Effects of Ramadan on cognitive functions in young boys

ABSTRACT

Fasting during Ramadan involves abstaining from food and drink from dawn to sunset, potentially influencing cognitive functions essential for the intellectual development of the youth. Therefore, understanding the effects of fasting on these functions in children/adolescents provides valuable perspectives to enhance education and promote mental well-being. However, studies on children/adolescents in this context are still limited. To evaluate the impact of Ramadan fasting on cognitive functions, including information processing speed, inhibition, decision-making, and auditory attention processes among children and adolescents aged 11 to 15 years. This study was conducted with 24 healthy children/adolescents (aged 12.84 ± 0.69 years). The experimental protocol consisted of two sessions: Before-Ramadan (BR) and at the beginning of the second week of Ramadan (R2). At each session, the boys were randomly tested on simple reaction time (SRT), choice reaction time (CRT), negative priming reaction time (NPRT), and auditory discrimination (P300). The tests were administered and scored by the same person in the different sessions. The study found that Ramadan fasting did not have an effect on various reaction times or on electro-physiological data, including P300 amplitude and latency. The current study, conducted with healthy children/adolescents, indicates that Ramadan fasting had no impact on various reaction times (SRT, CRT, NPRT), suggesting the preservation of information processing speed and decision-making, even in the face of increased task complexity. This is evident, on the one hand, through the maintenance of the ability to react to unexpected events, and, on the other hand, through the mastery of resistance to automatism, thus reflecting the preservation of inhibitory function (NPRT). Regarding P300 data, the absence of changes in latencies and amplitudes suggests that Ramadan fasting did not alter either the evaluation time of auditory stimuli or auditory attention processes.

KEYWORDS:

• Children/adolescents
• attention
• P300
• reaction time
• inhibition
• Ramadan

1. Introduction

Childhood and adolescence are two developmental periods characterized by structural and functional changes in the brain [1–3] that underpin cognitive functions. These functions are brain capacities through which humans receive information about their environment, acquire knowledge, think, adapt and interact with others.

According to the literature, cognitive processes can be influenced by dehydration [4], food intake [5], and sleep deprivation [6]. Variations in these factors can be observed during Ramadan fasting (RF), which is one of the five pillars of Islam. During each day of the Ramadan month, Muslims abstain from consuming food and fluids from dawn to sunset, leading to various impacts on an individual’s physiology and behavior [7–10]. Some studies have indicated an impact on the plasma levels of proteins [11], lipids, glucose and metabolic rate [12]. Furthermore, changes in meal timing may result in adjustments in sleep patterns [13], potentially influencing daytime alertness and, consequently, cognitive functions [14].

Based on studies examining the effects of Ramadan intermittent fasting on cognitive functions, the results have been both diverse and contradictory. Some studies have demonstrated the relative resilience of visual learning, working memory [15], reaction times [16–18], and vigilance [19] during fasting. However, other research has indicated that tasks requiring swift reactions (detection and identification tasks) are influenced by fasting [15]. These tasks have either shown improvement [15] or impairment [13,14,19,20]. Similarly, there have been findings indicating a significant increase in sustained attention during Ramadan [15,16]. Nevertheless, these results contradict those reported by Dolu et al. [19] who observed attention impairment.

The heterogeneity of the results can be explained by the fact that each study includes distinct methodological elements likely to influence the results, such as the measurement tools, the time of assessment, the age, sex and athletic profiles of the participants.

According to Islamic principles, this practice applies to all healthy Muslims as soon as they reach puberty [21]. Nevertheless, on an annual basis, numerous prepubescent Muslims demonstrate their eagerness to observe fasting during Ramadan for various reasons. These reasons may include encouragement from their parents, other adults, and friends, the desire to acclimate themselves to this discipline, to share a sense of equality with fasting peers, or to respond to psychological and spiritual motivations [22–24].

Even though the month of Ramadan advances by 11 days each year relative to the Gregorian calendar, it coincides with the school year. Therefore, understanding the impact of this practice on cognitive functions is essential.

To the best of our knowledge, most investigations exploring the repercussions of Ramadan fasting on male children/adolescents aged 11–15 years have concentrated primarily on its influence on physical abilities [25–29]. Only one study has delved into cognitive function within this age group [30]. However, cognitive functions present significance for the perceptual domain, encompassing not only the visuo-spatial aspect but also the auditory domain. Notably, the aforementioned study exclusively examined the visual domain, omitting an evaluation of auditory function and the measurements were exclusively conducted in the morning, potentially obscuring the actual impact of fasting [30].

The cognitive functions such as inhibitory control [31,32], processing speed [32], working memory, decision-making [33,34] and the P300 auditory component of the event-related potential associated with cognitive information processing(e.g. memory, attention, executive functions) [35]continue to develop at the end of childhood and throughout adolescence. The objective of this study was to assess the impact of Ramadan on perceptual motor function, the inhibitory mechanism of visual attention, the speed of information processing and decision-making measured by simple, negative priming, and choice reaction times (SRT, NPRT, and CRT), as well as on auditory attention (P300 amplitude and latency) in children/adolescents aged 11 to 15.Despite the literature indicating resilience or a change in the effects of fasting on cognitive functions, the majority of changes observed in athletes during Ramadan fasting tend to show improvement, while in non-athletes, they tend to indicate alteration. Our hypothesis was that the average values of SRT, CRT, NPRT, and P300 would be altered in non-athletic children/adolescents during Ramadan.

2. Population and methods

2.1. Study design

The study was conducted during Ramadan 2019 (from NaN Invalid Date NaNto NaN Invalid Date) where the fasting duration between the beginning and the end of Ramadan varied from 15:40 to 16:30 hours. This study was carried out in a private center for the functional exploration of the nervous system in Sousse (Tunisia).

Approval of the study was obtained by the Ethics Committee of the establishment (1504/2019). After learning about the different objectives of the experimental protocol, the parents of the pupils signed a letter of consent expressing their agreement in principle to their children’s participation in this work. For monitoring the fasting of the children/adolescents, we relied on the confirmation provided by the parents and study participants regarding adherence to this practice. The candidates were informed that they could withdraw from the study at any time.

2.2. Sample size

The software G*Power version 3.1.9.2 (Franz Faul, University of Kiel, Germany) was used to a priori calculate the least required sample size based on a study with similar paradigm [20]. Values for α were set at 0.05 and power at 80%. Effect sizes were estimated as 0.61. In total, to reach the desired power, data from at least 23 participants were deemed to be sufficient to minimize the risk of incurring a type 2 statistical error.

2.3. Study population

Figure 1 describes the study consort flowchart. Boys in this study were recruited from the college of Kalaa Sghira, Sousse, Tunisia.

Figure 1. Flow chart.

Participants were recruited from pupils attending local educational establishments. Inclusion criteria included age (e.g. between 11 and 15 years), current schooling status, and willingness to participate voluntarily in the study.

In this study, the term ‘boys’ was used to include the following two terms: ‘children’ (6 to 12 years old; ‘http://www.ncbi.nlm.nih.gov/mesh/68002648 last access 6 September 2021’) [36]and ‘adolescents’ (13 to 18 years old; ‘http://www.ncbi.nlm.nih.gov/mesh/68000293; last access: 6 September 2021’) [37].

Given the nature of the Ramadan effect study, eligible participants were those whose families observed the Ramadan fast. This was verified by preliminary interviews and questionnaires to ensure observance of the fast.

Prior to the participation of children and adolescents, written informed consent was obtained from their parents or legal guardians. Detailed information on the research protocol was provided to parents/guardians and to the participants themselves.

The non-inclusion criteria were brain damage, neurological disorders, personal or family history of mental illness, hyperactivity disorder, and visual and hearing problems. The exclusion criterion applied was the breaking of the fast for at least one day during the protocol.

2.4. Experimental protocol

Figure 2 shows the experimental protocol which was spread over two sessions: before Ramadan (BR) (control session: April 28^th-30^th) and at the beginning of the second week of Ramadan (R2) (experimental session: May 13^th −15^th).

Figure 2. Study protocol.

BR:one week before Ramadan. R2: at the beginning of second week of Ramadan.

SRT:Simple Reaction Time. CRT: Choice Reaction Time. NPRT: Negative Priming Reaction Time. P300: Event Related Potential.

A familiarization session with the assessment tests was carried out before the first session to avoid the learning effect.

During this session, all participants were instructed to document the number of hours they had slept each night throughout the protocol period. Additionally, in each session, participants were asked about the number of hours they had slept on the night preceding the test day.

Age and height were noted only during BR. Anthropometric parameters ((weight, kg),body mass index (BMI, kg/m²)) and cognitive tests were measured during BR and R2.

The P300 (cognitive evoked potential was used to assess auditory attention by the auditory discrimination task: a two-tone auditory oddball paradigm), Simple Reaction time (SRT), Choice Reaction time (CRT) and Negative Priming Reaction time (NPRT) were assessed. The assessment sessions were conducted at the same time of day in both sessions between 16:00 and 18:00 hours, approximately 1.36 to 3.36 hours before the end of fasting. These tests were conducted in a random order to avoid methodological bias in the interpretation of the results.

2.5. Collected data and cognitive tests

2.5.1. Anthropometric parameters

The height was measured with a height gauge (standing stadiometer type DETECTO ®). The weight was measured with a digital scale (Tanita TBF300WA, Tokyo, Japan). Body mass index (BMI, kg/m²) was calculated (Table 1).

Table 1. Anthropometric characteristics during the two sessions (BR and R2)in participants (n = 24).

	BR	R2	p
Weight (kg)	54.42 ± 10.6	55.23 ± 10.8	0.315
BMI (kg/m2)	20.22 ± 2.58	20.14 ± 2.65	0.283
Height (cm)	163 ± 8

Note. Data expressed as mean ± SD. BMI: Body Mass Index. BR: one week before Ramadan. R2: at the beginning of the second week of Ramadan.

p:t-test for dependent samples between the two sessions.

2.5.2. Sleep duration

In the initial contact session with the subjects and their parents/guardians, we instructed them to note the hours of sleep in the days leading up to the familiarization session. During each session (BR and R2), participants were queried about their sleep duration on the nights prior to the test day.

2.5.3. Simple, choice and negative priming reaction time

These tests were evaluated using ‘Superlab 4.5’ program (Cedrus Corporation, San Pedro, CA, USA) [17].

After 10 familiarization tests, each participant performed 20 SRT tests, 32 CRT and 30 NPRT tests at restaccording to the initial programming of the SUPERLAB software. The interval between the appearance of two consecutive stimuli on the monitor varied randomly between 10 and 1500 milliseconds (ms)to the SRT and CRT [17] and between 1 to 3600 ms for the NPRT [38]. Time variability prevents the brain from using mental timing.

In the SRT, the ‘target’ is a black square preceded by a warning signal (White Square). Between the appearance of the preparatory signal and the target stimulus, a cross appears in the center of the screen defining the visual field. The task is to press the space bar as quickly as possible when the black square (target) appears.

About the CRT the ‘target’ stimulus is a black square that can appear in any of the four quadrants of the screen. The appearance of a ‘target’ stimulus is always preceded by four white squares (warning signal) followed by the appearance of a black square on only one of the four quadrants without any indication of the location. The task is to press as quickly as possible one of the four buttons on the keyboard corresponding to the location of the black square.

For NPRT, the appearance of the ‘target stimulus’ is preceded by a distracting stimulus (an asterisk) in a different quadrant from the target to create a negative priming effect. The task is to press one of the four buttons corresponding to the location of the black square as quickly as possible and ignore the asterisk.

2.5.4. Event related potential (P300)

Participants performed an auditory discrimination task using the two-stimulus oddball paradigm. Each subject was exposed to 200 stimuli (160 standard tones and 40 target tones). The stimuli were a series of binaural tones 1000 Hz(non-targets) versus 3000 Hz (target) at 65 dB with a rise/fall time of 10 ms and a plateau time of 30 ms Tones were presented at a rate of 0.97/s with rare stimuli (target) applied randomly with a percentage set at 20% and frequent stimuli (non-targets) applied with a percentage of 80%.

The task is to count the rare stimuli and give the number of responses to the evaluator.

The potential linked to the event (P300) was measured at C_z(electrode placed on the central part of the skull)and P_z (electrode placed on the parietal part of the skull) and was referenced to linked ear. Data collected were, N200-P300 peak-to-peak amplitude and P300 latency measured from the onset of stimulus to the positive peaks with a range of 260-340 ms. The auditory ERP P300 was recorded and averaged using EMG 12 channels Sierra® Summit™ coupled to a Microsoft Windows™ based personal computer.

2.6. Statistical analysis

Normality was verified by Shapiro-Wilk test. Our results were expressed in terms of their means ± standard deviation.

The Student t-test was used to compare quantitative data (SRT, CRT, NPRT, and P300) of the same group between the two Experimental Session (ES) (BR and R2). Analyses were performed using Statistica software (Statistica Kernel version 6; StatSoft, Paris, France). The effect size (d) was calculated according to Cohen (1988) [39], to determine the magnitude of comparison. The significance level was set at 0.05 or lower.

3. Results

Among a sample of 40 adolescents, only 24 were engaged (Figure 1), Table 1 exposes the anthropometric characteristics of participants during the two sessions. Statistical analysis showed no significant differences between the two sessions.

In terms of sleep assessment, there was no significant difference between the two experimental sessions (p < 0.11), with the average sleep duration being 7.58 ± 0.46 hours in session BR and 7.33 ± 0.42 hours in session R2.

3.1. Effects of Ramadan fasting on SRT, CRT and NPRT

Figure 3 shows the values of the different reaction times (RT) during the two sessions.

Figure 3. Simple reaction time (SRT), choice reaction time (CRT) and negative priming reaction time (NPRT) expressed according to their means and standard deviation, during the two sessions (BR and R2).

BR:one week before Ramadan. R2: at the beginning of second week of Ramadan.

SRT: Simple Reaction Time. CRT: Choice Reaction Time. NPRT: Negative Priming

There was no significant difference between the means of SRT, CRT and NPRT during the two sessions (p > 0.05, d = 0.39; d = 0.04; d = 0.023, respectively), which expresses the absence of the effect of the Ramadan fasting.

3.2. Effects of Ramadan fasting on the evoked potential data (P300)

Table 2 illustrates the mean amplitude (μV) and latency (ms) values of P300 measured at C_z and P_z during the two sessions which results showed no significant difference between the means of amplitudes (at C_zand P_z)and latencies (at C_zand P_z) measured during the two sessions (BR and R2),(p > 0.05, d = 0.11; d = 0.02; d = 0.14; d = 0.08, respectively).

Table 2. P300 (amplitude and latency) values during the two sessions (BR and R2) in participants (n = 24).

	BR	R2	p
Amplitude N2-P300 (μV) at Cz	9.55 ± 5.18	8.68 ± 5.04	0.586
Amplitude N2-P300 (μV) at Pz	8.57 ± 5	8.69 ± 5.1	0.938
Latency (ms) at Cz	302 ± 25	297 ± 34	0.513
Latency (ms) at Pz	301 ± 25	298 ± 341	0.686

Note. Data expressed as mean ± SD. BR: one week before Ramadan. R2: at the beginning of the second week of Ramadan. P300:neurophysiological measures of attention.CzandPz: scalp electrodes sites.C: central. P: parietal. z: median line.

p: t-test for dependent samples between the two sessions.

4. Discussion

The aim of this study was to evaluate measures of cognitive function in children/adolescents aged 11 to 15 years who fasted during Ramadan.The different reaction times (simple, choice and negative priming) did not vary over the two study period. Similarly, the electrophysiological data collected during the hearing test (P300: amplitude and latency) did not change.

The null hypothesis that there is no difference between the two sessions is retained.

4.1. Effects of Ramadan fasting on SRT, CRT and NPRT

The results of this study showed that SRT, CRT and NPRT were not affected by Ramadan Fasting (Figure 3).

These findings are consistent with some studies and contradictory with others. Chamari et al. and Zarrouk et al. [16,17] showed the maintenance of SRT and CRT in cyclists and martial arts athletes. Similarly, Rachid et al. [40] found no effect of fasting on psychomotor function (information processing speed) in medical students. These results are in contradiction with those of Tian et al. [15] who showed that tasks requiring a rapid reaction (detection and identification tasks) are sensitive to fasting. Their findings indicate that detection performance is better during Ramadan. However, Roky et al. [14] reported an alteration in movement reaction time during the first week of Ramadan. According toBouhlel et al. [20], the relationship between fasting and RT performances is complex because it is context and moment dependent. They observed a complex effect of RF with a negative impact on SRT at the end of Ramadan and no effect on CRT.

About NPRT, our finding (Figure 3) was consistent with the results of Ghayour Najafabadiet al. [41]who showed that fasting during Ramadan does not negatively affect the inhibition ability of female athletes. It suggests that neuropsychological adaptation could develop in the context of intermittent fasting and that young healthy individuals could compensate for the possible negative effects by improving their mental effort and motivation.

The explanation given by Bouhlel et al.. (2014) mentioned that the lack of effect on CRT during fasting could be partly explained by the absence of significant changes in blood glucose level during fasting. However, despite the conservation of glucose levels throughout the evaluation period, the alteration of the SRT at the end of Ramadan could be a consequence of dehydration in athletes [20].

Consolidating this rationale, Zarrouk et al.. (2016) mentioned that the conservation of reaction times (SRT and CRT) was due to the stability of the dietary carbohydrate content [17]. Similarly, Tian et al.. (2011) propose that the alteration of psychomotor function/processing speed, verbal learning, and memory performance in the late afternoon may be attributed to the decrease in blood glucose [15].

According to the literature, the brain operates at a heightened metabolic rate, primarily relying on the oxidative utilization of glucose. This underscores the critical reliance of neural tissue on a consistent and ample supply of glucose. While it was initially believed that brain function could only be impacted by glucose deprivation (i.e. under hypoglycemic conditions), it has become evident that even minor fluctuations in central glucose availability can influence neural, and thus cognitive, performance [42]. Furthermore, a study of the effect of glucose administration dose and fasting interval on cognitive function in healthy young people (mean age 20) showed that the highest dose (60 g) increased working memory performance after an overnight fast, while the lowest dose (25 g) improved working memory performance after a 2-hour fast. The authors concluded that the optimal dosage of glucose for cognitive functions may vary according to different conditions of blood glucose resource depletion [43]. However, although demand for glucose specially during complex cognitive processing is high, and glucose/energy consumption is increased in parallel with the increased neural activity [42,44], a negative effects of high normal glucose on cognitive function were previously reported in euglycemic individuals of middle age, the elderly population and in young healthy adults (age range from 18–23 years) [45]. So we conclude that maintaining a more stable glycemic profile, avoiding drastic peaks and troughs in circulating glucose, is associated with sustain cognitive function and a reduced risk of cognitive impairments. Therefore, adopting a regular dietary regimen that ensures an optimal supply of glucose to the brain, both in the fed state and during fasting, appears to be the most beneficial strategy for maintaining cognitive functions, as could be the case in our population.

Given that, on the one hand, the cerebral glucose metabolism rate varies throughout life, and on the other hand, the current study did not include blood glucose measurements or collect nutritional logs, the proposed idea remains purely speculative. It requires in-depth exploration in the context of future research to clarify the relationship between various cognitive functions and blood glucose levels in this population, both during and outside of Ramadan.

4.2. Effects of Ramadan fasting on the P300 component

The P300 is a positive wave which arises when an attended stimulus is detected. It represents a change in the activation of neural networks’ in relation to cognitive operation [46]. This P300 parameter is used to assess neurophysiological measures of attention [47], whose latency and amplitude of P300 reflect different aspects of brain maturation [35]. Latency provides information on the neuronal speed or brain efficiency [35]. It is proportional to the time of evaluation of the stimulus, whose shorter latency is linked to a higher cognitive capacity and indicates a faster cognitive processing speed [46]. Regarding amplitude, it translates neuronal power of the cognitive resources [35]. It is associated with the attentional process [46,47] and the working memory [46]. According to Schubert et al.. (1998), the amplitude of the P300 is proportional to the amount of attentional resources allocated to a given task; greater amplitude of the P300 reflects a greater available attentional capacity and increased attention to a stimulus [48].

In this study, RF had no effect on the amplitudes and latencies in C_z and P_z (Table 2).

Research investigating the impact of food consumption on baseline electroencephalographic (EEG) activity and auditory event-related brain potentials (ERPs) found that subjects experienced a decrease in EEG delta spectral power and an increase in early theta and alpha frequencies following food intake, compared to the fasting state.

Furthermore, it was observed that food intake did not have a significant impact on the amplitude of the P300 component, although its peak latency did increase. These findings suggest that food consumption has a broader influence on general alertness rather than specific cognitive EEG or ERP factors [49].

In another study, P300 wave was measured at various times of a day, and daily fluctuations of this wave were examined as a function of food consumption and physiological parameters (heart rate and body temperature, etc). The researchers indicated that variations in the amplitude and latency of P300 were not directly influenced by the time of day. Nevertheless, people who had not eaten in the six hours prior the test had lower P300 amplitude than those who had eaten recently. The findings suggest that, while circadian rhythms do not affect the P3 ERP, it is associated with recent food intake and physiological factors that vary throughout the day [50].

Concerning the effect of fasting during Ramadan on evoked potentials, Dolu et al. [51] found that P300 latencies were decreased significantly in all regions (F_z, C_z, P_z & O_z) during non-fasting compared with the fasting group [51]. Also, there was an increase in P300 amplitude in the non-fasting group compared with the fasting group in all regions (F_z, C_z, P_z & O_z), but this increase was only significant in the Oz region [51]. Likely, the root cause behind these results can be attributed to glycemic levels. Given that glucose is the primary energy source for the brain [52], a plausible explanation for these findings lies in the significant decrease in glucose levels during Ramadan among fasting individuals compared to the post-Ramadan period in non-fasting individuals.

Numerous studies have demonstrated a substantial reduction in P300 amplitude and an increase in P300 latency under conditions of sleep deprivation [53–55]. These researchers proposed that these alterations can be attributed to increased sleepiness, potentially causing delays in cognitive processing and diminished mental processing efficiency.

In the present study, we did not detect any significant alterations in nocturnal sleep duration. Considering these results, we propose that the maintenance of performance during Ramadan can be partially attributed to the consistent sleep duration observed throughout the study period.

4.3. Limitations and recommendations for further research

This study has certain limitations that need to be taken into account. Firstly, it lacks a dietary survey capable of assessing meal composition in terms of quantity and quality. Such an evaluation would determine whether Ramadan fasting or nutritional factors (quantity and quality) have the greatest influence on cognitive performance. Secondly, sleep assessment remains subjective. It is advisable to incorporate objective assessments that comprehensively evaluate the quantity and quality of sleep. It would be beneficial to use objective measures of sleep, such as actigraphy or polysomnography, in addition to self-reports.

In terms of future research directions, consideration should be given to exploring physiological factors such as body temperature and autonomic nervous system activity, as well as studying neurotrophic factors such as Brain Derived Neurotrophic Factor and Nerve Growth Factor. In addition, the use of a battery of tests measuring a wide range of cognitive domains at different levels of difficulty could help clarify which functions are affected by Ramadan fasting and to what extent.

5. Conclusion

Evaluating our reaction time can be very helpful in various fields, especially in health and education. This will allow us to determine if a child has issues with perception, processing, or motor skills. Furthermore, evoked potentials are characterized by precise temporal resolution in the assessment of cognitive functions, such as the P300 in evaluating attentional processes. Since the measured variables were not altered during the experimental period, it is suggested that the academic performance and overall well-being of children/adolescents were not affected by Ramadan fasting. Taking into account the results of the present study, it appears that children/adolescents aged between 11 and 15 years can fast during Ramadan without fearing to compromise their academic performance and mental well-being. However, it is recommended to assess other cognitively demanding functions to generalize this result.

Abbreviations

BMI	=	Body mass index
BR	=	Before Ramadan
CRT	=	Choice reaction time
EEG	=	electroencephalographic
ERP	=	Event-related potential
ES	=	Experimental session
NPRT	=	Negative priming reaction time
P300	=	a positive deflection in the human event-related potential (neurophysiological measures of attention)
R2	=	at the beginning of the second week of Ramadan
RF	=	Ramadan fasting
RT	=	Reaction time
SRT	=	Simple reaction time

Authors’ contributions

All authors have agreed upon the content of the article and the order of authorship. The specific contributions of all authors are as follows:

1. Conception and design of the work: MILADI Amira; LATIRI Imed.

2. Data collection: MILADI Amira; LATIRI Imed; SAAFI Mohamed Ali

3. Data analysis and interpretation: MILADI Amira; LATIRI Imed.

4. Drafting the article: MILADI Amira; LATIRI Imed; SAAFI Mohamed Ali.

5. Critical revision of the article: MILADI Amira; LATIRI Imed

6. Final approval of the version to be published: MILADI Amira; LATIRI Imed; SAAFI Mohamed Ali.

Acknowledgments

The authors sincerely thank all study participants and extend their heartfelt appreciation for the invaluable assistance rendered by the CHATGPT linguistic model in refining and improving their scientific article.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.