Experiences and Needs Regarding Anti-Inflammatory Dietary Management in Sarcopenia Care: A Qualitative Study from a Multi-Stakeholder Perspective

Abstract

Background and Objectives

Sarcopenia is a prevalent geriatric syndrome, and nutritional intervention plays an important role in its prevention and management. In recent years, anti-inflammatory dietary strategies have received increasing attention in clinical guidelines; however, their awareness, implementation, and support needs in real-world care settings remain insufficiently explored. This study aimed to investigate the lived experiences and practical challenges of anti-inflammatory dietary management in sarcopenia care from a multi-stakeholder perspective, providing evidence for the development of continuous nutritional management strategies.

Research Design and Methods

A descriptive qualitative study design was adopted. Using purposive and snowball sampling, semi-structured interviews were conducted with older adults with and without sarcopenia, as well as relevant care professionals, across three care settings: hospitals, long-term care facilities, and communities. Data were analyzed using thematic analysis, and the identified themes were theoretically interpreted using the COM-B model and the Integrated Care Rainbow Model.

Results

A total of 63 participants were enrolled, including 35 older adults and 28 staff members. Five overarching themes were ultimately extracted: (1) Dietary management is influenced by setting structure and support systems; (2) The importance of diet is widely recognized, yet specialized knowledge remains weak; (3) Anti-inflammatory dietary management is constrained by inadequate intake and multiple implementation barriers; (4) Cross-setting dietary management exhibits fragmented transitions and insufficient continuous care mechanisms; and (5) Respondents expect more concrete, individualized, and continuous support.

Discussion and Implications

Anti-inflammatory dietary management among older adults with sarcopenia is influenced by multidimensional factors related to individual capability, environmental opportunity, and behavioral motivation. Translating anti-inflammatory dietary recommendations into routine care practice requires enhancing individuals’ dietary management capacity, strengthening supportive care environments, and establishing cross-setting continuous nutritional support pathways. Future intervention studies are needed to further evaluate the effectiveness of such strategies.

Plain Language Summary

Sarcopenia is a common geriatric syndrome, and nutritional intervention plays an important role in its management. Although anti-inflammatory dietary strategies have gained increasing attention, their implementation in real-world care remains limited. This multi-stakeholder study identified barriers related to individual capability, environmental opportunity, and behavioral motivation, as well as fragmented support across care settings. Addressing these challenges requires strengthening dietary self-management, optimizing supportive food environments, and establishing continuous nutritional care pathways. These findings provide insights for translating dietary recommendations into patient-centered and sustainable care practices for older adults with sarcopenia.

Introduction

Sarcopenia, a common geriatric syndrome, is primarily characterized by a progressive decline in muscle mass, strength, and physical function, increasing the risk of adverse events such as falls, fractures, and disability.¹ Surveys show that the prevalence of sarcopenia in the older adults is approximately 10–16%,² imposing a heavy burden on families and society. The pathogenesis of sarcopenia is complex, and chronic low-grade inflammation is considered one of the important mechanisms underlying its development and progression.³ Currently, exercise and nutritional intervention are regarded as effective strategies for the prevention and treatment of sarcopenia.⁴ The evidence-based expert consensus of the Asian Working Group for Sarcopenia proposes that diets with anti-inflammatory potential, ie, those containing specific antioxidant-rich foods, may help prevent sarcopenia.⁵ Anti-inflammatory dietary strategies do not target a single food component or nutrient; rather, they emphasize an overall dietary pattern characterized by increased consumption of potentially anti-inflammatory foods, including vegetables, fruits, whole grains, legumes, nuts, fish, and healthy unsaturated fats, while limiting the intake of red and processed meats, refined carbohydrates, ultra-processed foods, and foods rich in saturated fats and added sugars.⁶ Evidence suggests that adherence to a Mediterranean dietary pattern may improve muscle mass and physical function in older adults.⁷ Moreover, higher consumption of fruits and vegetables can enhance dietary antioxidant capacity, thereby counteracting systemic low-grade inflammation driven by multiple molecular mechanisms.⁸ Therefore, focusing on dietary inflammatory potential from an overall dietary pattern perspective represents a promising non-pharmacological approach that warrants further investigation in the nutritional management of sarcopenia.

It is noteworthy that dietary management for the elderly is not an isolated, static individual behavior but is embedded within a care network that links communities, hospitals, and nursing homes. Its effective implementation relies on the dynamic collaboration among patients, families, and staff.⁹ Hospitals tend to focus more on the diagnosis and treatment of current illnesses, and most have not adopted effective intervention strategies to promote healthy dietary choices for patients.¹⁰ Although nursing homes provide centralized meals, they generally face challenges such as feeding difficulties, considerable difficulty in personalized adjustments, and a high risk of malnutrition.^11,12 Dietary management in community home settings, in turn, is constrained by factors including family dietary habits, family support, and a lack of professional nutritional support.¹³ The lack of effective information linkage and shared responsibility mechanisms among these three settings leads to adverse events, such as medication errors and rehospitalization during the transition from hospital discharge to home.¹⁴ Furthermore, dietary behaviors are consistently shaped by sociocultural factors and regional food environments. Previous studies have demonstrated that dietary patterns among older adults in China are influenced by multiple factors, including cultural background, geographic location, socioeconomic conditions, and nutritional requirements, resulting in substantial dietary diversity.^15,16 Therefore, understanding anti-inflammatory dietary management within specific sociocultural and care contexts is essential for identifying implementation barriers and support needs. To date, existing research has primarily focused on the association between dietary inflammatory potential and sarcopenia risk, whereas the lived experiences and practical challenges involved in implementing anti-inflammatory dietary strategies remain insufficiently explored. For example, meta-analyses conducted by Haibin Xie, Houze Diao, and colleagues demonstrated that higher dietary inflammatory index scores were significantly associated with an increased risk of sarcopenia.^17,18 Moreover, previous studies have largely examined dietary management within single care settings,^10,19 with limited attention to the common challenges and context-specific barriers across different care environments. Therefore, this study adopts a multi-stakeholder perspective to explore the lived experiences and multidimensional support needs related to anti-inflammatory dietary management among older adults with sarcopenia across diverse care settings, providing a theoretical foundation for developing integrated dietary support strategies.

To systematically understand the experiences and support needs related to anti-inflammatory dietary management among older adults within sarcopenia care contexts, this study adopted the COM-B model and the Integrated Care Rainbow Model as complementary theoretical frameworks. The COM-B model proposes that behavior is shaped by the interaction of capability, opportunity, and motivation,²⁰ and provides a framework for examining individual-level determinants influencing anti-inflammatory dietary management behaviors. The Integrated Care Rainbow Model emphasizes person-centered and population-based care as its core principles and conceptualizes integrated care across macro-, meso-, and micro-levels, encompassing six dimensions: clinical integration, professional integration, organizational integration, system integration, functional integration, and normative integration.²¹ This model facilitates the analysis of care support structures across different settings, including hospitals, long-term care facilities, and community-based services. Although the two models address different levels of influence, they are theoretically complementary. Specifically, care system factors, such as service coordination, professional support, and resource allocation, are closely related to the opportunity component within the COM-B model and may further influence individuals’ capability and motivation. Therefore, integrating these two frameworks enables a comprehensive examination of both individual behavioral determinants and the broader care environments in which dietary management occurs.

Accordingly, this study employed a descriptive qualitative design and included six stakeholder groups comprising older adults and care professionals from hospitals, long-term care facilities, and community settings (including physicians, nurses, administrators, and caregivers). The study aimed to explore the practical experiences, implementation barriers, and support needs associated with anti-inflammatory dietary management across diverse care contexts. The findings were further interpreted using the COM-B model and the Integrated Care Rainbow Model to enhance understanding of the determinants influencing dietary management at both individual and care-system levels. This study provides a theoretical basis for developing multi-setting and interprofessional collaborative strategies to support anti-inflammatory dietary interventions for older adults with sarcopenia.

Methods

Study Design

This study adopted a descriptive qualitative research design. Semi-structured interviews were conducted to explore the experiences and needs of older adults and relevant staff regarding anti-inflammatory dietary management in hospital, long-term care institution, and community settings. The reporting of this study followed the reporting standards for qualitative research.²²

Study Participants

This study employed purposive sampling supplemented by snowball sampling to recruit older adults and relevant care professionals from hospitals, long-term care facilities, and community settings in Chongqing and Xinjiang, China. Older adults were recruited through on-site approaches and included participants with different sarcopenia statuses. Sarcopenia status was assessed according to the 2019 Asian Working Group for Sarcopenia (AWGS 2019) criteria. Older adults in long-term care facilities were evaluated using handgrip strength, bioelectrical impedance analysis (BIA), and the Short Physical Performance Battery (SPPB), whereas those recruited from hospitals and communities were screened using handgrip strength, calf circumference, and the SARC-F questionnaire. The inclusion of older adults without sarcopenia aimed to capture additional perspectives on dietary practices, implementation barriers, and support needs within the same care contexts. Care professionals were recruited through prior contact by the research team and included healthcare providers, long-term care staff, and community workers involved in older adults’ dietary care, health management, and related support services. All participants underwent eligibility screening and provided informed consent before participating in the interviews. The inclusion and exclusion criteria are presented in Table 1.

Table 1.

Inclusion and Exclusion Criteria of Participants

Older adults	Inclusion criteria
	① Age ≥60 years. ② From elderly care institutions, community, or hospital settings. ③ Sarcopenia status was assessed according to the 2019 criteria established by the Asian Working Group for Sarcopenia (AWGS 2019),23 and older adults with and without sarcopenia were eligible for inclusion. ④Alert, with basic verbal expression and communication ability, able to cooperate in completing the interview. ⑤ Provided informed consent and voluntarily participated in this study.
	Exclusion criteria
	① Critically ill or in excessively poor physical condition, unsuitable for being interviewed. ② Withdrew from the interview midway.
Staff	Inclusion criteria
	① Engaged in elderly care, medical care, nutrition, rehabilitation, nursing, public health or management work related to the elderly from nursing institutions, communities or hospital settings. ②Work experience ≥1 year, familiar with the service recipients and work procedures of the position. ③ Good communication skills, able to clearly articulate personal observations and work experience. ④ Provided informed consent and voluntarily participated in this study.
	Exclusion criteria
	①Unable to complete the interview due to work arrangements, physical condition, or other reasons. ② Had no actual contact with older adults’ dietary management. ③ Withdrew from the interview midway.

Operational Definition

Drawing on the nutrition expert consensus of the Asian Working Group for Sarcopenia and existing evidence on anti-inflammatory dietary patterns, this study defined anti-inflammatory dietary management as a dietary management process involving food selection, dietary composition, and intake modification to increase the consumption of foods with anti-inflammatory and antioxidant potential, reduce exposure to pro-inflammatory dietary factors, and simultaneously meet older adults’ energy and high-quality protein requirements.^5,6,24 This concept emphasizes the overall inflammatory characteristics of dietary patterns and is distinct from general healthy eating, protein supplementation, dietary restriction, or disease-specific therapeutic diets.

Data Collection

Data collection was conducted in April 2026. Semi-structured interviews were conducted by the principal investigator (S.L.) and a trained researcher (K.K.R.) Interviews were conducted either face-to-face or via Tencent Meeting according to participants’ preferences, geographical accessibility, and practical circumstances. Most interviews were conducted in person. Detailed information regarding interview formats and participant distribution across stakeholder groups is provided in Supplementary Table 1. All interviews followed the same semi-structured interview guide. The mean interview durations were 13.89 minutes for older adults and 21.00 minutes for care professionals. Data collection and preliminary analysis were conducted concurrently. Data saturation was assessed separately across different care settings and participant groups. Saturation was considered achieved when subsequent interviews generated no new themes or substantial information relevant to the research questions.

Based on the research objectives and the characteristics of different participant groups, the research team developed separate semi-structured interview guides and baseline information forms for older adults and care professionals. Although the specific wording of questions varied across care settings and participant types, all interviews addressed common domains, including dietary arrangements and contextual characteristics, the influence of physical function on dietary practices, perceptions of sarcopenia and anti-inflammatory dietary management, daily dietary intake, implementation barriers, available support resources, and service needs. During the interviews, researchers explained the concept of anti-inflammatory dietary management using standardized, accessible, and neutral language. Participants were informed about its distinction from general healthy eating, protein supplementation alone, traditional “light diets”, and disease-specific therapeutic diets. These explanations were provided solely to ensure a consistent understanding of the interview topic and were not intended to provide individualized dietary recommendations or influence participants’ responses. With participants’ consent, all interviews were audio-recorded, and non-verbal cues and contextual observations were documented concurrently. The detailed interview guides are presented in Table 2.

Table 2.

Interview Guide

Interview Topic	Key Interview Points for Older Adults	Key Interview Points for Staff
1. Dietary arrangements and setting characteristics
	Daily dietary arrangements, living/hospitalization/meal provision conditions, and cooking or eating support methods.	Characteristics of dietary arrangements for older adults in the setting, meal provision methods, and features of service recipients.
2. Physical function and dietary impact
	Impact of decreased physical strength, limited activity, masticatory and swallowing discomfort, and appetite changes on diet.	Common physical function problems in older adults and their impact on dietary management.
3. Awareness of sarcopenia and dietary management
	Understanding of sarcopenia, physical strength recovery, and anti-inflammatory/pro-inflammatory diets.	Knowledge of sarcopenia, the relationship between diet and muscle health, and nutritional management.
4. Daily diet and intake
	Meal structure, food choices, and intake of healthy and unhealthy foods.	Common dietary problems and signs of inadequate nutritional intake among older adults in different settings.
5. Barriers to implementing dietary management
	Difficulties encountered in following a healthy diet, such as taste, habits, appetite, illness, or functional limitations.	Major barriers at the patient, family, and service levels when implementing dietary management for older adults.
6. Support resources and collaboration
	Support provided by family members, caregivers, and elderly care institutions/communities/hospitals.	The role of family members, multi-role personnel, and cross-institutional collaboration in dietary management.
7. Service needs and improvement suggestions
	Needs for dietary guidance, individualized plans, tool support, and continuous follow-up.	Feasible service forms, key management content, implementation conditions, and improvement suggestions.

Data Analysis

Thematic analysis was employed to analyze the interview data. Following each interview, the recordings were transcribed verbatim by the researcher (S.L.) within 24 hours, with relevant contextual information supplemented using field notes. Two researchers (S.L. and K.K.R.) repeatedly reviewed the transcripts and conducted manual coding through an inductive analytical process involving open coding, constant comparison, and thematic integration.

During the analysis, variations across care settings (long-term care facilities, communities, and hospitals) and participant roles (older adults and care professionals) were considered. Older adults with and without sarcopenia were included in the overall thematic analysis and were not treated as predefined comparison groups. Similarly, geographic regions were not considered as predefined analytical dimensions but were used as contextual information for interpreting participants’ dietary experiences and implementation contexts.

The COM-B model and the Integrated Care Rainbow Model were not applied during initial coding or theme generation; instead, they were used after theme development for theoretical mapping and interpretation of the findings. To maintain conceptual clarity, the coding process distinguished anti-inflammatory dietary management from general healthy eating, protein supplementation, light dietary practices, and therapeutic diets based on interview contexts. Only content directly related to dietary inflammatory characteristics or the implementation of anti-inflammatory dietary management was incorporated into relevant themes.

Research Rigor and Quality Assurance

To ensure the credibility of the findings, all interview transcripts were cross-checked against the original audio recordings, and detailed records of coding processes and theme development were maintained to enhance the transparency and traceability of the analysis. Disagreements during data analysis were resolved through team discussions, comparison of coding interpretations, and re-examination of the original data. When necessary, further discussions were conducted with the research supervisor (Q.H.Z.) until consensus was reached. The same interview guide and analytical procedures were applied across different interview formats, and no substantial differences in thematic richness were identified between formats during the analysis. Representative quotations were translated into English and verified against the original Chinese transcripts by a bilingual researcher (H.H.H.). Formal member checking was not conducted in this study; instead, research rigor was ensured through systematic analytical procedures and collaborative reflexive practices within the research team.

Researcher Positionality and Reflexivity

The interviews were conducted by S.L. (a doctoral student) and K.K.R. (a master’s student), both of whom had received qualitative research training. Neither researcher had any prior medical, professional, or other direct relationship with the participants. Considering that the researchers’ health-related academic backgrounds might influence participants’ expressions, open-ended and non-judgmental questioning approaches were adopted throughout the interviews. Reflexive notes were documented after each interview, and team discussions were conducted to critically examine the potential influence of the researchers’ backgrounds, assumptions, and prior knowledge on data collection and interpretation.

Ethical Considerations

The study protocol was approved by the Ethics Committee of the First Affiliated Hospital of Chongqing Medical University (Approval No. 2025-959-01). Before the interviews, participants were informed of the study purpose, interview content, and confidentiality principles. With participants’ consent, the interviews were audio-recorded, and non-verbal information and field observations were documented simultaneously during the interviews.

To protect participants’ privacy, all respondents were assigned anonymous codes. Each code consists of a setting abbreviation, a role abbreviation, and a sequence number: “NH” denotes nursing home, “C” denotes community, “H” denotes hospital; “E” denotes elderly, and “S” denotes staff.

Results

Characteristics of the Participants

A total of 63 participants were recruited from three types of care settings—hospitals, long-term care facilities, and community settings—in Chongqing and Xinjiang Uygur Autonomous Region, China. The sample included 35 older adults and 28 care professionals. Specifically, participants from long-term care facilities comprised 15 older adults (NH-E01–NH-E15) and 11 staff members (NH-S01–NH-S11); hospital participants included 13 older adults with sarcopenia-related care needs (H-E01–H-E13) and 9 staff members (H-S01–H-S09); and community participants included 7 older adults (C-E01–C-E07) and 8 staff members (C-S01–C-S08). The care professionals represented diverse roles, including physicians, nurses, rehabilitation therapists, nutritionists, administrators, and caregivers. The basic characteristics of the 63 participants are shown in Table 3.

Table 3.

Characteristics of Participants Stratified by Care Setting and Participant Group

Characteristics	Nursing Homes (n=26)	Hospitals (n=22)	Community (n=15)	Total (n=63)
Older adults	n=15	n=13	n=7	n=35
Age, median (IQR)	84 (74–92)	70 (63–88)	63 (62–69)	74 (63–88)
Female, n (%)	11 (73.3)	8 (61.5)	4 (57.1)	23 (65.7)
Education, n (%)
Primary	5 (33.3)	2 (15.4)	1 (14.3)	8 (22.9)
Middle	6 (40.0)	7 (53.8)	2 (28.6)	15 (42.9)
High	4 (26.7)	1 (7.7)	1 (14.3)	6 (17.1)
College	0 (0.0)	3 (23.1)	3 (42.9)	6 (17.1)
Location, n (%)
Rural	1 (6.7)	2 (15.4)	3 (42.9)	6 (17.1)
Urban	14 (93.3)	11 (84.6)	4 (57.1)	29 (82.9)
Married, n (%)
Single	5 (33.3)	4 (30.8)	0 (0.0)	9 (25.7)
Married	10 (66.7)	9 (69.2)	7 (100.0)	26 (74.3)
Sarcopenia, n (%)	8 (53.3)	0 (0.0)	0 (0.0)	8 (22.9)
Possible sarcopenia, n (%)	0 (0.0)	10 (76.9)	2 (28.6)	12 (34.3)
Non-sarcopenia, n (%)	7 (46.7)	3 (23.1)	5 (71.4)	15 (42.9)
Staff	n=11	n=9	n=8	n=28
Age, median (IQR)	45(26–58)	39(36–45.5)	31.5(24.5–41.5)	39 (28.5–48)
Female, n (%)	10 (90.9)	8 (88.9)	7 (87.5)	25 (89.3)
Education, n (%)
Primary	3 (27.3)	0 (0.0)	0 (0.0)	3 (10.7)
Middle	5 (45.5)	0 (0.0)	0 (0.0)	5 (17.9)
High	1 (9.1)	1 (11.1)	1 (12.5)	3 (10.7)
College	2 (18.2)	8 (88.9)	7 (87.5)	17 (60.7)
Vocation, n (%)
Supervisor	7 (63.6)	0 (0.0)	3 (37.5)	10 (35.7)
Nurse	0 (0.0)	9 (100.0)	1 (12.5)	10 (35.7)
Caregiver	4 (36.4)	0 (0.0)	1 (12.5)	5 (17.9)
Doctor	0 (0.0)	0 (0.0)	3 (37.5)	3 (10.7)
Years of work experience, n (%)
1–3	8 (72.7)	0 (0.0)	4 (50.0)	12 (42.9)
4–10	3 (27.3)	0 (0.0)	2 (25.0)	5 (17.9)
>10	0 (0.0)	9 (100.0)	2 (25.0)	11 (39.2)

Through coding, comparison, and integrative analysis of the interview data from different settings, five overarching themes and fifteen sub-themes were identified: (1) Dietary management is influenced by setting structure and support systems; (2) The importance of diet is widely recognized, yet specialized knowledge remains weak; (3) Anti-inflammatory dietary management is constrained by inadequate intake and multiple implementation barriers; (4) Cross-setting dietary management exhibits fragmented transitions and insufficient continuous care mechanisms; and (5) Respondents expect more concrete, individualized, and continuous support. After themes and subthemes were generated through inductive thematic analysis, the COM-B model and the Integrated Care Rainbow Model were subsequently applied as interpretive frameworks to theoretically map the findings at both individual behavioral and care-system levels. Detailed theoretical mapping is provided in Supplementary Table 2.

Theme 1: Dietary Management is Influenced by Setting Structure and Support Systems

Multi-setting analysis revealed that dietary management for older adults is not solely determined by personal choice, but is shaped by the meal provision patterns and support system structures within different care settings.

Sub-Theme 1.1 Different Care Settings Shape the Meal Provision Patterns of Older Adults

Significant differences in dietary patterns exist among older adults across various care settings.

In nursing homes, daily meals are primarily provided uniformly by the institution, with relatively fixed three-meal schedules, demonstrating strong institutionalized characteristics.

NH-E02, Chongqing, 74 years, male, non-sarcopenia: Here (referring to the nursing home), meals are provided uniformly, covering breakfast, lunch, and dinner.

In community settings, older adults predominantly rely on their families to prepare meals, resulting in more flexible dietary arrangements.

C-E04, Chongqing, 63 years, female, sarcopenia: We usually cook at home. Generally, my husband does the grocery shopping and cooking.

In hospital settings, during hospitalization, meals are mainly supplied by the hospital cafeteria, with food choices typically taking into account the patient’s physical condition and inpatient needs.

H-E10, Chongqing, 83 years, female, sarcopenia: Recently I’ve been eating at the hospital. For breakfast, I have some milk, oatmeal, and an egg. The cafeteria lunch is fairly soft, the dishes are quite palatable, not very spicy, and generally acceptable.

Sub-Theme 1.2 Family Members and Caregivers Constitute an Important Support Network for Dietary Management

Further analysis revealed that family members or caregivers play a vital role across all three settings, albeit with differing modes of involvement.

In nursing homes, family members often assist staff in adjusting meal arrangements by providing personalized dietary suggestions, thereby better meeting the older adults’ needs.

NH-S01, Chongqing, female, Supervisor: Family members also provide suggestions, such as telling us what their elderly relatives like to eat, and we adjust accordingly based on these suggestions.

In community settings, family members not only participate in dietary decision-making but also shoulder the responsibility for daily supervision and implementation, acting as the key executing agents for whether dietary management can be truly implemented for older adults.

C-S01, Xinjiang, female, Supervisor: Family members can also play a role in supervising and guiding the elderly. If we can align the family’s perspective with ours, they can better guide the older adults in daily life.

In hospital settings, the role of family members is more diverse, encompassing responsibilities such as caregiving, meal delivery, and ongoing dietary management after discharge.

H-S07, Chongqing, female, Nurse: Family members can prepare appropriate foods based on the patient’s condition, ensuring that the patient receives adequate nutritional support.

Theme 2: The Importance of Diet is Widely Recognized, yet Specialized Knowledge Remains Weak

Older adults and staff generally acknowledge the important role of diet in physical recovery and health management, but their understanding of sarcopenia and anti-inflammatory diets is limited.

Sub-Theme 2.1 Older Adults Commonly Agree That Diet Plays a Vital Role in Maintaining Physical Strength and Health

Most older adults have a clear perception of the relationship between diet and physical health, particularly regarding physical recovery and health management. They generally understand that “eating well leads to better health” and believe that proper diet is crucial for strength and recovery.

H-E08, Chongqing, 88 years, female, sarcopenia: Of course, protein intake must be adequate. I eat eggs and milk every morning, and I also usually have deep-sea fishlike salmon and cod, so my protein intake is basically sufficient.

Sub-Theme 2.2 Understanding of Sarcopenia and Anti-Inflammatory Diets Mostly Remains at the Level of Experiential Knowledge

Older adults often interpret healthy eating as foods that are “light”, “nutritious”, or “good for the body”, lacking an in-depth understanding of specific nutritional requirements.

NH-E14, Chongqing, 92 years, female, sarcopenia: I think at this age, it’s enough to avoid spicy and salty foods and just eat a light diet.

Older adults’ awareness of sarcopenia is inadequate, mostly derived from life experience or fragmented health information.

H-E03, Chongqing, 62 years, male, sarcopenia: I don’t think it has much to do with muscles; poor health is mainly related to medication.

Many respondents lacked a systematic understanding of professional concepts such as “anti-inflammatory diet” or “pro-inflammatory diet”.

NH-E04, Chongqing, 84 years, female, Non-sarcopenia: For people our age, eating too much hotpot and chili still has an impact on health.

Sub-Theme 2.3 Staff Value General Nutritional Care but Lack Specialized Knowledge in Sarcopenia Management

Although staff acknowledge the importance of diet in principle, their professional knowledge is insufficient, highlighting an urgent need for training and intervention.

Many staff members recognize the significance of diet for the health of older adults, particularly in promoting the rehabilitation of physical function and recovery of strength. Some staff noted:

C-S03, Xinjiang, female, Caregiver: Diet is particularly important for older adults because their absorption capacity declines. We need to ensure they can obtain sufficient energy and nutrients from food.

However, most staff members’ knowledge remained at the level of general nutritional care.

C-S01, Xinjiang, female, Supervisor: We provide nutritional guidance once a month, and the community also organizes related lectures and awareness campaigns, but they mainly focus on general nutrition education.

There is a lack of systematic dietary guidance specifically targeting sarcopenia.

NH-S06, Chongqing, female, Caregiver: The nursing home hasn’t conducted any management training related to nutrition and diet. We just formulate the menus and then implement them.

Theme 3: Anti-Inflammatory Dietary Management is Constrained by Inadequate Intake and Multiple Implementation Barriers

The nutritional intake risk among older sarcopenia patients does not stem from a single source but is distinctly setting-specific. Moreover, the barriers to implementing an anti-inflammatory diet are not limited to “knowing but not doing”; they are also multiply constrained by physical function, lifestyle habits, and situational factors.

Sub-Theme 3.1 Inadequate Intake and Imbalanced Dietary Structure are Common Problems Across Settings

Across the three care settings, older adults commonly face problems of insufficient protein intake, unbalanced fruit and vegel consumption, and monotonous dietary structure.

Insufficient protein intake: Some older adults hold misunderstandings about meat consumption or prefer a vegetarian diet, leading to inadequate intake of high-quality protein.

C-S06, Chongqing, female, Supervisor: Some older adults believe a vegetarian diet benefits health, thereby neglecting the intake of high-quality protein.

Unbalanced fruit and vegetable intake: Dental problems or food preferences result in limited consumption of vegetables and fruits.

NH-E01, Chongqing, 83 years, female, non-sarcopenia: Due to poor dental condition, I generally don’t eat fruit, or just eat bananas to relieve constipation.

Monotonous dietary structure: Many older adults rely on a limited variety of foods over the long term, lacking dietary diversity.

C-S06, Chongqing, female, Supervisor: The variety of foods older adults eat is quite limited. once they get used to certain foods, they tend to keep eating them all the time.

Sub-Theme 3.2 Dietary Implementation in Nursing Homes is Jointly Constrained by Physical Functional Limitations and Collective Meal Provision

In the nursing home setting, uniform meal provision helps ensure regular eating and basic nutritional supply for older adults. However, this collective meal model often struggles to fully account for individual taste preferences and differences in physical function, lacking individualized adaptation.

Physical functional limitations: Missing teeth, difficulty using dentures, and decreased appetite affect the intake of fruits, fish, and legumes.

NH-E04, Chongqing, 84 years, female, non-sarcopenia: Recently, food has tasted bland and I don’t feel like eating; I think my appetite has gotten worse. Before, I could finish every meal, but now I can’t.

Limitations of collective meals: Uniform meals have difficulty satisfying individual tastes and preferences, forcing older adults to adapt to standardized food.

NH-E12, Chongqing, 63 years, male, non-sarcopenia: The meals are more suitable for the oldest old; if the food doesn’t suit my taste, I can only eat less.

Sub-Theme 3.3 Dietary Implementation in Community Settings is Affected by Entrenched Habits and Convenience Factors

In community settings, older adults’ dietary arrangements are mainly influenced by entrenched habits and convenience considerations. The phenomenon of simplified dietary arrangements is particularly evident when living alone.

Cooking as a hassle and time constraints: Some older adults choose convenience foods due to limited time or the burden of cooking, resulting in insufficient intake of vegetables and high-quality protein.

C-E04, Chongqing, 63 years, female, sarcopenia: Most of the time, eating is just for convenience; there isn’t that much time to cook. For example, I often eat pickled foods because they can be kept for a long time and still eaten.

Impact of living alone: Older adults living alone lack supervision, and their eating patterns are more casual and irregular.

C-S03, Xinjiang, female, Caregiver: Older adults living alone might not feel like cooking today, so they just eat whatever is available or skip the meal.

Lack of trust in external advice: Some older adults’ distrust or are unwilling to accept dietary guidance provided by the community.

C-E07, Chongqing, 70 years, female, sarcopenia: I’m not willing to try; I think the way we eat now is fine, no need to change.

Sub-Theme 3.4 Dietary Implementation in Hospitals is Mainly Restricted by Disease Status and Treatment Response

In the hospital setting, dietary arrangements during hospitalization are often limited by multiple factors, including the illness, treatment requirements, the hospital’s meal provision conditions, and the way family members deliver meals.

Decreased appetite and inadequate intake: Chemotherapy, post-surgical recovery, and physical discomfort lead to reduced food intake, with patients often relying on porridge or liquid diets.

H-E02, Chongqing, 88 years, female, sarcopenia: Poor appetite, sometimes I can only have a little porridge or milk all day.

Disease-related restrictions: Conditions such as diabetes or digestive diseases restrict the intake of fruits and normal diets.

H-E01, Chongqing, 61 years, male, sarcopenia: I have diabetes, so I generally don’t eat fruit, only occasionally an apple.

Mismatch between eating willingness and ability: Some patients, despite having the desire to eat, are unable to do so due to poor appetite, dental problems, or post-surgical effects.

H-E01, Chongqing, 61 years, male, sarcopenia: Because I’m on chemotherapy, my stomach feels unwell. I want to eat but can’t get it down.

Theme 4: Cross-Setting Dietary Management Exhibits Fragmented Transitions and Insufficient Continuous Care Mechanisms

The analysis revealed that dietary management is fragmented to varying degrees across nursing home, community, and hospital settings, with insufficient continuous care and closed-loop support being a common cross-setting problem.

Sub-Theme 4.1 The Nursing Home Setting Lacks a Specific Dietary Management Pathway for Sarcopenia

Although nursing homes possess the basic conditions for providing nutritional meals, the lack of individualized management and specific pathways makes it difficult to sustain anti-inflammatory dietary management for older adults with sarcopenia.

Basic meal provision is ensured: Nursing homes typically have professional dietitians who plan meals and make appropriate adjustments according to the older adults’ physical conditions.

NH-S01, Chongqing, female, Supervisor: Our weekly menus are planned by a dietitian and then adjusted according to the elderly’s conditions, such as making changes for those who cannot eat food that is too sweet or too salty.

Absence of a specific pathway: The institution lacks systematic management training and specific interventions targeting sarcopenia.

NH-S05, Chongqing, female, Caregiver: Currently, there are no management training sessions related to nutrition, diet, or sarcopenia.

Difficulty in sustaining individualized management: Due to the constraints of the collective meal provision model, nursing homes find it difficult to meet the personalized needs of older adults.

NH-S05, Chongqing, female, Caregiver: Nursing homes are a collective living environment, making it hard to prepare special foods for a specific group of people.

Sub-Theme 4.2 The Community Setting Has Not yet Formed a Complete Closed-Loop Support System Encompassing Screening, Guidance, and Referral

Dietary management in communities is affected by limited personnel, awareness, and resources. A closed-loop mechanism of education–screening–guidance–referral has not yet been formed, resulting in insufficient continuous care.

Unsystematic education and screening: Community attention to self-care-capable older adults is insufficient, with the main focus being on those with severe disability or chronic diseases.

C-S03, Xinjiang, female, Caregiver: The community mainly conducts health popularization through WeChat groups, but lacks precise screening for individual risks.

Lack of closed-loop support and insufficient community capacity: Community healthcare workers emphasize the importance of support from medical institutions, but this is currently limited by shortages of personnel and resources.

C-S08, Chongqing, female, Supervisor: Community healthcare resources are limited. When facing over a thousand older adults in our jurisdiction, it’s hard to conduct regular face-to-face visits and individualized guidance for every resident.

Sub-Theme 4.3 In the Hospital Setting, Post-Discharge Dietary Management Is Most Prone to Interruption

In the hospital setting, healthcare professionals typically provide dietary guidance and intervention during hospitalization, but management after discharge is prone to fragmentation, mainly manifested as insufficient community follow-up, limited family understanding, and difficulty in sustaining follow-up.

Guidance available during hospitalization but no continuation after discharge: Healthcare workers provide dietary guidance or intervention while patients are on the ward, but this lacks continuity after discharge.

H-S01, Xinjiang, male, Nurse: I think it’s very easy for management to become fragmented. While in the ward, we provide guidance or intervention, but after they go home, family members don’t pay much attention to these matters.

Insufficient community capacity for follow-up: There is a serious deficiency in the hospital–family–community continuous care chain, with a lack of effective linkage and institutional mechanisms among the three parties.

H-S02, Xinjiang, female, Nurse: Hospitals, communities, and families are all working in isolation without any coordination.

Limited family understanding: Whether family members live with the older adult and their level of concern affect the effectiveness of management.

H-S06, Chongqing, female, Nurse: If the care is provided by children, the management may be inadequate due to their busy work schedules.

Theme 5: Respondents Expect More Concrete, Individualized, and Continuous Support

Although the difficulties faced by older adults and staff vary across different settings, the majority of respondents were generally open to anti-inflammatory dietary management. Their genuine needs centered on more concrete, actionable, individualized, and sustainable forms of support.

Sub-Theme 5.1 Older Adults Expect More Concrete, Easy-to-Understand, and Implementable Dietary Guidance

Older adults’ expectations for dietary guidance are that it be “scientific, concrete, and actionable”, and capable of being gradually implemented in line with their own habits and abilities.

Older adults generally hope that the food provided can better suit their tastes.

H-E03, Chongqing, 62 years, male, sarcopenia: Although the nutritional meals provided by the hospital are scientific, the taste is not easily accepted by older adults. Eating them feels like eating protein powder, which is not very pleasant.

Older adults wish to receive recipes, food substitution lists, and shopping advice, so they can take action according to personal taste and ability.

H-E10, Chongqing, 83 years, female, sarcopenia: I’m willing to listen to whatever the doctor says, but some recipes are too complicated and hard to follow; what is needed are simpler, more actionable ones.

Older adults hope that the dietary plans provided are progressive and easy to follow.

C-E04, Chongqing, 63 years, female, sarcopenia: It needs to be scientifically balanced and implemented step by step, allowing older adults to gradually change their habits based on their current situation.

Sub-Theme 5.2 Different Settings Have Differentiated Needs Regarding Support Content and Delivery Methods

The priorities for dietary support differ across care settings, but all emphasize individualization, actionability, and continuity.

In the nursing home setting, respondents hoped for further optimization of meal provision, such as providing soft, low-salt meals suitable for priority groups, along with enhanced nutrition training and interprofessional collaboration within the institution.

NH-S04, Chongqing, female, Supervisor: Extra meals should be provided for priority groups and need regular assessment.

In the community setting, respondents expected trustworthy health education, simple and easy-to-understand cards or recipe tools, family involvement and support, as well as family doctor services, home-based services, or follow-up support.

C-S03, Xinjiang, female, Caregiver: The community can provide older adults with a weekly menu reference, combined with regular doctor follow-ups and health education, to improve their ability to implement dietary recommendations.

In the hospital setting, the focus was on risk screening during hospitalization, the development of individualized dietary plans, multidisciplinary collaboration, discharge education, and effective handover to community-based post-discharge management.

H-S01, Xinjiang, male, Nurse: Developing an individualized plan after screening can increase the level of attention paid by patients and families, making it much easier to carry out other interventions later.

Sub-Theme 5.3 Respondents Expect a Sustained Support Model Involving Multi-Stakeholder Collaboration

Respondents unanimously agreed that sustained, multi-stakeholder collaboration, along with policy and resource support, is the guarantee for both the implementation and long-term maintenance of anti-inflammatory dietary management plans for older sarcopenia patients.

Sustained support and policy safeguards are key to ensuring that anti-inflammatory dietary management for older sarcopenia patients is feasible and sustainable.

C-S01, Xinjiang, female, Supervisor: In fact, what we most need is support from medical institutions, as a medical perspective is more likely to benefit the residents. Moreover, training for community meal service staff is equally important.

The joint participation of families, institutions, communities, and hospitals is necessary to effectively promote the implementation and long-term execution of anti-inflammatory dietary management plans.

C-S03, Xinjiang, female, Caregiver: The joint participation of the government, community, family members, and screening institutions, together with precise screening and training, can enhance the effectiveness of the support.

Discussion

This study systematically explored the current practices, implementation barriers, and support needs related to anti-inflammatory dietary management for sarcopenia in real-world care contexts through multi-stakeholder interviews with older adults and care professionals across long-term care facilities, community settings, and hospitals. The findings demonstrated that anti-inflammatory dietary management is not solely dependent on individual dietary knowledge and behavioral change but is shaped by multiple interacting factors, including family support, professional guidance, service resources, and care environments. These findings suggest that future strategies for promoting anti-inflammatory dietary management should simultaneously address individual behavior change and broader care-system support.

Analysis of Individual Behavioral Barriers Based on the COM-B Model

This study finds that older adults’ anti-inflammatory dietary management behaviors are not hindered by a single factor, but are profoundly influenced by the interacting deficits in capability, opportunity, and motivation within the COM-B model.

First, at the capability dimension, this study identifies a theoretically significant phenomenon of a dual capability gap. On the one hand, older adults’ understanding of sarcopenia and anti-inflammatory dietary concepts remains limited. Previous studies have shown that inadequate awareness of sarcopenia may hinder older adults’ recognition of disease risks and engagement in preventive behaviors.^25,26 This study further found that some older adults equated healthy eating with “Qingdan” (a traditional Chinese concept referring to a light diet), characterized by reducing the intake of oil, meat, and salt, which is consistent with previous qualitative research among Chinese populations.²⁷ These findings suggest that barriers to anti-inflammatory dietary implementation arise not only from insufficient nutritional knowledge but also from culturally embedded dietary beliefs.²⁸ However, interpreting “Qingdan” as a reduction in meat and other nutrient-dense foods may increase the risk of inadequate intake of high-quality protein and essential nutrients.²⁹ Therefore, dietary guidance for older adults with sarcopenia should respect traditional dietary perspectives while redefining the concept of “Qingdan” to emphasize that dietary modification does not require restricting key nutrients essential for maintaining muscle health. On the one hand, older adults’ understanding of sarcopenia and anti-inflammatory diets largely remains at the level of experiential cognition. Studies by Van Ancum JM and Chiu HLalso found that older adults have insufficient awareness of sarcopenia, leading many to underestimate the serious consequences of the disease. On the other hand, staff members’ dietary management for older adults still lingers at the level of general nutritional care, lacking specialized management of and training on sarcopenia and anti-inflammatory diets, which is consistent with findings from Ji³⁰ and Daly.³¹ This means there simultaneously exists a dilemma where older adults “do not know how to do it” and caregivers “do not know how to teach it” forming a dual capability gap in the knowledge transmission chain. Furthermore, some older adults suffer from declining masticatory function and dysphagia, causing additional difficulties in food selection and eating, thereby increasing the risk of malnutrition. The results of Calvani,³² Sergi³³ and other studies confirm the findings of this study.

Second, the opportunity constraints faced by anti-inflammatory dietary management exhibit distinct setting-specific characteristics. Wang et al pointed out that older adults’ dietary behaviors are jointly influenced by multiple complex and interrelated factors across individual, social, and environmental domains.³⁴ At the physical opportunity level, the collective meal provision system in elderly care institutions, the structural reliance of community-dwelling older adults on convenience foods, and the disease-related restrictions of therapeutic diets in hospitals fundamentally limit the range of food variety and nutritional quality available to older patients. More critically, family members and caregivers are important supportive forces for dietary management in sarcopenia patients. However, insufficient professional knowledge or lack of support from family members can constrain patients’ healthy dietary behaviors, while healthcare professionals, constrained by workload and institutional limitations, also find it difficult to provide adequate individualized dietary guidance. van Oppenraaij et al found that family members dominate patients’ food choices, thereby influencing their willingness to adopt a plant-based diet.³⁵

Finally, in the motivation dimension, interviewees generally recognized the importance of dietary management for maintaining physical strength and restoring health, but this recognition did not automatically translate into behavioral motivation for anti-inflammatory diet and sarcopenia management. At the reflective motivation level, the motivation for healthy eating primarily stems from health awareness, external encouragement, and self-efficacy.³⁶ However, due to a lack of awareness of sarcopenia risks and understanding of the mechanisms of anti-inflammatory diets, older adults’ broad motivation oriented toward experiential health fails to gain sufficient intensity to trigger specific action decisions. At the automatic motivation level, a study by Herrema AL proposed that taste, convenience, knowledge of health benefits, and dietary habits are important drivers in dietary interventions for sarcopenia.³⁷ A qualitative study by Yin et al targeting community-dwelling older adults with sarcopenic obesity similarly found that past personal experiences and the need to prioritize grandchildren’s tastes posed significant barriers to changing dietary habits.³⁸ The superimposition of the dual motivation translation barriers, patients “knowing but not doing” and caregivers “willing but unable to facilitate”, provides a mechanistic explanation for the paradox of “acknowledging the value but being unwilling to improve” in current anti-inflammatory dietary management practices. Furthermore, some dietary barriers were closely associated with participants’ long-established sociocultural food environments.¹⁶ This suggests that the “opportunity” and “motivation” components of the COM-B model are influenced not only by healthcare resources and family support but also by local dietary preferences and culturally embedded eating norms.

Taken together, when limited capability coincides with restricted opportunities, even individuals with an intrinsic intention to modify their diet may experience difficulties in translating this intention into sustained reflective motivation and long-term behavioral maintenance. The interactive mechanisms proposed by the COM-B model indicate that future interventions should move beyond one-directional nutrition education and adopt comprehensive behavioral support strategies that integrate cultural adaptability, environmental facilitation, and individual needs.

Analysis of Care System Fragmentation Based on the Rainbow Model of Integrated Care

The Rainbow Model of Integrated Care further reveals the insufficient integration of anti-inflammatory dietary management support across different care settings.

From the perspective of macroscopic system integration, this study found significant gaps in dietary management in the three care scenarios of elderly care institutions, communities, and hospitals, resulting in fragmented support for the elderly at different stages. This finding corroborates the view of Landi et al that systematic nutritional monitoring and discharge planning are essential to ensuring continuity of nutritional care across different environments and are key to guaranteeing timely optimal interventions that support muscle mass and functional recovery.³⁹

From the perspectives of organizational and professional integration within the meso-level of the Integrated Care Rainbow Model, this study identified insufficient information transfer and service coordination among hospitals, community services, and long-term care facilities, with dietary management particularly vulnerable to disruption after hospital discharge. Moreover, unclear role delineation among different professionals may result in the marginalization of specialized dietary management. Deutz et al emphasized that multidisciplinary team involvement facilitates continuous assessment and comprehensive management of muscle health in older adults.⁴⁰ Within the Chinese healthcare context, integrated care networks (eg, medical alliances) could be leveraged to strengthen coordination and referral pathways between hospitals and primary care providers. Specifically, hospital teams could develop individualized dietary management plans before discharge, while primary care or family physician teams could provide follow-up support after discharge and facilitate referrals to relevant specialists when necessary, thereby improving continuity of cross-institutional care.^41,42

From the perspective of clinical integration at the micro level, hospital discharge represents a critical transition point for maintaining continuity of dietary management. Previous studies have shown that older adults in hospital settings experience a higher burden of sarcopenia and malnutrition compared with community-dwelling older adults,⁴³ suggesting a greater need for sustained nutritional and rehabilitation support after discharge. Therefore, sarcopenia and nutritional risk assessments, individualized dietary goals, and follow-up plans should be incorporated into discharge management. During subsequent follow-up, dietary strategies should be dynamically adjusted according to changes in nutritional status, muscle function, and dietary adherence.

From the perspective of promoting the integration of functional and normative elements in the core of the model, the lack of the three dimensions mentioned above is not isolated from each other, but collectively points to a systemic outcome, namely the structural failure of the human centered care concept. This study finds that existing dietary support still struggles to adequately accommodate older adults’ functional status, dietary preferences, comprehension abilities, and feasibility in daily life. Consequently, interviewees expect more specific, individualized, and continuous support, which precisely corresponds to the highest requirements of person-centered care and service integration in the Rainbow Model.

This indicates that the difficulties in anti-inflammatory dietary management for older adults do not originate solely from insufficient cognition at the individual level, but are also closely related to inadequate integration within and between care systems. Dent E proposes in their research that nutritional interventions should be individualized, and that all interventions should be incorporated into a holistic care plan.⁴⁴ In the future, a cross scenario anti-inflammatory diet support system can be established at the organizational and institutional levels, such as direct access to community nutrition clinics for anti-inflammatory diet prescriptions upon discharge, and completion of sarcopenia nutritional risk screening and personalized meal preparation upon institutional check-in, thereby promoting the transformation of anti-inflammatory diet plans from guidelines to practice.

Practical Implications

The multidimensional findings of this study on the experience and needs of anti-inflammatory diet management in elderly patients with sarcopenia, provide the following hierarchical insights for promoting anti-inflammatory diet practice in three types of care scenarios: community, elderly care institutions, and hospitals. Firstly, the promotion of anti-inflammatory diets should not be limited to knowledge education, but should also empower the dual deficiencies of psychological and physical abilities. For elderly people with difficulty chewing and swallowing, as well as poor appetite, soft and rotten foods with improved texture should be provided, and seasoning optimization should be used to enhance their desire to eat. Secondly, it is very necessary to provide intervention plans for different scenarios. Elderly care institutions should open up flexible options within the framework of collective feeding, provide texture improved and nutrient fortified foods, increase the ratio of protein to anti-inflammatory fruits and vegetables, etc. Thirdly, given the low awareness of sarcopenia, a cross-setting nutritional management pathway triggered by early sarcopenia screening should be established.⁴⁵ For example, the community includes screening for sarcopenia in its annual routine physical examination, and those who test positive for the disease are given preliminary anti-inflammatory dietary guidance and documented by their family doctor. Fourthly, at the policy level, the management of sarcopenia should gradually be incorporated into the basic content of elderly health promotion, and exploration should be made to include nutritional risk screening in the scope of family doctor contracted service packages or long-term care insurance. In addition, volunteer service, family participation, and diverse health education resources can also be utilized to promote the effective promotion of anti-inflammatory dietary intervention programs.

Limitations of the Study

It should be acknowledged that this study has several limitations. First, this study employed purposive sampling, and participants were primarily recruited from Chongqing and Xinjiang, resulting in an uneven regional distribution. As regional comparisons were not a predefined objective of the study, thematic differences across regions were not further examined, which may limit the interpretation of context-specific variations. Future studies should expand geographic coverage and include more diverse samples to further assess the transferability of these findings. Second, this study was conducted from a multi-stakeholder perspective, but there were differences in the depth of interviews across the various participant groups. Subsequent research could adopt adaptive strategies, such as multiple brief interview sessions for older patients, to enhance the richness of the data and the completeness of perspectives. Third, this study used a cross-sectional design, presenting only the experiences and perceptions of interviewees at a specific point in time. In the future, longitudinal tracking of dietary management changes in the same patient across different scenarios can be adopted to supplement a deeper understanding of dynamic mechanisms.

Conclusion

From a multi-stakeholder perspective, this study found that both older adults and care professionals had limited specific knowledge regarding sarcopenia and anti-inflammatory dietary management. Dietary practices were influenced by multiple factors, including declining physical function, limitations in food provision environments, and long-established dietary habits. Therefore, this study suggests that translating anti-inflammatory dietary recommendations for sarcopenia from guidelines into routine practice may require exploration of three key strategies: enhancing individuals’ capacity for dietary implementation, optimizing food provision environments, and establishing cross-setting continuity of care pathways. Together, these approaches may contribute to the development of a continuous nutritional support framework initiated through early screening and centered on patient experiences. The feasibility of these strategies and their effects on dietary behaviors, muscle health outcomes, and healthcare resource utilization require further validation through future intervention studies.

Funding Statement

This work was supported by the 2025 Nursing Discipline Research Projects Initiated by the Chinese Medical Association Journal Press [grant number CMAPH-NRG2025012].

Use of AI-Assisted Technologies

During the preparation of this manuscript, the authors used OpenAI ChatGPT (GPT-5.4) for language editing and translation to improve clarity and readability. All AI-assisted content was reviewed and verified by the authors, who confirm the originality and accuracy of the manuscript and take full responsibility for its integrity, including the accuracy of references. The authors also reviewed the terms of use of OpenAI ChatGPT (GPT-5.4) and confirm its suitability for publication.

Data Sharing Statement

The datasets generated and analyzed during the current study are not publicly available but are available from the corresponding author, Qinghua Zhao, upon reasonable request.

Ethics Approval and Consent to Participate

The study was approved by the Ethics Committee of the First Affiliated Hospital of Chongqing Medical University (Approval No. 2025-959-01). The study was conducted in accordance with the Declaration of Helsinki and relevant institutional regulations. All participants provided written informed consent prior to data collection, including consent for the publication of anonymized responses and direct quotations derived from their interviews.

Author Contributions

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Disclosure

The authors declare that they have no competing interests.