{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,23]],"date-time":"2026-08-23T14:41:11Z","timestamp":1787496071672,"version":"build-2736575974"},"reference-count":60,"publisher":"MDPI AG","issue":"16","license":[{"start":{"date-parts":[[2022,8,19]],"date-time":"2022-08-19T00:00:00Z","timestamp":1660867200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["IJERPH"],"abstract":"<jats:p>Introduction: Frailty syndrome occurs more frequently in patients with diabetes than in the general population. The reasons for this more frequent occurrence and the interdependence of the two conditions are not well understood. To date, there is no fully effective method for the diagnosis, prevention, and monitoring of frailty syndrome. This study aimed to assess the degree of metabolic control of diabetes in patients with frailty syndrome and to determine the impact of frailty on the course of diabetes using a retrospective analysis. Materials and Methods: A total of 103 individuals aged 60+ with diabetes were studied. The study population included 65 women (63.1%) and 38 men (36.9%). The mean age was 72.96 years (SD 7.55). The study was conducted in the practice of a general practitioner in Wielkopolska in 2018\u20132019. The research instrument was the authors\u2019 original medical history questionnaire. The questions of the questionnaire were related to age, education, and sociodemographic situation of the respondents, as well as their dietary habits, health status, and use of stimulants. Other instruments used were: the Mini-Mental State Examination (MMSE), Lawton Scale (IADL\u2014Instrumental Activities of Daily Living), Katz Scale (ADL\u2014Activities of Daily Living), Geriatric Depression Rating Scale (GDS), and SHARE-FI scale (Survey of Health, Aging, and Retirement in Europe). Anthropometric and biochemical tests were performed. Results: In the study, frailty syndrome was diagnosed using the SHARE-FI scale in 26 individuals (25%): 32 (31.1%) were pre-frailty and 45 (43.7%) represented a non-frailty group. Statistical analysis revealed that elevated HbA1c levels were associated with a statistically significant risk of developing frailty syndrome (p = 0.048). In addition, the co-occurrence of diabetes and frailty syndrome was found to be a risk factor for loss of functional capacity or limitation in older adults (p = 0.00) and was associated with the risk of developing depression (p &lt; 0.001) and cognitive impairment (p &lt; 0.001). Conclusions: Concerning metabolic control of diabetes, higher HbA1c levels in the elderly are a predictive factor for the development of frailty syndrome. No statistical significance was found for the other parameters of metabolic control in diabetes. People with frailty syndrome scored significantly higher on the Geriatric Depression Rating Scale and lower on the MMSE cognitive rating scale than the comparison group. This suggests that frailty is a predictive factor for depression and cognitive impairment. Patients with frailty and diabetes have significantly lower scores on the Basic Activities of Daily Living Rating Scale and the Complex Activities of Daily Living Rating Scale, which are associated with loss or limitation of functioning. Frailty syndrome is a predictive factor for loss of functional capacity in the elderly.<\/jats:p>","DOI":"10.3390\/ijerph191610327","type":"journal-article","created":{"date-parts":[[2022,8,21]],"date-time":"2022-08-21T22:23:13Z","timestamp":1661120593000},"page":"10327","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":11,"title":["Implications of the Metabolic Control of Diabetes in Patients with Frailty Syndrome"],"prefix":"10.3390","volume":"19","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-3267-6975","authenticated-orcid":false,"given":"Marta","family":"Muszalik","sequence":"first","affiliation":[{"name":"Department of Geriatrics, Faculty of Health Sciences, Nicolaus Copernicus University in Torun, Collegium Medicum in Bydgoszcz, 85-094 Bydgoszcz, Poland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hubert","family":"St\u0119pie\u0144","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine II, Asklepios Clinic Uckermark, 74-506 Schwedt, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0829-327X","authenticated-orcid":false,"given":"Gra\u017cyna","family":"Puto","sequence":"additional","affiliation":[{"name":"Department of Clinical Nursing, Institute of Nursing and Midwifery, Faculty of Health Sciences, Jagiellonian University Medical College Cracow, 31-501 Crakow, Poland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5116-3497","authenticated-orcid":false,"given":"Mateusz","family":"Cybulski","sequence":"additional","affiliation":[{"name":"Department of Integrated Medical Care, Faculty of Health Sciences, Medical University of Bialystok, 15-096 Bia\u0142ystok, Poland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6996-8920","authenticated-orcid":false,"given":"Donata","family":"Kurpas","sequence":"additional","affiliation":[{"name":"Department of Family Medicine, Wroclaw Medical University, 51-141 Wroclaw, Poland"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2022,8,19]]},"reference":[{"key":"ref_1","unstructured":"(2022, May 21). Ageing Europe\u2014Statistics on Population Developments. Available online: https:\/\/ec.europa.eu\/eurostat\/statistics-explained\/index.php?title=Ageing_Europe_-statistics_on_population_developments#Older_people_.E2.80.94_population_overview."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"M146","DOI":"10.1093\/gerona\/56.3.M146","article-title":"Cardiovascular Health Study Collaborative Research Group Frailty in Older Adults: Evidence for a Phenotype","volume":"56","author":"Fried","year":"2001","journal-title":"J. Gerontol. Ser. A. Biol. Sci. Med. Sci."},{"key":"ref_3","first-page":"6","article-title":"Frailty syndrome\u2014Guidelines for diagnosis therapy and prevention","volume":"25","author":"Kurpas","year":"2017","journal-title":"Med. Rodz."},{"key":"ref_4","first-page":"675","article-title":"Prevalence of Frailty in Middle-Aged and Older Community-Dwelling Europeans Living in 10 Countries","volume":"64","author":"Spagnoli","year":"2009","journal-title":"J.Gerontol. Ser. A Sci. Med. Sci."},{"key":"ref_5","doi-asserted-by":"crossref","unstructured":"Romero-Ortuno, R., Walsh, C.D., Lawlor, B.A., and Kenny, R.A. (2010). A Frailty Instrument for primary care: Findings from the Survey of Health, Ageing and Retirement in Europe (SHARE). BMC Geriatr., 10.","DOI":"10.1186\/1471-2318-10-57"},{"key":"ref_6","first-page":"301","article-title":"The SHARE frailty instrument for primary care predicts incident disability in a European population-based sample","volume":"19","author":"Ortuno","year":"2011","journal-title":"Qual. Prim. Care"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"497","DOI":"10.1111\/j.1447-0594.2012.00948.x","article-title":"The Frailty Instrument for primary care of the Survey of Health, Ageing and Retirement in Europe predicts mortality similarly to a frailty index based on comprehensive geriatric assessment","volume":"13","author":"Ortuno","year":"2013","journal-title":"Geriatr. Gerontol. Int."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"e006645","DOI":"10.1136\/bmjopen-2014-006645","article-title":"Frailty Instrument for primary care for those aged 75 years or more: Findings from the Survey of Health, Ageing and Retirement in Europe, a longitudinal population-based cohort study (SHARE-FI75+)","volume":"4","author":"Ortuno","year":"2014","journal-title":"BMJ Open"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"323","DOI":"10.1100\/tsw.2001.58","article-title":"Accumulation of Deficits as a Proxy Measure of Aging","volume":"1","author":"Mitnitski","year":"2001","journal-title":"Sci. World J."},{"key":"ref_10","first-page":"128","article-title":"Frailty screening and assessment tools: A review of characteristics and use in Public Health","volume":"30","author":"Gilardi","year":"2018","journal-title":"Ann. Ig. Med. Prev. Comunita"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"76","DOI":"10.1016\/j.outlook.2009.09.005","article-title":"Toward a conceptual definition of frail community dwelling older people","volume":"58","author":"Gobbens","year":"2010","journal-title":"Nurs. Outlook"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"103901","DOI":"10.1016\/j.archger.2019.103901","article-title":"Cross-sectional and Longitudinal Associations of Environmental Factors with Frailty and Disability in Older People","volume":"85","author":"Gobbens","year":"2019","journal-title":"Arch. Gerontol. Geriatr."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"45","DOI":"10.3389\/fendo.2019.00045","article-title":"Diabetes and Aging: From Treatment Goals to Pharmacologic Therapy","volume":"10","author":"Longo","year":"2019","journal-title":"Front. Endocrinol."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"106","DOI":"10.1016\/S2213-8587(13)70046-9","article-title":"Diabetes and risk of physical disability in adults: A systematic review and meta-analysis","volume":"1","author":"Wong","year":"2013","journal-title":"Lancet Diabetes Endocrinol."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"5S27","DOI":"10.1016\/S1262-3636(05)73649-1","article-title":"Diabetes mellitus in the elderly: Insulin resistance and\/or impaired insulin secretion?","volume":"31","author":"Scheen","year":"2005","journal-title":"Diabetes Metab."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"1329","DOI":"10.2337\/dc10-2377","article-title":"Glycemic Control, Complications, and Death in Older Diabetic Patients","volume":"34","author":"Huang","year":"2011","journal-title":"Diabetes Care"},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"1498","DOI":"10.2337\/diacare.28.6.1498","article-title":"Metabolic Alterations in Middle-Aged and Elderly Lean Patients With Type 2 Diabetes","volume":"28","author":"Meneilly","year":"2005","journal-title":"Diabetes Care"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"1365","DOI":"10.2337\/db08-1198","article-title":"Adaptive b-cell proliferation is severely restricted with advanced age","volume":"58","author":"Rankin","year":"2009","journal-title":"Diabetes"},{"key":"ref_19","unstructured":"International Diabetes Federation (2017, April 04). IDF Diabetes Atlas. Available online: http:\/\/www.diabetesatlas.org\/resources\/2015-atlas.html."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"603","DOI":"10.1111\/j.1464-5491.2010.02977.x","article-title":"Comparison of the prognostic importance of diagnosed diabetes, co-morbidity and frailty in older people","volume":"27","author":"Hubbard","year":"2010","journal-title":"Diabetes Med."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"251","DOI":"10.1007\/s00592-012-0413-2","article-title":"Clinical frailty and long-term mortality in elderly subjects with diabetes","volume":"50","author":"Cacciatore","year":"2013","journal-title":"Acta Diabetol."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"182","DOI":"10.4093\/dmj.2016.40.3.182","article-title":"Sarcopenia, frailty, and diabetes in older adults","volume":"40","author":"Jang","year":"2016","journal-title":"Diabetes Metab. J."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"165","DOI":"10.4235\/agmr.19.0036","article-title":"Frailty and Disability in Diabetes","volume":"23","year":"2019","journal-title":"Ann. Geriatr. Med. Res."},{"key":"ref_24","doi-asserted-by":"crossref","unstructured":"American Diabetes Association (2019). 12. Older adults: Standards of medical care in diabetes. Diabetes Care, 42, 139\u2013147.","DOI":"10.2337\/dc19-S012"},{"key":"ref_25","doi-asserted-by":"crossref","unstructured":"American Geriatrics Society Expert Panel on the Care of Older Adults with Diabetes Mellitus, Moreno, G., Mangione, C.M., Kimbro, L., and Vaisberg, E. (2013). Guidelines Abstracted from the American Geriatrics Society Guidelines for Improving the Care of Older Adults with Diabetes Mellitus: 2013 Update. J. Am. Geriatr. Soc., 61, 2020\u20132026.","DOI":"10.1111\/jgs.12514"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"461","DOI":"10.2337\/dc16-1229","article-title":"Cognitive Dysfunction in Older Adults With Diabetes: What a Clinician Needs to Know","volume":"40","author":"Munshi","year":"2017","journal-title":"Diabetes Care"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"507","DOI":"10.2337\/dc13-1384","article-title":"Edinburgh Type 2 Diabetes Study (ET2DS) Investigators Severe hypoglycemia and cognitive decline in older people with type 2 diabetes: The Edinburgh type 2 diabetes study","volume":"37","author":"Feinkohl","year":"2014","journal-title":"Diabetes Care"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"949","DOI":"10.1016\/j.jamda.2016.07.013","article-title":"Frailty as a Major Factor in the Increased Risk of Death and Disability in Older People With Diabetes","volume":"17","author":"Carnicero","year":"2016","journal-title":"J. Am. Med. Dir. Assoc."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"740","DOI":"10.1016\/j.exger.2009.08.008","article-title":"Frailty in the elderly is associated with insulin resistance of glucose metabolism in the postabsorptive state only in the presence of increased abdominal fat","volume":"44","author":"Goulet","year":"2009","journal-title":"Exp. Gerontol."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"189","DOI":"10.1016\/0022-3956(75)90026-6","article-title":"Mini-Mental State. A Practical Method for Grading the Cognitive State of Patients for the Clinician","volume":"12","author":"Folstein","year":"1975","journal-title":"J. Psychiatr. Res."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"37","DOI":"10.1016\/0022-3956(82)90033-4","article-title":"Development and validation of a geriatric depression screening scale: A preliminary report","volume":"17","author":"Yesavage","year":"1982","journal-title":"J. Psychiatr. Res."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"179","DOI":"10.1093\/geront\/9.3_Part_1.179","article-title":"Assessment of older people: Self-maintaining and instrumental activities of daily living","volume":"9","author":"Lawton","year":"1969","journal-title":"Gerontologist"},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"20","DOI":"10.1093\/geront\/10.1_Part_1.20","article-title":"Progress in Development of the Index of ADL","volume":"10","author":"Katz","year":"1970","journal-title":"Gerontologist"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"721","DOI":"10.1111\/j.1532-5415.1983.tb03391.x","article-title":"Assessing Self-maintenance: Activities of Daily Living, Mobility, and Instrumental Activities of Daily Living","volume":"31","author":"Katz","year":"1983","journal-title":"J. Am. Geriatr. Soc."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"36","DOI":"10.5114\/fmpcr.2018.73702","article-title":"Adaptation and reliability testing of the SHARE-FI instrument for the assessment of risk of frailty syndrome among older Polish patients","volume":"20","author":"Muszalik","year":"2018","journal-title":"Fam. Med. Prim. Care Rev."},{"key":"ref_36","unstructured":"(2022, April 15). SHARE-FI Calculator Females v. 1.0. Available online: https:\/\/sites.google.com\/a\/tcd.ie\/share-frailty-instrument-calculators\/translated-calculators."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"467","DOI":"10.1007\/s12170-011-0186-0","article-title":"Frailty in patients with cardiovascular disease: Why, when, and how to measure","volume":"5","author":"Afilato","year":"2011","journal-title":"Curr. Cardiovasc. Risk. Rep."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"1685","DOI":"10.1056\/NEJMra043430","article-title":"Inflammation, atherosclerosis, and coronary artery disease","volume":"352","author":"Hansson","year":"2005","journal-title":"N. Engl. J. Med."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"422","DOI":"10.1093\/ajcn\/78.3.422","article-title":"Frailty amplifies the effects of aging on protein metabolism: Role of protein intake","volume":"78","author":"Chevalier","year":"2003","journal-title":"Am. J. Clin. Nutr."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"570","DOI":"10.1080\/13607863.2013.827628","article-title":"Physical frailty: Vulnerability of patients suffering from late-life depression","volume":"18","author":"Collard","year":"2014","journal-title":"Aging Ment. Health"},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"1947","DOI":"10.2147\/CIA.S69632","article-title":"Depression and frailty in later life: A systematic review","volume":"10","author":"Vaughan","year":"2015","journal-title":"Clin. Interv. Aging"},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"78","DOI":"10.1016\/j.arr.2017.03.005","article-title":"Relationship between depression and frailty in older adults: A systematic review and meta-analysis","volume":"36","author":"Soysal","year":"2017","journal-title":"Ageing Res. Rev."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"36","DOI":"10.1016\/j.jamda.2015.07.016","article-title":"Physical Frailty and Cognitive Functioning in Depressed Older Adults: Findings From the NESDO Study","volume":"17","author":"Arts","year":"2016","journal-title":"J. Am. Med. Dir. Assoc."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"395","DOI":"10.1111\/ggi.12114","article-title":"Frailty among community-dwelling elderly Mexican people: Prevalence and association with sociodemographic characteristics, health state and the use of health services","volume":"14","author":"Arenas","year":"2014","journal-title":"Geriatr. Gerontol. Int."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"113","DOI":"10.1016\/j.jalz.2011.09.223","article-title":"Frailty syndrome and the risk of vascular dementia: The Italian Longitudinal Study on Aging","volume":"9","author":"Solfrizzi","year":"2013","journal-title":"Alzheimer\u2019s Dement."},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"266","DOI":"10.1016\/S0140-6736(14)62000-6","article-title":"Prospective Urban Rural Epidemiology (PURE) Study investigators Prognostic value of grip strength: Findings from the Prospective Urban Rural Epidemiology (PURE) study","volume":"386","author":"Leong","year":"2015","journal-title":"Lancet"},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"127","DOI":"10.1093\/aje\/kwr503","article-title":"Limited Lung Function: Impact of Reduced Peak Expiratory Flow on Health Status, Health-Care Utilization, and Expected Survival in Older Adults","volume":"176","author":"Roberts","year":"2012","journal-title":"Am. J. Epidemiol."},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"1021","DOI":"10.1016\/j.jamda.2018.12.013","article-title":"Definition of Respiratory Sarcopenia With Peak Expiratory Flow Rate","volume":"20","author":"Kera","year":"2019","journal-title":"J. Am. Med. Dir. Assoc."},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"111","DOI":"10.1016\/j.mehy.2008.01.025","article-title":"Chronic hypoxia-hypercapnia influences cognitive function: A possible new model of cognitive dysfunction in chronic obstructive pulmonary disease","volume":"71","author":"Zheng","year":"2008","journal-title":"Med. Hypotheses"},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"540","DOI":"10.1056\/NEJMoa1215740","article-title":"Glucose levels and risk of dementia","volume":"369","author":"Crane","year":"2013","journal-title":"N. Engl. J. Med."},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"391","DOI":"10.2337\/dc07-1152","article-title":"Health, Aging, and Body Composition Study Health, Aging, and Body Composition Study. Diabetes-related complications, glycemic control, and falls in older adults","volume":"31","author":"Schwartz","year":"2008","journal-title":"Diabetes Care"},{"key":"ref_52","doi-asserted-by":"crossref","first-page":"840","DOI":"10.1111\/j.1532-5415.2009.02196.x","article-title":"Is hyperglycemia associated with frailty status in older women?","volume":"57","author":"Blaum","year":"2009","journal-title":"J. Am. Geriatr. Soc."},{"key":"ref_53","first-page":"1223","article-title":"Glucose Levels and Risk of Frailty","volume":"71","author":"Zaslavsky","year":"2016","journal-title":"J.Gerontol. Ser. ABiol. Sci. Med. Sci."},{"key":"ref_54","doi-asserted-by":"crossref","first-page":"906103","DOI":"10.1155\/2014\/906103","article-title":"Hypoglycemia Is Independently Associated with Multidimensional Impairment in Elderly Diabetic Patients","volume":"2014","author":"Pilotto","year":"2014","journal-title":"BioMed Res. Int."},{"key":"ref_55","doi-asserted-by":"crossref","first-page":"2943","DOI":"10.2337\/db08-0391","article-title":"Lower Intrinsic ADP-Stimulated Mitochondrial Respiration Underlies In Vivo Mitochondrial Dysfunction in Muscle of Male Type 2 Diabetic Patients","volume":"57","author":"Phielix","year":"2008","journal-title":"Diabetes"},{"key":"ref_56","doi-asserted-by":"crossref","first-page":"1701","DOI":"10.1111\/j.1532-5415.2012.04099.x","article-title":"Hyperglycemia is associated with the incidence of frailty and lower extremity mobility limitations in older women","volume":"60","author":"Kalyani","year":"2012","journal-title":"J. Am. Geriatr. Soc."},{"key":"ref_57","doi-asserted-by":"crossref","first-page":"e180650","DOI":"10.1001\/jamanetworkopen.2018.0650","article-title":"Association of Frailty and Malnutrition With Long-term Functional and Mortality Outcomes Among Community-Dwelling Older Adults: Results From the Singapore Longitudinal Aging Study 1","volume":"1","author":"Wei","year":"2018","journal-title":"JAMA Netw. Open"},{"key":"ref_58","doi-asserted-by":"crossref","first-page":"419","DOI":"10.1111\/jdi.12698","article-title":"Low glycated hemoglobin level is associated with severity of frailty in Japanese elderly diabetes patients","volume":"9","author":"Yanagita","year":"2017","journal-title":"J. Diabetes Investig."},{"key":"ref_59","doi-asserted-by":"crossref","first-page":"419","DOI":"10.1016\/S0140-6736(10)60576-4","article-title":"Effect of intensive treatment of hyperglycemia on microvascular outcomes in type 2 diabetes: An analysis of the ACCORD randomized trial","volume":"376","author":"Craven","year":"2010","journal-title":"Lancet"},{"key":"ref_60","doi-asserted-by":"crossref","first-page":"262","DOI":"10.14336\/AD.2014.1022","article-title":"Low HbA1c and increased mortality risk-is frailty a confounding factor?","volume":"6","author":"Abdelhafiz","year":"2015","journal-title":"Aging Dis."}],"container-title":["International Journal of Environmental Research and Public Health"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1660-4601\/19\/16\/10327\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,11]],"date-time":"2025-10-11T00:12:27Z","timestamp":1760141547000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1660-4601\/19\/16\/10327"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2022,8,19]]},"references-count":60,"journal-issue":{"issue":"16","published-online":{"date-parts":[[2022,8]]}},"alternative-id":["ijerph191610327"],"URL":"https:\/\/doi.org\/10.3390\/ijerph191610327","relation":{},"ISSN":["1660-4601"],"issn-type":[{"value":"1660-4601","type":"electronic"}],"subject":[],"published":{"date-parts":[[2022,8,19]]}}}