Journal of Sports and Biomotor Sciences

Journal of Sports and Biomotor Sciences

The Effect of Combined Exercise Training and Black Seed Consumption on Blood Pressure and Some Indicators of Physical Performance in Postmenopausal Women with Prehypertension

Document Type : Original Article

Authors
1 M.Sc. Student, Faculty of Sport Sciences, Hakim Sabzevari University, Sabzevar, Iran
2 Associate Professor of Exercise Physiology, Faculty of Sport Sciences, Hakim Sabzevari University, Sabzevar, Iran
3 Professor of Exercise Physiology, Faculty of Sport Sciences, Hakim Sabzevari University, Sabzevar, Iran.
4 Ph.D. Student in Exercise Physiology, Faculty of Sport Sciences, Hakim Sabzevari University, Sabzevar, Iran
5 Ph.D. Student in Sport Management, Islamic Azad University, Shahroud, Iran
10.22034/sbs.2026.577607.1164
Abstract
Introduction and Purpose: Investigating the effect of combined exercise training and black seed consumption on blood pressure and physical performance in postmenopausal women with prehypertension.
Materials and Methods: 40 postmenopausal women with systolic blood pressure of 130-139 and diastolic blood pressure of 85-89 mmHg were purposefully selected and randomly assigned to four groups: combined T+BS (training + black seed), combined T+P (training + placebo), black seed, and placebo. The exercise groups did rope and Swiss ball exercises three times a week for eight weeks, and the supplement groups took 2000 mg of black seed twice a day.
Results: There was no significant difference between the groups in weight, thigh circumference, waist circumference, upper body functional strength, cardiorespiratory endurance, agility, and diastolic blood pressure, but there was a significant improvement in the hand strength of the T+BS group compared to the black seed and placebo groups, the fat percentage of the T+BS group compared to the placebo group, and the lower body functional strength of the T+BS and T+P compared to the other groups. The central strength and endurance of the T+P compared to the nigella group, the functional endurance of the lower body of the T+ N (training group + nigella) and T+P compared to the nigella and placebo groups, and the systolic blood pressure of the T+ N compared to the T+P, nigella, and placebo groups were observed.
Conclusion: It is possible that rope skipping+Swiss ball T+BS supplement can have a beneficial effect on systolic blood pressure and some performance indicators of women with prehypertensive conditions.
Keywords
Subjects

Extended Abstract

1.   Introduction and Objective

High blood pressure is one of the deadliest causes of cardiovascular disease in the world, but it is preventable. Its overall prevalence is 30-45% in adults and about 60% in people over 60 years old. According to the seventh report of the National Joint Committee on Prevention, Identification, Evaluation and Treatment of High Blood Pressure, Hypertension is known as systolic blood pressure above 140 mm Hg or diastolic blood pressure above 90 mm Hg. In women, after natural or surgical postmenopausal, estrogen levels decrease gradually or suddenly. Postmenopausal it can increase the risk of heart disease and metabolic disorders. Cross-sectional data have shown that hypertension is four times more common in postmenopausal women than in non-menopausal women. Changing the life style is the primary treatment for high blood pressure and can be like a drug treatment. These changes include reducing salt intake, avoiding alcohol, consuming plant-based foods, losing weight and regular physical activity .Among the non-pharmacological approaches to prevent and treat high blood pressure, exercise is probably the most promising .It is now well accepted that blood pressure decreases temporarily after short-term exercise, and this effect, called post-exercise hypotension (PEH), can last for several hours in hypertensive individuals. Frequent bouts of short-term sports activities are an important factor in long-term adaptations which prevents or delays the onset of high blood pressure.

Another type of treatment that has received attention in recent years is the use of medicinal plants. Black seed, also known as black cumin, has many therapeutic values, including for diabetes, tumors, high cholesterol, high blood pressure, inflammation, and digestive disorders. Among the possible mechanisms involved in lowering blood pressure are the cardiac suppressive effect (decreasing cardiac function), calcium channels and Diuretic effect.

However, the effect of aerobic and resistance training methods in combination with black seed consumption in patients with high blood pressure has been less investigated. In addition, research on people with prehypertensive conditions is more limited. Based on the information stated, this study aimed to investigate The effect of combined exercise and consumption of black seeds on some indicators of physical performance in postmenopausal women with prehypertension.

2.      Materials and Methods

40 postmenopausal women with systolic blood pressure of 130-139 and diastolic blood pressure of 85-89 mmHg were purposefully selected and randomly assigned to four groups of combined exercise + black seed, combined exercise, black seed + placebo. 24 hours before the training period and after the last session, anthropometric, functional, systolic, and diastolic blood pressure indicators were evaluated. The exercise groups did rope and Swiss ball exercises three times a week for eight weeks, and the supplement groups took 2000 mg of black seed (1000 mg capsules) twice a day.

Analysis of data: In the descriptive statistics section, mean and standard deviation were used. Normality hypothesis was assessed by Shapiro-Wilk test and homoscedasticity assumptions by Levene’s test for equality of variances. Analysis of MA-ANOVA tests were used to compare between groups. The significance level was p≤0.05.

3.   Results

There was no significant difference between the groups in weight, thigh circumference, waist circumference, upper body functional strength, cardiorespiratory endurance, agility and diastolic blood pressure (p < 0.05), but there was a significant improvement in the hand strength of the training + black seed group compared to the black seed and placebo groups, the fat percentage of the training + black seed group compared to the placebo group, and the lower body functional strength of the training + black seed and training groups compared to the group. The central strength and endurance of the training group compared to the nigella group and the functional endurance of the lower body of the training group + nigella compared to the nigella and placebo groups and the systolic blood pressure of the training group + nigella compared to the exercise, nigella and placebo groups were observed (p≤0.05).

4.   Conclusions

It is possible that rope skipping + Swiss ball training with black seed supplement can have a beneficial effect on systolic blood pressure and some performance indicators of women with prehypertensive conditions.

5.      Acknowledgment & Funding

Ethical considerations were followed based to the guidelines

Presented by the Ethics Committee of Hakim Sabzevari University.

6.   Ethical Considerations

This study was conducted without any financial sponsor.

7.   Authors' Contributions

All authors contributed to the editing, writing, and preparation of this article.

8. Conflict of Interest

The authors have no conflict of interest.

9. Acknowledgments

We are very grateful to the respected professors, colleagues, and others who cooperated in the implementation of this thesis.

1. Xiao J, editor. Physical exercise for human health. Singapore: Springer Singapore; 2020 Apr 27. DOI: 10.1007/978-981-15-1792-1.
2. Leong XF, Rais Mustafa M, Jaarin K. Nigella sativa and its protective role in oxidative stress and hypertension. Evidence‐Based Complementary and Alternative Medicine. 2013;2013(1):120732, DOI: 10.1155/2013/120732.
3. Talha J, Priyanka M, Akanksha A. Hypertension and herbal plants. Int Res J Pharm. [Internet]. 2011;2(8):26-30. Availablefrom:https://irjponline.org/index.php/irjp/article/view/1854.
4. Caligiuri SP, Pierce GN. A review of the relative efficacy of dietary, nutritional supplements, lifestyle, and drug therapies in the management of hypertension. Critical reviews in food science and nutrition. 2017 Nov 2;57(16):3508-27. DOI: 10.1080/10408398.2016.1142420.
5. Lin YY, Lee SD. Cardiovascular benefits of exercise training in postmenopausal hypertension. International journal of molecular sciences. 2018 Aug 25;19(9):2523. DOI: 10.3390/ijms19092523. 6. Maideen NM, Balasubramanian R, Ramanathan S. Nigella Sativa (Black Seeds), A potential herb for the pharmacotherapeutic management of hypertension: a review. Current Cardiology Reviews. 2021 Jul 7;17(4). DOI: 10.2174/1573403X16666201110125906.
7. Pescatello LS, MacDonald HV, Lamberti L, Johnson BT. Exercise for hypertension: a prescription update integrating existing recommendations with emerging research. Current hypertension reports. 2015 Nov;17:1-0. DOI: 10.1007/s11906-015-0600-y.
8. Liu SA, Goodman J, Nolan R, Lacombe S, Thomas SG. Blood pressure responses to acute and chronic exercise are related in prehypertension. Medicine & Science in Sports & Exercise. 2012 Sep 1;44(9):1644-52. DOI: 10.1249/MSS.0b013e31825408fb.
9. De Sousa EC, Abrahin O, Ferreira AL, Rodrigues RP, Alves EA, Vieira RP. Resistance training alone reduces systolic and diastolic blood pressure in prehypertensive and hypertensive individuals: meta-analysis. Hypertension Research. 2017 Nov;40(11):927-31. DOI:10.1038/hr.2017.69.
10. Marquina M, Lorenzo-Calvo J, Rivilla-García J, García-Aliaga A, Refoyo Roman I. Effects on strength, power and speed execution using exercise balls, semi-sphere balance balls and suspension training devices: a systematic review. International journal of environmental research and public health. 2021 Feb;18(3):1026. DOI: 10.3390/ijerph18031026.
11. Muniyar KD, Darade SB. Effect of swiss ball training and conventional physio-therapy to improve balance and mobility in post-stroke patients. Int J Physiother Res. 2018;6(4):2813-2. DOI:10.16965/ijpr.2018.156.
12. Kaviraja K, Sangma AK, Kumara P, Kaviraja N, Agustina SJ. A study to analyze the effectiveness of Swiss ball exercise versus resistance training in type 2 diabetes mellitus. Biomedicine. 2021 Sep 7;41(2):493-7. DOI:10.51248/.v41i2.1065.
13. Moratilla-Rivera I, Sánchez M, Valdés-González JA, Gómez-Serranillos MP. Natural Products as Modulators of Nrf2 Signaling Pathway in Neuroprotection. Int J Mol Sci. 2023 Feb 13;24(4):3748. doi: 10.3390/ijms24043748. PMID: 36835155; PMCID: PMC9967135.
14. Jaarin K, Foong WD, Yeoh MH, Kamarul ZY, Qodriyah HM, Azman A, Zuhair JS, Juliana AH, Kamisah Y. Mechanisms of the antihypertensive effects of Nigella sativa oil in L-NAME-induced hypertensive rats. Clinics (Sao Paulo). 2015 Nov;70(11):751-7. DOI: 10.6061/clinics/2015(11)07. PMID: 26602523; PMCID: PMC4642492.
15. Moreau, Kerrie L., Hildreth, Kerry L., Vascular Aging across the Menopause Transition in Healthy Women, Advances in Vascular Medicine, 2014, 204390, 12 pages, 2014. DOI: 10.1155/2014/204390.
16. Adebisi YA, Alshahrani NZ, Ogunkola IO, Lucero-Prisno III DE. Physical disability and risk of incident hypertension: a prospective cohort analysis. Journal of Human Hypertension. 2025 Oct;39(10):709-15. DOI:10.1038/s41371-025-01061-1.
17. Walankar P, Kini R, Panhale V, Desai N. Influence of menopausal status on physical function and performance: A cross-sectional study. Post Reproductive Health. 2023 Sep;29(3):129-33. DOI:10.1177/20533691231185414.
18. Moreau KL, Hildreth KL. Vascular aging across the menopause transition in healthy women. Advances in vascular medicine. 2014;2014(1):204390. DOI: 10.1155/2014/204390.
19. Hulteen RM, Marlatt KL, Allerton TD, Lovre D. Detrimental changes in health during menopause: the role of physical activity. International journal of sports medicine. 2023 Jun;44(06):389-96. DOI: 10.1055/a-2003-9406.
20.
Golpour-Hamedani S, Hadi A, SafariMalekabadi D, Najafgholizadeh A, Askari G, Pourmasoumi M. The effect of nigella supplementation on blood pressure: a systematic review and dose-response meta-analysis. Critical reviews in food science and nutrition. 2024 Feb 5;64(4):943-56. DOI: 10.1080/10408398.2022.2110566.
21. Cornelissen VA, Smart NA. Exercise training for blood pressure: a systematic review and meta‐analysis. Journal of the American heart association. 2013 Feb 1;2(1):e004473. DOI: 10.1161/JAHA.112.004473.
22. Kekelekis A, Knechtle B, Nikolaidis PT. Effect of a 5-month exercise program on blood pressure and glucose: A case study of a 68-year-old woman with diabetes mellitus type II and hypertension. Biomedical Human Kinetics. 2020 Jan 1;12(1):182-6. DOI:10.2478/bhk-2020-0023.
23. Caminiti G, Iellamo F, Mancuso A, Cerrito A, Montano M, Manzi V, Volterrani M. Effects of 12 weeks of aerobic versus combined aerobic plus resistance exercise training on short-term blood pressure variability in patients with hypertension. Journal of Applied Physiology. 2021 Apr 1;130(4):1085-92. DOI: 10.1152/japplphysiol.00910.2020.
            
24. Rizka A, Setiati S, Lydia A, Dewiasty E. Effect of Nigella sativa seed extract for hypertension in elderly: a double-blind, randomized controlled trial. Acta Med Indones. 2017 Oct 1;49(4):307-13. PMID: 29348380
25. Collier SR, Landram MJ. Treatment of prehypertension: lifestyle and/or medication. Vascular Health and Risk Management. 2012 Nov 15:613-9. DOI: 10.2147/VHRM.S29138.
26. Safi S, Razmpoosh E, Fallahzadeh H, Mazaheri M, Abdollahi N, Nazari M, Nadjarzadeh A, Salehi-Abargouei A. The effect of Nigella sativa on appetite, anthropometric and body composition indices among overweight and obese women: A crossover, double-blind, placebo-controlled, randomized clinical trial. Complementary Therapies in Medicine. 2021 Mar 1;57:102653 (Persian). DOI: 10.1016/j.ctim.2020.102653.     
27. Pouyafar M, Askari R, Hoseini Kakhk SA, Damavandi M, Maleki A. Comparing the effects of eight weeks of whole body vibration exercise combined with rope skipping at two different intensities on physical performance of older men: a randomized single-blind clinical trial. Iranian Journal of Ageing. 2021 Oct 10;16(3):376-95. DOI: 10.32598/sija.2021.16.3.2885.2.
28. Matsudo VK, Matsudo SM, Rezende LF, Raso V. Handgrip strength as a predictor of physical fitness in children and adolescents. Revista Brasileira de Cineantropometria & Desempenho Humano. 2015 Jan;17:01-10. DOI: 10.5007/1980-0037.
29. Rikli RE, Jones CJ. Development and validation of a functional fitness test for community-residing older adults. Journal of aging and physical activity. 1999 Apr 1;7(2):129-61. DOI: 10.1093/geront/gns071.
30. Krause DA, Youdas JW, Hollman JH, Smith J. Abdominal muscle performance as measured by the double leg-lowering test. Archives of physical medicine and rehabilitation. 2005 Jul 1;86(7):1345-8. DOI: 10.1093/geront/gns071.
31. Ozsoy G, Ilcin N, Ozsoy I, Gurpinar B, Buyukturan O, Buyukturan B, Kararti C, Sas S. The effects of myofascial release technique combined with core stabilization exercise in elderly with non-specific low back pain: A randomized controlled, single-blind study. Clinical Interventions in Aging. 2019 Oct 9:1729-40. DOI: 10.2147/CIA.S223905.
32. Montrezol F, Antunes H, Almeida V, Gomes R, Medeiros A. Resistance training promotes reduction in blood pressure and increase plasma adiponectin of hypertensive elderly patients. J Hypertens. 2014;3(185):1-6. DOI:10.4172/2167-1095.1000185.
33. Figueroa A, Park SY, Seo DY, Sanchez-Gonzalez MA, Baek YH. Combined resistance and endurance exercise training improves arterial stiffness, blood pressure, and muscle strength in postmenopausal women. Menopause. 2011 Sep 1;18(9):980-4. DOI: 10.1097/gme.0b013e3182135442.
34. Ciolac EG. Exercise training as a preventive tool for age-related disorders: a brief review. Clinics. 2013;68:710-7. DOI: 10.6061/clinics/2013(05)20.
35. BenedineD'souza P, Varadharajulu G. Influence of Swiss Ball Training on Menopause Specific Quality of Life. Int J Psychosoc Rehabil. 2020;24(6):13452-13460. DOI:10.61841/n5w1db09.
36. Lima AH, Correia MA, Soares AH, Farah BQ, Forjaz CL, Silva AS, Brasileiro‐Santos MS, Santos AC, Ritti‐Dias RM. Acute effects of walking and combined exercise on oxidative stress and vascular function in peripheral artery disease. Clinical physiology and functional imaging. 2018 Jan;38(1):69-75. DOI: 10.1111/cpf.12384.
37. Labott BK, Donath L. Agility performance in healthy older adults is associated with handgrip strength and force development: Results from a 1-year randomized controlled trial. European geriatric medicine. 2023 Jun;14(3):547-55.
DOI: 10.1007/s41999-023-00789-8.
38. Santos EJ, Janeira MA. The effects of resistance training on explosive strength indicators in adolescent basketball players. The journal of strength & conditioning research. 2012 Oct 1;26(10):2641-7. DOI: 10.1519/JSC.0b013e31823f8dd4.
39. González-Gálvez N, Moreno-Torres JM, Vaquero-Cristóbal R. Resistance training effects on healthy postmenopausal women: a systematic review with meta-analysis. Climacteric. 2024 May 3;27(3):296-304. DOI: 10.1080/13697137.2024.2310521.
40.Yang D, Tao S, Shao M, Huang L, Xiao X, Zhang J, Yao R, Sun Z. Effectiveness of exercise training on arterial stiffness and blood pressure among postmenopausal women: a systematic review and meta-analysis. Systematic Reviews. 2024 Jul 2;13(1):169. DOI: 10.1186/s13643-024-02589-y.
41. Gorostiaga EM, Izquierdo M, Iturralde P, Ruesta M, Ibáñez J. Effects of heavy resistance training on maximal and explosive force production, endurance and serum hormones in adolescent handball players. European Journal of Applied Physiology and Occupational Physiology. 1999 Sep;80:485-93. DOI: 10.1007/s004210050622.
42. Jahromi MS, Gholami M. The effect of jump-rope training on the physical fitness of 9 to 10 years old female students. Advances in Applied Science Research. 2015;6(4):135-40. ISSN: 0976-8610. (Persian).
43.Weggen JB, Hogwood AC, Decker KP, Darling AM, Chiu A, Richardson J, Garten RS. Vascular Responses to Passive and Active Movement in Premenopausal Females: Comparisons across Sex and Menstrual Cycle Phase. Medicine and science in sports and exercise. 2022 Dec 24;55(5):900-10. DOI: 10.1249/MSS.0000000000003107.
44. Mirzaei, B., & Rahmani-Nia, F. (2021). Determining the effect of Nigella sativa supplementation on the symptoms of delayed muscle onset soreness following an extrovert activity session in inactive girls. In The 9th International Conference on Sport Sciences and Physical Education. Civilica. https://en.civilica.com/doc/1507792/.  
45. Ghasemi KA, Haji KZ. The Simultaneous Effect of Four Weeks of Nigella Sativa Oil Supplementation and Aerobic Exercise on Some Stress and Growth Factors of Inactive Young Women. DOI: 10.61186/cmja-130241.
46. Rahman M, Yang DK, Kim GB, Lee SJ, Kim SJ. Nigella sativa seed extract attenuates the fatigue induced by exhaustive swimming in rats. Biomedical reports. 2017 Apr 1;6(4):468-74. DOI: 10.3892/br.2017.866.
47. Nuhmani S. Efficacy of dynamic Swiss ball training in improving the core stability of collegiate athletes. Physical Activity Review. 2021;1(9):9-15. DOI: 10.16926/par.2021.09.02.
48. Sekendiz B, Cug M, Korkusuz F. Effects of Swiss-ball core strength training on strength, endurance, flexibility, and balance in sedentary women. The Journal of Strength & Conditioning Research. 2010 Nov 1;24(11):3032-40. DOI: 10.1519/JSC.0b013e3181d82e70.
49. Batista GD, Beltrán SP, Passos MH, Calixtre LB, Santos LR, de Araújo RC. Comparison of the electromyography activity during exercises with stable and unstable surfaces: a systematic review and meta-analysis. Sports. 2024 Apr 18;12(4):111. DOI:10.3390/sports12040111.
50. Vera-Garcia FJ, Grenier SG, McGill SM. Abdominal muscle response during curl-ups on both stable and labile surfaces. Physical therapy. 2000 Jun 1;80(6):564-9. PMID: 10842409
51. Rahman M, Yang DK, Kim GB, Lee SJ, Kim SJ. Nigella sativa seed extract attenuates the fatigue induced by exhaustive swimming in rats. Biomedical reports. 2017 Apr 1;6(4):468-74. DOI: 10.3892/br.2017.866.
52. Gildenhuys GM, Toriola AL, Fourie M, Shaw I, Witthuhn J, Shaw BS. Evaluation of Pilates training on agility, functional mobility and cardiorespiratory fitness in elderly women and fitness. African Journal for Physical Health Education, Recreation and Dance. 2013 Jun 1;19(2):505-12.
 
53. Sonchan W, Moungmee P, Sootmongkol A. The effects of a circuit training program on muscle strength, agility, anaerobic performance and cardiovascular endurance. International Journal of Sport and Health Sciences. 2017 Apr 1;11(4):176-9. Corpus ID: 52258963.
54. Khalafi M, Sakhaei MH, Rosenkranz SK, Symonds ME. Impact of concurrent training versus aerobic or resistance training on cardiorespiratory fitness and muscular strength in middle-aged to older adults: A systematic review and meta-analysis. Physiology & Behavior. 2022 Oct 1;254:113888. DOI:10.1016/j.physbeh.2022.113888.
55.
Wei B, Cheng W and Qiu J (2025) The effects of 12 weeks of high-intensity interval rope skipping training on speed and power indexes in male soccer players. Front. Bioeng. Biotechnol. 13:1579535. doi: 10.3389/fbioe.2025.1579535.
56. Rasoulpour J. Afshar J. Gharani H. Sharifan S. Bahraminiya. The effect of eight weeks of plyometric exercises on some physical fitness factors related to Skill of male amateur basketball players. Sports Sciences Quarterly 2018; 10(29):70-89.
57. Hojka V, Stastny P, Rehak T, Gołas A, Mostowik A, Zawart M, Musálek M. A systematic review of the main factors that determine agility in sport using structural equation modeling. Journal of Human kinetics. 2016 Sep 10;52:115. DOI: 10.1515/hukin-2015-0199. 
58. Schroeder EC. Independent and combined effects of aerobic and resistance training on blood pressure (ART-B) (Doctoral dissertation, Iowa State University). DOI: 10.31274/ETD-180810-4084.
59. Edwards JJ, Deenmamode AH, Griffiths M, Arnold O, Cooper NJ, Wiles JD, O'Driscoll JM. Exercise training and resting blood pressure: a large-scale pairwise and network meta-analysis of randomised controlled trials. British journal of sports medicine. 2023 Oct 1;57(20):1317-26. doi:10.1136/bjsports-2022-106503. DOI: 10.1136/bjsports-2022-106503.
60. RAFATI FM, PAKFETRAT M, TAGHIAN F. The Effect of 8 Week Running on Treadmills on the Amount of blood pressure and excreted albumin protein in Patients with Chronic kidney.
61. Smelker CL, Foster C, Maher MA, Martinez R, Porcari JP. Effect of exercise intensity on postexercise hypotension. Journal of Cardiopulmonary Rehabilitation and Prevention. 2004 Jul 1;24(4):269-73. DOI: 10.1097/00008483-200407000-00012.      
62. Al Asoom LI. Coronary angiogenic effect of long-term administration of Nigella sativa. BMC complementary and alternative medicine. 2017 Dec;17(1):1-7. DOI: 10.1186/s12906-017-1795.
63. El-Bahai MN, Al-Hariri MT, Yar T, Bamosa AO. Cardiac inotropic and hypertrophic effects of Nigella sativa supplementation in rats. International Journal of Cardiology. 2009 Jan 24;131(3):e115-7. DOI: 10.1016/j.ijcard.2007.07.075.
64. Al-Asoom LI, Al-Shaikh BA, Bamosa AO, El-Bahai MN. Effect of Nigella sativa supplementation to exercise training in a novel model of physiological cardiac hypertrophy. Cardiovascular toxicology. 2014 Sep;14:243-50. DOI: 
10.1007/s12012-014-9248-0.
65. Al-Asoom LI, Al-Shaikh BA, Bamosa AO, El-Bahai MN. Comparison of Nigella sativa-and exercise-induced 5dels of cardiac hypertrophy: structural and electrophysiological features. Cardiovascular toxicology. 2014 Sep;14:208-13. DOI: 10.1007/s12012-014-9244-4.
 66. Iellamo F, Caminiti G, Montano M, Manzi V, Franchini A, Mancuso A, Volterrani M. Prolonged post-exercise hypotension: Effects of different exercise modalities and training statuses in elderly patients with hypertension. International Journal of Environmental Research and Public Health. 2021 Mar 20;18(6):3229. DOI: 10.3390/ijerph18063229. 

  • Receive Date 23 February 2026
  • Revise Date 05 September 2026
  • Accept Date 07 September 2026