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Food Science and Human Wellness 2024, 13(1): 254-264 https://doi.org/10.26599/FSHW.2022.9250021
Research Article | Open Access | Issue | Published: 01 June 2023

Longitudinal changes in body weight of breastfeeding mothers in the first year after delivery and its relationship with human milk composition: a combined longitudinal and cross-sectional cohort study

Show Author's Information Huijuan Ruana,,  Yajie Zhangb,  Qingya Tanga,  Xuan Zhaoa,  Xuelin Zhaoa,  Yi Xianga,  Wei Genga,  Yi Fenga,  Wei Caib,c( )
Department of Clinical Nutrition, Xinhua Hospital Affi liated to Shanghai Jiao Tong University School of Medicine, Shanghai 200092, China
Shanghai Key Laboratory of Pediatric Gastroenterology and Nutrition, Shanghai Institute of Pediatric Research, Shanghai 200092, China
Department of Pediatric Surgery, Xinhua Hospital Affi liated to Shanghai Jiao Tong University School of Medicine, Shanghai 200092, China

Peer review under responsibility of Tsinghua University Press.

Keywords:
Human milk, Milk composition, Body weight, Weight gain, Postpartum weight retention, Body mass index (BMI)
Cite this article:
Ruan H, Zhang Y, Tang Q, et al. Longitudinal changes in body weight of breastfeeding mothers in the first year after delivery and its relationship with human milk composition: a combined longitudinal and cross-sectional cohort study. Food Science and Human Wellness, 2024, 13(1): 254-264. https://doi.org/10.26599/FSHW.2022.9250021
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Abstract Full text About this article
Objective

Postpartum weight retention (PPWR) is a common problem among women after childbirth. The main objectives of this study are to understand the changes in body weight of breastfeeding mothers during long-term follow-up and preliminarily explore the relationship between maternal body weight and human milk composition, including macronutrients, leptin, and adiponectin.

Methods

The study included a longitudinal cohort (122 mothers), and a cross-sectional cohort (37 mothers). The human milk, maternal weight, and dietary surveys were collected in the longitudinal cohort at different follow-up time points (1−14 days postpartum, 2−4 months postpartum, 5−7 months postpartum, and 12−17 months postpartum). The maternal body weight was analyzed using the responses in the survey questionnaires. A milk analyzer based on the mid-infrared spectroscopy (MIRS) was used to determine milk composition, and nutrition analysis software evaluated dietary intakes. In the cross-sectional cohort, participating mothers were asked to provide blood and human milk samples and pertinent information related to maternal body composition. Maternal body composition was measured by bioelectrical impedance analysis (BIA), while ELISA analyzed leptin and adiponectin in milk and serum.

Results

At 5−7 months postpartum, the PPWR of breastfeeding mothers was (2.46 ± 3.59) kg. At 12−17 months postpartum, the PPWR was (0.98 ± 4.06) kg. PPWR was found to be negatively correlated with milk fat content within 14 days postpartum and positively correlated at 2−4 months postpartum. In addition, the maternal weight and body muscle mass were positively correlated with leptin and adiponectin in milk. Plasma leptin was positively correlated with the mother’s body weight, body mass index (BMI), FAT percentage, and body fat mass, while plasma adiponectin did not correlate with any parameter. The results also indicate that the PPWR did not correlate with leptin and adiponectin in plasma or milk.

Conclusions

Breastfeeding mothers may retain considerable weight gain one year after delivery. Human milk composition may be related to changes in maternal body weight. Leptin and adiponectin in breast milk and leptin in plasma are associated with the maternal body composition. This study supports the notion that maternal nutritional status may affect offspring health through lactation, and future research should focus on exploring weight management of postpartum mothers.


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Abstract
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About this article

Longitudinal changes in body weight of breastfeeding mothers in the first year after delivery and its relationship with human milk composition: a combined longitudinal and cross-sectional cohort study

Show Author's information Huijuan Ruana,, Yajie Zhangb, Qingya Tanga, Xuan Zhaoa, Xuelin Zhaoa, Yi Xianga, Wei Genga, Yi Fenga, Wei Caib,c( )
Department of Clinical Nutrition, Xinhua Hospital Affi liated to Shanghai Jiao Tong University School of Medicine, Shanghai 200092, China
Shanghai Key Laboratory of Pediatric Gastroenterology and Nutrition, Shanghai Institute of Pediatric Research, Shanghai 200092, China
Department of Pediatric Surgery, Xinhua Hospital Affi liated to Shanghai Jiao Tong University School of Medicine, Shanghai 200092, China

Peer review under responsibility of Tsinghua University Press.

Abstract

Objective

Postpartum weight retention (PPWR) is a common problem among women after childbirth. The main objectives of this study are to understand the changes in body weight of breastfeeding mothers during long-term follow-up and preliminarily explore the relationship between maternal body weight and human milk composition, including macronutrients, leptin, and adiponectin.

Methods

The study included a longitudinal cohort (122 mothers), and a cross-sectional cohort (37 mothers). The human milk, maternal weight, and dietary surveys were collected in the longitudinal cohort at different follow-up time points (1−14 days postpartum, 2−4 months postpartum, 5−7 months postpartum, and 12−17 months postpartum). The maternal body weight was analyzed using the responses in the survey questionnaires. A milk analyzer based on the mid-infrared spectroscopy (MIRS) was used to determine milk composition, and nutrition analysis software evaluated dietary intakes. In the cross-sectional cohort, participating mothers were asked to provide blood and human milk samples and pertinent information related to maternal body composition. Maternal body composition was measured by bioelectrical impedance analysis (BIA), while ELISA analyzed leptin and adiponectin in milk and serum.

Results

At 5−7 months postpartum, the PPWR of breastfeeding mothers was (2.46 ± 3.59) kg. At 12−17 months postpartum, the PPWR was (0.98 ± 4.06) kg. PPWR was found to be negatively correlated with milk fat content within 14 days postpartum and positively correlated at 2−4 months postpartum. In addition, the maternal weight and body muscle mass were positively correlated with leptin and adiponectin in milk. Plasma leptin was positively correlated with the mother’s body weight, body mass index (BMI), FAT percentage, and body fat mass, while plasma adiponectin did not correlate with any parameter. The results also indicate that the PPWR did not correlate with leptin and adiponectin in plasma or milk.

Conclusions

Breastfeeding mothers may retain considerable weight gain one year after delivery. Human milk composition may be related to changes in maternal body weight. Leptin and adiponectin in breast milk and leptin in plasma are associated with the maternal body composition. This study supports the notion that maternal nutritional status may affect offspring health through lactation, and future research should focus on exploring weight management of postpartum mothers.

Keywords: Human milk, Milk composition, Body weight, Weight gain, Postpartum weight retention, Body mass index (BMI)

References(61)

[1]

M. Bittman, E. Cleary, C. Wilkinson-Bibicos, et al., The social disorganization of eating: a neglected determinant of the Australian epidemic of overweight/obesity, BMC Public Health 19(Suppl 2) (2019) 454. https://doi.org/10.1186/s12889-019-6768-3.
DOI Google Scholar
[2]

A. Talmor, B. Dunphy, Female obesity and infertility, Best Pract. Res. Clin. Obstet. Gynaecol. 29 (2015) 498-506. https://doi.org/10.1016/j.bpobgyn.2014.10.014.
DOI Google Scholar
[3]

S Mitchell, D Shaw, The worldwide epidemic of female obesity, Best Pract. Res. Clin. Obstet. Gynaecol. 29 (2015) 289-299. https://doi.org/10.1016/j.bpobgyn.2014.10.002.
DOI Google Scholar
[4]

Y.C. Chooi, C. Ding, F. Magkos, The epidemiology of obesity, Metabolism. 92 (2019) 6-10. https://doi.org/10.1016/j.metabol.2018.09.005.
DOI Google Scholar
[5]

A.E. Joham, S. Palomba, R. Hart, Polycystic ovary syndrome, obesity, and pregnancy, Semin. Reprod. Med. 34 (2016) 93-101. https://doi.org/10.1055/s-0035-1571195.
DOI Google Scholar
[6]

R.M. Grivell, C.M. O’Brien, J.M. Dodd, Managing obesity in pregnancy: a change in focus from harm minimization to prevention, Semin. Reprod. Med. 34 (2016) e38-46. https://doi.org/10.1055/s-0036-1583532.
DOI Google Scholar
[7]

H. Åmark, M. Westgren, M. Persson, Prediction of large-for-gestational-age infants in pregnancies complicated by obesity: a population-based cohort study, Acta Obstet. Gynecol. Scand. 98 (2019) 769-776. https://doi.org/10.1111/aogs.13546.
DOI Google Scholar
[8]

L. Kong, I.A.K. Nilsson, M. Gissler, et al., Associations of maternal diabetes and body mass index with offspring birth weight and prematurity, JAMA Pediatr. 173 (2019) 371-378. https://doi.org/10.1001/jamapediatrics.2018.5541.
DOI Google Scholar
[9]

D.Y. Quansah, J. Gross, L. Gilbert, et al., Predictors and consequences of weight retention in the early and late postpartum period in women with gestational diabetes, Diabetes Res. Clin. Pract. 165 (2020) 108238. https://doi.org/10.1016/j.diabres.2020.108238.
DOI Google Scholar
[10]

R.K. Peters, S.L. Kjos, A. Xiang, et al., Long-term diabetogenic effect of single pregnancy in women with previous gestational diabetes mellitus, Lancet 347 (1996) 227-230. https://doi.org/10.1016/s0140-6736(96)90405-5.
DOI Google Scholar
[11]

C.P. Lambrinou, E. Karaglani, Y. Manios, Breastfeeding and postpartum weight loss, Curr. Opin. Clin. Nutr. Metab. Care 22 (2019) 413-417. https://doi.org/10.1097/MCO.0000000000000597.
DOI Google Scholar
[12]

D.C. Soria-Contreras, B. Trejo-Valdivia, A. Cantoral, et al., Patterns of weight change one year after delivery are associated with cardiometabolic risk factors at six years postpartum in Mexican women, Nutrients 12 (2020) 170. https://doi.org/10.3390/nu12010170.
DOI Google Scholar
[13]

J.L. Baker, M. Gamborg, B.L. Heitmann, et al., Breastfeeding reduces postpartum weight retention, Am. J. Clin. Nutr. 88 (2008) 1543-1551. https://doi.org/10.3945/ajcn.2008.26379.
DOI Google Scholar
[14]

C.G. Victora, R. Bahl, A.J. Barros, et al., Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect, Lancet 387 (2016) 475-490. https://doi.org/10.1016/S0140-6736(15)01024-7.
DOI Google Scholar
[15]

M. Jiang, H. Gao, G. Vinyes-Pares, et al., Association between breastfeeding duration and postpartum weight retention of lactating mothers: a meta-analysis of cohort studies, Clin. Nutr. 37 (2018) 1224-1231. https://doi.org/10.1016/j.clnu.2017.05.014.
DOI Google Scholar
[16]

A. Antonakou, D. Papoutsis, I. Panou, et al., Role of exclusive breastfeeding in energy balance and weight loss during the first six months postpartum, Clin. Exp. Obstet. Gynecol. 40 (2013) 485-488.
Google Scholar
[17]

M.F. Mastroeni, S. Mastroeni, S.A. Czarnobay, et al., Breast-feeding duration for the prevention of excess body weight of mother-child pairs concurrently: a 2-year cohort study, Public Health Nutr. 20 (2017) 2537-2548. https://doi.org/10.1017/S1368980017001239.
DOI Google Scholar
[18]

A.I. Daniel, S. Shama, S. Ismail, et al., Maternal BMI is positively associated with human milk fat: a systematic review and meta-regression analysis, Am. J. Clin. Nutr. 113 (2021) 1009-1022. https://doi.org/10.1093/ajcn/nqaa410.
DOI Google Scholar
[19]

M. Keikha, M. Bahreynian, M. Saleki, et al., Macro- and micronutrients of human milk composition: are they related to maternal diet? a comprehensive systematic review, Breastfeed Med. 12 (2017) 517-527. https://doi.org/10.1089/bfm.2017.0048.
DOI Google Scholar
[20]

G.E. Leghi, M.J. Netting, C.T. Lai, et al., Reduction in maternal energy intake during lactation decreased maternal body weight and concentrations of leptin, insulin and adiponectin in human milk without affecting milk production, milk macronutrient composition or infant growth, Nutrients 13 (2021) 1892. https://doi.org/10.3390/nu13061892.
DOI Google Scholar
[21]

G.E. Leghi, M. Netting, B.S. Muhlhausler, The short-term impact of dietary fat and sugar intake on breast milk composition: a clinical trial protocol, Nutr. Health 26 (2020) 65-72. https://doi.org/10.1177/0260106019895367.
DOI Google Scholar
[22]

E. Ward, N. Yang, B.S. Muhlhausler, et al., Acute changes to breast milk composition following consumption of high-fat and high-sugar meals, Matern. Child. Nutr. 17 (2021) e13168. https://doi.org/10.1111/mcn.13168.
DOI Google Scholar
[23]

F. Bravi, F. Wiens, A. Decarli, et al., Impact of maternal nutrition on breast-milk composition: a systematic review, Am. J. Clin. Nutr. 104 (2016) 646-662. https://doi.org/10.3945/ajcn.115.120881.
DOI Google Scholar
[24]

C.R. Sims, M.E. Lipsmeyer, D.E. Turner, et al., Human milk composition differs by maternal BMI in the first 9 months postpartum, Am. J. Clin. Nutr. 112 (2020) 548-557. https://doi.org/10.1093/ajcn/nqaa098.
DOI Google Scholar
[25]

S. Kugananthan, Z. Gridneva, C.T. Lai, et al.. Associations between maternal body composition and appetite hormones and macronutrients in human milk, Nutrients 9 (2017) 252. https://doi.org/10.3390/nu9030252.
DOI Google Scholar
[26]

H. Fang, R.L. Judd, Adiponectin regulation and function, Compr. Physiol. 8 (2018) 1031-1063. https://doi.org/10.1002/cphy.c170046.
DOI Google Scholar
[27]

B. Kocaadam, E. Koksal, K.E. Ozcan, et al., Do the adiponectin and leptin levels in preterm and term breast milk samples relate to infants’ short-term growth?, J. Dev. Orig. Health Dis. 10 (2019) 253-258. https://doi.org/10.1017/S2040174418000703.
DOI Google Scholar
[28]

C.A. Logan, L.P. Siziba, W. Koenig, et al., Leptin in human milk and child body mass index: results of the ULM birth cohort studies, Nutrients 11 (2019) 1883. https://doi.org/10.3390/nu11081883.
DOI Google Scholar
[29]

Z. Gridneva, S. Kugananthan, A. Rea, et al., Human milk adiponectin and leptin and infant body composition over the first 12 months of lactation, Nutrients 10 (2018) 1125. https://doi.org/10.3390/nu10081125.
DOI Google Scholar
[30]

H.M. Tian, Y.X. Wu, Y.Q. Lin, et al., Dietary patterns affect maternal macronutrient intake levels and the fatty acid profile of breast milk in lactating Chinese mothers, Nutrition 58 (2019) 83-88. https://doi.org/10.1016/j.nut.2018.06.009.
DOI Google Scholar
[31]

N. Li, X. Su, T. Liu, et al., Dietary patterns of Chinese puerperal women and their association with postpartum weight retention: results from the mother-infant cohort study, Matern. Child Nutr. 17 (2021) e13061. https://doi.org/10.1111/mcn.13061.
DOI Google Scholar
[32]

S.L. Matias, K.G. Dewey, C.P. Quesenberry, et al., Maternal prepregnancy obesity and insulin treatment during pregnancy are independently associated with delayed lactogenesis in women with recent gestational diabetes mellitus, Am. J. Clin. Nutr. 99 (2014) 115-121. https://doi.org/10.3945/ajcn.113.073049.
DOI Google Scholar
[33]

R. Huijuan, T. Qingya, Z. Xuan, et al., The levels of osteopontin in human milk of chinese mothers and its associations with maternal body composition, Food Science and Human Wellness 11 (2022) 1419-1427.
DOI Google Scholar
[34]

R. Huijuan, T. Qingya, Z. Yajie, et al., Comparing human milk macronutrients measured using analyzers based on mid-infrared spectroscopy and ultrasound and the application of machine learning in data fitting, BMC Pregnancy Childbirth 22 (2022) 562. https://doi.org/10.1186/s12884-022-04891-w.
DOI Google Scholar
[35]

M. Slutzah, C.N. Codipilly, D. Potak, et al., Refrigerator storage of expressed human milk in the neonatal intensive care unit, J. Pediatr. 156 (2010) 26-28. https://doi.org/10.1016/j.jpeds.2009.07.023.
DOI Google Scholar
[36]

J.T. Smilowitz, D.S. Gho, M. Mirmiran, et al., Rapid measurement of human milk macronutrients in the neonatal intensive care unit: accuracy and precision of fourier transform mid-infrared spectroscopy, J. Hum. Lact. 30 (2014) 180-189. https://doi.org/10.1177/0890334413517941.
DOI Google Scholar
[37]

H. Billard, L. Simon, E. Desnots, et al., Calibration adjustment of the mid-infrared analyzer for an accurate determination of the macronutrient composition of human milk, J. Hum. Lact. 32 (2016) Np19-27. https://doi.org/10.1177/0890334415588513.
DOI Google Scholar
[38]

V. Toffanin, M.D. Marchi, N. Lopez-Villalobos, et al., Effectiveness of mid-infrared spectroscopy for prediction of the contents of calcium and phosphorus, and titratable acidity of milk and their relationship with milk quality and coagulation properties, Int. Dairy J. 41 (2015) 68-73.
DOI Google Scholar
[39]

S.G. Baker, Maximum likelihood estimation with missing outcomes: from simplicity to complexity, Stat. Med. 38 (2019) 4453-4474. https://doi.org/10.1002/sim.8319.
DOI Google Scholar
[40]

J.H. Kim, Multicollinearity and misleading statistical results, Korean J. Anesthesiol. 72 (2019) 558-569. https://doi.org/10.4097/kja.19087.
DOI Google Scholar
[41]

V.L. Hedges, E.C. Heaton, C. Amaral, et al., Estrogen withdrawal increases postpartum anxiety via oxytocin plasticity in the paraventricular hypothalamus and dorsal raphe nucleus, Biol. Psychiatry 89 (2021) 929-938. https://doi.org/10.1016/j.biopsych.2020.11.016.
DOI Google Scholar
[42]

F. Pansini, G. Bonaccorsi, F. Genovesi, et al., Influence of estrogens on serum free fatty acid levels in women, J. Clin. Endocrinol. Metab. 71 (1990) 1387-1389. https://doi.org/10.1210/jcem-71-5-1387.
DOI Google Scholar
[43]

V. Swanson, A. Keely, F.C. Denison, Does body image influence the relationship between body weight and breastfeeding maintenance in new mothers?, Br. J. Health Psychol. 22 (2017) 557-576. https://doi.org/10.1111/bjhp.12246.
DOI Google Scholar
[44]

G. Ding, L. Niu, A. Vinturache, et al., “Doing the month” and postpartum depression among Chinese women: a Shanghai prospective cohort study, Women Birth. 33 (2020) e151-e158. https://doi.org/10.1016/j.wombi.2019.04.004.
DOI Google Scholar
[45]

L.W. Chen, Y.L. Low, D. Fok, et al., Dietary changes during pregnancy and the postpartum period in Singaporean Chinese, Malay and Indian women: the GUSTO birth cohort study, Public Health Nutr. 17 (2014) 1930-1938. https://doi.org/10.1017/S1368980013001730.
DOI Google Scholar
[46]

J.C. Kent, A.R. Hepworth, J.L. Sherriff, et al., Longitudinal changes in breastfeeding patterns from 1 to 6 months of lactation, Breastfeed Med. 8 (2013) 401-407. https://doi.org/10.1089/bfm.2012.0141.
DOI Google Scholar
[47]

Y. Zhang, S. Chua, Leptin function and regulation, Compr. Physiol. 8 (2017) 351-369. https://doi.org/10.1002/cphy.c160041.
DOI Google Scholar
[48]

U.K. Andersson-Hall, A. Pivodic, H.K. de Maré, et al., Infant body composition relationship to maternal adipokines and fat mass: the PONCH study, Pediatric Res. 89 (2021) 1756-1764. https://doi.org/10.1038/s41390-020-01115-9.
DOI Google Scholar
[49]

F. Mosca, M.L. Giannì, Human milk: composition and health benefits, Pediatr. Med. Chir. 39 (2017) 155. https://doi.org/10.4081/pmc.2017.155.
DOI Google Scholar
[50]

R. Bellù, M. Condò, Breastfeeding promotion: evidence and problems, Pediatr. Med. Chir. 39 (2017) 156. https://doi.org/10.4081/pmc.2017.156.
DOI Google Scholar
[51]

P. Huang, J. Yao, X. Liu, et al., Individualized intervention to improve rates of exclusive breastfeeding: a randomised controlled trial, Medicine 98 (2019) e17822. https://doi.org/10.1097/MD.0000000000017822.
DOI Google Scholar
[52]

C.D. Garner, S.L. Ratcliff, C.M. Devine, et al., Health professionals’ experiences providing breastfeeding-related care for obese women, Breastfeeding Med. 9 (2014) 503-509. https://doi.org/10.1089/bfm.2014.0104.
DOI Google Scholar
[53]

E.H. Anstey, M.L. Shoemaker, C.M. Barrera, et al., Breastfeeding and breast cancer risk reduction: implications for black mothers, Am. J. Prev. Med. 53 (2017) S40-46. https://doi.org/10.1016/j.amepre.2017.04.024.
DOI Google Scholar
[54]

S. Thapa, R.V. Short, M. Potts, Breast feeding, birth spacing and their effects on child survival, Nature 335 (1988) 679-682. https://doi.org/10.1038/335679a0.
DOI Google Scholar
[55]

F. Islami, Y. Liu, A. Jemal, et al., Breastfeeding and breast cancer risk by receptor status: a systematic review and meta-analysis, Ann. Oncol. 26 (2015) 2398-2407. https://doi.org/10.1093/annonc/mdv379.
DOI Google Scholar
[56]

L. Wang, J. Li, Z. Shi, Association between breastfeeding and endometrial cancer risk: evidence from a systematic review and meta-analysis, Nutrients 7 (2015) 5697-5711. https://doi.org/10.3390/nu7075248.
DOI Google Scholar
[57]

A. Babic, N. Sasamoto, B.A. Rosner, et al., Association between breastfeeding and ovarian cancer risk, JAMA Oncol. 6 (2020) e200421. https://doi.org/10.1001/jamaoncol.2020.0421.
DOI Google Scholar
[58]

B.L. Horta, N.P. de Lima, Breastfeeding and type 2 diabetes: systematic review and meta-analysis, Curr. Diab. Rep. 19 (2019) 1. https://doi.org/10.1007/s11892-019-1121-x.
DOI Google Scholar
[59]

S. Rajaei, J. Rigdon, S. Crowe, at al., Breastfeeding duration and the risk of coronary artery disease, J. Womens Health (Larchmt) 28 (2019) 30-36. https://doi.org/10.1089/jwh.2018.6970.
DOI Google Scholar
[60]

C.K. McClure, J. Catov, R. Ness, et al., Maternal visceral adiposity by consistency of lactation, Matern. Child Health J. 16 (2012) 316-321. https://doi.org/10.1007/s10995-011-0758-0.
DOI Google Scholar
[61]

I. Headen, A.K. Cohen, M. Mujahid, et al., The accuracy of self-reported pregnancy-related weight: a systematic review, Obes. Rev. 18 (2017) 350-369. https://doi.org/10.1111/obr.12486.
DOI Google Scholar
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Publication history

Received: 15 February 2022
Revised: 03 April 2022
Accepted: 01 August 2022
Published: 01 June 2023
Issue date: January 2024

Copyright

© 2024 Beijing Academy of Food Sciences. Publishing services by Tsinghua University Press.

Acknowledgements

We thank all participants in this study. We thank Mr. Zhongliang Jin for his help in drawing. We also thank all colleagues in the Department of Obstetrics and Gynecology of Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Ms. Jing Yang of the Brand Development Department, and Ms. Heng Zou of the Outpatient Department for their support in the recruitment process. This study was supported by grants from the Shanghai Key Laboratory of Pediatric Gastroenterology and Nutrition (17dz2272000), Foundation of Shanghai Municipal Health Commission (Key weak discipline construction project 2019ZB0101), and the Scientific research fund of China Nutrition Society (CNSHPNK2021-16).

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This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

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