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Prevalence of Food Addiction during Covid-19 Pandemic in Amman, Jordan: A Cross Sectional Study

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Research Article | DOI: https://doi.org/10.31579/2637-8914/050

Prevalence of Food Addiction during Covid-19 Pandemic in Amman, Jordan: A Cross Sectional Study

  • Ruba Mousa Musharbash 1*
  • Nour Amin Elsahoryi 2
  • Andrea McGrattan 3
  • Samantha Al-Alam 4
  • Lara Badawi 4

1 Clinical dietitian, Ruba Musharbash Center for Nutrition Counseling, Amman, Jordan. 
2 Nutrition Department, Faculty of Pharmacy and Medical Sciences, University of Petra, Amman, Jordan.
3 Research Associate & Dietitian, Population Health Sciences Institute, Newcastle University, NE4 5PL. UK.
4 Nutritionist, Ruba Musharbash Center for Nutrition Counseling, Amman, Jordan.

*Corresponding Author: Ruba Mousa Musharbash, Clinical dietitian, Ruba Musharbash Center for Nutrition Counseling.

Citation: Ruba M Musharbash, Nour A Elsahoryi, Andrea McGrattan, Samantha Al-Alam, Lara Badawi, (2021). Prevalence of Food Addiction during Covid-19 Pandemic in Amman, Jordan: A Cross Sectional study. J. Nutrition and Food Processing, 4(4); DOI:10.31579/2637-8914/050

Copyright: © This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Received: 13 April 2021 | Accepted: 30 April 2021 | Published: 05 May 2021

Keywords: food addiction; obesity; quarantine; COVID-19; food craving; chi-square test; insulin; leptin; ghrelin; homeostasis; etiology

Abstract

Aim: Emerging evidence highlights the impact of stressful conditions on eating behaviours, particularly the consumption of foods high in salt, sugar and fat. The impact of the Coronavirus disease-19 (COVID-19) pandemic on food addiction is still un-estimated. This study aimed to examine the prevalence of food addiction among the Jordanian population during the quarantine. 

Materials and methods: A Cross-sectional study has been conducted between the 27th of April and the 4th of June of 2020. An online survey of Yale food addiction scale v.2.0 (YFAS 2.0) was distributed. A convenience sample was collected through social media sites. Differences in socio-demographic characteristics were analysed using t-test and chi-square tests. Food addiction was classified based on the scoring scale. Determinants of food addition were predicted by using multivariate logistic regression. 

Results: The results revealed that the prevalence of food addiction was 21.5% among adults. Among food addiction participants, 76.4% were diagnosed as severely food addicted. More than 50% of the participants reported high consumption of foods rich in sugar, salt, and fat (48.2%, 51.8%, and 52.5%, respectively). Overweight and obese young adults were more likely to have food addiction compared to normal weight. The multinominal logistic regression model revealed that there was no determinants of food addiction among adults.

Conclusion: During the first months of the quarantine, the prevalence of food addiction was higher among obese and overweight adults compared to normal-weight adults.

Introduction

Coronavirus (COVID-19) is a severe respiratory syndrome caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) [31]. It spread rapidly and causes increased worldwide [46]. The World Health Organization (WHO) declared COVID-19 as a pandemic in March 2020. On the 17th of March, Jordan declared the national defence law, where a complete lockdown was launched with strict rules on citizens’ mobility, to mitigate the spread of the virus [27]. The lockdown and quarantine, due to COVID-19, affected people’s behaviors, economics [38], social and general health status [6]. Staying at home with limitations of outdoor activities, and less mobility, caused an increase in boredom and stress [31]. Consequently, all these stressful events are well known to affect eating patterns, affecting people’s choices of food [21].

Additional stress can encourage people to overeat, especially craving specific comfort and palatable foods [37]. This intense desire to consume specific foods was previously described as a food craving, which is a multidimensional concept, including emotional, cognitive and physiological processes [43].  The concept of Food Addiction (FA) can be presented as the phase where foods, mainly rich in sugar, salt and fat are potentially addictive, and that specific forms of overeating may be viewed as addictive behaviour [36]. It is now used to explain the etiology and maintenance of some forms of obesity [29]. The Yale food addiction scale 2nd version (YFAS 2.0) is used to examine FA, it is a diagnostic self–report questionnaire of addiction eating behaviour [1]. 

 To the best of the authors’ knowledge, the effect of COVID-19 on FA has not been studied before. Quarantine may have affected the eating behaviours of Jordanians. Thus, this study aimed to examine the FA prevalence among adults in Jordan during the first four weeks of the quarantine.

Materials and methods

1. Study Design

A cross-sectional study was conducted among Jordanian adults -aged more than 18 years. Data were collected from the 27th of April until the 4th of June 2020 by using an online questionnaire. The respondents were chosen using convenience sampling (non-probability sampling method) due to the lack of a population sampling system [10]. The online questionnaire opened from April to the end of June 2020. A consent form was included on the first page and ‘agree and continue’ choice could be selected for those who agreed to participate in the survey. 

The guidelines for strengthening the Reporting of Observational Studies in Epidemiology (STROBE-nut) were used to write this article [51].

2. Study Tool 

In the current study, the questionnaire included two parts; the first part included socio-demographic. The second part included YFAS 2.0, which is an instrument that assesses addictive-like eating behaviours using the criteria for substance use [28, 30]. Valid and reliable Arabic version copy was published in previous work in Jordan [16].

The scale is composed of a 35 item self-reported questionnaire that applies eleven Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) criteria [36,42]. The scale gives two scoring options, the YFAS symptoms count [34,41], which indicates the number of dependence symptoms that have been met and the dichotomous version [31,50]. The measures of items are scored using a scale count ranging from never (0) to every day (7) indicating the number of dependence symptoms [28]. The participants with FA are diagnosed when having at least 3 symptoms with clinically significant impairment or distress [26,45]. The scale finally will subdivide the participants into four groups according to the severity of FA: mild, moderate, severe FA and non-FA [34,41]. 

3. Participants

Participants were asked to complete the questionnaire and answer the questions related to their eating behaviours during the quarantine period from the beginning of the lockdown in Jordan. 

The inclusion criteria of this study were: (1) adults aged ≥ 18 years old; (2) currently living in Amman (capital city of Jordan) during the lockdown due to the COVID -19 pandemic. Submitted responses that did not match the inclusion criteria were excluded. The study was approved by the Institutional Review Board and the ethical committee of Petra University, Amman, Jordan (Grant number: 2Q/3/2020). 

4. Statistical Analysis

Descriptive statistics, including frequencies, percentages, and cross-tabulation were collated to find the relationship between FA and socio-demographic characteristics of the participants. Food addiction was classified as mild, moderate, severe based on the scale scoring [41] for the participants who have FA during the study time. The rest of the analysis was performed on the FA participants.  Cross-tabulation was used to assess the relationship between the symptoms of FA and the FA categories. Multinominal logistic regression was used to predict the socio-demographic characteristics that could be determinants for FA among adults in this study. The significant level (p-value) in this study is ≤ 0.05. The data were analysed using IBM SPSS Statistics for Windows, Version 26.0 (IBM Corp., Armonk, NY, USA). BMI was measured using self-reported weight and height and calculated by dividing weight in kilogram by height in meters squared [8].

Results

1. Participants Characteristics

The total number of 718 participants has completed the survey, only 652 met the inclusion criteria. The majority of the participants were women (94.2%), mean age was (30 ±7.7), and more than a quarter of the respondents were between 18-28 years old (46.62%). Moreover, the anthropometric results indicated that more than the half of participants were overweight or obese (59.6%), mean body mass index (BMI) was (26.9±5.5). Nearly half of participants consumed more foods that are rich in sugar, salt and fat occasionally (48.2%, 51.8%, 52.5%), respectively. 

2. Prevalence of FA categories among the study participants 

From the total sample, 21.5% (n=140) met the clinical threshold for FA. Based on YFAS scale score analysis, the FA is classified into three categories: mild, moderate and severe.  Within the FA group, the participants were distributed to 10%, 3.6% and 76.4% as mild FA, moderate FA and severe FA as shown in Table 1. 

Table 1. Socio-demographic characteristics of participants according to the food addiction groups (FA and Non-FA), n=652

3. Relationship between FA groups and the socio-demographic characteristics of the study population

As shown in Table 2, The relation between age, BMI, frequency of eating foods rich in (salt, sugar and fat) and FA variables were significant, X2 (1, N = 642) = 16.002, p= 0.001, = 47.434, p= 0.001, = 20.539, p= 0.001, = 39.016, p= 0.001, = 36.253, p= 0.001, respectively. Adults who are 29-39 years old, overweight, eating foods high in sugar daily and occasionally eating foods high in salt and fat, were more likely to be food addicted than others. 

4. Relationship between FA categories (mild, moderate and severe) and the socio-demographic characteristics of the study population

 As shown in Table 2, a chi-square test of independence was performed to examine the relationship between socio-demographic and eating lifestyle and the FA categories. The relation between frequency of consuming foods rich in sugar and FA categories was significant, X2 (1, N = 642) = 19.28, p= 0.004.

Table 2. Socio-demographic characteristics of participants according to the food addiction categories, n=140

Adults who eat foods high in sugar are more likely to be severely food addicted than others.

In table 3 the multinomial logistic regression results present a significant prediction between moderate FA and consumption of frequency of consuming foods high in sugar (b=-0.993, s.e.= .379, p 0.014) and these results are consistent with the chi-square test.

Table 3.  Multivariate logistic regression of the Socio-demographic characteristics and FA categories, n=140

5. The relationship between FA symptom scores and frequency of symptoms among food addicted participants.   

The mean symptoms score for the whole sample was 2.95± 3.50, and 7.95± 2.85 for the FA group. Table 4. Illustrates the percentages of individuals with different levels of FA that reported each of the eleven symptoms. The most frequent symptoms reported in the whole sample were “Important social, occupational, or recreational activities given up or reduced” (36.5%), and “Characteristic withdrawal symptoms; substance is taken to relieve withdrawal” (34.7%). Among individuals who have severe FA the main symptoms reported were, “Characteristic withdrawal symptoms; substance taken to relieve withdrawal” (82.1%), followed by “Persistent desire or repeated unsuccessful attempts at quitting symptom” (84.4%). Meanwhile, the less frequent symptom in both the whole sample and in the group, who met the FA criteria was “Use continues despite knowledge of adverse consequences (e.g., failure to fulfil role obligation, use when physically hazardous” 16.7%, 60%, respectively. 

Table 4. Food addiction symptom scores and frequency of symptoms in participants with Food addiction, n=140.

Discussion

Many studies have been published recently on eating behaviours during the COVID-19 quarantine [12,20,21]. To our knowledge, no studies are available on the prevalence of FA during the COVID-19 pandemic quarantine. 

 The percentage of participants who are Food addicted in our study is considered high compared to other countries [4,5,45]. A previous study conducted in Jordan concluded that the prevalence of FA (n=4479) was 36.7%, FA was significantly greater among young adults aged 18-34 years, overweight and obese participants [16]. Another study in Egypt concluded that the FA prevalence was 15.7% in the studied sample [26]. Furthermore, a cohort study additionally reported that FA among middle aged US young women was higher among the younger proportion, and the majority of the population that was diagnosed with FA fell into the overweight category [9]. Obesity and FA have been the most studied in the literature; recent meta-analysis studies concluded that the prevalence of FA was higher in the population that fell in the overweight and obese persons [36,39].

However, Jordan is considered one of the highest countries in the prevalence of obesity and overweight, consisting of 69.6% of the whole population who are overweight [52]. Most of the women with FA in our sample were overweight or obese, and this was also evidenced in previous studies [7,17,18,19,24]. Results from the same studies showed that youth scored the most for severe FA [45,36]. One possible explanation could be that respondents from young age groups are more exposed to food cues and changes in their dietary lifestyle and habits. Furthermore, they may be at greater risk of emotion-induced eating and exposure to stress factors [36]. The stress during the quarantine could be related to changing eating behaviours and emotional eating during the lockdown time. A very recent study in Saudi Arabia concluded that half of the women in the study sample have suffered from emotional eating during quarantine, and increased intake of foods rich in sugar and fat markedly with increased stress levels [2]. A similar study during quarantine reported an increase of daily food intake by almost 50% of the respondents and by the variety of food choices; hence, consuming fewer fruits and vegetables and consuming dairy, meat and fast foods [12,21]. 

 Stress can disrupt eating behaviour and encourage eating high palatable foods [14]. Therefore, the activation of the reward circuit; hence the mesolimbic dopaminergic system secretes dopamine in the ventral tegmental area (VTA) [16,25]. Insulin, leptin, and ghrelin also play a key role in the homeostasis of eating behaviors [11,23]. Leptin decreases food intake and decreases the firing rate of dopamine release through signalling in the ventral tegmental area (VTA) [15]. Ghrelin, leptin antagonist, increases food intake and influences the signaling in the VTA [22]. Insulin increases food intake by increasing the release and firing of dopamine in the VTA [3,13]. 

 The results of the current study showed that some of the respondents had consumed palatable foods during the stressful condition of quarantine due to the COVID-19 pandemic. Some studies were in agreement as they mentioned that the pandemic changed the consumption patterns [32]. Respondents reported high-stress levels during the COVID-19 pandemic that led to the increased binge-eating [48]. Stress and emotional eating have also been studied as there was a strong positive relationship between increased emotional eating and stress induced by quarantine [47,53]. 

 The mean symptoms score in the whole sample was high compared with other studies [1,29,49]. Also, higher in FA group, compared to in a previous Jordanian study [16].

There were many limitations to consider in this study. First, this study does not compare the presence of FA before and after the pandemic. Therefore, the results compared with different populations. Second, the majority of the participants who completed the online survey were women, this may be explained by higher interest in health topics in women compared to men. The strengths of this study are that it is the first study globally and in Jordan discussing the FA status during the quarantine, and the use of a strong scale to measure FA among the participants. More longitudinal studies are required in the future.    

Conclusion

In summary, the prevalence of food addiction and the mean symptoms score were high in the FA group compared to other previous studies. Younger aged adults and overweight respondents were more likely to have FA. Intervention studies are required to manage eating behaviours among adults during times of increased stress. This study recommends the need for more longitudinal studies on FA to coincide with the increasing quarantine duration in Jordan and other countries. Moreover, awareness training and programs are recommended to increase the responsiveness toward eating and stress management and its short and long term health effects among adults.

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Clearly Auctoresonline and particularly Psychology and Mental Health Care Journal is dedicated to improving health care services for individuals and populations. The editorial boards' ability to efficiently recognize and share the global importance of health literacy with a variety of stakeholders. Auctoresonline publishing platform can be used to facilitate of optimal client-based services and should be added to health care professionals' repertoire of evidence-based health care resources.

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Virginia E. Koenig

Journal of Clinical Cardiology and Cardiovascular Intervention The submission and review process was adequate. However I think that the publication total value should have been enlightened in early fases. Thank you for all.

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Delcio G Silva Junior

Journal of Women Health Care and Issues By the present mail, I want to say thank to you and tour colleagues for facilitating my published article. Specially thank you for the peer review process, support from the editorial office. I appreciate positively the quality of your journal.

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Ziemlé Clément Méda

Journal of Clinical Research and Reports I would be very delighted to submit my testimonial regarding the reviewer board and the editorial office. The reviewer board were accurate and helpful regarding any modifications for my manuscript. And the editorial office were very helpful and supportive in contacting and monitoring with any update and offering help. It was my pleasure to contribute with your promising Journal and I am looking forward for more collaboration.

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Mina Sherif Soliman Georgy

We would like to thank the Journal of Thoracic Disease and Cardiothoracic Surgery because of the services they provided us for our articles. The peer-review process was done in a very excellent time manner, and the opinions of the reviewers helped us to improve our manuscript further. The editorial office had an outstanding correspondence with us and guided us in many ways. During a hard time of the pandemic that is affecting every one of us tremendously, the editorial office helped us make everything easier for publishing scientific work. Hope for a more scientific relationship with your Journal.

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Layla Shojaie

The peer-review process which consisted high quality queries on the paper. I did answer six reviewers’ questions and comments before the paper was accepted. The support from the editorial office is excellent.

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Sing-yung Wu

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Orlando Villarreal

Dr. Katarzyna Byczkowska My testimonial covering: "The peer review process is quick and effective. The support from the editorial office is very professional and friendly. Quality of the Clinical Cardiology and Cardiovascular Interventions is scientific and publishes ground-breaking research on cardiology that is useful for other professionals in the field.

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Thank you most sincerely, with regard to the support you have given in relation to the reviewing process and the processing of my article entitled "Large Cell Neuroendocrine Carcinoma of The Prostate Gland: A Review and Update" for publication in your esteemed Journal, Journal of Cancer Research and Cellular Therapeutics". The editorial team has been very supportive.

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Testimony of Journal of Clinical Otorhinolaryngology: work with your Reviews has been a educational and constructive experience. The editorial office were very helpful and supportive. It was a pleasure to contribute to your Journal.

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Pedro Marques Gomes

Dr. Bernard Terkimbi Utoo, I am happy to publish my scientific work in Journal of Women Health Care and Issues (JWHCI). The manuscript submission was seamless and peer review process was top notch. I was amazed that 4 reviewers worked on the manuscript which made it a highly technical, standard and excellent quality paper. I appreciate the format and consideration for the APC as well as the speed of publication. It is my pleasure to continue with this scientific relationship with the esteem JWHCI.

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Bernard Terkimbi Utoo

This is an acknowledgment for peer reviewers, editorial board of Journal of Clinical Research and Reports. They show a lot of consideration for us as publishers for our research article “Evaluation of the different factors associated with side effects of COVID-19 vaccination on medical students, Mutah university, Al-Karak, Jordan”, in a very professional and easy way. This journal is one of outstanding medical journal.

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Prof Sherif W Mansour

Dear Hao Jiang, to Journal of Nutrition and Food Processing We greatly appreciate the efficient, professional and rapid processing of our paper by your team. If there is anything else we should do, please do not hesitate to let us know. On behalf of my co-authors, we would like to express our great appreciation to editor and reviewers.

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Hao Jiang

As an author who has recently published in the journal "Brain and Neurological Disorders". I am delighted to provide a testimonial on the peer review process, editorial office support, and the overall quality of the journal. The peer review process at Brain and Neurological Disorders is rigorous and meticulous, ensuring that only high-quality, evidence-based research is published. The reviewers are experts in their fields, and their comments and suggestions were constructive and helped improve the quality of my manuscript. The review process was timely and efficient, with clear communication from the editorial office at each stage. The support from the editorial office was exceptional throughout the entire process. The editorial staff was responsive, professional, and always willing to help. They provided valuable guidance on formatting, structure, and ethical considerations, making the submission process seamless. Moreover, they kept me informed about the status of my manuscript and provided timely updates, which made the process less stressful. The journal Brain and Neurological Disorders is of the highest quality, with a strong focus on publishing cutting-edge research in the field of neurology. The articles published in this journal are well-researched, rigorously peer-reviewed, and written by experts in the field. The journal maintains high standards, ensuring that readers are provided with the most up-to-date and reliable information on brain and neurological disorders. In conclusion, I had a wonderful experience publishing in Brain and Neurological Disorders. The peer review process was thorough, the editorial office provided exceptional support, and the journal's quality is second to none. I would highly recommend this journal to any researcher working in the field of neurology and brain disorders.

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Dr Shiming Tang

Dear Agrippa Hilda, Journal of Neuroscience and Neurological Surgery, Editorial Coordinator, I trust this message finds you well. I want to extend my appreciation for considering my article for publication in your esteemed journal. I am pleased to provide a testimonial regarding the peer review process and the support received from your editorial office. The peer review process for my paper was carried out in a highly professional and thorough manner. The feedback and comments provided by the authors were constructive and very useful in improving the quality of the manuscript. This rigorous assessment process undoubtedly contributes to the high standards maintained by your journal.

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Raed Mualem

International Journal of Clinical Case Reports and Reviews. I strongly recommend to consider submitting your work to this high-quality journal. The support and availability of the Editorial staff is outstanding and the review process was both efficient and rigorous.

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Andreas Filippaios

Thank you very much for publishing my Research Article titled “Comparing Treatment Outcome Of Allergic Rhinitis Patients After Using Fluticasone Nasal Spray And Nasal Douching" in the Journal of Clinical Otorhinolaryngology. As Medical Professionals we are immensely benefited from study of various informative Articles and Papers published in this high quality Journal. I look forward to enriching my knowledge by regular study of the Journal and contribute my future work in the field of ENT through the Journal for use by the medical fraternity. The support from the Editorial office was excellent and very prompt. I also welcome the comments received from the readers of my Research Article.

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Dr Suramya Dhamija

Dear Erica Kelsey, Editorial Coordinator of Cancer Research and Cellular Therapeutics Our team is very satisfied with the processing of our paper by your journal. That was fast, efficient, rigorous, but without unnecessary complications. We appreciated the very short time between the submission of the paper and its publication on line on your site.

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Bruno Chauffert

I am very glad to say that the peer review process is very successful and fast and support from the Editorial Office. Therefore, I would like to continue our scientific relationship for a long time. And I especially thank you for your kindly attention towards my article. Have a good day!

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Baheci Selen

"We recently published an article entitled “Influence of beta-Cyclodextrins upon the Degradation of Carbofuran Derivatives under Alkaline Conditions" in the Journal of “Pesticides and Biofertilizers” to show that the cyclodextrins protect the carbamates increasing their half-life time in the presence of basic conditions This will be very helpful to understand carbofuran behaviour in the analytical, agro-environmental and food areas. We greatly appreciated the interaction with the editor and the editorial team; we were particularly well accompanied during the course of the revision process, since all various steps towards publication were short and without delay".

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Jesus Simal-Gandara

I would like to express my gratitude towards you process of article review and submission. I found this to be very fair and expedient. Your follow up has been excellent. I have many publications in national and international journal and your process has been one of the best so far. Keep up the great work.

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Douglas Miyazaki

We are grateful for this opportunity to provide a glowing recommendation to the Journal of Psychiatry and Psychotherapy. We found that the editorial team were very supportive, helpful, kept us abreast of timelines and over all very professional in nature. The peer review process was rigorous, efficient and constructive that really enhanced our article submission. The experience with this journal remains one of our best ever and we look forward to providing future submissions in the near future.

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Dr Griffith

I am very pleased to serve as EBM of the journal, I hope many years of my experience in stem cells can help the journal from one way or another. As we know, stem cells hold great potential for regenerative medicine, which are mostly used to promote the repair response of diseased, dysfunctional or injured tissue using stem cells or their derivatives. I think Stem Cell Research and Therapeutics International is a great platform to publish and share the understanding towards the biology and translational or clinical application of stem cells.

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Dr Tong Ming Liu

I would like to give my testimony in the support I have got by the peer review process and to support the editorial office where they were of asset to support young author like me to be encouraged to publish their work in your respected journal and globalize and share knowledge across the globe. I really give my great gratitude to your journal and the peer review including the editorial office.

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Husain Taha Radhi

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S Munshi

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Tania Munoz

“The peer review process of JPMHC is quick and effective. Authors are benefited by good and professional reviewers with huge experience in the field of psychology and mental health. The support from the editorial office is very professional. People to contact to are friendly and happy to help and assist any query authors might have. Quality of the Journal is scientific and publishes ground-breaking research on mental health that is useful for other professionals in the field”.

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George Varvatsoulias

Dear editorial department: On behalf of our team, I hereby certify the reliability and superiority of the International Journal of Clinical Case Reports and Reviews in the peer review process, editorial support, and journal quality. Firstly, the peer review process of the International Journal of Clinical Case Reports and Reviews is rigorous, fair, transparent, fast, and of high quality. The editorial department invites experts from relevant fields as anonymous reviewers to review all submitted manuscripts. These experts have rich academic backgrounds and experience, and can accurately evaluate the academic quality, originality, and suitability of manuscripts. The editorial department is committed to ensuring the rigor of the peer review process, while also making every effort to ensure a fast review cycle to meet the needs of authors and the academic community. Secondly, the editorial team of the International Journal of Clinical Case Reports and Reviews is composed of a group of senior scholars and professionals with rich experience and professional knowledge in related fields. The editorial department is committed to assisting authors in improving their manuscripts, ensuring their academic accuracy, clarity, and completeness. Editors actively collaborate with authors, providing useful suggestions and feedback to promote the improvement and development of the manuscript. We believe that the support of the editorial department is one of the key factors in ensuring the quality of the journal. Finally, the International Journal of Clinical Case Reports and Reviews is renowned for its high- quality articles and strict academic standards. The editorial department is committed to publishing innovative and academically valuable research results to promote the development and progress of related fields. The International Journal of Clinical Case Reports and Reviews is reasonably priced and ensures excellent service and quality ratio, allowing authors to obtain high-level academic publishing opportunities in an affordable manner. I hereby solemnly declare that the International Journal of Clinical Case Reports and Reviews has a high level of credibility and superiority in terms of peer review process, editorial support, reasonable fees, and journal quality. Sincerely, Rui Tao.

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Rui Tao

Clinical Cardiology and Cardiovascular Interventions I testity the covering of the peer review process, support from the editorial office, and quality of the journal.

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Khurram Arshad

Clinical Cardiology and Cardiovascular Interventions, we deeply appreciate the interest shown in our work and its publication. It has been a true pleasure to collaborate with you. The peer review process, as well as the support provided by the editorial office, have been exceptional, and the quality of the journal is very high, which was a determining factor in our decision to publish with you.

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Gomez Barriga Maria Dolores

The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews journal clinically in the future time.

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Lin Shaw Chin

Clinical Cardiology and Cardiovascular Interventions, I would like to express my sincerest gratitude for the trust placed in our team for the publication in your journal. It has been a true pleasure to collaborate with you on this project. I am pleased to inform you that both the peer review process and the attention from the editorial coordination have been excellent. Your team has worked with dedication and professionalism to ensure that your publication meets the highest standards of quality. We are confident that this collaboration will result in mutual success, and we are eager to see the fruits of this shared effort.

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Maria Dolores Gomez Barriga

Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, I hope this message finds you well. I want to express my utmost gratitude for your excellent work and for the dedication and speed in the publication process of my article titled "Navigating Innovation: Qualitative Insights on Using Technology for Health Education in Acute Coronary Syndrome Patients." I am very satisfied with the peer review process, the support from the editorial office, and the quality of the journal. I hope we can maintain our scientific relationship in the long term.

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Dr Maria Dolores Gomez Barriga

Dear Monica Gissare, - Editorial Coordinator of Nutrition and Food Processing. ¨My testimony with you is truly professional, with a positive response regarding the follow-up of the article and its review, you took into account my qualities and the importance of the topic¨.

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Dr Maria Regina Penchyna Nieto

Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, The review process for the article “The Handling of Anti-aggregants and Anticoagulants in the Oncologic Heart Patient Submitted to Surgery” was extremely rigorous and detailed. From the initial submission to the final acceptance, the editorial team at the “Journal of Clinical Cardiology and Cardiovascular Interventions” demonstrated a high level of professionalism and dedication. The reviewers provided constructive and detailed feedback, which was essential for improving the quality of our work. Communication was always clear and efficient, ensuring that all our questions were promptly addressed. The quality of the “Journal of Clinical Cardiology and Cardiovascular Interventions” is undeniable. It is a peer-reviewed, open-access publication dedicated exclusively to disseminating high-quality research in the field of clinical cardiology and cardiovascular interventions. The journal's impact factor is currently under evaluation, and it is indexed in reputable databases, which further reinforces its credibility and relevance in the scientific field. I highly recommend this journal to researchers looking for a reputable platform to publish their studies.

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Dr Marcelo Flavio Gomes Jardim Filho

Dear Editorial Coordinator of the Journal of Nutrition and Food Processing! "I would like to thank the Journal of Nutrition and Food Processing for including and publishing my article. The peer review process was very quick, movement and precise. The Editorial Board has done an extremely conscientious job with much help, valuable comments and advices. I find the journal very valuable from a professional point of view, thank you very much for allowing me to be part of it and I would like to participate in the future!”

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Zsuzsanna Bene

Dealing with The Journal of Neurology and Neurological Surgery was very smooth and comprehensive. The office staff took time to address my needs and the response from editors and the office was prompt and fair. I certainly hope to publish with this journal again.Their professionalism is apparent and more than satisfactory. Susan Weiner

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Dr Susan Weiner

My Testimonial Covering as fellowing: Lin-Show Chin. The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews.

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Lin-Show Chin

My experience publishing in Psychology and Mental Health Care was exceptional. The peer review process was rigorous and constructive, with reviewers providing valuable insights that helped enhance the quality of our work. The editorial team was highly supportive and responsive, making the submission process smooth and efficient. The journal's commitment to high standards and academic rigor makes it a respected platform for quality research. I am grateful for the opportunity to publish in such a reputable journal.

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Sonila Qirko

My experience publishing in International Journal of Clinical Case Reports and Reviews was exceptional. I Come forth to Provide a Testimonial Covering the Peer Review Process and the editorial office for the Professional and Impartial Evaluation of the Manuscript.

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Luiz Sellmann