ORIGINAL ARTICLE
Ultra-Processed Foods Consumption Increases the Risk
of Hypertension in Adults: A Systematic Review and
Meta-Analysis
Mei Wang,1,2,3,4,* Xinyi Du,1,2,3,4,* Wei Huang,1,2,3,4 and Yong Xu1,2,3,4,
BACKGROUND
Effect of ultra-processed foods (UPFs) consumption on health has
attracted widespread attention in recent years. However, the re-
lationship between UPFs consumption and hypertension is un-
clear. This meta-analysis was conducted to analyze the above
association.
METHODS
We systematically searched PubMed, Embase, and Cochrane Library
for all relevant studies published up to 31 January 2022 without lan-
guage limitation. The random-effects model was selected to pool the
effect sizes and 95% confidence intervals (CIs).
RESULTS
Nine observational studies involving 111,594 participants were in-
cluded. Results from this meta-analysis showed that higher UPFs
consumption significantly increased the risk of hypertension (odds
With the rapid development in the technology related to
food production and processing, the global food system has
undergone significant changes in the past decades.1,2 Ultra-
processed foods (UPFs) rich in sugar and saturated fats domi-
nate the food supplies of high-income countries, and that UPFs
consumption is now rapidly increasing in middle-income
countries, which might attribute to its availability, afforda-
bility, and marketability.3 Additionally, UPFs are considered
to be the major source of energy in most countries.2
To study the effect of food processing on nutritional quality and
health, the NOVA classification system, most widely used system
for studying food processing, classifies foods into 4 groups based
on the extent and purpose of food processing: (i) unprocessed
or minimally processed foods, such as fruits, offal, eggs, milk,
fungi, algae, and water; (ii) processed culinary ingredients, such
*These authors have contributed equally to this work and share first
authorship.
Correspondence: Yong Xu (xywyll@swmu.edu.cn).
Initially submitted April 22, 2022; accepted for publication June 18,
2022; online publication June 24, 2022.
892 American Journal of Hypertension 35(10) October 2022
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ratio: 1.23; 95% CI: 1.11, 1.37; P = 0.034). Furthermore, analyses were
performed based on gender, study design, exposure assessment,
outcome assessment, body mass index, energy intake, and phys-
ical activity, which suggested that the results remained statistically
significant.
CONCLUSIONS
Our findings suggested that UPFs might have detrimental effects on
the incidence of hypertension in the general population. Although
current evidence is limited, it cannot be denied that reducing con-
sumption of UPFs may contribute to decrease the risk of chronic
noncommunicable diseases.
Keywords: blood pressure; hypertension; systematic review and meta-
analysis; ultra-processed foods.
https://doi.org/10.1093/ajh/hpac069
as oils, butter, sugar, and salt; (iii) processed foods, such as bottled
vegetables, canned fish, fruits in syrup, cheeses, and freshly made
breads; (iv) UPFs, such as sausages, savory packaged snacks,
reconstituted meat products.4 At the highest end of the pro-
cessing spectrum, UPFs are characteristically energy dense, high
in unhealthy types of fat, refined starches, free sugars and salt,
and poor sources of protein, dietary fiber, and micronutrients,5,6
many of these nutritional features being directly related to ad-
verse health. Moreover, ultra-processed products are made to
be hyperpalatable and attractive, with long shelf-life, and able to
be consumed anywhere, anytime.7 Therefore, UPFs have almost
replaced the minimally processed food and freshly prepared
dishes, and are high popularity worldwide.8
The evidence so far has demonstrated that UPFs are asso-
ciated with unhealthy dietary nutrient profiles and several
1Department of Endocrinology and Metabolism, Affiliated Hospital of
Southwest Medical University, Luzhou, Sichuan, China; 2Luzhou Key
Laboratory of Cardiovascular and Metabolic Diseases, Department of
Endocrinology and Metabolism, the Affiliated Hospital of Southwest
Medical University, Luzhou, Sichuan, China; 3Sichuan Clinical
Research Center for Nephropathy, Department of Endocrinology and
Metabolism, Luzhou, Sichuan, China; 4Metabolic Vascular Disease Key
Laboratory of Sichuan Province, Department of Endocrinology and
Metabolism, Luzhou, Sichuan, China.
© The Author(s) 2022. Published by Oxford University Press on
behalf of American Journal of Hypertension, Ltd. All rights reserved.
For permissions, please e-mail: journals.permissions@oup.com

noncommunicable chronic diseases.8 Several observational
studies have found that UPFs significantly increase the risk
of cardiovascular diseases,9,10 all-cause mortality,11,12 over-
weight and obesity,13,14 cancers,15,16 and depression.17,18
In contrast, there is evidence that consumption of cer-
tain unprocessed or minimally processed foods, such as
whole grains, fruits, and vegetables, is inversely associated
with weight gain.19–21 Recently, possible relationships be-
tween UPFs and hypertension are being more widespread
concerns. Some studies assessed the association between
intake of UPFs and hypertension,22–30 but the findings are
inconsistent. Therefore, a full understanding of the effect of
UPFs consumption on hypertension is greatly necessary.
Although 2 recent systematic reviews assessed the asso-
ciation between UPFs consumption and hypertension,31,32
some limitations would not be ignored. The results of
previous studies showed that there was no statistically
significant association between UPFs consumption and hy-
pertension,31 or it only reviewed the studies on UPFs con-
sumption and hypertension without quantitative analysis.32
As a result, the association between UPFs consumption and
hypertension remains unclear. Therefore, we aimed to con-
duct a comprehensive meta-analysis and systematic review
of observational studies to assess the relationship between
UPFs consumption and hypertension in adults.
METHODS
This meta-analysis was conducted based on the Preferred
Reporting Items for Systematic Reviews and Meta-Analyses
(PRISMA) guideline33 (Supplementary Table S1 online).
Ethical approval was not necessary because this study was
meta-analysis of published studies.
Search strategy and study selection
We conducted a comprehensive literature search for
all potentially relevant observational studies in PubMed,
Embase, and Cochrane Library up to 31 January 2022 with
no restriction on language. The search-relevant keywords
are as follows: ([Ultra processed foods OR Ultraprocessed
foods OR Ultra-processed foods OR Processed foods] AND
[Hypertension OR Blood pressure]). We also examined rel-
evant original studies and review articles to search for other
eligible studies. The search strategy is given in detail in
Supplementary Table S2 online.
Inclusion criteria
Studies were included if they met the following explicit
criteria: (i) the type of research was observational studies
(such as cohort, cross-sectional, and case–control studies);
(ii) they were population-based studies; (iii) participants
were ≥18 years old at baseline; (iv) the exposure interested
was UPFs (as defined by the NOVA classification system);
(v) the primary outcome of interest was hypertension; and
(vi) data provided as risk ratio, hazard ratio, or odds ratio
(OR) and corresponding 95% confidence intervals (CIs) for
the risk of hypertension.
Ultra-processed Foods and Hypertension
Exclusion criteria
The exclusion criteria were as follows: (i) duplicate
reports; (ii) not population-based studies; (iii) case
reports, comments, reviews, and conference summary;
(iv) nonobservational design; (v) not examined the associ-
ation between UPFs and the risk of hypertension; (vi) not
provided the relevant effect sizes and corresponding 95%
confidence; and (vii) unavailable full text or incomplete
data.
Selection and data extraction
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The titles and abstracts were screened independently
by 2 authors (MW and XYD). Then the full texts were
reviewed based on inclusion and exclusion criteria. Any
disagreement was resolved by the third party through ne-
gotiation. Studies would be included in this meta-analysis if
they examined the relationship between UPFs and the risk
of hypertension in populations, and provided outcomes of
hypertension and their risk estimates and 95% CIs. The fol-
lowing data from eligible published articles were extracted:
(i) first author’s last name; (ii) year of publication; (iii)
type of study design; (iv) study location; (v) number of
participants; (vi) age range and gender; (vii) duration of
follow-up for cohort studies; (viii) primary outcomes; (ix)
the most adjusted risk estimates (risk ratio, hazard ratio,
and OR) and corresponding 95% CIs; and (x) the covariates
used for adjustment.
Assessment of study quality
Two investigators (MW and XYD) separately assessed
the quality of included articles using the Newcastle-Ottawa
scale (NOS) which was adapted for cross-sectional and co-
hort studies. The NOS includes selection, comparability, and
outcome. Studies with NOS scores 1–3 stars indicated poor
quality, NOS scores 4–6 stars indicated fair quality, and NOS
scores 7–9 stars indicated high quality.34
Statistical analysis
We equated hazard ratio and risk ratio with OR in this
meta-analysis.35 The potential sources of heterogeneity
between studies were assessed by using the Q test and I2
statistics,36 and I2 > 50% or P < 0.05 indicated significant het-
erogeneity. The random-effect model would be selected to
pool the effect sizes and corresponding 95% CIs if there was
significant heterogeneity. Otherwise, the fixed-effect model
was employed. In order to further investigate whether the
relationship between UPFs and incidence of diabetes mel-
litus and hypertension was biased by some specific factors
(e.g., study design, type of diseases, gender, continent, expo-
sure assessment, outcome assessment, sample size, follow-up
time, and adjustments [such as body mass index, energy in-
take, and physical activity]), we conducted the subgroup
analyses based on above factors. All statistical analyses were
conducted with Stata software (version 12.0, Stata Corp LP,
College Station, TX).
American Journal of Hypertension 35(10) October 2022 893
Wang et al.
RESULTS
Literature search and study characteristics
We initially identified 1004 relevant articles from
PubMed, Embase, and Cochrane Library database. Finally,
9 articles met the inclusion criteria were included in this
meta-analysis after excluding duplicates, unrelated arti-
cles, reviews, meta-analyses, and other studies. The pro-
cess of literature screening is provided in the flow chart
(Figure 1). All of the included studies were observational,
including 4 cohort studies25,26,29,30 and 5 cross-sectional
studies.22–24,27,28 Two studies were conducted in the United
States,22,24 2 in Canada,23,27 2 in Brazil,29,30 1 in Spain,25 1
in Mexico,26 and 1 in Lebanon.28 Eight studies included
both men and women, 1 study only included women.
For exposure assessment, 6 studies used food-frequency
questionnaire as exposure assessment tools,22,25,26,28–30
while 3 studies were based on 24-hour dietary recall or
records.23,24,27 The characteristics of all included studies
are shown in Table 1.
UPFs consumption and the risk of hypertension
Nine studies, including 4 cohort studies and 5 cross-sec-
tional studies, explored the effect of UPFs consumption on
the incidence of hypertension. Results of the meta-analysis
of 9 studies indicated that higher consumption of UPFs
was significantly associated with incidence of hypertension
(pooled OR: 1.23; 95% CI: 1.11, 1.37; I2 = 51.9%, P = 0.034),
and the statistical heterogeneity was moderate with an I2 of
51.9% (Figure 2). Furthermore, analyses were performed
based on gender, study design, exposure assessment, out-
come assessment, body mass index, energy intake, and
physical activity, which suggested that the results remained
statistically significant (Table 2).
Figure 1. Flow diagram for the selection of eligible observational
articles.
894 American Journal of Hypertension 35(10) October 2022
Sensitivity analysis
Sensitivity analysis indicated that none of the included
studies had significant impact on the results of the meta-
analysis (Figure 3).
Publication bias
The Begg’s rank correlation test and the Egger’s regression
test confirmed that there was no publication bias for hyper-
tension (P = 0.348 and P = 0.247, respectively). As shown in
Figure 4, the funnel plots were symmetrical, which revealed
no clear publication bias.
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DISCUSSION
In our meta-analysis, we systematically summarized
the current published observational studies examining the
association between UPFs consumption and the risk of
hypertension.
The result suggested that higher consumption of UPFs
significantly increased the risk of hypertension in adults.
Subgroup analyses, conducted based on study design, sample
size, geographical location, body mass index, energy intake,
and physical activity, indicated that the results remained re-
markable correlation between UPFs consumption and risk
of hypertension.
As the subgroup analysis showed, there was no association
between UPFs consumption and hypertension in females,
although based on only 1 study.26 The potential explana-
tion may be that the ratio of energy contribution of UPFs
in different countries may variable. For instance, the ratio
of energy contribution of UPFs is 62% in the United States
but 29% in Chile, which perhaps causes the difference of in-
cidence of hypertension related to UPFs consumption.7,37
Besides, the effect of UPFs on health may be cumulative
outcome over a long period of time but not captured in
short term. Moreover, education and income may also be
important factors to influence the result because the study
was conducted based on Mexican Teachers’ Cohort. Future
studies are needed to explore the effect of UPF consumption
on hypertension of different genders.
Our findings of a positive association between higher in-
take of UPFs and hypertension are consistent with previous
studies. A recent meta-analysis of observational studies
showed that sugar-sweetened beverages, which are part of
the definition of UPFs, are considered to be significantly as-
sociated with hypertension, as well as obesity, T2DM, and
all-cause mortality.38 It is reported that participants with
higher intake of UPFs had a greater risk of overweight and
obesity compared with participants with lower intake of
UPFs.39 And it is well known that obesity is considered as an
important risk factor for hypertension.
Recently, several potential mechanisms have been suggested
to explain the association between UPFs intake and the risk of
hypertension. As we mentioned earlier, UPFs are nutritionally
unbalanced due to high levels of free/added sugars, saturated
and trans-fatty acids, and low levels of protein, dietary fiber,
and micronutrients. These differences in nutrient content of
 Table 1. Characteristics of included studies in this meta-analysis

Study Sample Exposure Diagnostic criteria for Study

Study ID Country design size Age Sex Comparison Exposure Reference assessment hypertension quality Adjustment

Nardocci Canada Cross- 13,608 ≥19 M + F Q3 vs. Q1 ≥58.7% of ≤38.5% of 24-Hour Self-declared AH— 7 stars Age, sex, smoking
et al.27 sectional TE TE dietary answer to question status, physical
recall on long-term activity, education,
health conditions income, residential
diagnosed by area, immigrant status,
healthcare provider: alcohol consumption,
“Do you have residential area, and
diabetes/ indigenous identity.
high blood
pressure?”
Rezende- Brazil Cohort 1,221 35.2 M + F Q5 vs. Q1 34.6%– 0.8%– FFQ Self-declared medical 8 stars Gender, age, marital
Alves 76.2% 16.6% of diagnosis or use of status, skin color, per
et al.29 of TE TE antihypertensive or capita income, physical
self-declared high activity, smoking,
BP (≥130/80 mm obesity, family history
Hg) according to of hypertension, and
recent cutoff points energy intake.
proposed by ACC/
AHA.
Mendonça Spain Cohort 14,790 36.3 M + F Q3 vs. Q1 NR NR FFQ Self-declared medical 8 stars Sex, age, physical
et al.25 diagnosis. activity, hours of TV
watching, baseline
BMI, smoking status,
use of analgesics,
following a special
diet at baseline, family
history of hypertension,
hypercholesterolemia,
alcohol consumption,
total energy intake,
olive oil intake,
consumption of fruits,
and vegetables.
Ivancovsky- United Cross- 789 58.83 ± 6.58 M + F Q4 vs. Q1 NR NR FFQ Systolic BP/diastolic 8 stars Age, gender, BMI, saturate
Wajcman States sectional BP ≥130/80 mm Hg fatty acids and protein
et al. 22 and/or medication. intake, physical activity,
coffee, and fibers.
Scaranni Brazil Cohort 8,754 35–74 M + F Q3 vs. Q1 15% of TE 35% of TE FFQ Measurement of BP 8 stars Age, sex, color or race,
et al.30 (SBP ≥140 mm Hg education, physical
or DBP ≥90 mm activity, smoking, alcohol
Hg) and use of consumption, Na intake
antihypertensive in measured by 12-hour
previous 2 weeks. urine sample, total daily
energy intake.
Lavigne- Canada Cross- 811 ≥18 M + F Q5 vs. Q1 83% of TE 21.1% of 24-Hour Measurement of BP 7 stars Age, sex, area of
Robichaud sectional TE dietary (SBP ≥130 mm Hg residence, current
et al. 23 recall or DBP ≥85 mm smoker, alcohol drinker,
Hg). and total dietary energy
intake.

American Journal of Hypertension 35(10) October 2022

895
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896
Wang et al.

Table 1. Continued

Study Sample Exposure Diagnostic criteria for Study

Study ID Country design size Age Sex Comparison Exposure Reference assessment hypertension quality Adjustment

Nasreddine Lebanon Cross- 302 ≥18 M + F Q4 vs. Q1 NR NR FFQ Measurement of BP 8 stars Age, gender, marital
et al.28 sectional (SBP ≥130 mm Hg status, BMI, area of
or DBP ≥85 mm residence, level of
Hg). education, income,
smoking status,
physical activity,
and total energy
intake.

American Journal of Hypertension 35(10) October 2022

Martínez United Cross- 6,385 ≥20 M + F Q5 vs. Q1 >71% of <40% of 24-Hour Measurement of BP 7 stars Sex, age, race/ethnicity,
Steele States sectional TE TE dietary (SBP ≥130 mm ratio of family income to
et al.24 recall Hg and/or DBP poverty and educational
≥85 mm Hg) or attainment + current
currently taking smoking status, and
antihypertensive physical activity.
medication.
Monge Mexico Cohort 64,934 ≥25 F Q5 vs. Q1 ≤20% of >45% of FFQ Self-declared medical 7 stars Age, indigenous,
et al.26 TE TE diagnosis or use of internet access,
antihypertensive. insurance, family
history of hypertension,
menopausal status,
smoking, physical
activity, energy intake,
and multivitamin
intake.

Abbreviations: AH, arterial hypertension; BMI, body mass index; BP, blood pressure; DBP, diastolic blood pressure; F, females; FFQ, food-frequency questionnaire; M, males; NR, not
reported; SBP, systolic blood pressure; TE, total energy.

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Figure 2. Forest plot of the association between consumption of ultra-processed foods (UPFs) and hypertension using a random-effects model. Meta-
analysis of the data from the 9 included studies demonstrated that higher consumption of UPFs significantly increased the risk of hypertension.
UPFs may play an important role in these mechanisms. Firstly,
highly processed foods tend to have higher levels of refined
carbohydrates, which are quickly absorbed into the blood-
stream, leading to high glycemic load (GL),40 the latter may
activate return-related neural circuits (such as the striatum)
similar to addictive substances and increase cravings and
hunger, thereby leading to an increase in energy intake,41–43
which is associated with higher hypertension prevalence, in-
cidence, and greater increases in blood pressure. Besides,
diets high in carbohydrate might elevate insulin secretion and
promote the partitioning of energy toward storage as fat; in
response, hunger and appetite increases.44 And excessive in-
take of fat also contributes to weight gain and the risk of over-
weight or obesity, the latter being recognized as an important
risk factor for cardiovascular diseases. Several studies have
shown that UPFs and beverages (e.g., confectionery snacks,
sugar-sweetened beverages, and cakes) might contain rela-
tively high levels of glucose-derived advanced glycation end
products, the latter enhancing oxidative stress and initiating
inflammatory responses, which over time could lead to or ac-
celerate vascular diseases.9,45–47 Moreover, data from animal
experimental studies suggested that fructose may increase
blood pressure by stimulating uric acid,48 inhibiting endothe-
lial nitric oxide synthase system,49,50 stimulating sympathetic
nervous system,51 or directly increasing sodium absorption in
the intestinal tract.52 Additionally, sodium is one of the main
ingredients added in the process of producing ready-to-eat
food such as processed meat,4,29,53 and it is well established that
avoiding excessive sodium consumption is crucial to prevent
hypertension and to reduce cardiovascular risk. Furthermore,
intake of UPFs is associated with low intake of protein, fiber,
Ultra-processed Foods and Hypertension
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vitamins, and minerals,53 which may also contribute to the de-
velopment of diabetes mellitus and hypertension.
Another potential mechanism may be associated with
the wide range of additives added to UPFs and chem-
ical compounds formed during their manufacturing
processes or released from their packaging materials. For
example, emulsifiers (e.g., carboxymethylcellulose and
polysorbate-80), detergent-like molecules that are a ubiq-
uitous component of processed foods, may affect the
gut microbiome and promote colitis and metabolic syn-
drome.54 Long-term consumption of artificial sweeteners
might accelerate atherosclerosis and senescence via impair-
ment of function and structure of apolipoprotein A–I and
high-density lipoprotein.55 High levels of polycyclic aro-
matic hydrocarbons have also been shown to be positively
associated with hypertension.56,57 Acrylamide and acrolein
produced during food heat treatments were linked to an
increased risk of cardiovascular diseases.58,59 However, it still
remains unclear what plays a leading role in the association.
It is urgent to need a better understanding of what really
matters and how various aspects influence those impacts.
Our study provided comprehensive evidence of the nega-
tive influence of UPFs intake on hypertension. The findings
indicate that more efforts should be put into reducing the
high consumption of UPFs, and attach importance to
promoting healthy and sustainable dietary habits.
Strengths and limitations
Our meta-analysis provides the most comprehensive as-
sessment on the associations of UPFs consumption with
American Journal of Hypertension 35(10) October 2022 897
Wang et al.

Table 2. Subgroup analyses of consumption of ultra-processed

foods (UPFs) and risk of hypertension

No. of
Subgroups studies OR (95% CI) I2 % P

All 9 1.23 (1.11–1.37) 51.9 0.034

Design
Cohort 4 1.16 (1.03–1.32) 55.20 0.082
Cross-sectional 5 1.35 (1.11–1.64) 44.30 0.127
Sex
M+F 8 1.27 (1.17–1.38) 14.50 0.317

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M — — — —
F 1 0.98 (0.84–1.14) — —
Sample size Figure 3. Sensitivity analysis of all included studies.
≥10,000 3 1.22 (0.96–1.54) 83.4 0.002
<10,000 6 1.24 (1.13–1.36) 0.00 0.576
Exposure assessment
FFQ 6 1.20 (1.06–1.37) 51.00 0.069
Food record 3 1.29 (1.01–1.65) 61.8 0.073
Continent
Europe 1 1.21 (1.06–1.38) — —
Asia 1 3.10 (0.58–16.61) — —
North America 5 1.23 (1.01–1.50) 72.20 0.006
South America 2 1.26 (1.10–1.44) 0.00 0.580
Outcome assessment
Measured 5 1.23 (1.11–1.35) 0.00 0.486
Self-reported 4 1.24 (1.02–1.51) 76.80 0.005
BMI
Yes 2 1.58 (1.11–2.24) 0.00 0.420 Figure 4. Funnel plot evaluating the publication bias for associa-
tion between the intake of ultra-processed foods (UPFs) and the risk of
No 7 1.21 (1.08–1.35) 55.80 0.035 hypertension.
Energy intake
Yes 6 1.16 (1.03–1.30) 40.20 0.137 UPFs consumption was not exactly the same in the included
No 3 1.39 (1.12–1.72) 60.60 0.079 studies of this meta-analysis, which made these comparisons
less straightforward; thus, we could only obtain a quantita-
Physical activity
tive rate of the association between the UPFs consumption
Yes 8 1.24 (1.11–1.39) 56.50 0.024 and hypertension but not a specific range. Finally, subgroup
No 1 0.99 (0.59–1.67) — — meta-analyses by common study characteristic do not com-
pletely eliminate substantial heterogeneity across studies.
Abbreviations: BMI, body mass index; CI, confidence interval; F, Improved analyses should be carried out as more informa-
females; FFQ, food-frequency questionnaire; M, males; OR, odds tion becomes available in the future.
ratio. Based on our findings, consumption of UPFs is signifi-
cantly associated with an increased risk of hypertension in
hypertension. Moreover, studies involving a large number adults. As the current evidence is limited, more longitudinal
of participants are expected to provide sufficient statis- studies and intervention studies are needed in the future to
tical power to examine the relationship between UPF and further explore the potential association between UPFs con-
hypertension. Nevertheless, there are also several limita- sumption and hypertension.
tions to be acknowledged. Firstly, our meta-analysis was
based on observational studies and thus some unmeasured
confounding factors may have various degrees of influence SUPPLEMENTARY MATERIAL
on the results. Secondly, the studies included in this meta-
analysis were used to assess UPFs consumption through Supplementary data are available at American Journal of
food-frequency questionnaire, food recording, and 24-hour Hypertension online.
recall, which are likely to recall bias. Thirdly, the definition of Supplementary Table 1. PRISMA checklist.

898 American Journal of Hypertension 35(10) October 2022


Supplementary Table 2. Search strategy to identify ob-
servational studies reporting the association between ultra-
processed foods (UPFs) consumption and hypertension.
FUNDING
This study was supported by the Sichuan Science and
Technology Program, Sichuan, China (grant numbers:
2020YFS0456 and 2019YFS0537) and the Luzhou-Southwest
Medical University cooperation project, Luzhou, Sichuan,
China (grant number: 2018LZXNYD—PT01).
ACKNOWLEDGMENTS
We thank all participants from the Department of
Endocrinology and Metabolism, the Affiliated Hospital
of Southwest Medical University for their assistance and
support.
AUTHORS’ CONTRIBUTIONS
Y.X. and W.H. were involved in the whole conception and
design process of the study. M.W. and X.D. contributed to
the selection of literature and participated in the process
of literature quality evaluation, data extraction, and anal-
ysis. M.W. wrote the paper. Y.X. and W.H. commented on
the manuscript. All authors read and approved the final
manuscript.
DISCLOSURE
The authors declared no conflict of interest.
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