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Association between composite dietary antioxidant index and erectile dysfunction: a cross-sectional study from NHANES

樱花视频 volume听24, Article听number:听3362 (2024) Cite this article

Abstract

Background

Individual antioxidants may not fully capture the comprehensive antioxidant intake from an individual鈥檚 diet. This study utilizes the Complex Dietary Antioxidant Index (CDAI) to evaluate the combined effects of various dietary antioxidants in the diet. The goal is to investigate the relationship between CDAI and the incidence of erectile dysfunction (ED), offering insights for dietary guidelines and intervention strategies aimed at mitigating the burden of ED.

Methods

This cross-sectional study utilized data from the National Health and Nutrition Examination Survey (NHANES) database in the years 2001鈥2004. We employed a weighted multivariate logistic regression model to validate the relationship between CDAI and ED. Subgroup analyses were conducted to explore the correlation between CDAI and ED across different subgroups. Additionally, we used propensity score matching (PSM) to adjust for several key confounding variables, enhancing the robustness of the results.

Results

In the fully adjusted multivariate logistic regression model for confounding variables, CDAI is negatively correlated with the risk of ED (OR鈥=鈥0.95, 95% CI: 0.92鈥0.99, P鈥=鈥0.005). When CDAI is transformed into a categorical variable based on quartiles, Q3 (OR鈥=鈥0.73, 95% CI: 0.53鈥0.99, P鈥=鈥0.040) and Q4 (OR鈥=鈥0.70, 95% CI: 0.51鈥0.96, P鈥=鈥0.026) show a negative correlation with the risk of ED. Subgroup analysis reveals no significant interaction. After adjusting for major confounding variables through PSM, the association between CDAI and reduced risk of ED remains significant.

Conclusion

In our study cohort, there is an association between CDAI and a reduced risk of ED, and further research is needed to validate and refine this conclusion.

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Introduction

In accordance with the guidelines outlined by the American Urological Association (AUA), erectile dysfunction (ED) is defined as the incapacity to attain or sustain an erection of adequate magnitude to fulfill sexual intercourse, attributed to impairment during the sexual arousal phase [1]. The prevalence of ED is commonly higher among elderly males. Nevertheless, research demonstrates that 25% of men under the age of 40 opt for medical intervention due to ED, and 22.1% exhibit lower scores on the Sexual Health Inventory for Men (SHIM) [2]. This indicates that ED may represent a widespread health issue among the male population. ED is regarded as a harbinger of various diseases, as studies unveil its intimate connection with numerous conditions, including cardiovascular diseases [3], chronic liver disease [4], and cirrhosis [5]. This phenomenon may be ascribed to the shared risk factors, such as smoking, alcohol consumption, obesity, and elevated cholesterol levels [6], with the occurrence of ED happening at an earlier stage. Therefore, as a multifaceted condition influenced by various physiological and lifestyle factors, comprehending the modifiable determinants of ED is crucial for public health.

Oxidative stress is a recognized factor contributing to vascular dysfunction and the pathophysiology of ED, Research indicates that oxidative stress increases the production of reactive oxygen species (ROS), leading to endothelial dysfunction, which reduces the availability of nitric oxide and disrupts vascular homeostasis. This results in decreased blood flow to the tissues and an inability to achieve or maintain an erection, ultimately leading to ED [7]. Dietary antioxidants have been confirmed to play a role in various diseases [8, 9]. The association between specific antioxidants and ED has been subject to research, including the examination of vitamin D [10], zinc [11], and lycopene found in tomatoes [12]. Nevertheless, these singular antioxidants may fall short in capturing the comprehensive antioxidant intake from an individual鈥檚 diet, given issues related to differences in bioavailability and absorption. Furthermore, an elevated intake of individual antioxidants may potentially transition into pro-oxidants [9, 13], which could have unfavorable implications for health. The Complex Dietary Antioxidant Index (CDAI) serves as a method for gauging the antioxidant capacity of one鈥檚 diet, Unlike indices such as Total Antioxidant Capacity (TAC), the CDAI is derived from food frequency questionnaires or dietary recalls, accounting for both the types and quantities of antioxidant-rich foods consumed. CDAI emphasizes the relationship between dietary habits and health outcomes, whereas TAC, despite its informative nature, may not fully capture the dietary context and can be influenced by factors beyond food intake, such as individual metabolism and environmental influences [14]. Previous studies have found that higher CDAI scores are associated with a reduced risk of kidney stone formation and that there is a negative correlation between CDAI and related cardiovascular diseases [15, 16]. This index delivers a comprehensive score that encapsulates a spectrum of dietary antioxidants, encompassing vitamin A, C, E, zinc, selenium, and carotenoids [17, 18]. The use of the CDAI offers a more holistic viewpoint in assessing the collective impact of diverse dietary antioxidants within one鈥檚 diet. Gaining insights into the relationship between the overall antioxidant effects in the diet and erectile function is of paramount importance for devising efficacious intervention strategies and nutritional guidance.

The principal objective of this research is to explore the correlation between the CDAI and the incidence of ED. The intention is to offer insights for dietary guidelines and intervention strategies aimed at mitigating the burden of ED.

Materials and methods

Data source and study population

This cross-sectional study utilized data from the National Health and Nutrition Examination Survey (NHANES) database. The survey is part of a program conducted by the National Center for Health Statistics (NCHS), which is affiliated with the Centers for Disease Control and Prevention (CDC) in the United States. NHANES employs a two-year survey cycle with a complex, multi-stage probability sampling design to select participants from various demographic and socioeconomic groups. The collected data include demographic information, dietary records, physical examinations, laboratory data, and various survey questionnaires. The incorporation of this comprehensive dataset aims to evaluate the health and nutritional status of adults or children.

The participant selection process for the study is illustrated in Fig.听1. The study population consisted of 10,301 adult males who participated in NHANES during the 2001鈥2004 period. Participants with missing ED data or incomplete dietary information were excluded from the analysis. The final study cohort comprised 3,807 participants, including 1,109 assessed with ED and 2,698 without ED. To better control for confounding factors and derive more robust conclusions, a 1:1 propensity score matching (PSM) was subsequently conducted, and a secondary analysis was performed on the matched 1,808 participants.

Fig. 1
figure 1

The flowchart for participant screening in this study

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Assessment of CDAI

The CDAI is a comprehensive score encompassing various dietary antioxidants, including vitamin A, C, E, carotenoids, selenium, and zinc [17, 19]. The average daily intake data for each dietary antioxidant are derived from the dietary interview records of the first and second days in the NHANES database. CDAI is calculated using the measurement method mentioned by Wright et al. [20], which involves subtracting mean intake of the study population from each individual鈥檚 intake of each dietary antioxidant the and then dividing the result by the population鈥檚 standard deviation. The sum of these values provides the CDAI, as expressed in the following formula:

$$CDAI={\sum}_{i=1}^{n=6}\frac{Individual\:Intake-Mean}{SD}$$

Assessment of ED

We conducted an assessment of ED using NHANES surveys for male participants aged 20 and above. These participants were asked about their capability to achieve and maintain an erection sufficient for satisfactory intercourse. Drawing on recent research [21, 22], responses of 鈥渁lways or almost always able to鈥 or 鈥渦sually able to鈥 were defined as non-ED participants, whereas responses of 鈥渟ometimes able to鈥 or 鈥渘ever able to鈥 were categorized as ED participants.

Covariates

In our study, we included various covariates to address potential confounding factors. These encompass age, race, educational level, marital status, economic status, smoking, alcohol consumption, body mass index (BMI), physical activity, hypertension, diabetes, hyperlipidemia, history of cardiovascular disease, history of prostate disease, and overall health status. Based on the smoking and alcohol consumption questionnaires administered to the participants, individuals who have smoked at least 100 cigarettes in their lifetime are defined as smokers, otherwise as non-smokers. Smoking status is further categorized into former smokers and current smokers based on current smoking habits. Participants who have consumed at least 12 alcoholic beverages in their lifetime are defined as drinkers, and daily alcohol consumption is classified as moderate (up to two drinks) or heavy (more than two drinks). Low physical activity is defined as frequent sitting or little movement, moderate physical activity involves regular walking but infrequent heavy lifting, and high physical activity encompasses frequent climbing of stairs or hills and heavy lifting. Participants鈥 blood pressure, measured four times, is averaged, and hypertension is defined as systolic blood pressure鈥夆墺鈥140mmHg, diastolic blood pressure鈥夆墺鈥90mmHg, or the use of antihypertensive medication. Diabetes is defined as fasting blood glucose鈥夆墺鈥126听mg/dL or glycated hemoglobin鈥夆墺鈥6.5%. High cholesterol is determined by a serum total cholesterol level鈥夆墺鈥240听mg/dL or the use of cholesterol-lowering medication. Participants with a history of congestive heart failure, coronary artery disease, or angina pectoris are classified as having a history of cardiovascular disease. A history of prostate disease is defined as a previous diagnosis of prostate-related conditions. Health status is self-assessed by participants and categorized as 鈥淕ood, very good, excellent鈥 or 鈥淔air or poor鈥. Considering the potential for multicollinearity among the covariates, we employed Stata software to assess multicollinearity using the Variance Inflation Factor (VIF). The analysis revealed a mean VIF value of 1.17 for all covariates, with each VIF being less than 2, indicating the absence of multicollinearity among the covariates.

Statistical analysis

This study utilized Stata 17 and SPSS as statistical software. Descriptive statistics were utilized to summarize the demographic characteristics of the study population. Categorical variables were represented using weighted proportions and 95% confidence intervals (95%CI), while continuous variables were presented using weighted means and standard errors (SE). Given the data spanned two survey cycles from 2001 to 2004, MEC weights 脳 0.5 were applied as the final weights. SPSS was used to conduct Pearson chi-square tests for categorical variables and t-tests for continuous variables to assess group differences. Binary logistic weighted regression analysis was employed to investigate the relationship between CDAI and ED. CDAI, treated as a continuous variable, was categorized based on quartile ranges for analysis. Unadjusted univariate logistic weighted regression analysis was designated as Model 1. Subsequent multivariate logistic weighted regression analyses included adjustments in Model 2 for age and race and in Model 3 for additional factors, namely education level, marital status, economic status, smoking, alcohol consumption, BMI, physical activity, hypertension, diabetes, hyperlipidemia, history of cardiovascular disease, history of prostate disease, and overall health status. Trend tests were conducted for each model to evaluate the linear trend of the impact of each CDAI interval on the outcome [23].

After conducting multivariate logistic weighted regression analyses for the three models, subgroup analyses were performed for age, race, education level, hypertension, diabetes, hyperlipidemia, and history of cardiovascular disease in Model 3, excluding the grouping variables. The objective of these analyses was to investigate the correlation between CDAI and ED across different subgroups. Interaction tests for CDAI with each subgroup were conducted using SPSS to offer more precise risk estimates for the subgroups in the population [24].

In order to minimize selection bias and alleviate the influence of confounding factors, PSM was employed. PSM is particularly valuable when dealing with datasets containing numerous potential confounding variables [25], Specifically, PSM reduces selection bias by balancing covariates between the groups. Propensity scores were calculated using a logistic regression model that included relevant covariates, and we assessed the balance of covariates in the matched groups to ensure similarity in baseline characteristics. Further analyses were conducted using the matched data. This approach helps ensure that observed differences in outcomes are less likely to be due to confounding variables [26]. We employed PSM to adjust for several key confounding variables, such as age, BMI, hypertension, diabetes, hyperlipidemia, and history of cardiovascular disease. The matching tolerance was set at 0.03. Subsequently, descriptive statistics were performed on the matched population, followed by secondary logistic weighted regression analyses using multiple models.

Results

Characteristics of study participants

The demographic characteristics of study participants, stratified by the definition of ED, are presented in Table听1. All results for demographic characteristics are weighted, and significant inter-group differences were observed (P鈥<鈥0.05). A total of 3807 participants were ultimately included in the study, with 1109 classified as ED patients and 2698 as non-ED individuals. The average age of study participants was 45.24 (SE鈥=鈥0.27), with the non-ED group having an average age of 41.32 (SE鈥=鈥0.27), and the ED group having a significantly higher average age of 61.70 (SE鈥=鈥0.56). After categorizing age, the ED group had a significantly higher proportion of participants aged 40 and above compared to the non-ED group (90.75% vs. 53.30%, P鈥&濒迟;鈥0.001). In terms of socio-economic characteristics, the ED group had a higher proportion of individuals with lower educational levels (28.38% vs. 13.52%, P鈥<鈥0.001), a higher proportion of individuals who were married or cohabiting with a partner (88.21% vs. 71.1%, P鈥<鈥0.001), and a lower proportion of individuals with higher economic status (32.51% vs. 39.85%, P鈥<鈥0.001) compared to the non-ED group. In terms of behavioral habits, the ED group had a higher proportion of current or former smokers (69.24% vs. 53.89%, P鈥<鈥0.001), fewer alcohol consumers (73.24% vs. 83.4%, P鈥<鈥0.001), and a higher proportion of individuals with a BMI of 25 or higher (73.03% vs. 68.71%, P鈥<鈥0.001), as well as more individuals with low physical activity (30.71% vs. 20.27%, P鈥&濒迟;鈥0.001). In terms of health, the ED group had a higher prevalence of hypertension, diabetes, cardiovascular diseases, and a history of prostate diseases, with all differences being statistically significant (P鈥&濒迟;鈥0.001).

Table 1 General characteristics of participants (N鈥=鈥3807) stratified by ED or no ED in the NHANES 2001鈥2004.a
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Association between the CDAI and ED

The weighted multivariate logistic regression models for the relationship between CDAI and ED are presented in Table听2. When CDAI is treated as a continuous variable, it exhibits a negative correlation with ED in all three models, including Model 1 (OR鈥=鈥0.92, 95% CI: 0.89鈥0.95, P鈥<鈥0.001), Model 2 adjusting for age and race (OR鈥=鈥0.93, 95% CI: 0.90鈥0.96, P鈥<鈥0.001), and Model 3 adjusting for all covariates (OR鈥=鈥0.95, 95% CI: 0.91鈥0.98, P鈥=鈥0.002). When CDAI is converted into a categorical variable based on quartile ranges, in Model 1, Q3 (OR鈥=鈥0.64, 95% CI: 0.50鈥0.82, P鈥<鈥0.001) and Q4 (OR鈥=鈥0.52, 95% CI: 0.40鈥0.68, P鈥<鈥0.001) show a negative correlation with ED. In Model 2, adjusting for age and race, CDAI Q3 (OR鈥=鈥0.64, 95% CI: 0.49鈥0.83, P鈥=鈥0.001) and Q4 (OR鈥=鈥0.55, 95% CI: 0.42鈥0.72, P鈥<鈥0.001) exhibit a negative correlation with ED. In Model 3, adjusting for all covariates, Q3 (OR鈥=鈥0.72, 95% CI: 0.53鈥0.97, P鈥=鈥0.033) and Q4 (OR鈥=鈥0.66, 95% CI: 0.48鈥0.90, P鈥=鈥0.010) are also negatively correlated with ED. In all three models, the protective effect against ED becomes more pronounced with increasing CDAI quartile ranges, and this trend is statistically significant (P鈥&濒迟;鈥0.001).

Table 2 The weighted multivariable logistic regression analysis of the relationship between the composite dietary antioxidant index and erectile dysfunction
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Subgroup analysis

Subgroup analysis results are shown in Fig.听2, indicating that there is no interaction between CDAI and ED across various subgroups. In the population aged 40 and above, CDAI is negatively correlated with ED (OR鈥=鈥0.96, 95% CI: 0.92鈥0.99, P鈥=鈥0.018). Non-Hispanic Black and Mexican American populations show a negative correlation between CDAI and ED (OR鈥=鈥0.89, 95% CI: 0.82鈥0.96, P鈥=鈥0.003; OR鈥=鈥0.90, 95% CI: 0.82鈥0.98, P鈥=鈥0.011). In populations with higher education levels, CDAI is negatively correlated with ED (OR鈥=鈥0.94, 95% CI: 0.89鈥0.99, P鈥=鈥0.015). Among those without hypertension (OR鈥=鈥0.92, 95% CI: 0.87鈥0.97, P鈥=鈥0.001), hyperlipidemia (OR鈥=鈥0.96, 95% CI: 0.93-1.00, P鈥=鈥0.03), and cardiovascular disease (OR鈥=鈥0.93, 95% CI: 0.90鈥0.97, P鈥=鈥0.001), CDAI is negatively correlated with ED. In both non-diabetic (OR鈥=鈥0.95, 95% CI: 0.92鈥0.99, P鈥=鈥0.013) and diabetic populations (OR鈥=鈥0.90, 95% CI: 0.83鈥0.97, P鈥=鈥0.008), CDAI is negatively correlated with ED, with the protective effect of CDAI being more significant in the diabetic population.

Fig. 2
figure 2

Subgroup analysis of CDAI and erectile dysfunction. Each group includes adjustment for all covariates except for the grouping factor

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PSM analysis

After PSM, a total of 1808 participants were included, with 904 in the ED group and 904 in the non-ED group. Descriptive statistics were performed on the matched population, as shown in Table S1. PSM adjusted for several key confounding variables, making the differences in confounding variables between the ED and non-ED groups more significant. Logistic weighted regression analysis was conducted on the included population in the second set of models, and the results are shown in Table听3. When CDAI is treated as a continuous variable, in all three models, CDAI still shows a significant negative correlation with ED (OR鈥=鈥0.93, 95% CI: 0.90鈥0.97, P鈥<鈥0.001; OR鈥=鈥0.93, 95% CI: 0.90鈥0.97, P鈥<鈥0.001; OR鈥=鈥0.95, 95% CI: 0.90鈥0.98, P鈥=鈥0.003). When CDAI is transformed into a categorical variable, in models 1 and 2, CDAI Q3 (OR鈥=鈥0.71, 95% CI: 0.51鈥0.98, P鈥=鈥0.037; OR鈥=鈥0.70, 95% CI: 0.51鈥0.98, P鈥=鈥0.035) and Q4 (OR鈥=鈥0.61, 95% CI: 0.43鈥0.85, P鈥=鈥0.004; OR鈥=鈥0.60, 95% CI: 0.43鈥0.85, P鈥=鈥0.004) are still negatively correlated with ED, and in model 3, CDAI Q4 (OR鈥=鈥0.66, 95% CI: 0.45鈥0.97, P鈥=鈥0.031) remains negatively correlated with ED.

Table 3 Weighted multivariable logistic regression analysis of the relationship between the composite dietary antioxidant index and erectile dysfunction after propensity score matching (PSM)
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Discussion

In this study, we systematically investigated the correlation between CDAI and ED, utilizing data from the NHANES database covering the period 2001鈥2004. Employing a thoroughly adjusted multivariate logistic regression model, which considered an array of confounding variables, we identified a substantial and negative correlation between CDAI and the risk of developing ED. After categorizing CDAI into quartiles, participants in the Q3 exhibited a 27% reduction in the risk of ED, while those in the Q4 experienced a more pronounced 30% decrease in ED risk. This quartile-based analysis enhances the dose-response nature of the observed association, indicating a consistent correlation between higher composite dietary antioxidant indices and a lowered risk of ED. In subgroup analyses, we explored the distribution of the negative correlation between CDAI and ED risk across different subgroups. Following PSM adjustments, the association between CDAI and reduced ED risk remained statistically significant. This reinforces the robustness of our study findings, suggesting that the observed relationship is less likely to be influenced by confounding factors.

Previous studies have already identified the potential correlation between CDAI and certain diseases. Wang et al.鈥榮 research discovered a positive correlation between CDAI and the decreased incidence of chronic kidney disease (CKD) [27]. A prospective cohort study with Singaporean Chinese participants also demonstrated the role of CDAI in lowering the incidence of colorectal cancer in the general population [28]. The intimate relationship between CDAI and cardiovascular diseases has been extensively documented in numerous studies [29, 30]. Antioxidant-rich diets are generally considered beneficial for health [31, 32], a conclusion that aligns with the findings of our study. Animal studies have demonstrated that long-term administration of antioxidants such as resveratrol can reverse ED in mice [33], and certain antioxidant extracts can alleviate ED in rats [34]. Additionally, some human studies have shown that carotenoids and lycopene are associated with a lower risk of ED [12, 35]. While these findings align with our study, it is important to note that these investigations often focus solely on the effects of individual antioxidants in animal models or human studies. The impact of single antioxidants may not comprehensively capture the overall effects of antioxidant-rich diets on ED, and excessive intake of certain individual antioxidants can even be detrimental to health [36]. Some studies suggest that the effects of individual antioxidant treatments on ED may be limited, whereas treatments involving combinations of antioxidant compounds are associated with improvements in ED [37]. Our study addresses this gap by considering the synergistic effects of multiple antioxidants, thereby reducing confounding biases that single antioxidants alone may not adequately explain. This approach enhances the reliability of our findings and provides a clearer understanding of the impact of antioxidant-rich diets on ED.

The onset mechanism of ED is closely associated with oxidative stress [38], Research indicates that dimethyl fumarate enhances erectile function in rats with cavernous nerve injury by activating the Nrf2/HO-1 signaling pathway to suppress oxidative stress [38]. Liraglutide improves ED by modulating oxidative stress through the inhibition of the RhoA/ROCK pathway [39], while apigenin prevents ED by ameliorating endothelial dysfunction and oxidative stress in rats [40]. Previous studies on the mechanisms by which antioxidants improve ED have primarily focused on reducing oxidative stress, which may also be one of the potential mechanisms underlying the association between the CDAI and the reduced risk of ED. CDAI is a comprehensive score derived from vitamin A, C, E, carotenoids, selenium, and zinc. Vitamin A has been identified as playing a pivotal role in reproductive processes [41, 42]. Research indicates that alpha-lipoic acid (ALA) may exert antioxidant effects by regenerating vitamin C and vitamin E, thus potentially preventing ED induced by diabetes [43]. A community cross-sectional study by Fujita et al. observed a correlation between low concentrations of blood alpha-carotene and beta-carotene and severe ED [44]. In animal experiments, zinc has demonstrated the ability to inhibit xanthine oxidase (XO) and uric acid (UA)-driven oxidative stress, leading to an improvement in ED through the upregulation of testosterone via Nrf2-mediated signaling [11]. Nevertheless, further investigations are required to delve into the potential mechanisms of the mixed interactions among these dietary antioxidants in the context of ED.

The present study boasts several strengths. Firstly, NHANES employs a sophisticated sampling design, and the rich sample size, diversity, and representativeness of the data enhance the reliability of the conclusions. We included numerous potential covariates and conducted 1:1 PSM, thereby reinforcing the robustness of the results. Lastly, our study, compared to the focus on individual antioxidants, may better represent the correlation between an antioxidant-rich diet and ED. However, it is crucial to acknowledge certain limitations in our study, including its cross-sectional design, which hinders the establishment of causal relationships. Secondly, our study findings may not be generalizable to other ethnicities, and future research should be designed to explore these relationships in different racial groups. Additionally, our study incorporated some questionnaire surveys, and when interpreting our results, reliance on self-reported data and the potential presence of unmeasured confounding factors, despite PSM adjustments, should be considered. ED may be influenced by sex steroid hormones; however, due to data limitations, we were unable to include sex steroid hormones in the analysis.

Conclusions

In our study cohort, there is support for the negative correlation between CDAI and the risk of ED. Future investigations, particularly prospective studies and intervention trials, are imperative to elucidate the potential mechanistic role of dietary intervention in mitigating the risk of ED.

Data availability

All the data involved in our study can be found in the NHANES database (), For additional inquiries, please contact the corresponding authors.

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Acknowledgements

We appreciate the data provided by the NHANES database.

Funding

The study received funding from the Chinese National Natural Science Funds (No.82171594).

Author information

Author notes

  1. Xuexue Hao, Xiangyu Chen and Congzhe Ren contributed equally to this work.

Authors and Affiliations

  1. Department of Urology, Tianjin Medical University General Hospital, 154 Anshan Road, Heping District, Tianjin, 300052, China

    Xuexue Hao,听Xiangyu Chen,听Congzhe Ren,听Yang Pan,听Zhunan Xu,听Qihua Wang听&听Xiaoqiang Liu

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  1. Xuexue Hao

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  2. Xiangyu Chen

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  3. Congzhe Ren

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  5. Zhunan Xu

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Contributions

XH and XC designed the research. XH and CR Collected the article鈥檚 data and conducted data analysis. YP, ZX and QW has carried out the preliminary drafting of the article. XL participated in the supervision and editing of this study. All authors of this study have contributed to this article and have unanimously agreed to its publication.

Corresponding author

Correspondence to Xiaoqiang Liu.

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All participants provided informed written consent and the study received ethics approval from the NCHS. The present analysis relies on openly accessible data and necessitates no additional ethical endorsement.

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Not applicable.

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The authors declare no competing interests.

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Hao, X., Chen, X., Ren, C. et al. Association between composite dietary antioxidant index and erectile dysfunction: a cross-sectional study from NHANES. 樱花视频 24, 3362 (2024). https://doi.org/10.1186/s12889-024-20880-4

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  • DOI: https://doi.org/10.1186/s12889-024-20880-4

Keywords

樱花视频

ISSN: 1471-2458

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