{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,30]],"date-time":"2026-07-30T14:03:12Z","timestamp":1785420192351,"version":"3.56.0"},"reference-count":47,"publisher":"MDPI AG","issue":"7","license":[{"start":{"date-parts":[[2026,4,2]],"date-time":"2026-04-02T00:00:00Z","timestamp":1775088000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/100017530","name":"Fresenius Kabi","doi-asserted-by":"crossref","id":[{"id":"10.13039\/100017530","id-type":"DOI","asserted-by":"crossref"}]},{"id":[{"id":"https:\/\/ror.org\/0050zy157","id-type":"ROR","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Nutrients"],"abstract":"<jats:p>Background\/Objectives: Chronic kidney disease (CKD) is associated with substantial clinical and economic burden, largely driven by progression to dialysis. Nutritional interventions have shown potential in delaying disease progression, yet evidence on their cost-effectiveness remains limited. This study evaluated the long-term cost\u2013utility profile of a low-protein diet supplemented with ketoanalogues (s-LPD) versus a standard low-protein diet (LPD) in patients with stage 4+ CKD from both the Italian National Health System (NHS) and societal perspectives. Methods: A Markov model with monthly cycles simulated disease progression from pre-dialysis to dialysis or death. Clinical inputs were derived from the published literature, while costs reflected 2024 Italian tariffs. Three effectiveness scenarios (optimistic, conservative, and pessimistic) were explored to account for uncertainty in the treatment effect. Outcomes included costs, life-years, quality-adjusted life-years (QALYs), and incremental cost\u2013utility ratios. Deterministic and probabilistic sensitivity analyses assessed model robustness. Results: Across all scenarios, s-LPD improved survival (up to +0.59 life-years), increased QALYs (up to +0.48), and delayed dialysis initiation (up to +2.88 years) compared with LPD. From the NHS perspective, s-LPD was dominant in the optimistic scenario and cost-effective in both conservative and pessimistic scenarios, with cost savings or only a marginal cost that increases under extreme assumptions. Probabilistic sensitivity analyses confirmed a high probability of cost-effectiveness across scenarios. Results remained robust in additional scenario analyses, including the societal perspective. Conclusions: This first Italian cost\u2013utility analysis of s-LPD highlights that s-LPD is a cost-effective strategy for patients with advanced CKD, offering clinically meaningful benefits while reducing or containing healthcare costs. These findings support the adoption of s-LPD as part of conservative management strategies aimed at safely delaying dialysis initiation.<\/jats:p>","DOI":"10.3390\/nu18071142","type":"journal-article","created":{"date-parts":[[2026,4,2]],"date-time":"2026-04-02T09:26:12Z","timestamp":1775121972000},"page":"1142","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Ketoanalogue-Supplemented Low-Protein Diet in Patients with Stage 4+ Chronic Kidney Disease in Italy: A Cost\u2013Utility Analysis"],"prefix":"10.3390","volume":"18","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-8532-0182","authenticated-orcid":false,"given":"Luca","family":"De Nicola","sequence":"first","affiliation":[{"name":"Nephrologic Unit, Department of Advanced Medical and Surgical Sciences, Universit\u00e0 della Campania Luigi Vanvitelli, 80138 Naples, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1027-7049","authenticated-orcid":false,"given":"Filippo","family":"Aucella","sequence":"additional","affiliation":[{"name":"Struttura Complessa di Nefrologia e Dialisi, Fondazione Casa Sollievo della Sofferenza, IRCCS, 71013 San Giovanni Rotondo, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1685-7263","authenticated-orcid":false,"given":"Antonio","family":"De Pascalis","sequence":"additional","affiliation":[{"name":"UOC Nefrologia e Dialisi, Ospedale VITO FAZZI, 73100 Lecce, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Giovanni","family":"Stallone","sequence":"additional","affiliation":[{"name":"Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia, 71122 Foggia, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0666-066X","authenticated-orcid":false,"given":"Massimiliano","family":"Povero","sequence":"additional","affiliation":[{"name":"AdRes, 10155 Turin, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0004-7053-1904","authenticated-orcid":false,"given":"Linet A.","family":"Odonde","sequence":"additional","affiliation":[{"name":"AdRes, 10155 Turin, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Roberta","family":"German\u00f2","sequence":"additional","affiliation":[{"name":"Nephrologic Unit, Department of Advanced Medical and Surgical Sciences, Universit\u00e0 della Campania Luigi Vanvitelli, 80138 Naples, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Chiara","family":"Ruotolo","sequence":"additional","affiliation":[{"name":"Nephrologic Unit, Department of Advanced Medical and Surgical Sciences, Universit\u00e0 della Campania Luigi Vanvitelli, 80138 Naples, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Maria Serena","family":"Russo","sequence":"additional","affiliation":[{"name":"Struttura Complessa di Nefrologia e Dialisi, Fondazione Casa Sollievo della Sofferenza, IRCCS, 71013 San Giovanni Rotondo, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2648-6021","authenticated-orcid":false,"given":"Dario","family":"Troise","sequence":"additional","affiliation":[{"name":"Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia, 71122 Foggia, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4861-0911","authenticated-orcid":false,"given":"Loreto","family":"Gesualdo","sequence":"additional","affiliation":[{"name":"Unit of Nephrology, Dialysis and Transplantation, Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), University of Bari \u201cAldo Moro\u201d, 70124 Bari, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,4,2]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"9609266","DOI":"10.1155\/2023\/9609266","article-title":"The Growing Challenge of Chronic Kidney Disease: An Overview of Current Knowledge","volume":"2023","author":"Borg","year":"2023","journal-title":"Int. J. Nephrol."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"2142","DOI":"10.12688\/f1000research.21374.1","article-title":"Humanistic burden and economic impact of chronic kidney disease: A systematic literature review","volume":"8","author":"Freeman","year":"2019","journal-title":"F1000Research"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"e19","DOI":"10.1016\/j.kisu.2019.11.002","article-title":"Framework for establishing integrated kidney care programs in low- and middle-income countries","volume":"10","author":"Tonelli","year":"2020","journal-title":"Kidney Int. Suppl."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"7","DOI":"10.1016\/j.kisu.2021.11.003","article-title":"Epidemiology of chronic kidney disease: An update 2022","volume":"12","author":"Kovesdy","year":"2022","journal-title":"Kidney Int. Suppl."},{"key":"ref_5","doi-asserted-by":"crossref","unstructured":"Elshahat, S., Cockwell, P., Maxwell, A.P., Griffin, M., O\u2019Brien, T., and O\u2019Neill, C. (2020). The impact of chronic kidney disease on developed countries from a health economics perspective: A systematic scoping review. PLoS ONE, 15.","DOI":"10.1371\/journal.pone.0230512"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"1765","DOI":"10.1056\/NEJMra1700312","article-title":"Nutritional Management of Chronic Kidney Disease","volume":"377","author":"Fouque","year":"2017","journal-title":"N. Engl. J. Med."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"S1","DOI":"10.1053\/j.ajkd.2020.05.006","article-title":"KDOQI Clinical Practice Guideline for Nutrition in CKD: 2020 Update","volume":"76","author":"Ikizler","year":"2020","journal-title":"Am. J. Kidney Dis. Off. J. Natl. Kidney Found"},{"key":"ref_8","doi-asserted-by":"crossref","unstructured":"Martino, F.K., Zattarin, A., Cinquini, C., Toniazzo, S., Francini Pesenti, F., Stefanelli, L.F., Cacciapuoti, M., Bettin, E., Cal\u00f2, L.A., and Spinella, P. (2024). Low-Protein Diet in Elderly Patients with Chronic Kidney Disease Stage 4 and 5 in Conservative Management: Focus on Sarcopenia Development. Nutrients, 16.","DOI":"10.3390\/nu16101498"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"360","DOI":"10.23736\/S2724-6507.25.04416-1","article-title":"Effects of low protein diet supplemented with ketoanalogues on kidney function and nutritional outcomes in a nonagenarian population with advanced chronic kidney disease: A pilot study","volume":"50","author":"Annunziata","year":"2025","journal-title":"Minerva Endocrinol."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"710","DOI":"10.4103\/1319-2442.185227","article-title":"Comparative evaluation of efficacy and safety profile of rhubarb and \u03b1-keto analogs of essential amino acids supplementation in patients with diabetic nephropathy","volume":"27","author":"Khan","year":"2016","journal-title":"Saudi J. Kidney Dis. Transplant."},{"key":"ref_11","unstructured":"(2025, June 11). KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Available online: https:\/\/kdigo.org\/wp-content\/uploads\/2024\/03\/KDIGO-2024-CKD-Guideline.pdf."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"1351","DOI":"10.1007\/s10157-018-1591-1","article-title":"Effect of essential amino acid \u043aetoanalogues and protein restriction diet on morphogenetic proteins (FGF-23 and Klotho) in 3b-4 stages chronic \u043aidney disease patients: A randomized pilot study","volume":"22","author":"Milovanova","year":"2018","journal-title":"Clin. Exp. Nephrol."},{"key":"ref_13","doi-asserted-by":"crossref","unstructured":"Garneata, L., Mocanu, C.A., Simionescu, T.P., Mocanu, A.E., Dragomir, D.R., and Mircescu, G. (2024). Low Protein Diet Reduces Proteinuria and Decline in Glomerular Filtration Rate in Advanced, Heavy Proteinuric Diabetic Kidney Disease. Nutrients, 16.","DOI":"10.3390\/nu16111687"},{"key":"ref_14","doi-asserted-by":"crossref","unstructured":"Yen, C.L., Fan, P.C., Chen, J.J., Kuo, G., Hsiao, C.C., Chen, C.Y., Tu, Y.R., Hsu, H.H., Chen, Y.C., and Chang, C.H. (2022). Ketoanalogues Supplemental Low Protein Diet Safely Decreases Short-Term Risk of Dialysis among CKD Stage 4 Patients. Nutrients, 14.","DOI":"10.3390\/nu14194020"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"15459","DOI":"10.1038\/s41598-023-42706-w","article-title":"The role of a low protein diet supplemented with ketoanalogues on kidney progression in pre-dialysis chronic kidney disease patients","volume":"13","author":"Ariyanopparut","year":"2023","journal-title":"Sci. Rep."},{"key":"ref_16","doi-asserted-by":"crossref","unstructured":"Li, A., Lee, H.Y., and Lin, Y.C. (2019). The Effect of Ketoanalogues on Chronic Kidney Disease Deterioration: A Meta-Analysis. Nutrients, 11.","DOI":"10.3390\/nu11050957"},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"2372","DOI":"10.1093\/ndt\/gfaf123","article-title":"Cost-effectiveness of a ketoanalogue-supplemented very low-protein diet in CKD","volume":"40","author":"Povero","year":"2025","journal-title":"Nephrol. Dial. Transplant."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"269","DOI":"10.1053\/j.jrn.2022.09.004","article-title":"Economic Analysis of a Ketoanalogue-Supplemented Very Low-Protein Diet in Patients with Chronic Kidney Disease in Taiwan and Thailand","volume":"33","author":"Praditpornsilpa","year":"2023","journal-title":"J. Ren. Nutr."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"189","DOI":"10.5414\/CN108560","article-title":"Early supplemented low-protein diet restriction for chronic kidney disease patients in Taiwan\u2014A cost-effectiveness analysis","volume":"84","author":"You","year":"2015","journal-title":"Clin. Nephrol."},{"key":"ref_20","doi-asserted-by":"crossref","unstructured":"Piccoli, G.B., Nazha, M., Capizzi, I., Vigotti, F.N., Mongilardi, E., Bilocati, M., Avagnina, P., and Versino, E. (2016). Patient Survival and Costs on Moderately Restricted Low-Protein Diets in Advanced CKD: Equivalent Survival at Lower Costs?. Nutrients, 8.","DOI":"10.3390\/nu8120758"},{"key":"ref_21","unstructured":"Italian Medicine Agency (2025, December 10). Guidelines for the Compilation of the Dossier to Support the Application for Reimbursement and Pricing of a Medicine, Available online: https:\/\/www.aifa.gov.it\/documents\/20142\/1283800\/Linee_guida_dossier_domanda_rimborsabilita.pdf."},{"key":"ref_22","doi-asserted-by":"crossref","unstructured":"Marino, C., Ferraro, P.M., Bargagli, M., Cascini, S., Agabiti, N., Gambaro, G., and Davoli, M. (2020). Prevalence of chronic kidney disease in the Lazio region, Italy: A classification algorithm based on health information systems. BMC Nephrol., 21.","DOI":"10.1186\/s12882-020-1689-z"},{"key":"ref_23","doi-asserted-by":"crossref","unstructured":"Garneata, L., Mocanu, C.A., Mocanu, A.E., Simionescu, T.P., Firta, A.M., Jafal, M., and Mircescu, G. (2019). Fo012 Vegetarian Severe Hypoproteic Diet Supplemented with Keto-Analogues for Predialysis Chronic Kidney Disease Patients: The Influence on Long Term Prognosis. Nephrol. Dial. Transplant., 34.","DOI":"10.1093\/ndt\/gfz096.FO012"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"441","DOI":"10.1007\/s40620-016-0366-6","article-title":"Survival and time-to-transplantation of peritoneal dialysis versus hemodialysis for end-stage renal disease patients: Competing-risks regression model in a single Italian center experience","volume":"30","author":"Rigoni","year":"2017","journal-title":"J. Nephrol."},{"key":"ref_25","doi-asserted-by":"crossref","unstructured":"Wyld, M., Morton, R.L., Hayen, A., Howard, K., and Webster, A.C. (2012). A systematic review and meta-analysis of utility-based quality of life in chronic kidney disease treatments. PLoS Med., 9.","DOI":"10.1371\/journal.pmed.1001307"},{"key":"ref_26","unstructured":"(2024, April 22). Codifa\u2014L\u2019Informatore Farmaceutico. Available online: https:\/\/www.codifa.it\/."},{"key":"ref_27","unstructured":"Ministero della Salute (2024). Definizione delle Tariffe Relative All\u2019assistenza Specialistica Ambulatoriale e Protesica, Decreto 11\/2024 pubblicato in GU Serie Generale n.302 del 27-12-2024."},{"key":"ref_28","unstructured":"Neri, L., Viglino, G., Vizzardi, V., and Russo, R. (2022). Peritoneal Dialysis in Italy: The 7th GSDP-SIN census 2019. G Ital. Nefrol., 39."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"107","DOI":"10.1007\/s40273-022-01215-w","article-title":"Role of Economic Evaluations on Pricing of Medicines Reimbursed by the Italian National Health Service","volume":"41","author":"Russo","year":"2023","journal-title":"Pharmacoeconomics"},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"e004251","DOI":"10.1136\/bmjopen-2013-004251","article-title":"Mortality in chronic kidney disease and renal replacement therapy: A population-based cohort study","volume":"4","author":"Neovius","year":"2014","journal-title":"BMJ Open"},{"key":"ref_31","doi-asserted-by":"crossref","unstructured":"Yen, C.L., Tu, K.H., Lin, M.S., Chang, S.W., Fan, P.C., Hsiao, C.C., Chen, C.Y., Hsu, H.H., Tian, Y.C., and Chang, C.H. (2018). Does a Supplemental Low-Protein Diet Decrease Mortality and Adverse Events After Commencing Dialysis? A Nationwide Cohort Study. Nutrients, 10.","DOI":"10.3390\/nu10081035"},{"key":"ref_32","unstructured":"National Institute of Statistics (ISTAT) (2025, November 27). 2024 Life Tables of the Resident Population by Geographical Area, Province and Region of Residence. Available online: https:\/\/demo.istat.it\/app\/?i=TVM&a=2024&l=en."},{"key":"ref_33","first-page":"A365","article-title":"A general model for the estimation of societal costs of lost production and informal care in Italy","volume":"18","author":"Pradelli","year":"2017","journal-title":"Farmeconomia Health Econ. Ther. Pathw."},{"key":"ref_34","unstructured":"(2025, May 14). ISTAT 2023: Employment and Unemployment (Provisional Estimates). Available online: https:\/\/www.istat.it\/it\/files\/\/2024\/01\/Employment-and-unemployment-202311.pdf."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"340","DOI":"10.1007\/s00415-023-11955-0","article-title":"Intravenous or subcutaneous natalizumab in patients with relapsing\u2013remitting multiple sclerosis: Investigation on efficiency and savings\u2014The EASIER study","volume":"271","author":"Filippi","year":"2024","journal-title":"J. Neurol."},{"key":"ref_36","doi-asserted-by":"crossref","unstructured":"Fletcher, B.R., Damery, S., Aiyegbusi, O.L., Anderson, N., Calvert, M., Cockwell, P., Ferguson, J., Horton, M., Paap, M.C., and Sidey-Gibbons, C. (2022). Symptom burden and health-related quality of life in chronic kidney disease: A global systematic review and meta-analysis. PLoS Med., 19.","DOI":"10.1371\/journal.pmed.1003954"},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"2801","DOI":"10.1111\/j.1523-1755.2005.00752.x","article-title":"Health-related quality of life and estimates of utility in chronic kidney disease","volume":"68","author":"Gorodetskaya","year":"2005","journal-title":"Kidney Int."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"2043","DOI":"10.1007\/s11255-017-1664-1","article-title":"Estimates of health utility scores in chronic kidney disease","volume":"49","author":"Sekercioglu","year":"2017","journal-title":"Int. Urol. Nephrol."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"S73","DOI":"10.1016\/j.jval.2023.09.385","article-title":"EE115 Cost-Effectiveness Analysis of Using Ketoanalogues of Essential Aminoacids in Patients with Chronic Kidney Disease in Kazakhstan","volume":"26","author":"Avdeyev","year":"2023","journal-title":"Value Health"},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"A458","DOI":"10.1016\/j.jval.2012.08.1454","article-title":"PUK16 Cost-Effectiveness of Ketosteril Treatment in Stage 3\u20134 CKD Patients","volume":"15","author":"Bacskai","year":"2012","journal-title":"Value Health"},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"750","DOI":"10.1111\/j.1440-1797.2009.01115.x","article-title":"Influence of ketoanalogs supplementation on the progression in chronic kidney disease patients who had training on low-protein diet","volume":"14","author":"Chang","year":"2009","journal-title":"Nephrology"},{"key":"ref_42","doi-asserted-by":"crossref","unstructured":"Chang, G., Shih, H.M., Pan, C.F., Wu, C.J., and Lin, C.J. (2023). Effect of Low Protein Diet Supplemented with Ketoanalogs on Endothelial Function and Protein-Bound Uremic Toxins in Patients with Chronic Kidney Disease. Biomedicines, 11.","DOI":"10.3390\/biomedicines11051312"},{"key":"ref_43","doi-asserted-by":"crossref","unstructured":"Wu, C.H., Yang, Y.W., Hung, S.C., Kuo, K.L., Wu, K.D., Wu, V.C., Hsieh, T.C., and National Taiwan University Study Group on Acute Renal Failure (NSARF) (2017). Ketoanalogues supplementation decreases dialysis and mortality risk in patients with anemic advanced chronic kidney disease. PLoS ONE, 12.","DOI":"10.1371\/journal.pone.0176847"},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"2113","DOI":"10.1007\/s40620-024-02065-9","article-title":"Efficacy and safety of ketoanalogue supplementation combined with protein-restricted diets in advanced chronic kidney disease: A systematic review and meta-analysis","volume":"37","author":"Chen","year":"2024","journal-title":"J. Nephrol."},{"key":"ref_45","doi-asserted-by":"crossref","unstructured":"Bellizzi, V., Garofalo, C., Ferrara, C., and Calella, P. (2022). Ketoanalogue Supplementation in Patients with Non-Dialysis Diabetic Kidney Disease: A Systematic Review and Meta-Analysis. Nutrients, 14.","DOI":"10.3390\/nu14030441"},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"2164","DOI":"10.1681\/ASN.2015040369","article-title":"Ketoanalogue-Supplemented Vegetarian Very Low\u2013Protein Diet and CKD Progression","volume":"27","author":"Garneata","year":"2016","journal-title":"J. Am. Soc. Nephrol."},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"1404","DOI":"10.1093\/ajcn\/nqab417","article-title":"No additional benefit of prescribing a very low-protein diet in patients with advanced chronic kidney disease under regular nephrology care: A pragmatic, randomized, controlled trial","volume":"115","author":"Bellizzi","year":"2022","journal-title":"Am. J. Clin. Nutr."}],"container-title":["Nutrients"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2072-6643\/18\/7\/1142\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,4,4]],"date-time":"2026-04-04T04:21:53Z","timestamp":1775276513000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2072-6643\/18\/7\/1142"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,4,2]]},"references-count":47,"journal-issue":{"issue":"7","published-online":{"date-parts":[[2026,4]]}},"alternative-id":["nu18071142"],"URL":"https:\/\/doi.org\/10.3390\/nu18071142","relation":{},"ISSN":["2072-6643"],"issn-type":[{"value":"2072-6643","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,4,2]]}}}