Dietary fiber in the prevention of obesity and obesity-related chronic diseases: From epidemiological evidence to potential molecular mechanisms.

Obesity is a mostly preventable diet-related disease and currently a major challenge for human populations worldwide. Obesity is a major risk factor for diseases such as type 2 diabetes mellitus (T2DM), cardiovascular disease (CVD) and certain cancers. Dietary fiber is a complex mixture of non-digestible molecules, mostly polysaccharides. Multiple epidemiological studies have demonstrated statistically significant reductions in risks of obesity, T2DM, CVD, colorectal cancer, and pre-menopausal breast cancer with higher dietary fiber intakes. Various direct and indirect mechanisms have been proposed including altered digestion and absorption, stimulation of gut hormones including glucagon-like-peptide-1 (GLP-1) and peptide YY (PYY), reduced appetite, and altered metabolism of bile and cholesterol. These may act via pathways involving G-protein-coupled receptors (GPRs), histone deacetylase (HDAC), and aromatase enzymes. Ultimately, fiber intake contributes to improving glucose levels and insulin sensitivity, lowering risk of T2DM, CVD and certain cancers. Therefore, diets rich in dietary fiber should be encouraged to prevent obesity and associated chronic disease.

Chromogenic Assay Is More Efficient in Identifying α-Amylase Inhibitory Properties of Anthocyanin-Rich Samples When Compared to the 3,5-Dinitrosalicylic Acid (DNS) Assay.

The inhibition of carbohydrate digestion by plant bioactive compounds is a potential dietary strategy to counteract type 2 diabetes. Indeed, inhibition of α-amylase, a key enzyme that carries out the bulk of starch digestion, has been demonstrated for a range of bioactive compounds including anthocyanins; however, sample pigmentation often interferes with measurements, affecting colorimetric assay outcomes. Therefore, the present study compared the performance of a direct chromogenic assay, using 2-chloro-4 nitrophenyl α-D-maltotrioside (CNPG3) as a substrate, with the commonly used 3,5-dinitrosalicylic acid (DNS) assay. The direct chromogenic assay demonstrated a 5-10-fold higher sensitivity to determine α-amylase inhibition in various samples, including acarbose as a reference, pure anthocyanins, and anthocyanin-rich samples. The IC50 values of acarbose presented as 37.6 µg/mL and 3.72 µg/mL for the DNS assay and the direct chromogenic assay, respectively, whereas purified anthocyanins from blackcurrant showed IC50 values of 227.4 µg/mL and 35.0 µg/mL. The direct chromogenic assay is easy to perform, fast, reproducible, and suitable for high-throughput screening of pigmented α-amylase inhibitors.

Pulse consumption improves indices of glycemic control in adults with and without type 2 diabetes: a systematic review and meta-analysis of acute and long-term randomized controlled trials.

PURPOSE: Findings from randomized controlled trials (RCTs) evaluating the effect of pulse intake on glycemic control are inconsistent and conclusive evidence is lacking. The aim of this study was to systematically review the impact of pulse consumption on post-prandial and long-term glycemic control in adults with and without type 2 diabetes (T2D). METHODS: Databases were searched for RCTs, reporting outcomes of post-prandial and long-term interventions with different pulse types on parameters of glycemic control in normoglycemic and T2D adults. Effect size (ES) was calculated using random effect model and meta-regression was conducted to assess the impact of various moderator variables such as pulse type, form, dose, and study duration on ES. RESULTS: From 3334 RCTs identified, 65 studies were eligible for inclusion involving 2102 individuals. In acute RCTs, pulse intake significantly reduced peak post-prandial glucose concentration in participants with T2D (ES - 2.90; 95%CI - 4.60, - 1.21; p ≤ 0.001; I2 = 93%) and without T2D (ES - 1.38; 95%CI - 1.78, - 0.99; p ≤ 0.001; I2 = 86%). Incorporating pulse consumption into long-term eating patterns significantly attenuated fasting glucose in normoglycemic adults (ES - 0.06; 95%CI - 0.12, 0.00; p ≤ 0.05; I2 = 30%). Whereas, in T2D participants, pulse intake significantly lowered fasting glucose (ES - 0.54; 95%CI - 0.83, - 0.24; p ≤ 0.001; I2 = 78%), glycated hemoglobin A1c (HbA1c) (ES - 0.17; 95%CI - 0.33, 0.00; p ≤ 0.05; I2 = 78) and homeostatic model assessment of insulin resistance (HOMA-IR) (ES - 0.47; 95%CI - 1.25, - 0.31; p ≤ 0.05; I2 = 79%). CONCLUSION: Pulse consumption significantly reduced acute post-prandial glucose concentration > 1 mmol/L in normoglycemic adults and > 2.5 mmol/L in those with T2D, and improved a range of long-term glycemic control parameters in adults with and without T2D. PROSPERO REGISTRY NUMBER: (CRD42019162322).

Short-time acoustic and hydrodynamic cavitation improves dispersibility and functionality of pectin-rich biopolymers from citrus waste.

Pectin is a valuable biopolymer used as a natural, clean label additive for thickening and gelling. However, industry faces issues with dispersibility and stability of pectin formulations. To address these issues, the effect of short processing time (30-180 s) with hydrodynamic (HC) and acoustic cavitation (AC) on the dispersibility and gelling functionality of mandarin pectin-rich polysaccharide (M-PRP) was investigated. Short-time processing with HC and AC did not affect polymer composition. HC, but not AC, decreased polydispersity index (PDI) from 0.78 to 0.68 compared to the control. Electron and atomic force microscopy showed that HC and AC decreased aggregation of fibrous and matrix polymers. Both treatments increased apparent viscosity significantly from 0.059 Pa s to 0.30 Pa s at 10 -s. The pectin dispersions showed good gelling capacity upon addition of calcium (final conc. 35 mM). HC and AC treatments for 150 s led to gels that were 7 and 4 times stronger (as measured by peak force) than the control with more homogeneous, less porous structures. In conclusion, short-time HC and AC can improve the dispersibility and functionality of citrus pectin without affecting composition, and are promising technologies to facilitate the use of pectin in industry applications.

A review of postharvest approaches to reduce fungal and mycotoxin contamination of foods.

Contamination of agricultural and food products by some fungi species that produce mycotoxins can result in unsafe food and feed. Mycotoxins have been demonstrated to have disease-causing activities, including carcinogenicity, immune toxicity, teratogenicity, neurotoxicity, nephrotoxicity, and hepatotoxicity. Most of mycotoxins are heat stable and cannot be easily destroyed by conventional thermal food processing or domestic cooking methods. Postharvest approaches to prevent growth of mycotoxin-producing fungi and detoxify mycotoxins from contaminated food are important topics in food safety research. Physical, chemical, and biological methods have been applied to prevent fungal growth or mycotoxin production, or to reduce mycotoxin content in the postharvest period and contribute toward mitigating against the effects of mycotoxins on human health. This literature review aims to evaluate postharvest approaches that have been applied to control both fungi growth and mycotoxin content in food and discuss their potential for upscaling to industrial scale.

Adsorption of aflatoxin B1 to corn by-products.

The adsorption of aflatoxin B1 (AFB1) to natural fiber materials prepared from corn by-products was investigated in this study. The results showed that corn cob powder (CCP) dose, particle size, time (0.25-24 h), temperature (4, 20, 37, 50 and 100 °C) and pH (2-8), had significant effects on adsorption. The maximum adsorption (98%) was with particles 500-355 µm in size at 20 °C for 8 h, at the dose of 50 mg mL-1. The adsorption fitted pseudo-second-order model and Langmuir isotherm well. Besides, CCP had a higher adsorption capacity to AFB1 than any single cell wall components of corn, which indicated that capillary effect happened in cell wall might be the main reason for adsorption. The results also suggested that CCP could reduce AFB1 content from both liquid and solid food matrixes. Briefly, CCP displayed promising properties that could be developed in nature-based practical applications for food aflatoxin decontamination.

Unveiling the nutritional spectrum: A comprehensive analysis of protein quality and antinutritional factors in three varieties of quinoa (Chenopodium quinoa Wild).

Quinoa (Chenopodium quinoa) is renowned for its high protein content and balanced amino acid profile. Despite promising protein characteristics, plant-based sources usually possess antinutritional factors (ANFs). This study aimed to analyze the nutritional and ANFs composition of three quinoa varieties (Black, Yellow, and Red), and assessed the protein quality. Among these varieties, Black quinoa showed the highest protein content (20.90 g/100 g) and total dietary fiber (TDF) (22.97 g/100 g). In contrast, Red quinoa exhibited the highest concentration of phenolic compounds (338.9 mg/100 g). The predominant ANFs identified included oxalates (ranging from 396.9 to 715.2 mg/100 g), saponins (83.27-96.82 g/100 g), and trypsin inhibitors (0.35-0.46 TUI/100 g). All three varieties showed similar in vitro protein digestibility (IVPD) (> 76.9 %), while Black quinoa exhibited the highest protein quality. In conclusion to ensure reduction of ANFs, processing methods are necessary in order to fully benefit from the high protein and nutritional value of quinoa.

Evolution of energy and nutrient supply in Zambia (1961-2013) in the context of policy, political, social, economic, and climatic changes.

An adequate supply of energy, micronutrients and macronutrients is essential to achieve food and nutrition security to prevent malnutrition. Socio-economic, political, and climatic events, however, can affect the supply of food and nutrients. We assessed country-level supply trends of food and nutrients and their sources within the context of policy changes and political, socio-economic and climatic events from 1961 to 2013 in Zambia. Due to the lack of national food consumption data, food supply data from the FAO food balance sheets, matched to food composition tables, were used to estimate the energy, macronutrient and micronutrient content of 264 food items available to Zambia. We calculated historical nutrient supplies based on demographic characteristics and population-level dietary requirements. Results showed that Zambia was nutrition insecure from 1961 to 2013 for key micronutrients vitamin A, folate, riboflavin, vitamin B12, calcium, zinc, iron, and energy-deficient from the late-1980s. The diet has not substantially changed over time, with maize being the dominant food source. However, refined energy-dense food has steadily increased in the diet coupled with a reduction in fibre. These nutrient supply and dietary pattern trends coincide with specific socio-economic, policy, political, and climatic events from the 1970s to the early-mid 2000s, such as population growth, maize subsidy and crop diversification policies, regime change and drought. This study shows how policy, political and climatic events have been central features shaping nutrient supplies and the consequences for nutrition security. The study provides a context to inform future food policies to improve food and nutrition security. Supplementary Information: The online version contains supplementary material available at 10.1007/s12571-022-01329-1.

Expression of mung bean pectin acetyl esterase in potato tubers: effect on acetylation of cell wall polymers and tuber mechanical properties.

A mung bean (Vigna radiata) pectin acetyl esterase (CAA67728) was heterologously expressed in tubers of potato (Solanum tuberosum) under the control of the granule-bound starch synthase promoter or the patatin promoter in order to probe the significance of O-acetylation on cell wall and tissue properties. The recombinant tubers showed no apparent macroscopic phenotype. The enzyme was recovered from transgenic tubers using a high ionic strength buffer and the extract was active against a range of pectic substrates. Partial in vivo de-acetylation of cell wall polysaccharides occurred in the transformants, as shown by a 39% decrease in the degree of acetylation (DA) of tuber cell wall material (CWM). Treatment of CWM using a combination of endo-polygalacturonase and pectin methyl esterase extracted more pectin polymers from the transformed tissue compared to wild type. The largest effect of the pectin acetyl esterase (68% decrease in DA) was seen in the residue from this extraction, suggesting that the enzyme is preferentially active on acetylated pectin that is tightly bound to the cell wall. The effects of acetylation on tuber mechanical properties were investigated by tests of failure under compression and by determination of viscoelastic relaxation spectra. These tests suggested that de-acetylation resulted in a stiffer tuber tissue and a stronger cell wall matrix, as a result of changes to a rapidly relaxing viscoelastic component. These results are discussed in relation to the role of pectin acetylation in primary cell walls and its implications for industrial uses of potato fibres.

Loss-of-function mutation of REDUCED WALL ACETYLATION2 in Arabidopsis leads to reduced cell wall acetylation and increased resistance to Botrytis cinerea.

Nearly all polysaccharides in plant cell walls are O-acetylated, including the various pectic polysaccharides and the hemicelluloses xylan, mannan, and xyloglucan. However, the enzymes involved in the polysaccharide acetylation have not been identified. While the role of polysaccharide acetylation in vivo is unclear, it is known to reduce biofuel yield from lignocellulosic biomass by the inhibition of microorganisms used for fermentation. We have analyzed four Arabidopsis (Arabidopsis thaliana) homologs of the protein Cas1p known to be involved in polysaccharide O-acetylation in Cryptococcus neoformans. Loss-of-function mutants in one of the genes, designated REDUCED WALL ACETYLATION2 (RWA2), had decreased levels of acetylated cell wall polymers. Cell wall material isolated from mutant leaves and treated with alkali released about 20% lower amounts of acetic acid when compared with the wild type. The same level of acetate deficiency was found in several pectic polymers and in xyloglucan. Thus, the rwa2 mutations affect different polymers to the same extent. There were no obvious morphological or growth differences observed between the wild type and rwa2 mutants. However, both alleles of rwa2 displayed increased tolerance toward the necrotrophic fungal pathogen Botrytis cinerea.

Impact of food processing on postprandial glycaemic and appetite responses in healthy adults: a randomized, controlled trial.

Chickpeas are among the lowest glycaemic index carbohydrate foods eliciting protracted digestion and enhanced satiety responses. In vitro studies suggest that mechanical processing of chickpeas significantly increases starch digestion. However, there is little evidence regarding the impact of processing on postprandial glycaemic response in response to chickpea intake in vivo. Therefore, the aim of this study was to determine the effect of mechanical processing on postprandial interstitial glycaemic and satiety responses in humans. In a randomised crossover design, thirteen normoglycaemic adults attended 4 separate laboratory visits following an overnight fast. On each occasion, one of four test meals, matched for available carbohydrate content and consisting of different physical forms of chickpeas (whole, puree, and pasta) or control (mashed potato), was administered followed by a subsequent standardised lunch meal. Continuous glucose monitoring captured interstitial glucose responses, accompanied by periodic venous blood samples for retrospective analysis of C-peptide, glucagon like peptide-1 (GLP-1), ghrelin, leptin, resistin, and cortisol. Subjective appetite responses were measured by Visual Analogue Scale (VAS). Postprandial glycaemic responses were comparable between chickpea treatments albeit significantly lower than the control (p < 0.001). Similarly, all chickpea treatments elicited significantly lower C-peptide and GLP-1 responses compared to the control (p < 0.05), accompanied by enhanced subjective satiety responses (p < 0.05), whilst no significant differences in satiety hormones were detected among different intervention groups (p > 0.05). Chickpea consumption elicits low postprandial glycaemic responses and enhanced subjective satiety responses irrespective of processing methods.

K-Clique Multiomics Framework: A Novel Protocol to Decipher the Role of Gut Microbiota Communities in Nutritional Intervention Trials.

The availability of omics data providing information from different layers of complex biological processes that link nutrition to human health would benefit from the development of integrated approaches combining holistically individual omics data, including those associated with the microbiota that impacts the metabolisation and bioavailability of food components. Microbiota must be considered as a set of populations of interconnected consortia, with compensatory capacities to adapt to different nutritional intake. To study the consortium nature of the microbiome, we must rely on specially designed data analysis tools. The purpose of this work is to propose the construction of a general correlation network-based explorative tool, suitable for nutritional clinical trials, by integrating omics data from faecal microbial taxa, stool metabolome (1H NMR spectra) and GC-MS for stool volatilome. The presented approach exploits a descriptive paradigm necessary for a true multiomics integration of data, which is a powerful tool to investigate the complex physiological effects of nutritional interventions.

Effects of combined abiotic stresses on nutrient content of European wheat and implications for nutritional security under climate change.

Climate change is causing problems for agriculture, but the effect of combined abiotic stresses on crop nutritional quality is not clear. Here we studied the effect of 10 combinations of climatic conditions (temperature, CO2, O3 and drought) under controlled growth chamber conditions on the grain yield, protein, and mineral content of 3 wheat varieties. Results show that wheat plants under O3 exposure alone concentrated + 15 to + 31% more grain N, Fe, Mg, Mn P and Zn, reduced K by - 5%, and C did not change. Ozone in the presence of elevated CO2 and higher temperature enhanced the content of Fe, Mn, P and Zn by 2-18%. Water-limited chronic O3 exposure resulted in + 9 to + 46% higher concentrations of all the minerals, except K. The effect of climate abiotic factors could increase the ability of wheat to meet adult daily dietary requirements by + 6% to + 12% for protein, Zn and Fe, but decrease those of Mg, Mn and P by - 3% to - 6%, and K by - 62%. The role of wheat in future nutrition security is discussed.

Meeting sustainable development goals via robotics and autonomous systems.

Robotics and autonomous systems are reshaping the world, changing healthcare, food production and biodiversity management. While they will play a fundamental role in delivering the UN Sustainable Development Goals, associated opportunities and threats are yet to be considered systematically. We report on a horizon scan evaluating robotics and autonomous systems impact on all Sustainable Development Goals, involving 102 experts from around the world. Robotics and autonomous systems are likely to transform how the Sustainable Development Goals are achieved, through replacing and supporting human activities, fostering innovation, enhancing remote access and improving monitoring. Emerging threats relate to reinforcing inequalities, exacerbating environmental change, diverting resources from tried-and-tested solutions and reducing freedom and privacy through inadequate governance. Although predicting future impacts of robotics and autonomous systems on the Sustainable Development Goals is difficult, thoroughly examining technological developments early is essential to prevent unintended detrimental consequences. Additionally, robotics and autonomous systems should be considered explicitly when developing future iterations of the Sustainable Development Goals to avoid reversing progress or exacerbating inequalities.

Mapping the production-consumption gap of an urban food system: an empirical case study of food security and resilience.

Urban food systems are complex and increasingly recognised as not being sustainable, equitable or resilient. Though globalisation and lengthening of agrifood supply chains has brought many benefits, such as year-long availability of fresh produce and modernisation opportunities for some developing regions, they have increased reliance on food imports and reduced the food and nutrition resilience of many cities. This premise has been widely witnessed following recent financial, climatic and pandemic driven disruptions to food supplies. A greater understanding is thus needed of the lived reality of a modern city's ability to sustainably and equitably feed itself in a crisis situation or otherwise. In a changing world, such knowledge is valuable on a variety of strategic planning levels. Employing publically available data, the scale of food security and resilience, and options for their improvement, are holistically assessed through a case study spatial analysis of the urban food system of the city of Leeds in the United Kingdom. The case study found that the Leeds city region is home to a significant and diverse food production and provision system, but it is not food secure in terms of providing sufficient energy or macronutrients, or functioning in an equitable manner for all of its residents. Options for improving the performance of the system, including urban farming and industrial symbiosis, were found to be nuanced and would only be effective alongside a range of complimentary interventions as well as high levels of investment, multi-sector cooperation and strong governance. Though food system evolution and development are grounded in local context, the methods, general findings and circular economy focussed recommendations emanating from the case study, are widely applicable. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s12571-021-01142-2.

Systematic Review and Meta-Analysis on the Effects of Astaxanthin on Human Skin Ageing.

CONTEXT: Astaxanthin (ASX), a xanthophyll carotenoid derived from microalgae Haematococcus pluvialis, mitigating skin photoaging and age-related skin diseases by its antioxidant and anti-inflammatory effects in animal studies. OBJECTIVE: The aim was to systematically evaluate if ASX applications have anti-ageing effects in humans. METHODS: A comprehensive search of PubMed, Scopus and Web of Science found a total of eleven studies. Nine randomised, controlled human studies assessed oral ASX effects and two open-label, prospective studies evaluated topical, oral-topical ASX effects on skin ageing. GetData Graph Digitizer was used to extract mean values and standard deviations of baseline and endpoint, and Cochrane Collaboration's tool assessed RoB for all included studies. Review Manager 5.4 was used to conduct meta-analysis of RCTs; the results were reported as effect size ± 95% confidence interval. RESULTS: Oral ASX supplementation significantly restored moisture content (SMD = 0.53; 95% CI = 0.05, 1.01; I2 = 52%; p = 0.03) and improved elasticity (SMD = 0.77; 95% CI = 0.19, 1.35; I2 = 75%; p = 0.009) but did not significantly decrease wrinkle depth (SMD = -0.26; 95% CI = -0.58, 0.06; I2 = 0%; p = 0.11) compared to placebo. Open-label, prospective studies suggested slightly protective effects of topical and oral-topical ASX applications on skin ageing. CONCLUSIONS: Ingestion and/or topical usages of ASX may be effective in reducing skin ageing and have promising cosmetical potential, as it improves moisture content and elasticity and reduces wrinkles.

Inhibitory effect of polysaccharides on acrylamide formation in chemical and food model systems.

The inhibitory effect of three polysaccharides (alginate, pectin and chitosan) on acrylamide formation was investigated in chemical and fried potato food model systems, under two heating regimes (heating block and microwave). In the chemical system, acrylamide formation followed a second order reaction kinetic behaviour. Activation energies (Ea) were 17.85 and 110.78 kJ/mol for conventional and microwave heating respectively. Acrylamide content was highest at 180 °C after 60 min conventional heating (27.88 ng/ml) and 3.5 fold higher after microwave heating for 60 s (800 W, 98.02 ng/ml). Alginate (0.3% w/v) and pectin (0.2% w/v) solutions efficiently inhibited acrylamide formation by 65% and 56% respectively under conventional heating, and 36% and 30% respectively under microwave heating. Coating potatoes with alginate, pectin and chitosan (1% w/v) prior to frying dramatically inhibited acrylamide formation by 54%, 51% and 41% respectively. However only alginate and pectin slightly reduced acrylamide by 5% in the microwave.

Green extraction of polyphenols from citrus peel by-products and their antifungal activity against Aspergillus flavus.

Aspergillus flavus is a pathogenic fungus associated with food safety issues worldwide. This study investigated the antifungal activity of citrus peel extracts prepared using food-grade solvents (hot water or ethanol). Mandarin (Citrus reticulata) peel ethanol extracts inhibited the mycelial growth of A. flavus (39.60%) more effectively than those of orange (32.31%) and lemon (13.51%) after 7 days of incubation. The growth of A. flavus could be completely inhibited by mandarin extracts at 300-400 mg mL-1, depending on the extraction solvent. Solid-phase extraction (SPE) separated the polyphenol-rich fractions, which showed up to 40% higher antifungal activity than crude extracts. Twelve polyphenols (2 phenolic acids and 10 flavonoids) were identified by HPLC-DAD, narirutin and hesperidin were the most abundant. In conclusion, citrus peels are promising bioresources of antifungal agents with potential applications in food and other industries.

Synergistic gelling mechanism of RG-I rich citrus pectic polysaccharide at different esterification degree in calcium-induced gelation.

RG-I rich pectic polysaccharide is common in fruit and vegetable and possesses health benefits. However, it is removed during commercial pectin production because of poor gelling properties. Synergistic gelation can improve rheological properties of RG-I pectic polysaccharide and expand its application in functional food hydrocolloids. In the study, RG-I rich pectic polysaccharides at different degree of esterification was extracted from citrus membrane by sequential mild acidic (0.4% HCl, 28 °C) and alkaline (0.6% NaOH, 32 °C) treatment. The pectic polysaccharide from acid water (PA) composes of 41% RG-I and 44% HG with DM of 45%, while the pectic polysaccharide from basic water (PB) composed of 63% RG-I and 19% HG with DM of 15%. PA/PB blend gel under CaCO3-glucono-δ-lactone system showed improved rheological properties compared with pure gels. Ca-bridges connected pectin aggregates and promoted the three-dimensional structure of PA/PB blend gels, while neutral sugar side-chains prompted hydrogen bonds and strengthened gel network.

Unveiling the Correlation between Inadequate Energy/Macronutrient Intake and Clinical Alterations in Volunteers at Risk of Metabolic Syndrome by a Predictive Model.

Although lifestyle-based interventions are the most effective to prevent metabolic syndrome (MetS), there is no definitive agreement on which nutritional approach is the best. The aim of the present retrospective analysis was to identify a multivariate model linking energy and macronutrient intake to the clinical features of MetS. Volunteers at risk of MetS (F = 77, M = 80) were recruited in four European centres and finally eligible for analysis. For each subject, the daily energy and nutrient intake was estimated using the EPIC questionnaire and a 24-h dietary recall, and it was compared with the dietary reference values. Then we built a predictive model for a set of clinical outcomes computing shifts from recommended intake thresholds. The use of the ridge regression, which optimises prediction performances while retaining information about the role of all the nutritional variables, allowed us to assess if a clinical outcome was manly dependent on a single nutritional variable, or if its prediction was characterised by more complex interactions between the variables. The model appeared suitable for shedding light on the complexity of nutritional variables, which effects could be not evident with univariate analysis and must be considered in the framework of the reciprocal influence of the other variables.