Reformulation of ultra-processed products in Colombia after the introduction of public health regulations

Abstract

Background

The surge in ultra-processed food (UPF) intake and its association with the upsurge in non-communicable diseases in Colombia have motivated the implementation of multifaceted strategies to enhance the food landscape. These interventions include maximum sodium content in UPF, the introduction of front-of-package warning labeling (FOPL), and the implementation of taxes on sugar-sweetened beverages and UPF with excess sodium, sugars, and/or saturated fat content. These measures can effectively incentivize the reformulation of UPF, an area where empirical evidence remains limited within the country. Thus, this study aims to describe the changes in the content of nutrients between 2015 and 2024, when strategies promoting the reformulation of UPF were implemented.

Methods

This study is a quantitative observational repeated cross-sectional that analyzes the shifts in the nutritional profiles of UPF marketed in Colombia from 2015 to 2024. The researchers collected 200 matched product samples, comparing data from the 2015 National Nutrition Survey and in-store surveys conducted in Bogotá in 2024. The median values for energy and key nutrients, including sodium, sugars, saturated fats, calcium, zinc, iron, and vitamin A, were compared. Additionally, the team evaluated the use of FOPL based on established thresholds.

Results

The study revealed substantial decreases in the levels of sugars and sodium in UPF. The median sugar content in beverages plummeted from 8.9 to 4.8 g per 100 ml, whereas median sodium content in food products decreased from 400 to 296 mg per 100 g. Energy counts also saw significant decreases in beverages and processed meats. However, changes in saturated fat content were minimal, and certain subcategories, such as carbonated drinks, even presented increases in sodium. Regarding other micronutrients, an increase in calcium was observed in baked goods, but no consistent patterns emerged for the remaining vitamins and minerals.

Conclusions

Regulatory actions in Colombia appear to have changed the food landscape, fostering reformulation of UPF that drastically curtail the levels of detrimental nutrients such as sugars and sodium. Forthcoming studies should explore the dietary and health implications of these product changes, in addition to scrutinizing shifts in the use of additives and other ingredients.

Trial registration

Not applicable.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12916-025-04215-7.

Background

In recent decades, the food systems in various countries have transformed, with traditional foods being replaced by the consumption of ultra-processed food (UPF) [1]. UPF are industrial formulations manufactured from substances derived from food or synthesized from other organic sources. These products may contain little to no natural food components and are typically high in fat, sodium, and/or sugars but low in fiber, protein, and other bioactive compounds [2]. Globally, per capita sales volumes and sales trends of UPF have been steadily increasing, which has led to a transition toward a more processed dietary pattern [3]. In Latin America, UPF sales increased by 8.3% between 2009 and 2014 and were estimated to rise by 7.8% from 2015 to 2019. This increase corresponded to 7.7% in Colombia, especially in the food category [4]. Studies have shown that ultra-processed food consumption in Colombia increased by 7.7% between 2009 and 2014, particularly in the food category. Furthermore, UPF intake among the Colombian population rose by 12.8% from 2005 to 2015, with higher levels observed among urban residents, wealthier individuals, children, and adolescents [5]. These trends have been attributed to the industrialization of food systems, technological advancements, market expansion, and the proliferation of transnational food corporations [6].

Diets high in UPF are associated with markers of poor dietary quality, which relate to chronic diseases’ prevalence and incidence through various pathways, including inflammatory mechanisms [7]. This association has been linked to food matrix changes affecting digestion, nutrient absorption, and satiety [2]. Additionally, exposure to additives in UPF, including non-caloric sweeteners, may affect the gut microbiome [8]. Intensive industrial processing can also produce potentially harmful substances such as acrolein, acrylamide, furans, and industrial fatty acids, which have been linked to increased risks of chronic diseases [7]. Furthermore, increased exposure to UPFs has been directly associated with an increased risk of all-cause mortality, cardiovascular disease-related mortality, mental disorders, overweight, and type 2 diabetes [7, 9].

Given the global burden of non-communicable diseases (NCD), which account for 74% of all mortality worldwide, the World Health Organization established the importance of an acceleration plan for preventing and controlling obesity and NCD at the 7th Health Conference. This plan compiles various environmental modification strategies, including restrictions on ultra-processed food marketing, fiscal policies, physical activity promotion, and nutrition labeling regulation [9]. Several countries in Latin America have implemented initiatives to reduce UPF consumption. For example, Chile has launched a front-of-package warning labeling (FOPL) law, along with restrictions on marketing to children and promoting healthy school environments, leading to the reformulation of UPF and changes in household UPF purchases [10, 11]. Similarly, Peru has implemented FOPL, which has prompted companies to reformulate foods and beverages to decrease the content of nutrients of concern [11].

These measures aimed to incentivize the food industry to reformulate their products by improving the quality of nutrients [12, 13], thereby avoiding front-end warning labels and subsequent taxation. From a public health perspective, product reformulation may be a desirable intervention to enhance dietary quality without necessarily changing consumer behavior [14]. To the best of our knowledge, there appears to be a lack of studies examining the effects of UPF reformulation in Colombia after introducing FOPL and taxation policies targeting such products.

This study aims to describe the changes in the contents of critical nutrients, including sodium, sugars, and/or saturated fats, between 2015 and 2024, when strategies promoting the reformulation of UPF were implemented. Additionally, the study will review whether there have been alterations in the levels of other nutrients often lacking in the Colombian diet, such as calcium, iron, zinc, and vitamin A, which have been incorporated into ultra-processed products.

Public policies to reduce consumption of ultra-processed foods in Colombia

Several strategies have been implemented in Colombia to reduce the consumption of ultra-processed foods [15–18]. These include maximum sodium content (MSC), the introduction of FOPL, and the implementation of taxes on sugar-sweetened beverages and UPFs with excess sodium, sugars, and/or saturated fat content [15–18]. These strategies have been implemented since 2022 (see Fig. 1).

Fig. 1.

Timeline of the issuance and implementation strategies in Colombia

According to Fig. 1, the first strategy was to establish MSC. This resolution mandates that 59 food groups reduce their sodium content through two targets, to be implemented in November 2022 and November 2024 [18]. The second strategy was FOPL, which included two types of warning labels. In 2021, circular warning labels were implemented for UPF: “high” in sodium, added sugars, and saturated fat. However, with Law 2120, they were replaced by octagonal warning labels in 2023. Additional changes included incorporating the term “excess” on warning labels and introducing warnings for non-sweeteners and trans fats. Moreover, the Pan American Health Organization (PAHO) nutrient profile was adopted to establish limits for the use warning labels [15, 16]. Finally, a third strategy corresponds to UPF taxation, established by Law 2722 in 2022 [17]. For beverages, the tax is determined based on their added sugar content (see Table 1).

Table 1.

Colombian tax rate per 100 ml in COP$

Sugar content in SSBs (grams of added sugar per 100 ml)	Tax rate (per 100 ml) in COP$
	2023	2024	2025
< 6 g	$0	$0	< 5 g	$0
≥ 6 g and < 10 g	$18	$28	≥ 5 g and < 9 g	$38
≥ 10 g	$35	$55	≥ 9 g	$65

Source: Law 2277 of 2022

For UPF, an ad valorem tax on the retail price of UPF with FOPL on sodium, added sugars, and/or saturated fat, with a tax rate of 10% in 2023, 15% in 2024, and 20% in 2025; the tax base excludes artisan products such as arequipe (dulce de leche), guava paste (bocadillo), and bread [17].

The potential effect of implementing FOPL and taxation policies targeting UPF has not been investigated.

Methods

This is a quantitative observational study that follows a cohort of ultra-processed products. The contents of energy, sodium, added sugars, saturated fats, calcium, iron, zinc, and vitamin A were compared for the same products at two time points: 2015 and 2024. Additionally, the use of FOPL was reviewed according to the cut-off points established in the regulation (see Table 2).

Table 2.

Colombian front-of-package warning labels 2022 threshold

Nutrient	Solids (100 g)—semi solids	Liquids (100 ml)
Sodium	≥ 1 mg/kcal and/or ≥ 300 mg/100 g	≥ 1 mg/kcal or non-alcoholic beverages without energy content: ≥ 40 mg/100 ml
Sugars	≥ 10% of total energy from free sugars	≥ 10% of total energy from free sugars
Saturated fat	≥ 10% of total energy from saturated fats	≥ 10% of total energy from saturated fats
Trans fat	≥ 1% of total energy from trans fats	≥ 1% of total energy from trans fats

Source: Resolution 2492 of 2022

The analysis also focused on the UPF categories required to reduce the sodium content and incorporated the limits specified by the Minister of Health [18].

Data

The initial time point of observation—year 2015: we employ a secondary source of data, the 2015 National Nutrition Survey (ENSIN, an acronym in Spanish). The ENSIN 2015 included a dietary intake module that uses 24-h recall, which consists of the individual application of a detailed interview about all foods and beverages consumed during the 24 h before the interview. A sample of 34,096 people aged 0 to 64 years, including pregnant women, was obtained for this module. Once the information was collected, the database was reviewed for data quality purposes. This process was conducted by a team of trained nutrition professionals who acted as interviewers, data reviewers, and data cleaners. When nutritional information was not available in the Food Composition Table, data from other composition tables were used. For packaged products, the nutritional information was obtained directly from the nutrient fact panels by the team responsible for this component of the ENSIN [19].

Subsequently, and for this study, we used the food composition database developed during ENSIN, which includes 2711 food and beverages. These items were grouped according to the NOVA classification by their degree of processing [20]. The classification of these items according NOVA system was previously conducted in Colombia [5]. According to this system, food and beverages are categorized into one of four NOVA categories. The categories are mutually exclusive and vary depending on their extent and purpose of processing. They include (1) unprocessed or minimally processed foods, (2) processed culinary ingredients, (3) processed foods, and (4) ultra-processed products [2]. For this study, we selected all products categorized as ultra-processed food (category 4), resulting in a baseline dataset with 795 ultra-processed products.

The second point of observation—year 2024: we used a convenience sampling approach. In Bogota, supermarket chains do not allow or authorize access for photographing their products. Therefore, we visited several establishments and could only obtain permission from one medium-sized supermarket to conduct the data collection procedure. Three researchers participated in the data collection. The food and beverage available for sale in the supermarket were classified according to the NOVA system, and those identified as UPF were selected for data collection. The researchers photographed the front, nutrition facts panel, and ingredient list of 308 UPF using three camera phones. One of the researchers then downloaded, stored, and classified these images by group and identification code from the ENSIN 2015 database.

A second database with the same nutritional variables as the 2015 dataset was generated. It also included information on the presence or absence of warning labels and ingredient lists. Nine product images were discarded due to poor legibility. Two researchers independently examined a random sample of 10% of the entered data, identifying a discrepancy in just 1 product’s ingredient list, which was promptly corrected.

This study was conducted to determine whether and what changes were made in the nutritional composition of UPF, which are maybe because of the regulatory approaches directed in Colombia. For this reason, the analysis focused on comparing the same products available in both 2015 and 2024. A total of 200 matching products were identified and included in the analysis. Analyzing only the matched products allowed us to directly assess reformulation within the same items overtime, ensuring a more accurate evaluation of the impact of the regulations.

Food and beverage classification

The UPF selected for this study were initially classified into two main groups: food items or beverage products. Subsequently, these primary groups were further subdivided into more specific subcategories in alignment with the methodological framework proposed by prior research conducted in Colombia [21]. Beverages included carbonates, concentrates, energy/sports drinks, ready-to-drink/tea, and flavored milk and juice drinks/nectars, excluding diet cola due to its absence from the 2015 database. The food category included baked goods, breakfast cereals, dairy, frozen desserts, processed meat/seafood, ready meals, sauces/condiments, savory snacks, soups, and sweet snacks. For solid products requiring dilution, the nutritional data was reported as-is from the 100 g nutrition table, without adjusting for preparation.

Analysis

A comprehensive analysis of the nutritional content of 200 products was conducted, comparing nutrients such as energy, sodium, saturated fats, added sugars, calcium, iron, zinc, and vitamin A across different product groups and subgroups. Adhering to the FOPL guidelines set by the Ministry of Health [16], they examined the reported nutrient levels against the established thresholds and the presence of warning labels on the product packaging. For total sugar content in beverages, we also analyzed changes in relation to the tax rate based on sugar content (see Table 1). Furthermore, for the UPF covered by the sodium content reduction strategy, a separate analysis was undertaken to quantify the extent of changes after the initial reduction target was implemented in 2022, in accordance with the applicable regulations [18].

In this cross-sectional investigation, we conducted statistical analyses using STATA version 18 [22]. To assess changes in median nutrient contents per 100 g/ml of ultra-processed food and beverage products between 2015 and 2024, we employed the Wilcoxon matched-pairs signed-rank test, as the data were not normally distributed. This non-parametric test evaluates the null hypothesis that the distribution of the differences is symmetric about 0. We report the median nutrient contents for each year, along with the interquartile range, 25th, and 75th percentiles. Statistical significance was determined at the 0.1%, 1%, and 5% levels.

Results

The sample analyzed comprised 200 UPF, with 162 food items and 38 beverages. Sweet snacks dominate the food category, followed by baked goods and processed meats. Meanwhile, carbonated drinks accounted for most of the beverage segment, complemented by nectars/juices and concentrates.

Our findings reflect the potential effects of the implementation of three key policy interventions in Colombia on the UPF’s reformulation: MSC, the introduction of FOPL, and the implementation of taxes on sugar-sweetened beverages and UPFs with excess sodium, sugars, and/or saturated fat content. In particular, 34 UPFs analyzed were mandated to undergo MSC.

With respect to the median amounts of nutrients, between 2015 and 2024, we found that the median energy content per 100 ml decreased significantly in beverages (see Table 2). The total sugar content also decreased, from 10.7 to 8.1 g per 100 g in foods and from 8.9 to 4.8 g per 100 ml in beverages. The sodium content in food and beverages was changed significantly, in food the reduction in the median was 400 g per 100 g to 296 g per 100 g in 2024; in beverages increased from 8.3 g per 100 ml in 2015 to 15 g per 100 ml in 2024. The median content of saturated fats did not change significantly for either foods or beverages. In food, calcium and iron increased, and zinc decreased. Beverages showed no notable changes.

The analysis revealed significant reductions in the sodium content of the 38 ultra-processed food products that were mandatorily required to undergo reformulation (see Table 3). Specifically, the baked goods subcategory exhibited a significant decrease, with the median sodium level declining from 608 mg in 2015 to 545 mg per 100 g in 2024. Similarly, the snacks subcategory experienced a sodium reduction from 725 to 412 mg per 100 g (Table 4).

Table 3.

Medians of nutrient content per 100 g/ml for beverages and solid foods

Category	Critical nutrients
	n	Energy (kcal)		Total sugars (g)		Sodium (mg)		Saturated fat (g)
		2015	2024	2015	2024	2015	2024	2015	2024
Food	162	354	367	10.7	8.1***	400	296***	4.8	4
IQR		(238, 430)	(186, 432)	(0, 33)	(0, 30)	(105, 720)	(84, 557)	(1, 8)	(1, 8)
Beverages	38	41	24***	8.9	4.8***	8.3	15*	0	0
IQR		(37, 45)	(20, 62)	(5.8, 10.8)	(4.2, 4.9)	(4, 29)	(7, 41)	(0, 0)	(0, 0)
Category	Other nutrients
	n	Calcium (mg)		Iron (mg)		Vitamin A (er)		Zinc (mg)
		2015	2024	2015	2024	2015	2024	2015	2024
Food	162	33	52***	1.2	1.6***	0	0	0.7	0.2***
IQR		(0, 80)	(13, 96)	(0, 2)	(0, 3)	(0, 0)	(0, 10)	(0.3, 1.1)	(0, 0.9)
Beverages	38	0	0	0	0	0	0	0	0
IQR		(0, 5)	(0, 81)	(0, 0)	(0, 0)	(0, 0)	(0, 0)	(0, 0)	(0, 0.3)

Significance p value: *0.05, **0.01, ***0.001

Table 4.

Changes in medians of sodium content in the UPF subgroup included in the regulations

Subgroup	2015	2024
Total	797.4	395.5***
IQR	(650, 1254)	(275, 663)
Baked	608.7	545***
IQR	(475, 697)	(275, 653)
Snacks	725	412*
IQR	(633, 924)	(275, 578)

Units expressed in mg per 100 g. Significance p value: *0.05, **0.01, ***0.001

.

Figure 2 shows significant changes in sugars, sodium, and caloric contents by subcategory. Beverages exhibited reductions in total sugars, with juices showing greater decreases than carbonated drinks. Solid foods had lower sugars in frozen desserts, sweet snacks, and yogurt. Sodium decreased in solid food in baked goods, snacks, soups, and processed meats. However, the sodium content increased in carbonated beverages. Energy levels decreased in carbonated from 41 kcal per 100 ml in 2015 to 20 kcal per 100 ml in 2024 and juice from 44 kcal per 100 ml to 20 kcal per 100 ml; solid foods also result in significant reductions in energy levels in soups and processed meats. Saturated fats decreased in processed meat from 6.2 g per 100 mg in 2015 to 4.8 g per 100 mg in 2024.

Fig. 2.

Changes in nutrients by subcategory

Figure 3 highlights calcium and iron changes for food categories with deficiencies in the Colombian diet. For this type of nutrient, solid foods presented the most notable shifts—calcium increased in baked goods, processed meat, and sweets but decreased in yogurt. Iron increased in baked goods and sweet snacks. Vitamin A increased from 0 in 2015 to 6 er per 100 mg in processed meat while zinc dipped 1 mg per 100 mg, in processed meats. The results for every subcategory are shown in an additional file (see Additional file 1).

Fig. 3.

Changes in calcium and iron by subcategory

The data in Table 5 reveal notable gaps in the implementation of mandatory nutrition labeling. While 85% of the analyzed products met the sodium label requirement and 87% complied with the sugars label, there remains a concerning 15% and 13% that fall short, respectively. Strikingly, some products that should not display these FOPL according to regulations have done so nonetheless, with 12% carrying the sodium FOPL and 3% the sugars FOPL despite not meeting the criteria.

Table 5.

Implementation of a mandatory front-of-package warning label

Requirement		Mandatory
		Sodium				Sugars
		Yes		No		Yes		No	%
Met requirement	Yes	70	85.4%	14	11.9%	100	87.0%	3	3.5%
	No	12	14.6%	104	88.1%	15	13.0%	82	96.5%
Total mandatory		82		118		115		85

Discussion

After the implementation of three key policy interventions in Colombia on the UPF reformulation: the maximum sodium content levels in ultra-processed food products, the introduction of FOPL, and the imposition of taxes on sugar-sweetened beverages and UPF with excess sodium, sugars, and/or saturated fat content. We found that nutrients such as energy, sugars, and sodium presented changes in the formulation of UPF.

The observed changes in caloric content are likely to have resulted primarily from the substitution of caloric sweeteners with non-caloric alternatives. These findings align with evidence from Chile and Australia, where the implementation of labeling policies prompted reformulation processes that led to the reduction of critical nutrients and/or their replacement with other ingredients [9, 18]. Similarly, Hashem et al. reported reductions in sugar content. This study analyzed beverage samples over a 2-year period (2015–2017), focusing on energy drinks available in the nine main UK retailers, three health and beauty retailers, and one convenience store. They collected nutritional information panels of energy drinks and found a 10% decrease in sugar levels and a 6% decline in energy content [23].

In the case of Colombia, the reduction in the sugar content in beverages has been bolstered through a multi-pronged approach, encompassing both FOPL and the implementation of a tax on sugary drinks since the end of 2023. Our findings indicate that following the adoption of these strategies, the beverage industry has lowered the sugar content in 32 of the 38 products examined to levels below the threshold, triggering the tax (< 5 g of sugars per 100 ml to 2025) (see Table 1).

The implementation of mandatory sodium reduction policies in Colombia has yielded mixed results since 2022. Our results show significant differences in the sodium content across the 59 ultra-processed food categories that were required to reduce sodium levels. In contrast, the subgroup of carbonated beverages exhibited an increase in sodium content, though this rise did not necessitate the implementation of warning labels, as it remained within the regulatory thresholds. This increase warrants further investigation, given the links between sodium consumption and NCD [8]. Similarly, the experience in Peru has been inconclusive, with no notable changes in sodium levels and a low number of UPF bearing warning labels during the initial phase of policy implementation [11].

Our results showed no significant changes in saturated fat levels, suggesting the need to strengthen regulations on these nutrients. This is consistent with the experience in Chile, where limited reformulation efforts were observed, and in some products, the saturated fat content actually increased [9].

The evidence shows that the simultaneous implementation of policies aimed at MCS, introducing FOPL, and imposing taxes on UPF yields more favor outcomes and amplifies the effects compared with adopting these measures independently [9, 12, 24]. For example, a microsimulation study in Mexico found that a combination of taxes, warning labels, and restrictions on UPF advertising could potentially reduce UPF purchases by 24%, an impact comparable in magnitude to FOPL alone [24]. Nonetheless, the existing evidence lacks insight into the influence of taxes on the reformulation of UPF.

The mandatory implementation of the three policy strategies in Colombia appears to have prompted reformulation efforts to reduce the levels of sugar and sodium in UPF. The evidence indicates that a mandatory regulatory approach is more effective than a voluntary one in driving reformulation processes [25, 26]. Furthermore, these findings suggest that the food industry possesses the capacity to reduce the content of critical nutrients if motivated to do so and can thus take proactive steps to contribute to improving population health, akin to the experience reported by [11] in the Chilean context. The rapid and substantial reformulation observed in Chile was attributed to the mandatory nature of the regulations and the comprehensive set of policy measures implemented.

Similarly, studies have shown that the implementation of the Chilean food labeling law led to the reformulation of a substantial number of products, particularly in the dairy, sugary beverage, and flour-based food categories [27]. This reformulation process resulted in a decline in the expected number of products that would carry the “high in” warning label. A similar trend was observed in Colombia, where the number of UPF that would have received the sodium-related warning label decreased by 8.8% between 2015 and 2024, following product reformulation efforts. Likewise, the number of products that would have received the sugar-related warning label presented a 12.2% reduction.

This study provides insights into the evolving food landscape in Colombia, contributing to the growing evidence that Colombian consumers now have greater access to UPF without FOPL, and that the consumption of sugars and sodium in these products has primarily decreased. However, the findings also suggest a potential increase in the use of non-caloric sweeteners and other additives employed in the reformulation processes. The results presented herein can empower stakeholders’ efforts to evaluate, complement, and/or reinforce the various regulatory initiatives in Colombia, as well as offer valuable lessons to guide the implementation and/or adjustment of similar policies in other contexts.

Nonetheless, public policy strategies such as FOPL and taxes are aimed at reducing the content of sodium, sugars, and saturated fats, but the industry has little incentive to increase favorable nutrients like calcium, iron, or fiber to promote healthy ingredients like whole grains, fruits, vegetables, or legumes [28]. There is a pressing need to create incentives that drive the increased use of healthier ingredients in product formulations.

This investigation has certain limitations. The analysis did not account for product sales volumes or the relative contribution of each item to the Colombian diet. Future research could address these aspects, as well as directly assess the nutritional composition through laboratory testing. Another limitation is the use of observational data and descriptive analyses to evaluate changes in the proportion of regulated products and shifts in nutrients of concern following the implementation of the three public health regulations. As such, our study design does not allow us to establish causality. While the trend analysis reveals associations over time, it cannot isolate the potential effects of the staggered policy implementation from other influencing factors.

It would also be valuable to examine how the reformulation of ultra-processed foods has affected the number and types of ingredients used. Additionally, our analyses rely on information available on nutritional labels. However, data collection was carried out systematically by previously trained researchers. Lastly, the implications of the observed reductions in sodium and sugar content for the overall quality of the Colombian diet warrant further investigation.

Conclusions

The implementation of front-of-package labeling (FOPL), taxes on sugary beverages, and maximum sodium content (MSC) policies in Colombia can effectively encourage ultra-processed product reformulation, contributing to the development of healthier food environments. The key findings indicate a reduction in sugar and sodium levels across various product categories, reflecting the industry’s capacity to adapt to regulatory requirements. Future research should evaluate the dietary impacts of these reformulated products—particularly their effects on public health outcomes—and consider a thorough review of the ingredients used in the reformulation process.

Abbreviations

UPF

Ultra-processed food

NCD

Non-communicable diseases

FOPL

Front-of-package warning labeling

MSC

Maximum sodium content

PAHO

Pan American Health Association

ENSIN

Encuesta Nacional de Situación Nutricional (in Spanish)

Authors’ contributions

EC: Conceptualization, methodology, formal analysis, writing - review & editing. IG: Conceptualization, methodology, formal analysis, writing - review & editing. VES: Conceptualization, methodology, writing, review & editing. All authors read and approved the final manuscript.

Funding

This research received no external funding.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

The Ethics Committee of the Universidad Icesi, Approval Act Number 641, approved the study.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.