"}}],"article-number":"271"}}