Investigation Of The Relationship Between Orthorexia Tendencies And Nutritional Status Of Individuals In The Covid-19 Pandemic

Rabia Berber; Dide Kılıçalp Kılınç

doi:10.46237/amusbfd.1179507

Research Article

Investigation Of The Relationship Between Orthorexia Tendencies And Nutritional Status Of Individuals In The Covid-19 Pandemic

Year 2024, Volume: 8 Issue: 1, 69 - 78, 31.01.2024

Rabia Berber Dide Kılıçalp Kılınç

https://doi.org/10.46237/amusbfd.1179507

Abstract

Objective: The aim of this study is to examine the orthorexia tendencies of individuals and especially the nutritional status of orthorexic people in the Covid 19 pandemic.
Methods: 1129 people participated in the study conducted through Google Forms in June 2020, 297 people were excluded due to being under the age of 18, filling in the form and/or scale incompletely/incorrectly, and 832 participants were included in the study. The ORTO-11 Test and the developed questionnaire were used to collect the data. The variables of the research are the participants' gender, body weight, nutritional status, orthorexic tendencies, exercise status, occupation and social media use. The data of the study were evaluated using the SPSS program.
Results: The risk of orthorexia was found to be higher in Instagram users, dietitians, and those who did not exercise during the pandemic. There was no statistically significant difference between body weight before and during the pandemic. Increase in consumption of meat and meat products, legumes; decrease in consumption of bread, rice, pasta, sugary drinks and sweets was mostly in orthorexic individuals. Considering all participants, highest consumption increase in vegetables and fruits, sweets, nuts, tea and coffee; consumption decreased mostly in bread, rice, pasta, sugary drinks and chips.
Conclusion: Despite the studies that found an increase in body weight in the pandemic, no significant change was found in body weight according to the results of this study. In addition, it was observed that the participants, especially orthorexic individuals, preferred healthier foods during the pandemic.

Keywords

covid, nutrition, orthorexia

References

1. Cena, H., Barthels, F., Cuzzolaro, M., Bratman, S., Brytek-Matera, A., Dunn, T., et al. (2019). Definition and diagnostic criteria for orthorexia nervosa: A narrative review of the literature. Eating and Weight Disorders. 24(2), 209–46.
2. Tremelling, K., Sandon, L., Vega, GL., & McAdams, CJ. (2017). Orthorexia nervosa and eating disorder symptoms in registered dietitian nutritionists in the united states. Journal of the Academy of Nutrition and Dietetics, 117(10), 1612–7.
3. Oberle, CD., Klare, DL., & Patyk, KC. (2019). Health beliefs, behaviors, and symptoms associated with orthorexia nervosa. Eating and Weight Disorders. 24(3), 495–506.
4. Baǧci Bosi, AT., Çamur, D., & Güler, Ç. (2007). Prevalence of orthorexia nervosa in resident medical doctors in the faculty of medicine (Ankara, Turkey). Appetite, 49(3), 661–6.
5. Aksoydan, E., & Camci, N. (2009). Prevalence of orthorexia nervosa among Turkish performance artists. Eating and Weight Disorders, 14(1), 33–7.
6. McComb, SE., & Mills, JS. (2019). Orthorexia nervosa: A review of psychosocial risk factors. Appetite, 140, 50–75.
7. Bert, F., Gualano, MR., Voglino, G., Rossello, P., Perret, JP., & Siliquini, R. (2019). Orthorexia nervosa: A cross-sectional study among athletes competing in endurance sports in Northern Italy. PLoS ONE, 14(8), e0221399.
8. Brytek-Matera, A., Czepczor-Bernat, K., Jurzak, H., Kornacka, M., & Kołodziejczyk, N. (2019). Strict health- oriented eating patterns (orthorexic eating behaviours) and their connection with a vegetarian and vegan diet. Eating and Weight Disorders, 24(3), 441–52.
9. Gorrasi, ISR., Bonetta, S., Roppolo, M., Abbate Daga, G., Bo, S., Tagliabue, A., et al. (2020). Traits of orthorexia nervosa and muscle dysmorphia in Italian university students: a multicentre study. Eating and Weight Disorders, 25(5), 1413–23.
10. Tarı Selçuk, K., & Çevik, C. (2020). Use of dietary supplements among nursing students in Turkey in the last 12 months and its relation with orthorexia nervosa. Perspectives in Psychiatric Care, 56(4), 885–93.
11. Caccialanza, R., Laviano, A., Lobascio, F., Montagna, E., Bruno, R., Ludovisi, S., et al. (2020). Early nutritional supplementation in non-critically ill patients hospitalized for the 2019 novel coronavirus disease (COVID-19): Rationale and feasibility of a shared pragmatic protocol. Nutrition, 74, 110835.
12. Yépiz-Gómez, MS., Gerba, CP., & Bright, KR. (2013). Survival of respiratory viruses on fresh produce. Food and Environmental Virology, 5(3), 150–6.
13. Kopel, J., Perisetti, A., Roghani, A., Aziz, M., Gajendran, M., & Goyal, H. (2020). Racial and gender-based differences in COVID-19. Frontiers in Public Health, 8(418), 1–8.
14. Nikolich-Zugich, J., Knox, KS., Rios, CT., Natt, B., Bhattacharya, D., & Fain, MJ. (2020). SARS-CoV-2 and COVID-19 in older adults: what we may expect regarding pathogenesis, immune responses, and outcomes. GeroScience, 42(2), 505–14.
15. Shahid, Z., Kalayanamitra, R., McClafferty, B., Kepko, D., Ramgobin, D., Patel, R., et al. (2020). COVID-19 and older adults: What we know. Journal of the American Geriatrics Society, 68(5), 926–9.
16. She, J., Liu, L., & Liu, W. (2020). COVID-19 epidemic: Disease characteristics in children. Journal of Medical Virology, 92(7), 747–54.
17. Hussain, A., Bhowmik, B., & do Vale Moreira, NC. (2020). COVID-19 and diabetes: Knowledge in progress. Diabetes Research and Clinical Practice, 162(108142), 1–9.
18. de Lucena, TMC., da Silva Santos, AF., de Lima, BR., de Albuquerque Borborema, ME., & de Azevêdo Silva, J. (2020). Mechanism of inflammatory response in associated comorbidities in COVID-19. Diabetes and Metabolic Syndrome: Clinical Research and Reviews, 14(4), 597–600.
19. Caci, G., Albini, A., Malerba, M., Noonan, DM., Pochetti, P., & Polosa, R. (2020). COVID-19 and obesity: Dangerous liaisons. Journal of Clinical Medicine, 9(8), 2511.
20. Ritter, A., Kreis, NN., Louwen, F., & Yuan, J. (2020). Obesity and covid-19: Molecular mechanisms linking both pandemics. International Journal of Molecular Sciences., 21(16), 5793.
21. Bae, M., & Kim, H. (2020). Mini-review on the roles of vitamin c, vitamin d, and selenium in the ımmune system against COVID-19. Molecules, 25(22), 5346.
22. Fernández-Lázaro, D., González-Bernal, JJ., Sánchez-Serrano, N., Navascués, LJ., del Río, AA., & Mielgo- Ayuso, J. (2020). Physical exercise as a multimodal tool for COVID-19: Could it be used as a preventive strategy? International Journal of Environmental Research and Public Health 17(22), 8496.
23. Mason, TB., Barrington-Trimis, J., & Leventhal, AM. (2021). Eating to cope with the COVID-19 pandemic and body weight change in young adults. Journal of Adolescent Health, 68(2), 277–83.
24. Reyes-Olavarría, D., Latorre-Román, PÁ., Guzmán-Guzmán, IP., Jerez-Mayorga, D., Caamaño-Navarrete, F., & Delgado-Floody, P.(2020). Positive and negative changes in food habits, physical activity patterns, and weight status during covid-19 confinement: Associated factors in the chilean population. International Journal of Environmental Research and Public Health, 17(15), 5431.
25. Duong, T van., Pham, KM., Do, BN., Kim, GB., Dam, HTB., Le, VTT., et al. (2020). Digital healthy diet literacy and self-perceived eating behavior change during COVID-19 pandemic among undergraduate nursing and medical students: A rapid online survey. International Journal of Environmental Research and Public Health, 17(19), 7185.
26. Phillipou, A., Meyer, D., Neill, E., Tan, EJ., Toh, WL., van Rheenen, TE., et al. (2020). Eating and exercise behaviors in eating disorders and the general population during the COVID-19 pandemic in Australia: Initial results from the COLLATE project. International Journal of Eating Disorders, 53(7), 1–8.
27. Komaroff, M. (2016). For researchers on obesity: Historical review of extra body weight definitions. Journal of Obesity, 2016, 1–9.
28. Arusoǧlu, G., Kabakçi, E., Köksal, G., & Merdol, TK. (2008). Ortoreksiya nervoza ve Orto-11’in türkçeye uyarlama çalişmasi.( Turkish adaptation of Orthorexia nervosa and Orto-11.). Turkish journal of psychiatry, 19(3), 283–91.
29. Özpak Akkuş, Ö., Asil, E., & Yılmaz, MV. (2022). COVID-19 pandemisi sürecinde bireylerin beslenme davranışlarının ve ortorektik eğilimlerinin değerlendirilmesi (Evaluation of nutritional behaviors and orthorexic tendency of ındividuals during the COVID-19 pandemic process.). Journal of Nutrition and Dietetics, 49(3), 29–38.
30. Turner, PG., & Lefevre, CE. (2017). Instagram use is linked to increased symptoms of orthorexia nervosa. Eating and Weight Disorders, 22(2), 277–84.
31. Cheshire, A., Berry, M., & Fixsen, A. (2020). What are the key features of orthorexia nervosa and influences on its development? A qualitative investigation. Appetite, 155, 104798.
32. Abdullah, MA., al Hourani, HM., & Alkhatib, B. (2020). Prevalence of orthorexia nervosa among nutrition students and nutritionists: Pilot study. Clinical Nutrition ESPEN, 40, 144–8.
33. Asil, E., & Sürücüoğlu, MS. (2015). Orthorexia nervosa in turkish dietitians. Ecology of Food and Nutrition, 54(4), 303–13.
34. Ammar, A., Brach, M., Trabelsi, K., Chtourou, H., Boukhris, O., Masmoudi, L., et al. (2020). Effects of COVID-19 home confinement on eating behaviour and physical activity: Results of the ECLB-COVID19 international online survey. Nutrients, 12(6), 1583.
35. di Renzo, L., Gualtieri, P., Pivari, F., Soldati, L., Attinà, A., Cinelli, G., et al. (2020). Eating habits and lifestyle changes during COVID-19 lockdown: An Italian survey. Journal of Translational Medicine, 12(7), 2152.
36. Ruiz-Roso, MB., Padilha, P de C., Mantilla-Escalante, DC., Ulloa, N., Brun, P., Acevedo-Correa, D., et al. (2020). Covid-19 confinement and changes of adolescent’s dietary trends in Italy, Spain, Chile, Colombia and Brazil. Nutrients, 12(6), 1807.
37. Sánchez-Sánchez, E., Ramírez-Vargas, G., Avellaneda-López, Y., Orellana-Pecino, JI., García-Marín, E., & Díaz-Jimenez, J. (2020). Eating habits and physical activity of the spanish population during the covid-19 pandemic period. Nutrients, 12(2826), 1–12.
38. Ruissen, MM., Regeer, H., Landstra, CP., Schroijen, M., Jazet, I., Nijhoff, MF., et al. (2021). Increased stress, weight gain and less exercise in relation to glycemic control in people with type 1 and type 2 diabetes during the COVID-19 pandemic. BMJ Open Diabetes Research and Care, 9(1), 2035.
39. Rodgers, RF., Lombardo, C., Cerolini, S., Franko, DL, Omori, M., Fuller-Tyszkiewicz, M., et al. (2020). The impact of the COVID-19 pandemic on eating disorder risk and symptoms. International Journal of Eating Disorders, 53(7), 1-5.

CCovid-19 Pandemisinde Bireylerin Ortoreksiya Eğilimleri ile Beslenme Durumları Arasındaki İlişkinin İncelenmesi

Year 2024, Volume: 8 Issue: 1, 69 - 78, 31.01.2024

Rabia Berber Dide Kılıçalp Kılınç

https://doi.org/10.46237/amusbfd.1179507

Abstract

Amaç: Bu çalışmanın amacı Covid-19 pandemisinde bireylerin ortoreksiya eğilimlerinin ve özellikle ortorektik kişilerin beslenme durumlarının incelenmesidir.
Yöntem: Haziran 2020'de Google Formlar üzerinden gerçekleştirilen çalışmaya 1129 kişi katılmış, 297 kişi 18 yaş altı olma, form ve/veya ölçeği eksik/yanlış doldurma nedeniyle çalışmadan çıkarılmış ve 832 katılımcı çalışmaya dahil edilmiştir. Verilerin toplanmasında ORTO-11 Test ve geliştirilen anket formu kullanılmıştır. Araştırmanın değişkenleri katılımcıların cinsiyeti, vücut ağırlığı, beslenme durumu, ortorektik eğilimleri, egzersiz durumu, mesleği ve sosyal medya kullanımıdır. Çalışmanın verileri SPSS programı kullanılarak değerlendirilmiştir.
Bulgular: Ortoreksiya riski Instagram kullanıcılarında, diyetisyen olanlarda, pandemide egzersiz yapmayanlarda daha yüksek saptanmıştır. Pandemi öncesi ve pandemi sırasında vücut ağırlığı arasında istatistiksel olarak anlamlı bir fark bulunamamıştır. Et ve et ürünleri, kuru baklagillerin tüketim artışı; ekmek, pilav, makarna, şekerli içecek ve tatlıların tüketim azalışı en çok ortorektik bireylerde olmuştur. Tüm katılımcılara bakıldığında ise en çok sebze ve meyve, tatlı, kuruyemiş, çay ve kahvede tüketim artışı; en çok ekmek, pilav, makarna, şekerli içecek, cipste tüketim azalışı olduğu bireyler tarafından belirtilmiştir.
Sonuç: Pandemide vücut ağırlığında artış saptayan çalışmalara rağmen, bu çalışmanın sonuçlarına göre vücut ağırlığında anlamlı bir değişim saptanamadı. Ayrıca pandemide katılımcıların özellikle ortorektik bireylerin daha sağlıklı besinler tercih ettikleri görülmüştür.

Keywords

covid, beslenme, ortoreksiya

References

1. Cena, H., Barthels, F., Cuzzolaro, M., Bratman, S., Brytek-Matera, A., Dunn, T., et al. (2019). Definition and diagnostic criteria for orthorexia nervosa: A narrative review of the literature. Eating and Weight Disorders. 24(2), 209–46.
2. Tremelling, K., Sandon, L., Vega, GL., & McAdams, CJ. (2017). Orthorexia nervosa and eating disorder symptoms in registered dietitian nutritionists in the united states. Journal of the Academy of Nutrition and Dietetics, 117(10), 1612–7.
3. Oberle, CD., Klare, DL., & Patyk, KC. (2019). Health beliefs, behaviors, and symptoms associated with orthorexia nervosa. Eating and Weight Disorders. 24(3), 495–506.
4. Baǧci Bosi, AT., Çamur, D., & Güler, Ç. (2007). Prevalence of orthorexia nervosa in resident medical doctors in the faculty of medicine (Ankara, Turkey). Appetite, 49(3), 661–6.
5. Aksoydan, E., & Camci, N. (2009). Prevalence of orthorexia nervosa among Turkish performance artists. Eating and Weight Disorders, 14(1), 33–7.
6. McComb, SE., & Mills, JS. (2019). Orthorexia nervosa: A review of psychosocial risk factors. Appetite, 140, 50–75.
7. Bert, F., Gualano, MR., Voglino, G., Rossello, P., Perret, JP., & Siliquini, R. (2019). Orthorexia nervosa: A cross-sectional study among athletes competing in endurance sports in Northern Italy. PLoS ONE, 14(8), e0221399.
8. Brytek-Matera, A., Czepczor-Bernat, K., Jurzak, H., Kornacka, M., & Kołodziejczyk, N. (2019). Strict health- oriented eating patterns (orthorexic eating behaviours) and their connection with a vegetarian and vegan diet. Eating and Weight Disorders, 24(3), 441–52.
9. Gorrasi, ISR., Bonetta, S., Roppolo, M., Abbate Daga, G., Bo, S., Tagliabue, A., et al. (2020). Traits of orthorexia nervosa and muscle dysmorphia in Italian university students: a multicentre study. Eating and Weight Disorders, 25(5), 1413–23.
10. Tarı Selçuk, K., & Çevik, C. (2020). Use of dietary supplements among nursing students in Turkey in the last 12 months and its relation with orthorexia nervosa. Perspectives in Psychiatric Care, 56(4), 885–93.
11. Caccialanza, R., Laviano, A., Lobascio, F., Montagna, E., Bruno, R., Ludovisi, S., et al. (2020). Early nutritional supplementation in non-critically ill patients hospitalized for the 2019 novel coronavirus disease (COVID-19): Rationale and feasibility of a shared pragmatic protocol. Nutrition, 74, 110835.
12. Yépiz-Gómez, MS., Gerba, CP., & Bright, KR. (2013). Survival of respiratory viruses on fresh produce. Food and Environmental Virology, 5(3), 150–6.
13. Kopel, J., Perisetti, A., Roghani, A., Aziz, M., Gajendran, M., & Goyal, H. (2020). Racial and gender-based differences in COVID-19. Frontiers in Public Health, 8(418), 1–8.
14. Nikolich-Zugich, J., Knox, KS., Rios, CT., Natt, B., Bhattacharya, D., & Fain, MJ. (2020). SARS-CoV-2 and COVID-19 in older adults: what we may expect regarding pathogenesis, immune responses, and outcomes. GeroScience, 42(2), 505–14.
15. Shahid, Z., Kalayanamitra, R., McClafferty, B., Kepko, D., Ramgobin, D., Patel, R., et al. (2020). COVID-19 and older adults: What we know. Journal of the American Geriatrics Society, 68(5), 926–9.
16. She, J., Liu, L., & Liu, W. (2020). COVID-19 epidemic: Disease characteristics in children. Journal of Medical Virology, 92(7), 747–54.
17. Hussain, A., Bhowmik, B., & do Vale Moreira, NC. (2020). COVID-19 and diabetes: Knowledge in progress. Diabetes Research and Clinical Practice, 162(108142), 1–9.
18. de Lucena, TMC., da Silva Santos, AF., de Lima, BR., de Albuquerque Borborema, ME., & de Azevêdo Silva, J. (2020). Mechanism of inflammatory response in associated comorbidities in COVID-19. Diabetes and Metabolic Syndrome: Clinical Research and Reviews, 14(4), 597–600.
19. Caci, G., Albini, A., Malerba, M., Noonan, DM., Pochetti, P., & Polosa, R. (2020). COVID-19 and obesity: Dangerous liaisons. Journal of Clinical Medicine, 9(8), 2511.
20. Ritter, A., Kreis, NN., Louwen, F., & Yuan, J. (2020). Obesity and covid-19: Molecular mechanisms linking both pandemics. International Journal of Molecular Sciences., 21(16), 5793.
21. Bae, M., & Kim, H. (2020). Mini-review on the roles of vitamin c, vitamin d, and selenium in the ımmune system against COVID-19. Molecules, 25(22), 5346.
22. Fernández-Lázaro, D., González-Bernal, JJ., Sánchez-Serrano, N., Navascués, LJ., del Río, AA., & Mielgo- Ayuso, J. (2020). Physical exercise as a multimodal tool for COVID-19: Could it be used as a preventive strategy? International Journal of Environmental Research and Public Health 17(22), 8496.
23. Mason, TB., Barrington-Trimis, J., & Leventhal, AM. (2021). Eating to cope with the COVID-19 pandemic and body weight change in young adults. Journal of Adolescent Health, 68(2), 277–83.
24. Reyes-Olavarría, D., Latorre-Román, PÁ., Guzmán-Guzmán, IP., Jerez-Mayorga, D., Caamaño-Navarrete, F., & Delgado-Floody, P.(2020). Positive and negative changes in food habits, physical activity patterns, and weight status during covid-19 confinement: Associated factors in the chilean population. International Journal of Environmental Research and Public Health, 17(15), 5431.
25. Duong, T van., Pham, KM., Do, BN., Kim, GB., Dam, HTB., Le, VTT., et al. (2020). Digital healthy diet literacy and self-perceived eating behavior change during COVID-19 pandemic among undergraduate nursing and medical students: A rapid online survey. International Journal of Environmental Research and Public Health, 17(19), 7185.
26. Phillipou, A., Meyer, D., Neill, E., Tan, EJ., Toh, WL., van Rheenen, TE., et al. (2020). Eating and exercise behaviors in eating disorders and the general population during the COVID-19 pandemic in Australia: Initial results from the COLLATE project. International Journal of Eating Disorders, 53(7), 1–8.
27. Komaroff, M. (2016). For researchers on obesity: Historical review of extra body weight definitions. Journal of Obesity, 2016, 1–9.
28. Arusoǧlu, G., Kabakçi, E., Köksal, G., & Merdol, TK. (2008). Ortoreksiya nervoza ve Orto-11’in türkçeye uyarlama çalişmasi.( Turkish adaptation of Orthorexia nervosa and Orto-11.). Turkish journal of psychiatry, 19(3), 283–91.
29. Özpak Akkuş, Ö., Asil, E., & Yılmaz, MV. (2022). COVID-19 pandemisi sürecinde bireylerin beslenme davranışlarının ve ortorektik eğilimlerinin değerlendirilmesi (Evaluation of nutritional behaviors and orthorexic tendency of ındividuals during the COVID-19 pandemic process.). Journal of Nutrition and Dietetics, 49(3), 29–38.
30. Turner, PG., & Lefevre, CE. (2017). Instagram use is linked to increased symptoms of orthorexia nervosa. Eating and Weight Disorders, 22(2), 277–84.
31. Cheshire, A., Berry, M., & Fixsen, A. (2020). What are the key features of orthorexia nervosa and influences on its development? A qualitative investigation. Appetite, 155, 104798.
32. Abdullah, MA., al Hourani, HM., & Alkhatib, B. (2020). Prevalence of orthorexia nervosa among nutrition students and nutritionists: Pilot study. Clinical Nutrition ESPEN, 40, 144–8.
33. Asil, E., & Sürücüoğlu, MS. (2015). Orthorexia nervosa in turkish dietitians. Ecology of Food and Nutrition, 54(4), 303–13.
34. Ammar, A., Brach, M., Trabelsi, K., Chtourou, H., Boukhris, O., Masmoudi, L., et al. (2020). Effects of COVID-19 home confinement on eating behaviour and physical activity: Results of the ECLB-COVID19 international online survey. Nutrients, 12(6), 1583.
35. di Renzo, L., Gualtieri, P., Pivari, F., Soldati, L., Attinà, A., Cinelli, G., et al. (2020). Eating habits and lifestyle changes during COVID-19 lockdown: An Italian survey. Journal of Translational Medicine, 12(7), 2152.
36. Ruiz-Roso, MB., Padilha, P de C., Mantilla-Escalante, DC., Ulloa, N., Brun, P., Acevedo-Correa, D., et al. (2020). Covid-19 confinement and changes of adolescent’s dietary trends in Italy, Spain, Chile, Colombia and Brazil. Nutrients, 12(6), 1807.
37. Sánchez-Sánchez, E., Ramírez-Vargas, G., Avellaneda-López, Y., Orellana-Pecino, JI., García-Marín, E., & Díaz-Jimenez, J. (2020). Eating habits and physical activity of the spanish population during the covid-19 pandemic period. Nutrients, 12(2826), 1–12.
38. Ruissen, MM., Regeer, H., Landstra, CP., Schroijen, M., Jazet, I., Nijhoff, MF., et al. (2021). Increased stress, weight gain and less exercise in relation to glycemic control in people with type 1 and type 2 diabetes during the COVID-19 pandemic. BMJ Open Diabetes Research and Care, 9(1), 2035.
39. Rodgers, RF., Lombardo, C., Cerolini, S., Franko, DL, Omori, M., Fuller-Tyszkiewicz, M., et al. (2020). The impact of the COVID-19 pandemic on eating disorder risk and symptoms. International Journal of Eating Disorders, 53(7), 1-5.

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Details

Primary Language	English
Subjects	Health Care Administration
Journal Section	Research Articles
Authors	Rabia Berber 0000-0002-2105-138X Dide Kılıçalp Kılınç 0000-0003-3234-5911
Early Pub Date	January 31, 2024
Publication Date	January 31, 2024
Published in Issue	Year 2024 Volume: 8 Issue: 1

Cite

APA	Berber, R., & Kılıçalp Kılınç, D. (2024). Investigation Of The Relationship Between Orthorexia Tendencies And Nutritional Status Of Individuals In The Covid-19 Pandemic. Adnan Menderes Üniversitesi Sağlık Bilimleri Fakültesi Dergisi, 8(1), 69-78. https://doi.org/10.46237/amusbfd.1179507

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