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Effect of dietary patterns on functional dyspepsia in adults: a systematic review

Journal of Health, Population and Nutrition volume 44, Article number: 132 (2025) Cite this article

Abstract

Objectives

Dietary patterns may play important roles in functional dyspepsia (FD) which is one of the widely prevalent functional gastrointestinal disorders (FGID)s. This systematic review aimed to investigate the effect of various dietary patterns on FD in adults.

Methods

We searched Embase, Medline (accessed via PubMed), Web of Science (WoS), Scopus, and Cochrane from inception to March 2025. Eligible studies included randomized clinical trials and observational studies enrolling adults (≥ 18 years old). We assessed the risk of bias and evaluated the quality of evidence using the GRADE approach.

Results

Seven studies (three RCTs and four cross-sectional studies) were included. Moderate-quality evidence suggests that a protein-rich DASH diet (Absolute risk (AR):140 more, 95%CI: 58 to 252 more in 1,000) and an unsaturated fat-rich DASH diet (AR: 113 more, 95%CI: 31 to 227 more in 1,000), compared to baseline diet, are likely to increase Postprandial Distress Syndrome (PDS). Moderate-quality evidence indicates that high versus low adherence to the Mediterranean diet (MD), a diet rich in fibers, mono- and polyunsaturated fatty acids, antioxidants, and polyphenols, reduced the likelihood of FD (AR:151 fewer, 95%CI: 74 to 203 fewer in 1,000). It is uncertain whether vegetarian and vegan diets, compared to a usual diet, affect PDS due to the very low quality of evidence.

Conclusion

Rigorously conducted RCTs and observational studies are needed to establish the association between dietary patterns and functional dyspepsia.

Introduction

Dyspeptic symptoms are among the most prevalent reasons for referral to outpatient clinics worldwide [1]. Despite through evaluations, these symptoms often lack a clear cause, leading to a diagnosis of functional dyspepsia (FD), a well-recognized and prevalent functional gastrointestinal disorder (FGID) [2]. Dyspeptic symptoms encompass various forms of gastrointestinal (GI) discomforts, such as epigastric pain, epigastric burning, postprandial fullness, early satiety, nausea, and bloating [2].

Although the exact causes of dyspeptic symptoms remain unclear, they are likely influenced by a combination of biological, psychological, physiological, and environmental factors, including diet. Many patients with dyspeptic symptoms report that certain foods trigger or worsen their condition [3], highlighting the role of diet in dyspepsia [4]. Several foods, such as fatty and spicy dishes, as well as soft drinks may worsen dyspeptic symptoms [5]. While most previous studies have explored the effects of an individual nutrient or food on dyspeptic symptoms [5,6,7,8], it is crucial to recognize that nutrients and foods are typically consumed in combination, leading to complex interactions that can influence symptom development. Studying dietary patterns (DPs) offers a broader perspective on food and nutrient consumption, as well as their synergistic and interactive effects. Consequently, nutritional epidemiology has gradually shifted from focusing individual nutrients to examining DPs, which reflect the overall combinations, quantities, and frequencies of different types of food and drinks consumed over time [9]. Recent studies have mainly adopted the DP approach, recognizing it as a potentially more effective strategy in reducing disease symptoms compared to focusing on individual foods or nutrients [10,11,12].

Given the current state of research on the association between dyspepsia and DPs, it is surprising that the existing literature lacks definitive conclusions, leaving a major gap in our understanding [13]. To date, no systematic review has comprehensively addressed the relationship between dyspeptic symptoms and various DPs, including but not limited to Dietary Approaches to Stop Hypertension (DASH), Mediterranean, and vegetarian diets. Conducting such a review could help clarify the complex interplay between GI health and nutrition, ultimately leading to more effective management strategies and improved patient care.

Therefore, we aimed to conduct a systematic review to explore the effect of various DPs on functional dyspepsia.

Methods

We registered our protocol with PROSPERO (CRD42022338353) and adhered to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) checklist [14].

Search strategy

A medical librarian developed the search strategy using a combination of controlled vocabulary and keywords, including (“Dietary pattern” OR “Mediterranean diet” OR “Vegetarian Diet” OR “Western diet” OR “DASH Diet”) AND (Dyspepsia OR “epigastric pain syndrome” OR “postprandial distress syndrome”). The search strategy underwent pilot testing and was reviewed by content experts. We adapted the search strategy and performed comprehensive searches in Embase, Medline (accessed via PubMed), Web of Science, Scopus, and Cochrane. The search was conducted from inception to March 2025, and results were limited to references published exclusively in English.

Study selection

We included experimental (e.g., randomized controlled trials (RCT)) and observational studies involving adults (≥ 18 years old) that assessed the effect of any DP as an exposure or intervention compared to any control. The outcome of interest is the presence, severity, or frequency of dyspeptic symptoms including pain, burning, fullness, early satiety, bloating, and nausea utilizing validated patient-reported outcome measures (PROMs), researcher-designed tools, or culturally adapted measures (e.g., feeling uncomfortably full after meal). As mentioned earlier, these symptoms often persist despite thorough evaluation, leading to a diagnosis of FD. According to the Rome IV criteria, FD is categorized into postprandial distress syndrome (PDS), marked by meal-related symptoms like postprandial fullness and early satiety, and epigastric pain syndrome (EPS), characterized by meal-independent epigastric pain and burning [3, 15]. We excluded studies assessing other dietary interventions or exposures, such as elimination diets (e.g., Low fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAP) diet, gluten-free diet). We excluded animal studies, commentaries, editorials, reviews, case reports, case series, conference abstracts, unpublished studies, gray literature and studies involving patients with structural or metabolic diseases (e.g., inflammatory bowel disease, celiac disease), and studies enrolled children and adolescents. Studies requiring additional data were excluded if the authors did not respond after two contact attempts [16].

Study selection

Two reviewers (PH and EZ) independently screened the titles, abstracts, and full-text articles of potentially eligible studies using the web-based systematic review software Rayyan (https://www.rayyan.ai/), ensuring consistency in the review process [17]. Conflicts were resolved through discussion, or if necessary, by consulting a senior reviewer (PA).

Data extraction and quality assessment

The following data were extracted independently by same pair of reviewers (EZ and SZH): first author’s last name, publication year, country, study design, diagnostic criteria, participant characteristics (number, age and sex), intervention/exposure and control diets, duration, randomization (simple, block, stratified, ect.), outcome measures, and corresponding results.

Risk of bias assessment

For parallel RCT, we used Cochrane Risk of Bias Tool (ROB2), which covers five domains: bias arising from the randomization process, bias due to deviations from intended interventions, bias due to missing outcome data (> 20% missing data considered high risk), bias in measurement of the outcome, and reporting bias [18]. For crossover trials, we used the Revised Cochrane risk of bias tool for randomized trials (ROB2), with additional considerations for crossover trials [19]. The risk of bias was assessed independently by two reviewers (PH and EZ) across eight domains: bias arising from the randomization process, bias due to deviations from intended interventions, bias due to missing outcome data (> 20% missing data considered high risk), bias in the measurement of the outcome, bias in the selection of reported results, bias due to unequal numbers of participants in each arm, bias from period effect in analysis, and bias from carryover effect.

For observational studies, the same pair of reviewers assessed the risk of bias using the ROBINS-I tool, which covers seven domains: bias due to confounding, bias in the selection of participants, bias in classification of interventions, bias due to deviations from intended interventions, bias due to missing data, bias in measurement of the outcome, and bias in selection of the reported result [20]. Disagreements and uncertainties were resolved through discussion and, if necessary, adjudication by a third reviewer.

Data analysis and synthesis

We narratively summarized and reported effect estimates. For binary outcomes, the evidence synthesis team aimed to report baseline probability for the outcome, a measure of association (e.g., relative risk (RR), odds ratio (OR)), and a corresponding 95% confidence interval (CI). Relative measures of association (RR and OR) were complemented with the absolute risk change for each outcome. The evidence synthesis team aimed to synthesize findings narratively across different study and outcome types. We did not conduct quantitative meta-synthesis for any outcomes.

Certainty (quality) of evidence

We assessed the certainty of evidence using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach [21]. According to GRADE, evidence from randomized controlled trials (RCTs) starts as high certainty, whereas evidence from observational studies starts as low certainty but can be rated down due to risk of bias, indirectness, imprecision, or publication bias. We rated up one level when the effect in observational studies was sufficiently large, i.e., direct evidence—RR between 2 and 5 or between 0.5 and 0.2 with no plausible confounders and very large with RR larger than 5 or RR less than 0.2 and no serious problems with risk of bias or precision (sufficiently narrow CIs) [22].

Results

Search results and study selection

We identified 2,276 unique records, of which 9 studies met the eligibility criteria. One of these nine studies was excluded due to ambiguity in the dyspepsia definition [12], and another was removed due to missing data, as the authors did not respond after two contact attempts [16]. The seven studies that met the eligibility criteria included one parallel RCT, two crossover RCTs, and four cross-sectional studies (see Fig. 1).

Fig. 1
figure 1

Flow chart of reviewed studies

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Study characteristics

Table 1 summarizes the key characteristics of the three RCTs, which included 10 interventions and a total of 739 participants [23,24,25]. All studies, conducted in the USA, focused on adults with prehypertension or hypertension. The mean of age across three RCTs ranged from 48 to 52 years, and the proportion of females varies from 45 to 57% [23,24,25].

Table 1 Characteristics of RCTs included in the systematic review
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Table 2 summarizes four cross-sectional studies involving 5,217 participants [11, 26,27,28], conducted in Poland [11], India [26], Greece [27], and Italy [28]. Participants’ age ranged from 18 to 83 years, and the proportion of females varied between 43 and 52%. Three studies enrolled healthy adults [11, 26, 27], while one study compared individuals with irritable bowel syndrome (IBS) and functional dyspepsia to healthy adults [28].

Table 2 Characteristics of cross-sectional studies included in the systematic review
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Risk of bias

The two crossover trials and one parallel trial were assessed as having high risk of bias due to the lack of blinding of participants and caregivers to the interventions [23,24,25] (Fig. 2). Among the observational studies, three were found to have a high risk of bias for various reasons [11, 26, 27], while one was considered to have a low risk of bias [28] (Fig. 3).

Fig. 2
figure 2

Risk of bias assessment of included RCTs

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Fig. 3
figure 3

Risk of Bias Assessment of Included Observational Studies

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Findings

Effect of dietary patterns on dyspeptic symptoms in RCTs

Wu et al. conducted a four-arm crossover trial with 163 participants to investigate the effects of four types of DASH diet, each varying in carbohydrate content and glycemic index [24]. Moderate-quality evidence indicated that all diets probably increase PDS (bloating) (Relative risk (RR): 1.59, 95%CI: 1.25 to 2; Absolute risk increase (ARI): 137 more, 95% CI: 58 to 233 more per 1000 participants) [24].

Zhang et al. enrolled 164 subjects to compare the effect of carbohydrate-rich, protein-rich, and unsaturated fat-rich diets versus a baseline diet [25]. Moderate-quality evidence suggests that a protein-rich diet (RR: 1.78, 95% CI: 1.32 to 2.40; ARI: 140 more, 95% CI: 58 to 252 more per 1000 participants) and an unsaturated fat-rich diet (RR: 1.63, 95%CI: 1.17 to 2.26; ABI: 113 more, 95%CI: 31 to 227 more per 1000 participants) likely increases PDS (bloating). Furthermore, moderate-quality evidence suggests that a protein-rich diet versus a carbohydrate-rich diet, is likely to increase PDS (bloating) (RR: 1.40, 95%CI: 1.03 to 1.88; ARI: 96 more, 95%CI: 7 to 221 more in 1000 participants). Additionally, moderate-quality evidence indicates that a protein-rich diet is likely to increase PDS (bloating) compared to a carbohydrate-rich diet (RR: 1.40, 95% CI: 1.03 to 1.88; ABI: 96 more, 95% CI: 7 to 221 more per 1,000 participants). Low-quality evidence suggested no significant difference in PDS (bloating) between the carbohydrate-rich diet versus the baseline, unsaturated fat-rich versus carbohydrate-rich, and protein-rich versus unsaturated fat-rich diets [25].

Peng et al. randomized 412 participants into a high-fiber DASH diet (32 g of fiber) and a low-fiber control diet (11 g of fiber), with each group undergoing three 30-day periods with varying sodium levels [23]. The primary objective was to explore the effect of DASH versus control diet on blood pressure, but for this review, we focus on the effect on PDS, include bloating and an uncomfortably full feeling, regardless of sodium levels. Moderate-quality evidence suggests that the DASH diet likely increases PDS regardless of sodium intake levels. (RR: 1.41, 95% CI: 1.22 to 1.64; ARI: 151 more, 95% CI: 81 to 236 more per 1000 participants) [23](see Table 3).

Table 3 GRADE evidence profile
Full size table

Effect of dietary patterns on dyspeptic symptoms in observational studies

Ostrowski et al. investigated how the transition to a vegetarian or vegan diet affected PDS, defined in this context as bloating and a sense of fullness [11]. It is uncertain whether switching to a vegetarian diet reduces feelings of fullness and bloating, based on very low-quality evidence (RR: 0.23, 95% CI: 0.19 to 0.28; Absolute Risk Reduction (ARR): 40, 95% CI: 37 to 42 per 100 participants). Similarly, it is unclear whether transitioning to vegan diet reduces these symptoms, according to very low-quality evidence (RR: 0.22, 95% CI: 0.12 to 0.39; ARR: 47, 95% CI: 37 to 53 per 100 participants) [11].

Ghoshal et al. investigated the prevalence and risk factors associated with functional gastrointestinal disorders—defined as dyspepsia, IBS, and dyspepsia-IBS overlap—using adjusted analysis in a rural Indian community [26]. In this study, dyspepsia was defined as epigastric pain syndrome, PDS, and both. For this review, we examine the association between dietary patterns (vegetarian vs. non-vegetarian) as the independent variable and dyspepsia as the outcome. It is uncertain whether a vegetarian diet, compared to a non-vegetarian diet, increases the risk of dyspepsia due to very low-quality evidence (adjusted OR: 5.80, 95% CI: 1.81 to 18.54; Absolute Increase: 104, 95% CI: 19 to 297 more per 1000 participants) [26].

Mitsou et al. explored the association between adherence to a Mediterranean diet and gastrointestinal symptoms in an adult population. They used the MedDietScore, where a higher score indicates greater adherence to the Mediterranean diet, while a lower score reflects adherence to a Westernized diet. The MedDietScore was used as the predictor, and gastrointestinal symptoms were the outcome. For this review, we report abdominal pain and bloating. Very low-quality evidence from linear regression models suggests that, although highly uncertain, adherence to the Mediterranean diet may be associated with increased abdominal pain (Increase score 0.17, 95% CI: 0.16 to 0.19, ranging 0–28) and increased bloating (Increase score 0.2, 95%CI: 0.01 to 0.38, ranging 0–28) [27].

Similarly, Zito et al. examined the association between varying levels of adherence to the Mediterranean diet and functional gastrointestinal disorders, such as irritable bowel syndrome and functional dyspepsia [28]. For the purpose of this review, we focus specifically on dyspepsia.

To enhance the clinical applicability of evidence, we calculated the odds ratio (OR) to assess how increasing adherence to the Mediterranean diet—from mild or intermediate to high—affects FD. Moderate-quality evidence showed that high versus low adherence to the Mediterranean diet reduced the likelihood of FD (OR: 0.41, 95% CI: 0.25 to 0.68; ARR: 151 fewer, 95% CI: 74 to 203 fewer per 1000 participants). Very low-quality evidence indicated that it is uncertain whether high versus intermediate adherence reduce the likelihood of FD (very low-quality evidence; OR 0.75, 95% CI: 0.49 to 1.14; ARI: 42 more, 95% CI: 91 fewer to 22 more per 1000 participants) [28].

Discussion

Summary of results

This systematic review gathered evidence from seven studies (three RCTs and four observational studies) regarding specific DPs (i.e., DASH diet, Mediterranean diet, Vegetarian diet, and the Vegan diet) and FD or its symptoms in adults. Moderate-quality evidence suggests that a protein-rich diet and an unsaturated fat-rich diet, compared to baseline diet, are likely to increase PDS. There is conflicting evidence regarding adherence to the Mediterranean diet and its association with functional dyspepsia symptoms. Zito et al. found that moderate-quality evidence suggests high adherence to the Mediterranean diet, compared to low adherence, reduces the likelihood of functional dyspepsia. Conversely, Mitsou et al. reported that it is very uncertain whether adherence to the Mediterranean diet is associated with increased abdominal pain and bloating. Given that the findings from Zito et al. are based on higher-quality evidence, high adherence to the Mediterranean diet may reduce the risk of functional dyspepsia. It is uncertain whether vegetarian and vegan diets, compared to a usual diet, affect postprandial distress syndrome (PDS) due to the very low quality of evidence.

To the best of our knowledge, this is the first systematic review that explored the relationship between DPs and dyspeptic symptoms in adults. The recent systematic review on the efficacy of DPs in FGIDs in children and adolescents, concluded that good adherence to MD may have beneficial effects on preventing FGIDs occurrence and alleviating their symptoms [29].

Patients with FD report that some food groups trigger or worsen their symptoms, while others help alleviate the dyspeptic symptoms. Therefore, dietary recommendation can be considered a crucial part of the medical management of FD [30]. Due to the cumulative and synergetic effect of consumed food and nutrients, considering overall diet quality rather than individual nutrients and food groups provides a more informative approach to understand diet-disease relationship [31]. To date, several studies have suggested that a healthy dietary pattern, such as MD, which is rich in plant-based food, may modulate the gut microbiota, enhance its diversity, improve the gut barrier integrity, reduce inflammation, and ultimately lower the risk of FIGDs [32, 33]. Furthermore, higher adhering to MD results in increased production of short chain fatty acids (SCFAs), which are involved in the modulation of immune and inflammatory response. These beneficial effects of the MD might be attributed to its high contents of fibers (from whole grain, vegetables, legumes, fruits and nuts), mono- and poly-unsaturated fatty acids, as well as antioxidants and polyphenols (such as vitamins, flavonoids, phytosterols, minerals, and phenols) [33]. Given that there was only one study showed the beneficial effects of higher adherence to MD on FD [28], it is remains uncertain whether the MD improves dyspeptic symptoms. Further long-term, large-scale RCTs are required to shed light on this issue.

It is important to note that many high-quality DPs, such as DASH diet and vegetarian diets, are rich in FODMAPs (fermentable oligo-, di-, monosaccharides, and polyols) and gluten, both of which have been shown to exacerbate FGIDs symptoms [5, 34]. For instance, DASH diet emphasizes high consumption of fruits, vegetables, whole grains, nuts, and legumes; moderate intake of low-fat dairy products, seafood and poultry; and limiting consumption of sugars, sodium and red and processed meat [35]. There is insufficient evidence regarding the effects of the DASH diet on FD and its symptoms. Additionally, the reasons behind adverse effects of DASH diets on dyspeptic symptoms, especially bloating, remain unclear. As previously mentioned, one possible reason could be the high amount of FODMAPs in plant-based diets, which may increase osmotic activity, fermentation, and gas production, as well as delay gastric emptying and gas transit, consequently triggering dyspeptic symptoms [5, 36, 37]. Furthermore, high gluten content in the DASH diet, has been shown to worsen dyspeptic symptoms, including bloating [38]. It has been suggested that gluten may play a role in immune system activation, alteration in intestinal permeability, induction of dysbiosis, and microbiota translocation [39]. However, the existing evidence indicates that transitioning from low-fiber diet to a higher-fiber diet should be done gradually to prevent these adverse effects [40].

It is worth mentioning that Zhang et al. evaluated the effects of three different high-fiber, and isocaloric, modified version of the DASH diet on bloating in a crossover RCT [25]. They revealed that all three high-fiber diets increased the risk of bloating; however, the protein-rich DASH diet was associated with the highest risk of bloating [25]. They suggested that these adverse effects might not be due to protein itself. Instead, their protein-rich diet emphasized plant-based proteins (e.g., beans, legumes, nuts, seeds, wheat, and soy products), which are rich in FODMAPs and could contribute to increased bloating [25].

Limitation and strength

During our systematic review, we could not find high-quality RCTs examining how different DPs could influence dyspeptic symptoms. Moreover, there is a notable discrepancy in how DPs are defined across different studies, as each article interpret the concept based on their own perspectives. In addition, the inclusion of only seven articles (three RCTs and four observational studies), with small sample sizes and potential selection bias, may limit the generalizability of the findings. Furthermore, the variability in study designs, interventions, and patient-reported outcome measures across the studies make it challenging to conduct a meta-analysis and draw definitive conclusions. Moreover, all but one of the included studies were found to have high risk of bias, which limits the precision of the findings. Furthermore, the observed associations could be influenced by confounding factors, as these studies did not account all variables that could affect dyspeptic symptoms.

Despite these limitations, the systematic review has notable strengths, including the use of a comprehensive search strategy, inclusion of various study designs, independent screening and data extraction, risk of bias assessment, and the application of the GRADE approach to evaluate the quality of evidence. Additionally, the study protocol was registered in PROSPERO, all of enhance the overall robustness of this systematic review.

Future lines of research (Conclusion)

Moderate-quality evidence suggests that a protein-rich diet and an unsaturated fat-rich diet, compared to baseline diet, are likely to increase PDS. Moderate-quality evidence indicates that high versus low adherence to the Mediterranean diet reduced the likelihood of Functional Dyspepsia. Rigorously conducted RCTs and observational studies are needed to establish the association between dietary patterns and functional dyspepsia.

Data availability

No datasets were generated or analysed during the current study.

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Acknowledgements

The authors would like to thank the research chancellor of Isfahan University of Medical Sciences for support of the conduct of this research.

Funding

There was no financial support for this research.

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Authors and Affiliations

  1. Humber River Hospital, Toronto, ON, Canada

    Vahid Ashoorion

  2. Isfahan Gastroenterology and Hepatology Research Center, Isfahan University of Medical Sciences, Isfahan, Iran

    Seyedeh-Zeynab Hosseinian, Niloufar Rezaei, Parisa Hajihashemi, Elahe Zare-Farashbandi & Peyman Adibi

  3. Health Information Technology Research Center, Isfahan University of Medical Sciences, Isfahan, Iran

    Elahe Zare-Farashbandi

Authors
  1. Vahid Ashoorion
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  2. Seyedeh-Zeynab Hosseinian
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  3. Niloufar Rezaei
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  4. Parisa Hajihashemi
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  5. Elahe Zare-Farashbandi
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  6. Peyman Adibi
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Contributions

VA, PA, EZF and PH contributed to the design of the review protocol, defining the research theme, and screening the eligible studies. PH, EZF and contributed to screening the eligible studies, conducting data extraction, and revising the article. VA, EZF, NR, ZH and PH contributed to making the tables, and writing the article. PA, and VA contributed to interpreting the results and giving expert advice on the article.

Corresponding authors

Correspondence to Parisa Hajihashemi or Elahe Zare-Farashbandi.

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Ashoorion, V., Hosseinian, SZ., Rezaei, N. et al. Effect of dietary patterns on functional dyspepsia in adults: a systematic review. J Health Popul Nutr 44, 132 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s41043-025-00884-5

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  • DOI: https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s41043-025-00884-5

Keywords

Journal of Health, Population and Nutrition

ISSN: 2072-1315

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