Abstract
Background
Food allergy is a chronic condition with psychosocial consequences for both children and their families. Strict elimination diets and fear of adverse reactions may contribute to maladaptive coping including behaviors avoidant/restrictive food intake disorder (ARFID)‐related eating patterns. Therefore, this study aimed to compare ARFID‐related eating behavior scores between children with food allergy and healthy controls and to identify the affected domains.
Methods
In this prospective controlled study, 234 children aged 2–9 years were enrolled, including 117 children with physician‐diagnosed food allergy and 117 age‐ and sex‐matched healthy controls. Eating behaviors were assessed using the Nine Item Avoidant/Restrictive Food Intake Disorder Screen—Parent Report (NIAS‐PR). Total and subscale scores (picky eating, fear, and appetite) were compared between groups. Within the food allergy group, associations between clinical characteristics and NIAS‐PR scores were analyzed.
Results
Children with food allergy demonstrated significantly higher NIAS‐PR total scores compared with controls. The median total NIAS score was higher in the patient group than in the control group (17 [11–24] vs. 12 [7–18], p < .001). This difference was primarily driven by higher fear‐ and picky‐eating‐related scores, whereas appetite scores did not differ significantly. Fear subscale scores were significantly higher in children with a history of urticaria or anaphylaxis.
Conclusion
Pediatric food allergy is associated with increased ARFID‐related eating behaviors, particularly fear‐ and picky‐eating patterns. In addition, fear‐related scores were higher among children with a history of immediate‐type reactions, such as urticaria and anaphylaxis. These findings suggest that ARFID‐related eating behaviors should be considered in the assessment of children with food allergy.
Keywords: avoidant/restrictive food intake disorder (ARFID), children, eating disorders, fear, food allergy, NIAS‐PR, picky‐eating
Abbreviations
- ARFID
Avoidant/Restrictive Food Intake Disorder
- CEBQ
Children's Eating Behavior Questionnaire
- DSM‐5‐TR
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision
- EAACI
European Academy of Allergy and Clinical Immunology
- FPIES
Food protein–induced enterocolitis syndrome
- IgE
Immunoglobulin E
- NIAS‐PR
Nine Item Avoidant/Restrictive Food Intake Disorder Screen–Parent Report
Key message.
Children with food allergy showed higher NIAS‐PR scores mainly in the picky eating and fear‐related domains, while appetite‐related scores did not differ from healthy controls. Fear scores were higher in those with urticaria or anaphylaxis, suggesting that food allergy may be associated with food selectivity and fear around eating.
1. INTRODUCTION
The prevalence of food allergy in children has been reported to be approximately 8%, and its frequency has been increasing in recent years. 1 The current standard treatment relies on a strict elimination diet targeting the responsible allergen. However, in childhood, eating is not only a physiological necessity but also a fundamental component of daily life and social interaction. Children with food allergy may experience a persistent state of vigilance in order to prevent potential allergic reactions, which can gradually lead to excessive avoidance behaviors. 2 Such avoidance may restrict participation in social activities that peers can easily engage in and may cause eating to become an increasing source of stress. This sustained burden has been associated with anxiety, behavioral problems, and disruptions in feeding behaviors. 2 , 3
In recent years, the relationship between food allergy and eating disorders has received growing attention. 4 Previous reactions to food may lead families to adopt excessive avoidance behaviors due to fear of experiencing the same reaction again. Patients and parents may implement unnecessary dietary restrictions, including the avoidance of foods to which the child is not allergic. 5 This may result in reduced dietary variety and negatively affect growth and nutritional status. 5
Recent studies have reported that the prevalence of eating disorders among individuals with food allergy ranges widely, from 0.8% to 63%. 6 Avoidant/Restrictive Food Intake Disorder (ARFID) is among the most commonly reported eating and feeding disorders in this patient population. 6 ARFID is classified among eating and feeding disorders in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM‐5‐TR) and is characterized by a lack of interest in eating, selectivity based on the sensory characteristics of food, avoidance related to concerns about the negative consequences of eating (e.g., choking). It is associated with insufficient nutritional and energy intake. As a result, it may lead to weight loss, nutritional deficiencies, dependence on enteral feeding, and impairment in psychosocial functioning. 7 The absence of body image disturbance or fear of weight gain distinguishes ARFID from anorexia nervosa. 7 Given the growing recognition of maladaptive eating behaviors among children with food allergy, there is a need for prospective, controlled studies using standardized screening tools, particularly in younger pediatric populations. 6 The Nine Item ARFID Screen–Parent Report (NIAS‐PR) is a validated scale designed to assess ARFID‐related eating behaviors through parental observation. 8 , 9 Using this scale, we aimed to compare ARFID‐related eating behavior scores between children with food allergy and healthy controls. We also aimed to determine which specific domains, including selectivity, fear related avoidance, and appetite related restriction, were most affected.
2. MATERIALS AND METHODS
2.1. Study design and setting
This single‐center, prospective, controlled study was conducted at the Pediatric Immunology and Allergy Outpatient Clinic between September 15, 2025, and February 5, 2026. Children aged 2–9 years with a diagnosis of food allergy were consecutively recruited during routine outpatient visits. Patients with IgE‐mediated food allergy and those with mixed‐type food allergy presenting with atopic dermatitis were included in the study. Food allergy was confirmed by pediatric allergists based on oral food challenge and/or a compatible clinical history supported by food‐specific IgE and/or skin prick test results. Patients with non‐IgE mediated food allergy and those with eosinophilic gastrointestinal diseases were excluded. The control group consisted of age‐ and sex‐matched healthy children recruited from the general pediatric outpatient clinic during routine visits.
Children were excluded if written informed consent was not obtained from their parents or legal guardians, or if they had underlying chronic or systemic diseases, congenital oral or gastrointestinal anomalies, gastrointestinal disorders affecting feeding (e.g., gastroesophageal reflux disease or eosinophilic esophagitis), dependence on enteral tube feeding due to metabolic or neurological disorders (e.g., cerebral palsy), or neurodevelopmental disorders such as intellectual disability or autism spectrum disorder, to minimize potential confounding factors that may independently influence feeding behaviors.
2.2. Data collection
Demographic characteristics, comorbidities, specific type of food allergy, foods requiring dietary elimination, age at the initial allergic reaction, type of allergic reaction, presence of concomitant allergic diseases, and family history of food allergy were recorded for all participants. Anthropometric measurements, including height and weight, were obtained during routine outpatient visits and recorded. The NIAS‐PR was administered to parents of participants in both the study and control groups. 9
2.3. The nine item ARFID screen—Parent report
The NIAS‐PR is a brief, validated screening tool, and its validity and reliability have been established in the Turkish language. 8 , 9 NIAS‐PR is a validated 9‐item parent‐report screening tool assessing three domains of ARFID‐related eating behaviors: picky eating (Items 1–3), lack of interest/appetite (Items 4–6), and fear of aversive consequences (Items 7–9). Items are rated on a 6‐point Likert scale ranging from 0 (strongly disagree) to 5 (strongly agree). Each subscale yields a total score ranging from 0 to 15, while the overall NIAS‐PR total score ranges from 0 to 45. Higher subscale scores indicate greater severity in the corresponding eating‐related domain, whereas higher total scores reflect a greater overall burden of ARFID‐related symptoms. As the NIAS‐PR is a screening tool, no definitive DSM‐5‐TR based psychiatric diagnosis was made within the scope of this study.
2.4. Ethics committee
The study was conducted in accordance with the Declaration of Helsinki and approved by the local Ethics Committee of the University Of Health Sciences, Prof. Cemil Tascioglu City Hospital (Protocol No: 2025/267). Written informed consent was obtained from the parents or legal guardians of all participants.
2.5. Statistical analysis
Statistical analyses were performed using SPSS statistical software package (version 26.0). Continuous variables were presented as mean ± standard deviation or median (interquartile range), as appropriate. Normality was assessed using the Shapiro–Wilk test. Between‐group comparisons were conducted using the independent samples t‐test or the Mann–Whitney U test, and categorical variables were analyzed using the chi‐square test. NIAS‐PR item, subscale, and total scores were compared between children with and without food allergy. Additional subgroup analyses were performed within the food allergy group to evaluate associations between NIAS‐PR scores and clinical characteristics. A two‐tailed p value <.05 was considered statistically significant.
3. RESULTS
A total of 234 children were included in the study, comprising 117 children with food allergy and 117 healthy controls. The patient and control groups were comparable in terms of sex and age (female: 33.3% vs. 34.2%). The median age was 5.2 years (IQR: 3.7–7.2) in the patient group and 5.9 years (IQR: 3.6–7.3) in the control group (p = .598). Children with food allergy demonstrated significantly lower weight for age z‐scores (−0.20 ± 1.10 vs. 0.26 ± 1.05, p = .001) and height for age z‐scores (−0.40 ± 1.18 vs. 0.15 ± 1.18, p < .001) compared with controls. There was no significant difference in body mass index (BMI) z‐scores between the patient and control groups (p = .117) (Table 1).
TABLE 1.
Demographic and anthropometric characteristics of the study groups.
| Study groups | |||
|---|---|---|---|
| Patient (n = 117) | Control (n = 117) | p | |
| Female sex, n (%) | 39 (33.3) | 40 (34.2) | 0.890* |
| Age (years) median (IQR) | 5.2 (3.7–7.2) | 5.9 (3.6–7.3) | 0.598** |
| Weight‐for‐age z‐score, mean ± SD | −0.20 ± 1.10 | 0.26 ± 1.05 | 0.001*** |
| Height‐for‐age z‐score, mean ± SD | −0.40 ± 1.18 | 0.15 ± 1.18 | <0.001*** |
| BMI z‐score, mean ± SD | ‐0,10 ± 1,27 | 0.17 ± 1.29 | 0.117*** |
Note: Values are presented as n (%), median (interquartile range), or mean ± standard deviation.
Abbreviations: BMI: Body mass index; IQR, interquartile range; SD, standard deviation.
Comparisons were performed using the Pearson chi‐square test.
Comparisons were performed using the Mann–Whitney U test.
Comparisons were performed using the independent samples t‐test.
3.1. Clinical characteristics of children with food allergy
A total of 117 patients were included in the study. The most common food allergens were cow's milk and egg. Multiple food allergy (2–13 foods) was present in 44% of the patients. The most frequent reaction types were urticaria, followed by anaphylaxis and atopic dermatitis (Table 2).
TABLE 2.
Clinical characteristics of children with food allergy (n = 117).
| n | (%) | |
|---|---|---|
| Concomitant allergic diseases | 72 | (62) |
| Asthma | 34 | (29) |
| Allergic rhinitis | 38 | (32) |
| Atopic dermatitis | 43 | (37) |
| Chronic urticaria | 1 | (0.9) |
| Food allergy in family | 19 | (16) |
| Tolerance to ≥1 previously diagnosed food allergen | 12 | (10) |
| Multiple food allergy | 51 | (44) |
| Food allergens | ||
| Cow's milk allergy | 52 | (44) |
| Egg allergy | 52 | (44) |
| Tree nut allergy | 47 | (40) |
| Sesame allergy | 18 | (15) |
| Peanut allergy | 16 | (14) |
| Legume allergy (excluding peanut) | 7 | (6) |
| Fruit allergy | 12 | (10) |
| Other food allergy (e.g., fish, beef, wheat) | 8 | (7) |
| Reaction types | ||
| Urticaria | 103 | (88) |
| Anaphylaxis | 65 | (56) |
| Atopic dermatitis | 50 | (43) |
3.2. Comparison of NIAS‐PR total and subscale scores
The median total NIAS‐PR score was significantly higher in the patient group than in the control group (17 [11–24] vs. 12 [7–18], p < .001). No statistically significant difference was observed in total NIAS‐PR scores between males and females (p = .471). At the subscale level, children with food allergy had higher picky eating and fear scores compared with controls (both p < .001), whereas appetite subscale scores did not differ significantly between groups (p = .311) (Table 3).
TABLE 3.
Comparison of NIAS‐PR subscale and total scores between children with food allergy and healthy controls.
| Subscale scores | Study groups | ||||||
|---|---|---|---|---|---|---|---|
| Patient | Control | ||||||
| Median | (IQR) | min‐max | Median | (IQR) | min‐max | p | |
| Picky eating | 9 | (5–11) | (0–15) | 6 | (3–9) | (0–15) | <0.001 |
| Appetite | 5 | (3–9) | (0–15) | 5 | (3–8) | (0–15) | 0.311 |
| Fear | 3 | (0–5) | (0–15) | 0 | (0–3) | (0–8) | <0.001 |
| Total | 17 | (11–24) | (0–42) | 12 | (7–18) | (0–35) | <0.001 |
Note: Comparisons were performed using the Mann–Whitney U test. Values are presented as median (IQR; min–max).
Abbreviations: IQR, interquartile range; min–max, minimum–maximum.
3.3. Comparison of NIAS‐PR item scores between groups
Children with food allergy scored higher on items reflecting picky eating and fear‐related behaviors (Items 1–3 and 7–9), whereas appetite‐related items did not differ between groups. NIAS‐PR item scores for both groups are presented in Table 4.
TABLE 4.
Comparison of NIAS‐PR item scores between children with food allergy and healthy controls.
| Study groups | |||||
|---|---|---|---|---|---|
| Patient | Control | ||||
| Median | IQR | Median | IQR | p | |
| Item 1: My child is a picky eater | 4 | (2–4) | 3 | (1–4) | 0.007 |
| Item 2: My child doesn't like many of the foods that other kids his or her age eat easily | 3 | (1–4) | 1 | (1–3) | <0.001 |
| Item 3: My child refuses to eat everything but a short list of preferred foods | 2 | (1–4) | 1 | (0–3) | 0.001 |
| Item 4: My child does not appear very interested in eating; s/he has a smaller appetite than other kids the same age | 1 | (1–4) | 1 | (0–3) | 0.089 |
| Item 5: Left to his/her own devices, my child would not eat a large enough volume of food | 3 | (1–4) | 3 | (1–4) | 0.322 |
| Item 6: It is difficult to get my child to eat a large enough volume, even when I offer foods that s/he really likes | 1 | (0–3) | 1 | (1–3) | 0.953 |
| Item 7: My child refuses to eat because s/he is afraid of discomfort, choking, or vomiting | 1 | (0–1) | 0 | (0–1) | <0.001 |
| Item 8: My child restricts him/herself to certain foods because s/he is afraid that other foods will cause discomfort, choking, or vomiting | 1 | (0–2) | 0 | (0–1) | <0.001 |
| Item 9: My child does not eat enough food because s/he is afraid of discomfort, choking, or vomiting. | 1 | (0–1) | 0 | (0–1) | <0.001 |
| Total score | 17 | (11–24) | 12 | (7–18) | <0.001 |
Note: Comparisons were performed using the Mann–Whitney U test.
3.4. Clinical factors associated with NIAS scores in children with food allergy
Among children with food allergy, those with asthma had significantly higher total NIAS‐PR scores compared with those without asthma (19 [14–39] vs. 16 [10–22], p = .043). In contrast, no associations were observed with other atopic conditions, reaction type, tolerance development, or specific culprit foods (all p > .05).
3.5. Subscale analyses within the food allergy group
Within the food allergy group, children with urticaria‐type reactions had significantly higher fear subscale scores compared with those without urticaria (p = .009). Fear scores were also significantly higher in children with a history of anaphylaxis (p = .014).
In contrast, neither picky eating nor fear subscale scores were significantly associated with the number of food allergens (single vs. multiple) or with specific culprit foods (all p > .05).
4. DISCUSSION
Our findings indicate that children with food allergy exhibit higher NIAS‐PR scores compared to healthy peers. ARFID‐related eating behaviors were more affected by picky eating and fear dimensions. In the food allergy group, fear‐based eating behaviors were more affected in those with early‐type reactions such as urticaria and anaphylaxis.
A recent European Academy of Allergy and Clinical Immunology (EAACI) Task Force systematic review reported that the prevalence of feeding difficulties in children with food allergy ranges between 13.6% and 40%. 10 However, most of the included studies were heterogeneous, using different terminologies such as selective eating, food refusal, avoidant or restrictive eating patterns, food neophobia, and slow eating to describe feeding difficulties. Most studies predominantly included children with non–IgE‐mediated food allergies, while fewer focused specifically on IgE‐mediated phenotypes, and a wide range of diagnostic instruments was employed. 10
In the large cohort study by Kuno and Frankel, children were grouped into four eating behavior profiles using latent profile analysis based on Children's Eating Behavior Questionnaire (CEBQ) measures: Apathetic Eaters, Motivated Eaters, Enthusiastic Eaters, and Mixed Eaters. 11 These profiles were primarily characterized by patterns of appetitive traits. Children with food allergy were not clustered within any specific profile. 11 These findings indicate that food allergy status alone may not be a determining factor in appetitive trait–based eating patterns. Our study also demonstrated that appetite‐related assessments were not affected. In contrast, Nemet et al., in a retrospective study based on ICD codes, reported appetite loss in children with a history of food‐induced anaphylaxis. 12 Differences in the study population and methodology may explain these findings.
In our study, children with food allergy had higher fear‐related NIAS‐PR scores than controls. This may be related to the anxiety and fear around eating that can follow food‐related allergic reactions. Le et al. showed that children who had experienced adverse reactions to food may develop state anxiety when imagining ingestion of the culprit food. 13 However, families have reported that anxiety may persist long after the reaction and that they continue to fear the possibility of future reactions. 14 Similarly, adolescents with food allergy have also reported higher levels of anxiety when they are not under parental supervision, particularly fear related to eating in settings such as school, restaurants, or friends' homes. 15 Su et al. reported that food aversion, defined as reluctance, avoidance, or fear of eating or drinking, was common in children with food protein–induced enterocolitis syndrome, particularly among those with multiple food triggers. 16
Reaction severity or type may also play a role in fear‐related eating patterns. Anaphylaxis is potentially life‐threatening and is often experienced as one of the most frightening allergic reactions. 17 This is supported by reports showing acute stress symptoms in children with food allergy and in their parents after food‐induced anaphylaxis. 17 Le et al. reported that children with more severe reactions, including generalized urticaria, respiratory symptoms, or cardiovascular involvement, exhibited higher anxiety levels and greater food avoidance compared with those with milder symptoms. 13 In our cohort, fear subscale scores were also higher in children with a history of immediate‐type reactions, especially urticaria and anaphylaxis. These findings suggest that previous allergic reactions may contribute to persistent fear of adverse consequences related to food intake.
Parents of children with food allergy have been reported to experience greater mealtime concerns and maladaptive feeding practices. 18 , 19 In addition, children with food allergy may demonstrate higher rates of food avoidance compared to healthy peers. 16 Polloni et al. evaluated feeding difficulties in children with IgE‐mediated food allergy and found that these children often had a monotonous diet and reluctance to try new foods. 20 Similarly, Maslin et al. assessed long‐term eating behaviors in children who had followed a cow's milk exclusion diet during infancy and reported higher avoidant eating behavior scores compared with controls. 21 They also showed that early dietary elimination may influence later taste preferences. 22 Based on these findings, picky eating in children with food allergy may be influenced by several factors, including maladaptive parental feeding behaviors, food avoidance in the child, altered taste preferences, and dietary restriction. These findings may explain why picky eating scores were higher in our cohort. Furthermore, Fitzgerald and Frankum reported that a substantial proportion of food avoidance was driven by perceived rather than objectively confirmed food allergy or intolerance. 23 This observation further underscores that not only confirmed allergy, but also perceived or presumed risk, may shape eating behaviors.
The NIAS, developed by Zickgraf and Ellis, assesses the core ARFID dimensions of picky eating, lack of interest in eating, and fear. 8 The Turkish validation study also supported convergent validity, as the NIAS‐PR picky eating and appetite subscales showed expected correlations with related CEBQ food‐avoidance and food‐approach subscales. 9 Although the NIAS‐PR has demonstrated satisfactory validity and reliability in Turkish pediatric populations, it remains a screening tool. 9 Therefore, our findings should be interpreted as reflecting ARFID‐related symptom severity rather than a formal ARFID diagnosis.
Few studies in the literature have evaluated eating disorders or feeding difficulties in children with food allergy, and these studies have used various questionnaires focusing on different aspects of eating behavior. However, no study has used the NIAS‐PR to assess the relationship between food allergy and ARFID‐related eating behaviors in children; therefore, we were unable to directly compare our findings with previous NIAS‐PR–based studies in this population. In a study using the NIAS, Fink et al. reported a high prevalence of ARFID symptoms among adults with organic gastrointestinal conditions, including eosinophilic esophagitis. 24 However, they also suggested that screening tools such as the NIAS may overestimate pathological food avoidance in the context of chronic gastrointestinal disease because of symptom overlap, particularly fear related to gastrointestinal discomfort. 24 Furthermore, distinguishing between truly necessary food elimination and excessive maladaptive responses can be challenging. A similar diagnostic complexity may arise in food allergy, where dietary elimination is medically indicated. 25 As emphasized by Patrawala et al., food avoidance that extends beyond medically necessary restrictions in food allergy may represent a treatable complication. 25 However, the absence of established guidelines for the diagnosis and management of ARFID in pediatric food allergy populations further complicates this distinction. Therefore, careful clinical evaluation and management by an experienced multidisciplinary team are essential.
The main limitations of our study include its single‐center design. In addition, psychosocial variables that may influence eating behaviors, such as parental and child anxiety, were not assessed. A formal psychiatric evaluation to establish a diagnosis of ARFID was not performed, which represents another important limitation. Moreover, no validated cut‐off value has been established for the NIAS‐PR to confirm a diagnosis of ARFID. Therefore, our findings should be interpreted as differences in ARFID‐related eating behavior scores between children with food allergy and healthy controls, rather than as evidence of ARFID risk or diagnosis. In addition, fear scores are relatively low among children with food allergies and in the healthy group. Therefore, these findings should be interpreted with caution. This may be a result of the adaptation necessary to avoid reactions rather than behaviors clinically associated with ARFID. Further studies are needed to assess how clinically significant this is in terms of ARFID.
Although interest in the relationship between food allergy and eating disorders is increasing, prospective controlled studies using validated screening instruments remain limited. Our study contributes to the existing literature through its relatively large sample size, prospective controlled design, and its emphasis on the picky eating and fear‐related dimensions of eating disturbance in children with food allergy.
5. CONCLUSION
In conclusion, food allergy is a chronic condition with psychosocial consequences that affect the entire family. 12 Children with food allergy showed higher NIAS‐PR scores than healthy controls in the fear‐related and picky eating domains, whereas no significant difference was observed in the appetite domain. In addition, fear‐related scores were higher among children with a history of immediate‐type reactions, such as urticaria and anaphylaxis. These findings suggest that food allergy may be associated with differences in specific ARFID‐related eating behavior domains, particularly food selectivity and fear around eating.
AUTHOR CONTRIBUTIONS
Merve Karaca Şahin: Methodology; formal analysis; writing – original draft; conceptualization; validation; visualization; writing – review and editing. Hasan Tunç Şarman: Investigation; data curation. Aslı Berivan Topçak: Investigation; data curation. Şefika İlknur Kökcü Karadağ: Data curation; investigation. Eren Güzeloğlu: Investigation; data curation. Güler Yıldırım: Investigation; data curation. Çağla Öztürk Turan: Data curation; investigation. Nilay Çalışkan: Data curation; investigation; writing – review and editing. Deniz Özçeker: Writing – review and editing; supervision; methodology; conceptualization. Hilal Güngör: Data curation; investigation. Hamit Boloğur: Investigation; data curation. Şule Papağan: Data curation; investigation. Muhammed Fatih Erbay: Data curation; investigation. Ömer Yılmaz Ulutaş: Investigation; data curation.
FUNDING INFORMATION
The authors have nothing to report.
CONFLICT OF INTEREST STATEMENT
The authors declare no conflicts of interest.
ETHICAL APPROVAL
The study was conducted in accordance with the Declaration of Helsinki and approved by the local Ethics Committee of the University Of Health Sciences, Prof. Cemil Tascioglu City Hospital (Protocol No: 2025/267). Written informed consent was obtained from the parents or legal guardians of all participants.
ACKNOWLEDGMENTS
We sincerely thank Zickgraf HF and Ellis JM for developing the NIAS and for granting permission to use the scale. We are particularly grateful to Zickgraf for helpful clarifications regarding the scale. We also thank Akçay E et al. for their work on the Turkish adaptation of the NIAS‐PR and for permitting its use in this study.
Karaca Şahin M, Çalışkan N, Şarman HT, et al. Fear and picky eating‐related ARFID behaviors in children with food allergy. Pediatr Allergy Immunol. 2026;37:e70403. doi: 10.1111/pai.70403
Editor: Ömer Kalayci
DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.