Feasibility and acceptability of a multi-domain intervention to increase Mediterranean diet adherence and physical activity in older UK adults at risk of dementia: protocol for the MedEx-UK randomised controlled trial

Oliver M Shannon, Vivian Lee, Rafe Bundy, Rachel Gillings, Amy Jennings, Blossom Stephan, Michael Hornberger, George Balanos, Stella Maria Paddick, Sarah Hanson, Wendy Hardeman, Rebecca Holmes, Nikki Garner, Sarah Aldred, Mario Siervo, John C Mathers, Anne Marie Minihane, Oliver M Shannon, Vivian Lee, Rafe Bundy, Rachel Gillings, Amy Jennings, Blossom Stephan, Michael Hornberger, George Balanos, Stella Maria Paddick, Sarah Hanson, Wendy Hardeman, Rebecca Holmes, Nikki Garner, Sarah Aldred, Mario Siervo, John C Mathers, Anne Marie Minihane

Abstract

Introduction: Dementia prevalence continues to increase, and effective interventions are needed to prevent, delay or slow its progression. Higher adherence to the Mediterranean diet (MedDiet) and increased physical activity (PA) have been proposed as strategies to facilitate healthy brain ageing and reduce dementia risk. However, to date, there have been no dementia prevention trials in the UK focussed on combined dietary and PA interventions. This study aims to: (1) assess feasibility and acceptability of a theory-underpinned digital and group-based intervention for dementia risk reduction in an 'at risk' UK cohort; (2) evaluate behaviour change responses to the intervention; and, (3) provide information on cognitive, neurological, vascular and physiological outcomes to inform the design of a follow-on, full-scale efficacy trial.

Methods: One hundred and eight participants aged 55 to 74 years with a QRISK2 score of ≥10% will be recruited to take part in this 24-week multi-site study. Participants will be randomised into three parallel arms: (1) Control; (2) MedDiet; and, (3) MedDiet+PA. The study will evaluate a personalised website, group session and food delivery intervention to increase MedDiet adherence and PA in older adults at risk of dementia. Diet and PA will be monitored prior to, during and following the intervention. Feasibility, acceptability and hypothesised mediators will be assessed in addition to measures of cognitive function, brain structure/perfusion (MRI), vascular function and metabolic markers (blood, urine and faecal) prior to, and following, the intervention.

Discussion: This trial will provide insights into the feasibility, acceptability and mechanism of effect of a multi-domain intervention focussed on the MedDiet alone and PA for dementia risk reduction in an 'at risk' UK cohort.

Ethics and dissemination: The study has received NHS REC and HRA approval (18/NI/0191). Findings will be disseminated via conference presentations, public lectures, and peer-reviewed publications.

Trial registration details: ClinicalTrials.gov NCT03673722.

Keywords: dementia; nutrition & dietetics; public health.

Conflict of interest statement

Competing interests: None declared.

© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Figures

Figure 1
Figure 1
Flow of participants through the MedEx-UK trial. MedDiet, Mediterranean diet; PA, physical activity,

References

    1. World Health Organisation . Dementia: key facts, 2018. Available:
    1. ONS . Deaths registered in England and Wales, 2019. Available:
    1. Prince M, Knapp M, Guerchet M. Dementia UK: update. UK: Alzheimer’s Society, 2014.
    1. Livingston G, Sommerlad A, Orgeta V, et al. . Dementia prevention, intervention, and care. The Lancet 2017;390:2673–734. 10.1016/S0140-6736(17)31363-6
    1. Stevenson EJ, Shannon OM, Minihane AM, et al. . NuBrain: UK Consortium for optimal nutrition for healthy brain ageing. Nutr Bull 2020;45:223–9. 10.1111/nbu.12429
    1. Cummings JL, Morstorf T, Zhong K. Alzheimer's disease drug-development pipeline: few candidates, frequent failures. Alzheimers Res Ther 2014;6:37. 10.1186/alzrt269
    1. Deckers K, van Boxtel MPJ, Schiepers OJG, et al. . Target risk factors for dementia prevention: a systematic review and Delphi consensus study on the evidence from observational studies. Int J Geriatr Psychiatry 2015;30:234–46. 10.1002/gps.4245
    1. Lewis F, Karlsberg Schaffer S, Sussex J. The trajectory of dementia in the UK – making a difference. office of health economics, 2014.
    1. Bach-Faig A, Berry EM, Lairon D, et al. . Mediterranean diet pyramid today. science and cultural updates. Public Health Nutr 2011;14:2274–84. 10.1017/S1368980011002515
    1. Trichopoulou A, Martínez-González MA, Tong TY, et al. . Definitions and potential health benefits of the Mediterranean diet: views from experts around the world. BMC Med 2014;12:112. 10.1186/1741-7015-12-112
    1. Petersson SD, Philippou E. Mediterranean diet, cognitive function, and dementia: a systematic review of the evidence. Adv Nutr 2016;7:889–904. 10.3945/an.116.012138
    1. Radd-Vagenas S, Duffy SL, Naismith SL, et al. . Effect of the Mediterranean diet on cognition and brain morphology and function: a systematic review of randomized controlled trials. Am J Clin Nutr 2018;107:389–404. 10.1093/ajcn/nqx070
    1. Martínez-Lapiscina EH, Clavero P, Toledo E, et al. . Mediterranean diet improves cognition: the PREDIMED-NAVARRA randomised trial. J Neurol Neurosurg Psychiatry 2013;84:1318–25. 10.1136/jnnp-2012-304792
    1. Martínez-Lapiscina EH, Galbete C, Corella D, et al. . Genotype patterns at CLU, CR1, PICALM and APOE, cognition and Mediterranean diet: the PREDIMED-NAVARRA trial. Genes Nutr 2014;9:393. 10.1007/s12263-014-0393-7
    1. Valls-Pedret C, Sala-Vila A, Serra-Mir M, et al. . Mediterranean diet and age-related cognitive decline: a randomized clinical trial. JAMA Intern Med 2015;175:1094–103. 10.1001/jamainternmed.2015.1668
    1. Shannon OM, Stephan BCM, Granic A, et al. . Mediterranean diet adherence and cognitive function in older UK adults: the European prospective investigation into cancer and Nutrition-Norfolk (EPIC-Norfolk) study. Am J Clin Nutr 2019;110:938–48. 10.1093/ajcn/nqz114
    1. Shannon OM, Stephan BCM, Minihane A-M, et al. . Nitric oxide boosting effects of the Mediterranean diet: a potential mechanism of action. J Gerontol A Biol Sci Med Sci 2018;73:902–4. 10.1093/gerona/gly087
    1. Shannon OM, Mendes I, Köchl C, et al. . Mediterranean diet increases endothelial function in adults: a systematic review and meta-analysis of randomized controlled trials. J Nutr 2020;150:1151–9. 10.1093/jn/nxaa002
    1. Cowell OR, Mistry N, Deighton K, et al. . Effects of a Mediterranean diet on blood pressure: a systematic review and meta-analysis of randomized controlled trials and observational studies. J Hypertens 2020. 10.1097/HJH.0000000000002667. [Epub ahead of print: 14 Oct 2020].
    1. De Filippis F, Pellegrini N, Vannini L, et al. . High-Level adherence to a Mediterranean diet beneficially impacts the gut microbiota and associated metabolome. Gut 2016;65:1812–21. 10.1136/gutjnl-2015-309957
    1. Berti V, Walters M, Sterling J, et al. . Mediterranean diet and 3-year Alzheimer brain biomarker changes in middle-aged adults. Neurology 2018;90:e1789–98. 10.1212/WNL.0000000000005527
    1. Vassilaki M, Aakre JA, Syrjanen JA, et al. . Mediterranean diet, its components, and amyloid imaging biomarkers. J Alzheimers Dis 2018;64:281–90. 10.3233/JAD-171121
    1. Xu W, Wang HF, Wan Y, et al. . Leisure time physical activity and dementia risk: a dose-response meta-analysis of prospective studies. BMJ Open 2017;7:e014706. 10.1136/bmjopen-2016-014706
    1. Sanders LMJ, Hortobágyi T, la Bastide-van Gemert S, et al. . Dose-Response relationship between exercise and cognitive function in older adults with and without cognitive impairment: a systematic review and meta-analysis. PLoS One 2019;14:e0210036. 10.1371/journal.pone.0210036
    1. Sabia S, Dugravot A, Dartigues J-F, et al. . Physical activity, cognitive decline, and risk of dementia: 28 year follow-up of Whitehall II cohort study. BMJ 2017;357:j2709. 10.1136/bmj.j2709
    1. Lamb SE, Sheehan B, Atherton N, et al. . Dementia and physical activity (DAPA) trial of moderate to high intensity exercise training for people with dementia: randomised controlled trial. BMJ 2018;361:k1675. 10.1136/bmj.k1675
    1. Angevaren M, Aufdemkampe G, Verhaar HJJ. Physical activity and enhanced fitness to improve cognitive function in older people without known cognitive impairment. Cochrane Database Syst Rev 2008:CD005381.
    1. Adlard PA, Perreau VM, Pop V, et al. . Voluntary exercise decreases amyloid load in a transgenic model of Alzheimer's disease. J Neurosci 2005;25:4217–21. 10.1523/JNEUROSCI.0496-05.2005
    1. Cotman CW, Berchtold NC, Christie L-A. Exercise builds brain health: key roles of growth factor cascades and inflammation. Trends Neurosci 2007;30:464–72. 10.1016/j.tins.2007.06.011
    1. van Praag H, Shubert T, Zhao C, et al. . Exercise enhances learning and hippocampal neurogenesis in aged mice. J Neurosci 2005;25:8680–5. 10.1523/JNEUROSCI.1731-05.2005
    1. Isaacs KR, Anderson BJ, Alcantara AA, et al. . Exercise and the brain: angiogenesis in the adult rat cerebellum after vigorous physical activity and motor skill learning. J Cereb Blood Flow Metab 1992;12:110–9. 10.1038/jcbfm.1992.14
    1. Radak Z, Hart N, Sarga L, et al. . Exercise plays a preventive role against Alzheimer's disease. J Alzheimers Dis 2010;20:777–83. 10.3233/JAD-2010-091531
    1. Ngandu T, Lehtisalo J, Solomon A, et al. . A 2 year multidomain intervention of diet, exercise, cognitive training, and vascular risk monitoring versus control to prevent cognitive decline in at-risk elderly people (finger): a randomised controlled trial. Lancet 2015;385:2255–63. 10.1016/S0140-6736(15)60461-5
    1. Moll van Charante EP, Richard E, Eurelings LS, et al. . Effectiveness of a 6-year multidomain vascular care intervention to prevent dementia (preDIVA): a cluster-randomised controlled trial. Lancet 2016;388:797–805. 10.1016/S0140-6736(16)30950-3
    1. Andrieu S, Guyonnet S, Coley N, et al. . Effect of long-term omega 3 polyunsaturated fatty acid supplementation with or without multidomain intervention on cognitive function in elderly adults with memory complaints (MAPT): a randomised, placebo-controlled trial. Lancet Neurol 2017;16:377–89. 10.1016/S1474-4422(17)30040-6
    1. Hardman RJ, Kennedy G, Macpherson H, et al. . A randomised controlled trial investigating the effects of Mediterranean diet and aerobic exercise on cognition in cognitively healthy older people living independently within aged care facilities: the Lifestyle Intervention in Independent Living Aged Care (LIILAC) study protocol [ACTRN12614001133628]. Nutr J 2015;14:53. 10.1186/s12937-015-0042-z
    1. Heffernan M, Andrews G, Fiatarone Singh MA, et al. . Maintain your brain: protocol of a 3-year randomized controlled trial of a personalized multi-modal digital health intervention to prevent cognitive decline among community dwelling 55 to 77 year olds. J Alzheimers Dis 2019;70:S221–37. 10.3233/JAD-180572
    1. Ordovas JM, Ferguson LR, Tai ES, et al. . Personalised nutrition and health. BMJ 2018;361:bmj.k2173. 10.1136/bmj.k2173
    1. Celis-Morales C, Lara J, Mathers JC. Personalising nutritional guidance for more effective behaviour change. Proc Nutr Soc 2015;74:130–8. 10.1017/S0029665114001633
    1. Celis-Morales C, Livingstone KM, Marsaux CF. Effect of personalized nutrition on health-related behaviour change: evidence from the Food4Me European randomized controlled trial. Int J Epidemiol 2017;46:578–88.
    1. Jennings A, Berendsen AM, de Groot LCPGM, et al. . Mediterranean-Style diet improves systolic blood pressure and arterial stiffness in older adults. Hypertension 2019;73:578–86. 10.1161/HYPERTENSIONAHA.118.12259
    1. Justin BN, Turek M, Hakim AM. Heart disease as a risk factor for dementia. Clin Epidemiol 2013;5:135–45. 10.2147/CLEP.S30621
    1. de Bruijn RFAG, Ikram MA. Cardiovascular risk factors and future risk of Alzheimer's disease. BMC Med 2014;12:130. 10.1186/s12916-014-0130-5
    1. Song R, Xu H, Dintica CS, et al. . Associations between cardiovascular risk, structural brain changes, and cognitive decline. J Am Coll Cardiol 2020;75:2525–34. 10.1016/j.jacc.2020.03.053
    1. Chan A-W, Tetzlaff JM, Gøtzsche PC, et al. . Spirit 2013 explanation and elaboration: guidance for protocols of clinical trials. BMJ 2013;346:e7586. 10.1136/bmj.e7586
    1. Knopman D, Boland LL, Mosley T, et al. . Cardiovascular risk factors and cognitive decline in middle-aged adults. Neurology 2001;56:42–8. 10.1212/WNL.56.1.42
    1. Raz N, Rodrigue KM, Acker JD. Hypertension and the brain: vulnerability of the prefrontal regions and executive functions. Behav Neurosci 2003;117:1169–80. 10.1037/0735-7044.117.6.1169
    1. Debette S, Seshadri S, Beiser A, et al. . Midlife vascular risk factor exposure accelerates structural brain aging and cognitive decline. Neurology 2011;77:461–8. 10.1212/WNL.0b013e318227b227
    1. Sabia S, Fayosse A, Dumurgier J, et al. . Association of ideal cardiovascular health at age 50 with incidence of dementia: 25 year follow-up of Whitehall II cohort study. BMJ 2019;366:l4414. 10.1136/bmj.l4414
    1. Carson N, Leach L, Murphy KJ. A re-examination of Montreal cognitive assessment (MoCA) cutoff scores. Int J Geriatr Psychiatry 2018;33:379–88. 10.1002/gps.4756
    1. Martínez-González Miguel Ángel, Corella D, Salas-Salvadó J, et al. . Cohort profile: design and methods of the PREDIMED study. Int J Epidemiol 2012;41:377–85. 10.1093/ije/dyq250
    1. Rzewnicki R, Vanden Auweele Y, De Bourdeaudhuij I. Addressing overreporting on the International physical activity questionnaire (IPAQ) telephone survey with a population sample. Public Health Nutr 2003;6:299–305. 10.1079/PHN2002427
    1. Nasreddine ZS, Phillips NA, Bédirian V, Bédirian Valérie, et al. . The Montreal cognitive assessment, MoCA: a brief screening tool for mild cognitive impairment. J Am Geriatr Soc 2005;53:695–9. 10.1111/j.1532-5415.2005.53221.x
    1. Rattanabannakit C, Risacher SL, Gao S, et al. . The cognitive change index as a measure of self and informant perception of cognitive decline: relation to neuropsychological tests. J Alzheimers Dis 2016;51:1145–55. 10.3233/JAD-150729
    1. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med 2001;16:606–13. 10.1046/j.1525-1497.2001.016009606.x
    1. Spitzer RL, Kroenke K, Williams JBW, et al. . A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med 2006;166:1092–7. 10.1001/archinte.166.10.1092
    1. Galvin JE, Roe CM, Powlishta KK, et al. . The AD8: a brief informant interview to detect dementia. Neurology 2005;65:559–64. 10.1212/01.wnl.0000172958.95282.2a
    1. Lawton MP, Brody EM. Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist 1969;9:179–86. 10.1093/geront/9.3_Part_1.179
    1. Trichopoulou A, Costacou T, Bamia C, et al. . Adherence to a Mediterranean diet and survival in a Greek population. N Engl J Med 2003;348:2599–608. 10.1056/NEJMoa025039
    1. Sofi F, Macchi C, Abbate R, et al. . Mediterranean diet and health status: an updated meta-analysis and a proposal for a literature-based adherence score. Public Health Nutr 2014;17:2769–82. 10.1017/S1368980013003169
    1. WHO . Global recommendations on physical activity for health, 2011. Available:
    1. Lara J, O'Brien N, Godfrey A, et al. . Pilot randomised controlled trial of a web-based intervention to promote healthy eating, physical activity and meaningful social connections compared with usual care control in people of retirement age recruited from workplaces. PLoS One 2016;11:e0159703. 10.1371/journal.pone.0159703
    1. Moore SE, McEvoy CT, Prior L, et al. . Barriers to adopting a Mediterranean diet in northern European adults at high risk of developing cardiovascular disease. J Hum Nutr Diet 2018;31:451–62. 10.1111/jhn.12523
    1. Tuomilehto J, Lindström J, Eriksson JG, et al. . Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. N Engl J Med 2001;344:1343–50. 10.1056/NEJM200105033441801
    1. Knowler WC, Barrett-Connor E, Fowler SE, et al. . Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002;346:393–403. 10.1056/NEJMoa012512
    1. Borek AJ, Abraham C. How do small groups promote behaviour change? an integrative conceptual review of explanatory mechanisms. Appl Psychol Health Well Being 2018;10:30–61. 10.1111/aphw.12120
    1. Michie S, van Stralen MM, West R. The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implement Sci 2011;6:42. 10.1186/1748-5908-6-42
    1. Michie S, Wood CE, Johnston M, et al. . Behaviour change techniques: the development and evaluation of a taxonomic method for reporting and describing behaviour change interventions (a suite of five studies involving consensus methods, randomised controlled trials and analysis of qualitative data). Health Technol Assess 2015;19:1–188. 10.3310/hta19990
    1. Bellg AJ, Borrelli B, Resnick B, et al. . Enhancing treatment fidelity in health behavior change studies: best practices and recommendations from the NIH behavior change Consortium. Health Psychology 2004;23:443–51. 10.1037/0278-6133.23.5.443
    1. Tong TYN, Imamura F, Monsivais P, et al. . Dietary cost associated with adherence to the Mediterranean diet, and its variation by socio-economic factors in the UK Fenland study. Br J Nutr 2018;119:685–94. 10.1017/S0007114517003993
    1. CVD risk assessment and management . Management of people with an estimated risk of 10% or more. UK: National Institute for Health and Care Excellence, 2019.
    1. Simpson E, Bradley J, Poliakov I, et al. . Iterative development of an online dietary recall tool: INTAKE24. Nutrients 2017;9:188. 10.3390/nu9020118
    1. Foster E, Lee C, Imamura F, et al. . Validity and reliability of an online self-report 24-h dietary recall method (Intake24): a doubly labelled water study and repeated-measures analysis. J Nutr Sci 2019;8:e29. 10.1017/jns.2019.20
    1. Bradley J, Simpson E, Poliakov I, et al. . Comparison of INTAKE24 (an online 24-h dietary recall tool) with Interviewer-Led 24-h recall in 11–24 year-old. Nutrients 2016;8:358. 10.3390/nu8060358
    1. Nelson EC, Verhagen T, Noordzij ML. Health empowerment through activity trackers: an empirical smart wristband study. Comput Human Behav 2016;62:364–74. 10.1016/j.chb.2016.03.065
    1. Harrison J, Minassian SL, Jenkins L, et al. . A neuropsychological test battery for use in Alzheimer disease clinical trials. Arch Neurol 2007;64:1323–9. 10.1001/archneur.64.9.1323
    1. Tu S, Wong S, Hodges JR, et al. . Lost in spatial translation - A novel tool to objectively assess spatial disorientation in Alzheimer's disease and frontotemporal dementia. Cortex 2015;67:83–94. 10.1016/j.cortex.2015.03.016
    1. Tu S, Spiers HJ, Hodges JR, et al. . Egocentric versus allocentric spatial memory in behavioral variant frontotemporal dementia and Alzheimer's disease. J Alzheimers Dis 2017;59:883–92. 10.3233/JAD-160592
    1. Coughlan G, Flanagan E, Jeffs S, et al. . Diagnostic relevance of spatial orientation for vascular dementia: a case study. Dement Neuropsychol 2018;12:85–91. 10.1590/1980-57642018dn12-010013
    1. Ritchie K, Carrière I, Howett D, et al. . Allocentric and egocentric spatial processing in middle-aged adults at high risk of late-onset Alzheimer's disease: the prevent dementia study. J Alzheimers Dis 2018;65:885–96. 10.3233/JAD-180432
    1. Coutrot A, Schmidt S, Coutrot L, et al. . Virtual navigation tested on a mobile app is predictive of real-world wayfinding navigation performance. PLoS One 2019;14:e0213272. 10.1371/journal.pone.0213272
    1. Coughlan G, Laczó J, Hort J, et al. . Spatial navigation deficits - overlooked cognitive marker for preclinical Alzheimer disease? Nat Rev Neurol 2018;14:496–506. 10.1038/s41582-018-0031-x
    1. Coughlan G, Coutrot A, Khondoker M, et al. . Toward personalized cognitive diagnostics of at-genetic-risk Alzheimer's disease. Proc Natl Acad Sci U S A 2019;116:9285–92. 10.1073/pnas.1901600116
    1. Stergiou G, Palatini P, Asmar R, et al. . Blood pressure measurement and hypertension diagnosis in the 2017 us guidelines: first things first. Hypertension 2018;71:963–5. 10.1161/HYPERTENSIONAHA.118.10853
    1. Raitakari OT, Celermajer DS. Flow-Mediated dilatation. Br J Clin Pharmacol 2000;50:397–404. 10.1046/j.1365-2125.2000.00277.x
    1. Moore GF, Audrey S, Barker M, et al. . Process evaluation of complex interventions: medical Research Council guidance. BMJ 2015;350:h1258. 10.1136/bmj.h1258
    1. Creswell JW. A Concise introduction to mixed methods research. London: SAGE Publications, 2014.
    1. Sekhon M, Cartwright M, Francis JJ. Acceptability of healthcare interventions: an overview of reviews and development of a theoretical framework. BMC Health Serv Res 2017;17:88. 10.1186/s12913-017-2031-8
    1. Ajzen I. The theory of planned behavior. Organ Behav Hum Decis Process 1991;50:179–211. 10.1016/0749-5978(91)90020-T
    1. Cress ME, Buchner DM, Prohaska T, et al. . Physical activity programs and behavior counseling in older adult populations. Medicine & Science in Sports & Exercise 2004;36:1997–2003. 10.1249/01.MSS.0000145451.08166.97
    1. Rivera-Torres S, Fahey TD, Rivera MA. Adherence to exercise programs in older adults: informative report. Gerontol Geriatr Med 2019;5:233372141882360. 10.1177/2333721418823604
    1. Brunt A, Albines D, Hopkins-Rosseel D. The effectiveness of exercise on cognitive performance in individuals with known vascular disease: a systematic review. J Clin Med 2019;8:294. 10.3390/jcm8030294
    1. Schulze MB, Martínez-González MA, Fung TT, et al. . Food based dietary patterns and chronic disease prevention. BMJ 2018;361:k2396. 10.1136/bmj.k2396
    1. Staudacher HM, Irving PM, Lomer MCE, et al. . The challenges of control groups, placebos and blinding in clinical trials of dietary interventions. Proc Nutr Soc 2017;76:203–12. 10.1017/S0029665117000350
    1. Irimata KE, Dugger BN, Wilson JR. Impact of the presence of select cardiovascular risk factors on cognitive changes among dementia subtypes. Curr Alzheimer Res 2018;15:1032–44. 10.2174/1567205015666180702105119
    1. Lara J, McCrum L-A, Mathers JC. Association of Mediterranean diet and other health behaviours with barriers to healthy eating and perceived health among British adults of retirement age. Maturitas 2014;79:292–8. 10.1016/j.maturitas.2014.07.003
    1. Robinson E, Boyland E, Chisholm A, et al. . Obesity, eating behavior and physical activity during COVID-19 lockdown: a study of UK adults. Appetite 2021;156:104853. 10.1016/j.appet.2020.104853

Source: PubMed

Patrocinadores y Colaboradores

Condiciones médicas

Intervenciones de drogas

3
Suscribir