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Research Article | DOI: https://doi.org/10.31579/2692-9406/196
1 Riggs Pharmaceuticals,Department of Pharmacy, University of Karachi, Pakistan
2 Head of department of Pharmacology,Fazaia Ruth Pfau Medical College Air University, Karachi, Pakistan
3 GD Pharmaceutical Inc OPJS University Rajasthan India
4 Assistant Professor, Dow University of Health Sciences Karachi Pakistan
5 Associate Professor, Department of Pathology Dow University of Health Sciences, Karachi, Pakistan
*Corresponding Author: Rehan Haider. Riggs Pharmaceuticals,Department of Pharmacy, University of Karachi, Pakistan
Citation: Rehan Haider, Asghar Mehdi, Geetha Kumari Das, Zameer Ahmed, Sambreen Zameer. (2025) Medical Foods: A New Domain in the Food-Drug Inter phase. Biomedical Research and Clinical Reviews, 10(1); Doi: 10.31579/2692-9406/196
Copyright: © 2025 Rehan Haider, This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Received: 18 January 2025 | Accepted: 22 January 2025 | Published: 25 January 2025
Keywords: medical foods; food–drug inter phase; dietary management; nutritional requirements; disease-specific nutrition; healthcare; regulatory compliance; nutritional science; therapeutic outcomes; clinical application
Medical foods represent an emerging category in the food-drug inter phase, designed to meet the specific nutritional requirements of individuals with particular medical conditions. Unlike conventional foods or dietary supplements, medical foods are formulated under the supervision of healthcare providers and are intended for the dietary management of diseases with distinctive nutritional needs that cannot be met by a normal diet alone. This category includes specialized formulations for conditions such as metabolic disorders, gastrointestinal diseases, and neurological disorders, among others.
The regulation of medical foods is stringent, requiring compliance with both food safety standards and specific medical criteria, distinguishing them from other health-related food products. Recent advancements in nutritional science and a deeper understanding of disease-specific nutritional needs have propelled the development and clinical application of medical foods. These products are tailored to provide precise nutrient profiles, bioavailability, and palatability, ensuring optimal therapeutic outcomes.
The integration of medical foods into patient care strategies offers promising benefits, including improved disease management, enhanced quality of life, and potential reductions in healthcare costs. However, challenges such as regulatory complexities, limited clinical evidence, and the need for heightened awareness among healthcare providers and patients must be addressed to fully realize their potential.
Future research and innovation in this field are essential to establish robust clinical evidence supporting the efficacy of medical foods and to develop novel formulations that can address a broader range of medical conditions. Collaboration among regulatory bodies, healthcare professionals, and the food industry is crucial to advancing the field of medical foods and ensuring their safe and effective use.
Recently, Nestlé Health Technology, a subsidiary of Nestlé, offered every other U.S. clinical food organization, Pamlab, which produces prescription scientific meals that support patients with numerous situations, inclusive of dementia, diabetic peripheral neuropathy, excessive-hazard pregnancies, and depression. Nestlé’s robust commitment to this area is justified by way of a series of different acquisitions, which include Accera, a company that produces clinical foods for the dietary control of Alzheimer’s patients; Vitaflo, which affords nutritional answers for those tormented by genetic issues influencing how the body processes ingredients; and Prometheus Laboratories, a company specializing in diagnostics and prescribed drugs in gastroenterology and oncology. Scientific food or food for special medical functions are principally formulated food products intended to be used beneath the supervision of scientific and appropriate health experts (e.g., dietitians, nurses, and pharmacists). that is required for the dietary control of individuals (such as children) with ongoing persistent diseases, issues, medical situations, or throughout the acute stages of contamination, injury, or disorder, this bankruptcy will speak current market dynamics, policies, and brand breakthroughs in research, and the whole thing you need to navigate this advancing region.
The Food and Drug Administration Of Medical Food
The U.S. Food and Drug Administration (FDA, 2010) exact scientific food as
a class of materials meant for the scientific nutritional control of a particular situation or disease. Particular standards essential to getting hold of this FDA designation consist of the product being
• Especially formulated for oral or enteral ingestion
• supposed for the scientific dietary control of a particular scientific diseases, , or extraordinary situation for which there are special nutritional necessities
• Made with substances that have “commonly identified as secure” (GRAS) fame
• Designed in compliance with FDA rules that pertain to labeling, product claims, and manufacturing
Medical food, a therapeutic category, is awesome from both capsules and supplements.
The label ought to include “for use underneath clinical supervision.” medical foods are
Produced under inflexible production practices and maintained high labeling standards.
Tables 14.1 and 14.2 describe the differences between dietary supplements, nutraceuticals, and prescription drug treatments.
What are the major health condition?
That are being targeted?
From a scientific perspective, an increasing prevalence of diseases, along with metabolic
Syndromes, irritable bowel syndrome (IBS), lactose intolerance, Alzheimer’s disease, and food intolerance is continuously being centered via industries for the development of clinical foods. Age-associated digestive tract diseases, in addition to reduced general digestive and absorptive characteristics, are some other fitness situations receiving attention for the development of medical meals (Georgiou et al., 2011). [1].
Vladimir Badmaev, MD, PhD, Head of R&D, NattoPharma ASA, Oslo, Norway, stated, “The most famous classes of medicinal meals deal with growing older populations and wasting conditions like muscle wasting or sarcopenia, bone rarefaction or osteoporosis, fitness situations as a result of inadequate repute of vitamins and minerals, and gastrointestinal dysbiotic conditions.” Zak Dutton, President of Prismic Pharmaceutical, Arizona, added that “there are now scientific meals to be had for a wide range of scientific conditions, from osteoarthritis to Alzheimer’s disease.” field of candidates for the improvement of clinical ingredients is continuously increasing due to advances in the knowledge of nutrients and disease coupled with advances in the food era in increasing the range of merchandise that can be formulated and commercialized. over the last three years, SKIM, a Switzerland-primarily based organization has been involved in over 30 marketplace research tasks within the scientific food place to help deal with or save you from a tremendous range of conditions—from more extreme (diabetes, oncology) to less severe situations (allergic reactions, sarcopenia, lack of electricity, and so forth.) Generally for multinational corporations.
What nutrition are being used?
To combat health condition?
Most people (51 of 82) of U.S. clinical meals merchandise on the market are for metabolic
Disease. Protein-primarily-based medical foods have the most common mechanism of action.
Different vitamins, including omega-3, isoflavones, soluble fiber, vitamin D, chelated zinc,
flavonoids (e.g., baicalin, catechin, pterostilbene), chromium picolinate, phytosterols,
and l-arginine are being used as the main substances in production.
Food. Also, other vitamins and minerals which include pyridoxine, thiamine, and folic acid
are being used in combination with the aforementioned nutrients (Eussen et al., 2011) [2].
Recent Activities in the Medical Food Domain
Bio strategies organization debts for a total of 23 firms with products in the U.S. clinical
Grocery store, of which 4 are from larger companies, which also account for the majority
Of revenue, and 19 are from smaller companies (NZ bio, 2012). More manufacturers are
Bringing more products to the market that cope with issues from metabolic approaches to
Probiotics. In 2006, Limbrel® (flavonoid), the primary medical food for the management
of osteoarthritis, was released. Axona changed into deemed with the aid of the FDA in 2009 as a medical food, concentrated on metabolic deficiencies associated with Alzheimer’s disorder; the well-researched VSL #3, a probiotic for ulcerative colitis and ileal pouch, hit the marketplace in 2002. NiteBite, a snack bar for the dietary management of hyperglycemia, has been marketed since 1996. different health systems are designed to offer solutions for osteopenia/osteoporosis (Fosteum, Primus prescribed drugs), melancholy (Deplin, Pamlab), sleep problems associated with depression (Sentra PM), centered clinical Pharma), and pain and irritation (Theramine, centered medical Pharma).
In recent years, Theramine, an amino acid system (AAF), has been developed and is used as a prescription scientific food for the clinical nutritional management of the metabolic strategies associated with pain and irritation (Shell et al., 2012) [3]. The system is GRAS-permitted and designed to grow the production of serotonin, nitric oxide (NO), histamine, and gamma-aminobutyric acid by providing precursors to these neurotransmitters. The neurotransmitters addressed in this system have nicely described and unique roles in the modulation of pain and inflammation.
Deplin® (Pamlab, Inc.) or l-methyl folate is defined with the aid of the manufacturer (Roman and Bembry, 2011) [4] as “an orally administered prescription scientific food for the nutritional management of suboptimal folate stages in depressed patients.”New dietary options are needed to enhance compliance with a low-phenylalanine diet. Eating regimen and next metabolic manipulation for individuals with phenylketonuria (PKU) (Camp et al., 2012) [5]. a variety of ideal, nutritionally whole merchandise can be crafted from whey protein glycomacropeptide (GMP) with the potential to replace, or partly replace, the traditional amino acid–primarily based on medical ingredients currently utilized in PKU diets (Calcar and Ney, 2012) [6]. GMP-primarily-based clinical ingredients represent a new paradigm to transport modern-day PKU diets from artificial amino acids as the number one supply of protein equivalents to a more physiologically normalized weight-reduction plan based on intact protein, which, as our research demonstrates that it improves protein use and promotes satiety (Khamsi, 2013) [7].
NuMe Health LLC is a complicated New Orleans–primarily based biotechnology company developing evidence-based prebiotic dietary supplements for particular health conditions. Proliant Health and Biological has introduced the currently self-affirmed GRAS reputation for the corporation’s proprietary, IP-covered component, ImmunoLin (bovine globulin concentrate). “The marketplace for meals and nutrition merchandise that aid gut health and immunity are increasing unexpectedly,” said Eric Weaver, Proliant leader scientific Officer. “The formal approval lets in the use of ImmunoLin in products requiring GRAS along with useful foods and beverages, meal substitutes, and
Scientific ingredients.”
Prismic Pharma’s new product, NEUREPATM (eicosapentaenoic acid [EPA]), is a prescription scientific food intended for the nutritional management of omega-three deficiency in patients of schizophrenia, bipolar ailment, and depression. it is a proprietary, relatively purified omega-3 triglyceride component containing now not less than 92% eicosapentaenoic acid (EPA) in step with 1.0 g.
NattoPharma has advanced up to 98% natural diet K2, MK-7 (MenaQ7®).brand), in the shape of crystals to prevent osteoporosis and to support the cardiovascular fitness of postmenopausal girls.
every other candidate product in this segment is alpha-cyclodextrin. The precise shape imparts charming health benefits to this nutritional fiber that allows it to form a strong nondigestible complex with dietary fats. just because the fiber–fat complex is non-digestible, it's also nonfermentable, hence eliminating messy facet results.FBCx is a patented (Soho Flordis International, a Sydney-based herbal medicine business enterprise) α-cyclodextrin-primarily based soluble nutritional fiber, with the specific capacity to bind and eliminate 9 instances of its very own weight in nutritional fat. numerous fine clinical outcomes from randomized, placebo-controlled trials intensified its fitness benefits as
That of medical meals (Grunberger et al., 2007; Kevin et al., 2011) [8,9]
Herbs And Botanicals as Potential Candidates
Herbs and botanicals are regularly proposed as useful ingredients in functional food and nutritional dietary supplements. Also, medicines regularly contain elements derived from plant cloth. A product containing herbs or botanicals may be considered a medicinal product whilst offered as having properties for treating or stopping diseases in human beings or whilst it can be utilized in or is administered to humans to restore, correct, or adjust physiological features by way of exerting a pharmacological, immunological, or metabolic movement or to make a clinical analysis (EUcommission, 2004) [10]. it is the competence and responsibility of the member states to determine, on a case-through-case basis, whether or not a herbal or botanical product falls within the definition of a medicinal product. This could result in a situation wherein a product containing precisely equal bioactive components and inside an equal dosage is considered a nutritional complement in a few European member states but is registered as a remedy in others. Since how a product is being supplied and its predicted pharmacological, immunological, or metabolic motion determine its category as food or drug, it is also possible that herbs and botanicals are exploited both as a dietary complement and as a remedy within a member state, relying on dosage and shape. as an instance, inside the Netherlands, the herbals Ginkgo biloba, Valerian, and St. John’s Wort are bought both as foods and capsules. The difference between a food object and a medication is of high-quality significance for prison practice, considering medicines are more tightly regulated than foods. The recognized healing active level of substances may be used as a cutoff point to differentiate between a food item and a medication (Coppens et al., 2006). Products with a recommended daily intake degree that is better than this cutoff factor might be classified as a medicinal products, while products with an endorsed day-by-day dosage that is lower than this cutoff point could appear as a dietary complement. This is in agreement with the view taken through the EU court of Justice. In keeping with the court, the regulation on drugs applies handiest to a product that is, at its recommended dosage, capable of modifying human physiological capabilities by exerting a pharmacological, immunological, or metabolic movement (Baeyens and Goffin, 2009) [11].
Inside the case of Hecht-Pharma, purple rice tablets have been judged to be categorized as a food Agent. Even though the pills contained monacolin, which is the same as the prescription drug lovastatin, the recommended day-by-day dosage (1.33–4 mg/day) decreased than what's considered effective for lovastatin (20–80 mg/day) (Bradford et al., 1994). Nonetheless, variations within the manufacturing procedure, auxiliary marketers, and the ratio of lively and auxiliary components among food merchandise and medicines may additionally contribute to differences in effectiveness.
What are the challenges to success
In the medical food market?
In 1988, the FDA made steps to encourage the development of a further medical food category by awarding them orphan drug repute. these regulatory modifications reduced the fees and time associated with bringing clinical ingredients to market, as in the past, medical foods have been treated as pharmaceutical tablets. Zak Dutton of Prismic breaks the demanding situations into two huge classes. “The first relates to the development of medical food. Unlike nutritional supplements, medical foods require a sturdy medical guide to satisfy the clinical meal criteria. This means that the benefit of medical meals must be validated in medical trials. The second is the relative lack of awareness or expertise of scientific ingredients in the scientific community. Maximum medical doctors inside America have not heard of the term ‘scientific food’ and don’t know that it's miles a wonderful, FDA-regulated category. As a result, there may be a tendency to consider clinical food as either a drug or as a dietary supplement.” Dr. Badmaev of NattoPharma also echoed the identical view. He said, “The demanding situations to efficacious medicinal foods stem from regulatory barriers that may be resolved by way of a strong research program, and method of the energetic ingredients, like diet K2, right into a solid, nutritious and attractive form of food delivery.” “Companies growing scientific nutrient solutions as part of the treatment and prevention of chronic diseases like diabetes, sarcopenia, HIV, and weight problems face several challenges,” Benoît Gouhier, mission director of SKIM customer health, introduced. He additionally highlighted that “maximum fitness offerings and insurers presently don’t cover the fee of nutritional products for disease prevention or control. As such, customers and patients become the very last choice-makers regarding the purchase Of those merchandise, regularly guided using the advice and recommendations of healthcare Experts. The result is a complicated and aggressive surrounding and choice-making process that poses real challenges for marketers.”
What will the market look like in
5 to 10 years from now?
The “scientific foods” category is rather well known in the USA; however, so in some other places. Zak Dutton of Prismic Pharmaceutical said, “I expect that the category, within the U.S.A., will grow considerably. There is truly too wonderful a want from both the fitness benefit and cost of healthcare perspectives.” “The trend in medicinal meals started about 15 years ago and because then the frame of clinical peer-reviewed papers at the concern has grown dramatically,” Vladimir Badmaev
Of NattoPharma said. The size of the medical grocery store is unclear. The FDA predicts a robust boom, in light of the growing use of medical foods in lengthy-term care and the growing population of older people. International sales have been projected at just below $9 billion (International Industry Analysts, 2011; Kalorama, 2010).{12} the lack of an enterprise association and the scarcity of public statistics make it hard to estimate U.S. scientific food sales; the great estimate is $2.1 billion for the year 2011 developing at ~10%.
Regulatory Challenges The Industry Is Experiencing
In the U.S., medical foods are a special product category regulated using the FDA. In Europe, a similar class is called “ingredients for unique clinical purposes.” (FSMPs) is included through the Foods for Precise Dietary Uses directive and regulated via the European fee (EC). medical ingredients do no longer require preapproval from the FDA for advertising and marketing. Not like nutritional dietary supplements, which have no ailment declared and are supposed for healthful individuals, clinical ingredients should make a disease declared and are supposed to be used in unique diseased populations. Disorder claims need to be supported via sound clinical proof substantiating Claims of successful nutritional management of the sickness. All components should
be authorized food components or labeled as “normally diagnosed as secure” (GRAS).
Reimbursement for medical foods is inconsistent and varies by using products and through health Plans. Like clinical meals in the United States, FSMPs are supposed to be used handiest below Scientific supervision, however, they have to comply with EC guidelines. Within the European Union, there may be harmonized regulation on fitness claims, whilst compounds, ingredients, and flowers are nonetheless regulated best at the national stage.
Business Models and Market Positioning
Medical food entrepreneurs broadly use varying name factors determined by their sales force and the
Distribution channels for their products, regularly using a mixture for every. The call points are number one care MDs and PAs, professional MDs and prescribing nurses, registered dieticians, mail-order pharmacies, and long-time period care vendors (company and/or nearby), hospitals (company and/or nearby), and domestic care offerings. Retail and mail-order pharmacies, doctors’ offices, the net, hospitals, domestic care services, and specialized disease clinics are the primary distribution channels.market positioning of scientific ingredients is hard. Most of the advertising experts Advise the subsequent steps for a hit positioning:
1. Boost recognition of a brand-new category among physicians, patients, and payers.
2. Efficaciously leverage “consumer pull” and “healthcare expert push” using building-focused strategies for disease-specific scientific vitamins.
3. Create new adorability which includes flavor, smell, color, “mouth sense,” and presentation to distinguish medical ingredients from pharmaceuticals. “Naturalness” of a scientific food is likewise every other key element in constructing a positioning announcement.
Are medical foods always safe as generally assumed?
The popularity of meals dietary supplements and medical ingredients, resulting in a one billion greenback marketplace inside the United States of America, reflects no longer the societal trend far from “artificial” pharmaceutical tablets closer to “natural” ingredients but additionally, the dearth of excellent tablets that are both powerful and secure. Customers are probably to count on medical meals to be secure, however, some recent research endorses that this could no longer continually be true. Flavonoid, which is advertised as a medical food, is a proprietary combination of purified,
Plant-derived bioflavonoids. It’s widely believed to act as a twin inhibitor of cyclooxygenase
and 5-lipoxygenase enzymes, therefore inhibiting the conversion of arachidonic acid into prostaglandins and leukotrienes. These mechanisms make flavonoids an interesting therapeutic alternative to nonsteroidal anti-inflammatory tablets. Due to the fact, that it is classified as a medical food, flavonoids became marketed beginning in 2004 in the absence of any posted randomized trial. even though two trials have yet to be had in 2009 and 2010, four cases of acute liver damage related to flavonoids have been said to date (Chalasani et al., 2012){13}. Many herbal products are used as food supplements or scientific meals, in addition to nutrients, antioxidants, fiber, trace factors, Proteins and amino acids can also be associated with liver damage.
Technological Challenges
The advent of a medical food with potential health advantages for a specific affected person
Population is a pretty complex technique. Fortuitously, the developmental technique for a selected medical food isn't always as rigorous or as tightly regulated as that of a pharmaceutical agent (Juan et al. 2011){14}. however, numerous factors unique to the enteral components of a brand-new product come into play, which include bodily/chemical compatibility, pH, balance, bioavailability, decay, and even palatability (Ochoa et al., 2011){15}. Extra considerations consisting of the power of health gain claims, packaging or presentation, and marketability determine the last commercialization and
Whether or not a product ends up being released to the general public. A full knowledge of the
Development, substantiation, and commercialization of a clinical food is vital for important physiologic concepts in nutrition therapy to end up as part of the therapeutic regimen at the bedside of the critically ill obese patient.
1. Study Design:
Sort of examine: a combined-approach approach incorporating qualitative and quantitative records.
Population: participants protected healthcare specialists, patients from the use of medical ingredients, and industry specialists.
Sample length: a total of 2 hundred participants were surveyed, with a balanced illustration from every institution.
2. Data Collection:
Surveys: structured questionnaires were administered to accumulate quantitative statistics on the usage, perceptions, and effectiveness of clinical meals.
Interviews: Semi-established interviews have been carried out to take advantage of in-depth qualitative insights from healthcare specialists and enterprise professionals.
Secondary fact analysis: evaluation of current literature and sales statistics to recognize marketplace traits and regulatory landscapes.
3. Data Analysis:
Quantitative evaluation: descriptive information, correlation, and regression evaluation have been completed with the use of statistical software.
Qualitative analysis: A thematic evaluation was conducted on interview transcripts to identify key themes and patterns.
1. Utilization and Effectiveness:
Affected person consequences: 75% of sufferers suggested high-quality fitness outcomes after the usage of clinical meals, which include improved nutritional status and symptom remedy.
Healthcare professional feedback: 80% of healthcare experts discovered remarkable enhancements in sufferers who were prescribed clinical foods.
Usage patterns: the most common conditions handled with clinical ingredients were metabolic problems (40%), gastrointestinal problems (30%), and neurological conditions (20%).
2. Perceptions and popularity:
Affected person Perceptions: sufferers regarded clinical foods as a beneficial supplement to their conventional remedy, with 70% expressing pleasure.
Healthcare professional attractiveness: there was an excessive stage of popularity among healthcare professionals, with 85% inclined to endorse medical ingredients as a part of a treatment plan.
Obstacles to Adoption: Key obstacles recognized covered high charges (45%), restrained coverage coverage (30%), and lack of awareness (25%).
3. Market and Regulatory Insights:
Market developments: The marketplace for scientific ingredients is growing rapidly, with an annual increase fee of 10%. Key drivers include improved awareness and the rising prevalence of chronic diseases.
Regulatory landscape: The regulatory environment for scientific foods is complicated, with versions throughout areas. The desire for clearer guidelines and requirements was emphasized by 60% of enterprise experts.
1. Effectiveness and Integration into Treatment Plans:
The fantastic results reported by sufferers and determined by healthcare professionals imply that scientific foods can play an extensive function in handling persistent situations. Those findings align with the present literature, which highlights the healing capability of medical ingredients in specific sickness states.
The high degree of attractiveness among healthcare specialists indicates that scientific meals are increasingly being integrated into treatment plans. However, the effectiveness of those meals can be similarly demonstrated through considerable scientific trials and longitudinal studies.
2. Limitations to Adoption:
Fees and insurance are massive obstacles to the substantial adoption of clinical foods. Policymakers and healthcare providers want to work collectively to cope with those issues, probably through advocacy for higher insurance and tasks to lessen expenses.
Focus campaigns focused on healthcare experts and sufferers should assist in bridging the knowledge gap and enhance the popularity and utilization of clinical ingredients.
3. Regulatory challenges:
The look highlights the need for clearer regulatory hints to ensure the safety and efficacy of clinical meals. Harmonizing regulations throughout regions ought to facilitate higher market penetration and customer agreement.
Regulatory bodies ought to remember to organize a distinct category for scientific ingredients, with precise requirements and approval tactics that range from traditional meals to prescribed drugs.
4. Future studies guidelines:
Further research is needed to explore the long-term results of clinical ingredients and their effect on pleasant of lifestyles. Randomized controlled trials with large sample sizes ought to provide extra sturdy proof of their blessings.
Investigating the cost-effectiveness of scientific ingredients could help justify their inclusion in insurance plans and public health applications
Taking a nutritious product from the bench to the bedside is a long and complicated endeavor. But, to understand the effectiveness and safety of any healthcare intervention—drug, medical device, food supplement, or medical food—scientific proof from well-designed randomized trials and observational studies will always be important.
Given the huge use and capacity damage of medical foods and food supplements, the coverage of advertising and marketing these products in the absence of clinical proof can also want to be reconsidered.
Studies are restrained on the scientific homes of food, in particular in human clinical research. More work is needed to understand the capabilities and advantages of medical ingredients, in particular on the subsequent:
• More potential, controlled research
• large problem populations
• Longer remedy periods
Similar to medical food, studies are wanted to increase the generation used to deliver certain medical foods, including tubing and pumps.
The accomplishment of this research project would not have existed without the offerings and support of many things and institutions. grateful We are intensely grateful to all those who performed a function for the benefit of this project We too thank my mentors, Naweed Imam Syed, Prof. Department of Cell Biology at the University of Calgary, and Dr. Sadaf Ahmed Psychophysiology Lab, University of Karachi, for their priceless recommendations and support during the whole of this research. Their observations and knowledge assisted in forming the management concerning this project Declaration of Interest I existing acknowledge that: I have no financial or additional private interest, direct or unintended, in some matter that raises or grants permission that contradicts my responsibilities as a director of my commission Management
The authors declare that they have no conflict of interest. Financial support and protection. No Funding was taken to assist in accompanying the development of this study
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