Gebe ve Emziklilikte Krono-nütrisyon
Özet
Krono-nütrisyon, beslenme zamanlamasının metabolik sağlık ve kronik hastalıklar üzerindeki etkilerini inceleyen bir bilim dalıdır. Bu kavram aynı zamanda, gebelik ve emzirme dönemlerinde annelerin biyolojik saatlerine uygun olarak beslenmelerini düzenlemeyi amaçlar. Gebelik ve emzirme dönemlerinde doğru zamanlarda yemek yemenin, hem anne hem de bebek sağlığı üzerinde olumlu etkileri vardır. Krono-nütrisyon, bu dönemlerde metabolik sağlığı iyileştirmek ve kilo yönetimini kolaylaştırmak için kullanılabilir.
Anahtar Kelimeler: Krono-nütrisyon, sirkadiyen ritim, öğün sıklığı, gebe ve emzikli beslenmesi.
Konu Alanı: Biyoloji -> Biyoloji (diğer) -> Beslenme
Abdi, T. A., Andreou, E., Papageorgiou, A., Heraclides, A., & Philippou, E. (2020). Personality, Chrono-nutrition and Cardiometabolic Health: A Narrative Review of the evidence. Advances in Nutrition, 11(5), 1201–1210. https://doi.org/10.1093/advances/nmaa051
Acosta-Rodríguez, V. A., Rijo-Ferreira, F., Green, C. B., & Takahashi, J. S. (2021). Importance of circadian timing for aging and longevity. Nature Communications, 12(1), 2862. https://doi.org/10.1038/s41467-021-22922-6
Ahluwalia, M. K. (2022). Chrononutrition—When we eat is of the essence in tackling obesity. Nutrients, 14(23), 5080. https://doi.org/10.3390/nu14235080
Ahmed, R., Chibsa, S. E., Hussen, M. A., Bayisa, K., Kefeni, B. T., Gezimu, W., & Bidira, K. (2024). Undernutrition among exclusive breastfeeding mothers and its associated factors in Southwest Ethiopia: A community-based study. Women S Health, 20, 17455057241231478. https://doi.org/10.1177/17455057241231478
Ainscough, K. M., Kennelly, M. A., Lindsay, K. L., O’Brien, E. C., O’Sullivan, E. J., Mehegan, J., Gibney, E. R., & McAuliffe, F. M. (2019). An observational analysis of meal patterns in overweight and obese pregnancy: exploring meal pattern behaviours and the association with maternal and fetal health measures. Irish Journal of Medical Science (1971 -), 189(2), 585–594. https://doi.org/10.1007/s11845-019-02099-0
Alzaheb, R. A. (2017). A review of the factors associated with the timely initiation of breastfeeding and exclusive breastfeeding in the Middle East. Clinical Medicine Insights Pediatrics, 11, 1179556517748912. https://doi.org/10.1177/1179556517748912
Aoyama, T., Li, D., & Bay, J. L. (2022). Weight Gain and Nutrition during Pregnancy: An Analysis of Clinical Practice Guidelines in the Asia-Pacific Region. Nutrients, 14(6), 1288. https://doi.org/10.3390/nu14061288
Baran, J., Weres, A., Czenczek-Lewandowska, E., Leszczak, J., Kalandyk-Osinko, K., Łuszczki, E., Sobek, G., & Mazur, A. (2020). Excessive Gestational Weight gain: Long-Term Consequences for the child. Journal of Clinical Medicine, 9(12), 3795. https://doi.org/10.3390/jcm9123795
Beccuti, G., Monagheddu, C., Evangelista, A., Ciccone, G., Broglio, F., Soldati, L., & Bo, S. (2017). Timing of food intake: Sounding the alarm about metabolic impairments? A systematic review. Pharmacological Research, 125(Pt B), 132–141. https://doi.org/10.1016/j.phrs.2017.09.005
Booker, L. A., Spong, J., Deacon-Crouch, M., & Skinner, T. C. (2022). Preliminary Exploration into the Impact of Mistimed Expressed Breast Milk Feeding on Infant Sleep Outcomes, Compared to Other Feeding Patterns. Breastfeeding Medicine. https://doi.org/10.1089/bfm.2022.0125
Booker, L. A., Wilson, D., Spong, J., Fitzgibbon, C., Deacon-Crouch, M., Lenz, K. E., & Skinner, T. C. (2023). Maternal Circadian Disruption from Shift Work and the Impact on the Concentration of Melatonin in Breast Milk. Breastfeeding Medicine, 19(1), 33–39. https://doi.org/10.1089/bfm.2023.0252
Bravi, F., Wiens, F., Decarli, A., Pont, A. D., Agostoni, C., & Ferraroni, M. (2016). Impact of maternal nutrition on breast-milk composition: a systematic review,. American Journal of Clinical Nutrition, 104(3), 646–662. https://doi.org/10.3945/ajcn.115.120881
Caba-Flores, M. D., Ramos-Ligonio, A., Camacho-Morales, A., Martínez-Valenzuela, C., Viveros-Contreras, R., & Caba, M. (2022). Breast milk and the importance of chrononutrition. Frontiers in Nutrition, 9, 867507. https://doi.org/10.3389/fnut.2022.867507
Carretero-Krug, A., Montero-Bravo, A., Morais-Moreno, C., Puga, A. M., De Lourdes Samaniego-Vaesken, M., Partearroyo, T., & Varela-Moreiras, G. (2024). Nutritional Status of Breastfeeding Mothers and Impact of Diet and Dietary Supplementation: A Narrative review. Nutrients, 16(2), 301. https://doi.org/10.3390/nu16020301
Chauhan, R., Chen, K., Kent, B. A., & Crowther, D. C. (2017). Central and peripheral circadian clocks and their role in Alzheimer’s disease. Disease Models & Mechanisms, 10(10), 1187–1199. https://doi.org/10.1242/dmm.030627
Chawla, S., Beretoulis, S., Deere, A., & Radenkovic, D. (2021). The window matters: A systematic review of time restricted eating strategies in relation to cortisol and melatonin secretion. Nutrients, 13(8), 2525. https://doi.org/10.3390/nu13082525
Chen, Y., Loy, S., & Chen, L. (2023). Chrononutrition during Pregnancy and Its Association with Maternal and Offspring Outcomes: A Systematic Review and Meta-Analysis of Ramadan and Non-Ramadan Studies. Nutrients, 15(3), 756. https://doi.org/10.3390/nu15030756
Clarke, G. S., Gatford, K. L., Young, R. L., Grattan, D. R., Ladyman, S. R., & Page, A. J. (2021). Maternal adaptations to food intake across pregnancy: Central and peripheral mechanisms. Obesity, 29(11), 1813–1824. https://doi.org/10.1002/oby.23224
Crispim, C. A., & Mota, M. C. (2018). New perspectives on chrononutrition. Biological Rhythm Research, 50(1), 63–77. https://doi.org/10.1080/09291016.2018.1491202
Dashti, H. S., Gómez-Abellán, P., Qian, J., Esteban, A., Morales, E., Scheer, F. A., & Garaulet, M. (2020). Late eating is associated with cardiometabolic risk traits, obesogenic behaviors, and impaired weight loss. American Journal of Clinical Nutrition, 113(1), 154–161. https://doi.org/10.1093/ajcn/nqaa264
D’cunha, K., Park, Y., Protani, M. M., & Reeves, M. M. (2022). Circadian rhythm disrupting behaviours and cancer outcomes in breast cancer survivors: a systematic review. Breast Cancer Research and Treatment, 198(3), 413–421. https://doi.org/10.1007/s10549-022-06792-0
Di Maso, M., Eussen, S. R. B. M., Bravi, F., Moro, G. E., Agostoni, C., Tonetto, P., Quitadamo, P. A., Salvatori, G., Profeti, C., Kazmierska, I., Vacca, E., Decarli, A., Stahl, B., Bertino, E., & Ferraroni, M. (2021). Dietary intake of breastfeeding mothers in Developed countries: A systematic review and results of the MEDIDIET study. Journal of Nutrition, 151(11), 3459–3482. https://doi.org/10.1093/jn/nxab258
Englund-Ögge, L., Birgisdottir, B. E., Sengpiel, V., Brantsæter, A. L., Haugen, M., Myhre, R., Meltzer, H. M., & Jacobsson, B. (2017). Meal frequency patterns and glycemic properties of maternal diet in relation to preterm delivery: Results from a large prospective cohort study. PLoS ONE, 12(3), e0172896. https://doi.org/10.1371/journal.pone.0172896
Falize, C., Savage, M., Jeanes, Y. M., & Dyall, S. C. (2023). Evaluating the relationship between the nutrient intake of lactating women and their breast milk nutritional profile: a systematic review and narrative synthesis. British Journal of Nutrition, 131(7), 1196–1224. https://doi.org/10.1017/s0007114523002775
Flanagan, A., Bechtold, D. A., Pot, G. K., & Johnston, J. D. (2020). Chrono‐nutrition: From molecular and neuronal mechanisms to human epidemiology and timed feeding patterns. Journal of Neurochemistry, 157(1), 53–72. https://doi.org/10.1111/jnc.15246
Gila-Díaz, A., Alcántara, N. D., Carrillo, G. H., Singh, P., Arribas, S. M., & Ramiro-Cortijo, D. (2021). Multidimensional Approach to Assess Nutrition and Lifestyle in Breastfeeding Women during the First Month of Lactation. Nutrients, 13(6), 1766. https://doi.org/10.3390/nu13061766
Goldstein, R. F., Abell, S. K., Ranasinha, S., Misso, M. L., Boyle, J. A., Harrison, C. L., Black, M. H., Li, N., Hu, G., Corrado, F., Hegaard, H., Kim, Y. J., Haugen, M., Song, W. O., Kim, M. H., Bogaerts, A., Devlieger, R., Chung, J. H., & Teede, H. J. (2018). Gestational weight gain across continents and ethnicity: systematic review and meta-analysis of maternal and infant outcomes in more than one million women. BMC Medicine, 16(1), 153. https://doi.org/10.1186/s12916-018-1128-1
Gontijo, C. A., Balieiro, L. C. T., Teixeira, G. P., Fahmy, W. M., Crispim, C. A., & De Paiva Maia, Y. C. (2020). Higher energy intake at night effects daily energy distribution and contributes to excessive weight gain during pregnancy. Nutrition, 74, 110756. https://doi.org/10.1016/j.nut.2020.110756
Grenier, L. N., Atkinson, S. A., Mottola, M. F., Wahoush, O., Thabane, L., Xie, F., Vickers‐Manzin, J., Moore, C., Hutton, E. K., & Murray‐Davis, B. (2020). Be Healthy in Pregnancy: Exploring factors that impact pregnant women’s nutrition and exercise behaviours. Maternal and Child Nutrition, 17(1), e13068. https://doi.org/10.1111/mcn.13068
Gupta, C. C., Centofanti, S., Dorrian, J., Coates, A., Stepien, J. M., Kennaway, D., Wittert, G., Heilbronn, L., Catcheside, P., Noakes, M., Coro, D., Chandrakumar, D., & Banks, S. (2019). Altering meal timing to improve cognitive performance during simulated nightshifts. Chronobiology International, 36(12), 1691–1713. https://doi.org/10.1080/07420528.2019.1676256
Hahn-Holbrook, J., Saxbe, D., Bixby, C., Steele, C., & Glynn, L. (2019). Human milk as “chrononutrition”: implications for child health and development. Pediatric Research, 85(7), 936–942. https://doi.org/10.1038/s41390-019-0368-x
Henry, C. J., Kaur, B., & Quek, R. Y. C. (2020). Chrononutrition in the management of diabetes. Nutrition and Diabetes, 10(1), 6. https://doi.org/10.1038/s41387-020-0109-6
Hong, F., Pan, S., Xu, P., Xue, T., Wang, J., Guo, Y., Jia, L., Qiao, X., Li, L., & Zhai, Y. (2020). Melatonin Orchestrates Lipid Homeostasis through the Hepatointestinal Circadian Clock and Microbiota during Constant Light Exposure. Cells, 9(2), 489. https://doi.org/10.3390/cells9020489
Imamura, M., Sasaki, H., Shinto, T., Tahara, Y., Makino, S., Kuwahara, M., Tada, A., Abe, N., Michie, M., & Shibata, S. (2022). Association between NA, K, and lipid intake in each meal and blood pressure. Frontiers in Nutrition, 9, 853118. https://doi.org/10.3389/fnut.2022.853118
Italianer, M. F., Naninck, E. F. G., Roelants, J. A., Van Der Horst, G. T. J., Reiss, I. K. M., Van Goudoever, J. B., Joosten, K. F. M., Chaves, I., & Vermeulen, M. J. (2020). Circadian Variation in Human Milk Composition, a Systematic review. Nutrients, 12(8), 2328. https://doi.org/10.3390/nu12082328
Jamshed, H., Beyl, R., Della Manna, D., Yang, E., Ravussin, E., & Peterson, C. (2019). Early Time-Restricted feeding improves 24-Hour glucose levels and affects markers of the circadian clock, aging, and autophagy in humans. Nutrients, 11(6), 1234. https://doi.org/10.3390/nu11061234
Katsi, V., Papakonstantinou, I. P., Soulaidopoulos, S., Katsiki, N., & Tsioufis, K. (2022). Chrononutrition in cardiometabolic health. Journal of Clinical Medicine, 11(2), 296. https://doi.org/10.3390/jcm11020296
Katzer, D., Pauli, L., Mueller, A., Reutter, H., Reinsberg, J., Fimmers, R., Bartmann, P., & Bagci, S. (2016). Melatonin concentrations and antioxidative capacity of human breast milk according to gestational age and the time of day. Journal of Human Lactation, 32(4), NP105–NP110. https://doi.org/10.1177/0890334415625217
Kent, B. A., Rahman, S. A., St Hilaire, M. A., Grant, L. K., Rüger, M., Czeisler, C. A., & Lockley, S. W. (2022). Circadian lipid and hepatic protein rhythms shift with a phase response curve different than melatonin. Nature Communications, 13(1), 681. https://doi.org/10.1038/s41467-022-28308-6
Kim, H., Chijiki, H., Fukazawa, M., Okubo, J., Ozaki, M., Nanba, T., Higashi, S., Shioyama, M., Takahashi, M., Nakaoka, T., & Shibata, S. (2021). Supplementation of protein at breakfast rather than at dinner and lunch is effective on skeletal muscle mass in older adults. Frontiers in Nutrition, 8, 797004. https://doi.org/10.3389/fnut.2021.797004
Ku, C. W., Loo, R. S. X., Tiong, M. M. Y., Eng, S. Y. C., Cheung, Y. B., Ong, L. S., Tan, K. H., Chong, M. F., Chan, J. K. Y., Yap, F., & Loy, S. L. (2022). Nocturnal Lifestyle Behaviours and Risk of Poor Sleep during Pregnancy. Nutrients, 14(11), 2348. https://doi.org/10.3390/nu14112348
Lonnie, M., Hooker, E., Brunstrom, J., Corfe, B., Green, M., Watson, A., Williams, E., Stevenson, E., Penson, S., & Johnstone, A. (2018). Protein for Life: Review of optimal protein intake, sustainable dietary sources and the effect on appetite in ageing adults. Nutrients, 10(3), 360. https://doi.org/10.3390/nu10030360
Loy, S. L., Chan, J. K. Y., Wee, P. H., Colega, M. T., Cheung, Y. B., Godfrey, K. M., Kwek, K., Saw, S. M., Chong, Y., Natarajan, P., Müller-Riemenschneider, F., Lek, N., Chong, M. F., & Yap, F. (2016). Maternal Circadian Eating Time and Frequency Are Associated with Blood Glucose Concentrations during Pregnancy. Journal of Nutrition, 147(1), 70–77. https://doi.org/10.3945/jn.116.239392
Loy, S. L., Cheung, Y. B., Cai, S., Colega, M. T., Godfrey, K. M., Chong, Y., Shek, L. P., Tan, K. H., Chong, M. F., Yap, F., & Chan, J. K. Y. (2019). Maternal night-time eating and sleep duration in relation to length of gestation and preterm birth. Clinical Nutrition, 39(6), 1935–1942. https://doi.org/10.1016/j.clnu.2019.08.018
McHill, A. W., Phillips, A. J., Czeisler, C. A., Keating, L., Yee, K., Barger, L. K., Garaulet, M., Scheer, F. A., & Klerman, E. B. (2017). Later circadian timing of food intake is associated with increased body fat. American Journal of Clinical Nutrition, 106(5), 1213–1219. https://doi.org/10.3945/ajcn.117.161588
Messika, A., Toledano, Y., Hadar, E., Shmuel, E., Tauman, R., Shamir, R., & Froy, O. (2022). Relationship among chrononutrition, sleep, and glycemic control in women with gestational diabetes mellitus: a randomized controlled trial. American Journal of Obstetrics & Gynecology MFM, 4(5), 100660. https://doi.org/10.1016/j.ajogmf.2022.100660
Middleton, P., Gomersall, J. C., Gould, J. F., Shepherd, E., Olsen, S. F., & Makrides, M. (2018). Omega-3 fatty acid addition during pregnancy. Cochrane Database of Systematic Reviews, 2018(11), CD003402. https://doi.org/10.1002/14651858.cd003402.pub3
Moon, S., Kang, J., Kim, S. H., Chung, H. S., Kim, Y. J., Yu, J. M., Cho, S. T., Oh, C., & Kim, T. (2020). Beneficial Effects of Time-Restricted Eating on Metabolic Diseases: A Systemic Review and Meta-Analysis. Nutrients, 12(5), 1267. https://doi.org/10.3390/nu12051267
Moran-Lev, H., Mimouni, F. B., Ovental, A., Mangel, L., Mandel, D., & Lubetzky, R. (2015). Circadian Macronutrients Variations over the First 7 Weeks of Human Milk Feeding of Preterm Infants. Breastfeeding Medicine, 10(7), 366–370. https://doi.org/10.1089/bfm.2015.0053
Morisaki, N., Nagata, C., Yasuo, S., Morokuma, S., Kato, K., Sanefuji, M., Shibata, E., Tsuji, M., Senju, A., Kawamoto, T., Ohga, S., Kusuhara, K., & Group, J. E. a. C. S. (2018). Optimal protein intake during pregnancy for reducing the risk of fetal growth restriction: the Japan Environment and Children’s Study. British Journal of Nutrition, 120(12), 1432–1440. https://doi.org/10.1017/s000711451800291x
Mousa, A., Naqash, A., & Lim, S. (2019). Macronutrient and Micronutrient Intake during Pregnancy: An Overview of Recent Evidence. Nutrients, 11(2), 443. https://doi.org/10.3390/nu11020443
Mulaw, G. F., Mare, K. U., & Anbesu, E. W. (2021). Nearly one-third of lactating mothers are suffering from undernutrition in pastoral community, Afar region, Ethiopia: Community-based cross-sectional study. PLoS ONE, 16(7), e0254075. https://doi.org/10.1371/journal.pone.0254075
Nulty, A. K., Bovbjerg, M. L., Herring, A. H., Siega-Riz, A. M., Thorp, J. M., & Evenson, K. R. (2022). Meal patterning and the onset of spontaneous labor. PubMed, 49(1), 123–131. https://doi.org/10.1111/birt.12583
Paulaviciene, I. J., Liubsys, A., Molyte, A., Eidukaite, A., & Usonis, V. (2020). Circadian changes in the composition of human milk macronutrients depending on pregnancy duration: a cross-sectional study. International Breastfeeding Journal, 15(1), 49. https://doi.org/10.1186/s13006-020-00291-y
Pot, G. K. (2021). Chrono‐nutrition – an emerging, modifiable risk factor for chronic disease? Nutrition Bulletin, 46(2), 114–119. https://doi.org/10.1111/nbu.12498
Qin, Y., Shi, W., Zhuang, J., Liu, Y., Tang, L., Bu, J., Sun, J., & Bei, F. (2019). Variations in melatonin levels in preterm and term human breast milk during the first month after delivery. Scientific Reports, 9(1), 17984. https://doi.org/10.1038/s41598-019-54530-2
Ross, M. G., Kavasery, M. P., Cervantes, M. K., Han, G., Horta, B., Coca, K. P., Costa, S. O., & Desai, M. (2024). High-Fat, High-Calorie Breast Milk in Women with Overweight or Obesity and Its Association with Maternal Serum Insulin Concentration and Triglycerides Levels. Children, 11(2), 141. https://doi.org/10.3390/children11020141
Ruan, H., Zhang, Y., Tang, Q., Zhao, X., Zhao, X., Xiang, Y., Geng, W., Feng, Y., & Cai, W. (2022). Sleep duration of lactating mothers and its relationship with feeding pattern, milk macronutrients and related serum factors: A combined longitudinal cohort and cross-sectional study. Frontiers in Nutrition, 9, 973291. https://doi.org/10.3389/fnut.2022.973291
Ruddick‐Collins, L. C., Morgan, P. J., & Johnstone, A. M. (2020). Mealtime: A circadian disruptor and determinant of energy balance? Journal of Neuroendocrinology, 32(7), e12886. https://doi.org/10.1111/jne.12886
St-Onge, M., Ard, J., Baskin, M. L., Chiuve, S. E., Johnson, H. M., Kris-Etherton, P., & Varady, K. (2017). Meal Timing and Frequency: Implications for Cardiovascular Disease Prevention: A scientific statement from the American Heart Association. Circulation, 135(9), e96–e121. https://doi.org/10.1161/cir.0000000000000476
Tahara, Y., & Shibata, S. (2014). Chrono-biology, chrono-pharmacology, and chrono-nutrition. Journal of Pharmacological Sciences, 124(3), 320–335. https://doi.org/10.1254/jphs.13r06cr
Telang, S. (2018). Lactoferrin: a critical player in neonatal host defense. Nutrients, 10(9), 1228. https://doi.org/10.3390/nu10091228
Tran, N. T., Nguyen, L. T., Berde, Y., Low, Y. L., Tey, S. L., & Huynh, D. T. T. (2019). Maternal nutritional adequacy and gestational weight gain and their associations with birth outcomes among Vietnamese women. BMC Pregnancy and Childbirth, 19(1), 468. https://doi.org/10.1186/s12884-019-2643-6
Vandenberghe, A., Lefranc, M., & Furlan, A. (2022). An overview of the circadian clock in the frame of chronotherapy: from bench to bedside. Pharmaceutics, 14(7), 1424. https://doi.org/10.3390/pharmaceutics14071424
Verd, S., Ginovart, G., Calvo, J., Ponce-Taylor, J., & Gaya, A. (2018). Variation in the Protein Composition of Human Milk during Extended Lactation: A Narrative Review. Nutrients, 10(8), 1124. https://doi.org/10.3390/nu10081124
Wang, J. B., Patterson, R. E., Ang, A., Emond, J. A., Shetty, N., & Arab, L. (2013). Timing of energy intake during the day is associated with the risk of obesity in adults. Journal of Human Nutrition and Dietetics, 27(s2), 255–262. https://doi.org/10.1111/jhn.12141
Wubetie, B. Y., & Mekonen, T. K. (2022). Undernutrition and associated factors among lactating mothers in rural Yilmana Densa District, Northwest Ethiopia: A community‐based cross‐sectional study. Food Science & Nutrition, 11(3), 1383–1393. https://doi.org/10.1002/fsn3.3176
Xiong, W., Cui, S., Dong, J., Su, Y., Han, Y., Qu, Z., Jin, S., Li, Z., Gao, L., Cui, T., & Zhang, X. (2023). Effect of circadian distribution of energy and macronutrients on gestational weight gain in Chinese pregnant women. Nutrients, 15(9), 2106. https://doi.org/10.3390/nu15092106
Yimer, B., & Wolde, A. (2022). Prevalence and predictors of malnutrition during adolescent pregnancy in southern Ethiopia: a community-based study. BMC Pregnancy and Childbirth, 22(1), 130. https://doi.org/10.1186/s12884-022-04460-1
Yong, G., Jing, Q., Yao, Q., Yang, K., & Ye, X. (2022). Changing meal sequence affects glucose excursions in gestational diabetes mellitus. Journal of Diabetes Research, 2022, 1–7. https://doi.org/10.1155/2022/7083106
Young, I. E., Poobalan, A., Steinbeck, K., O’Connor, H. T., & Parker, H. M. (2022). Distribution of energy intake across the day and weight loss: A systematic review and meta‐analysis. Obesity Reviews, 24(3), e13537. https://doi.org/10.1111/obr.13537
Żelaźniewicz, A., & Pawłowski, B. (2018). Maternal breast volume in pregnancy and lactation capacity. American Journal of Physical Anthropology, 168(1), 180–189. https://doi.org/10.1002/ajpa.23734
Zhu, Y., Zheng, Q., Pan, Y., Jiang, X., Li, J., Liu, R., & Huang, L. (2024). Association between prepregnancy body mass index or gestational weight gain and adverse pregnancy outcomes among Chinese women with gestational diabetes mellitus: a systematic review and meta-analysis. BMJ Open, 14(2), e075226. https://doi.org/10.1136/bmjopen-2023-075226