The chronic character of inflammatory bowel diseases, such as Crohn’s disease and ulcerative colitis, results in various complications. One of them is osteoporosis, manifested by low bone mineral density, which leads to an increased risk of fractures. The aetiology of low bone mineral density is multifactorial and includes both diet and nutritional status. Calcium and vitamin D are the most often discussed nutrients with regard to bone mineral density. Moreover, vitamins A, K, C, B12; folic acid; calcium; phosphorus; magnesium; sodium; zinc; copper; and selenium are also involved in the formation of bone mass. Patients suffering from inflammatory bowel diseases frequently consume inadequate amounts of the aforementioned minerals and vitamins or their absorption is disturbed, resulting innutritional deficiency and an increased risk of osteoporosis. Thus, nutritional guidelines for inflammatory bowel disease patients should comprise information concerning the prevention of osteoporosis. Inflammatory bowel diseases (IBD), including Crohn’s Disease (CD) and Ulcerative Colitis (UC), are chronic conditions, the aetiology of which is not entirely known. Possible risk factors comprise genetic predisposition, immunological disorders, and environmental conditions . FurtherNormal: T-score ≥ −1 SD;Osteopenia (low bone mass): T-score < −1 SD and >−2.5 SD;Osteoporosis: T-score ≤ −2.5 SD;Severe osteoporosis: T-score ≤ −2.5 SD with fragility fractures .The World Health Organisation (WHO) classifies Bone Mineral Density (BMD) on the basis of Dual-Energy X-ray Absorptiometry (DEXA)—i.e., the gold standard in the diagnosis of osteoporosis:Risk factors of osteoporosis in IBD include early age onset; steroid therapy; malnutrition; low body mass; hormonal disorders, including a decreased oestrogen level; and malabsorption causing a nutritional deficiency, particularly in terms of vitamin D and calcium. However, osteoporosis may also stem from genetic factors. In the course of IBD, pro-inflammatory molecules TNF-α, IL-1β, IL-6, and IL-17 levels are elevated and lead to increased bone resorption, causing a decrease in bone mineral density . In factAn important risk factor for BMD loss in IBD patients is the use of certain medications. Corticosteroids (CS) are a group of medications whose prolonged use is associated with side effects involving bone tissue . CS incrAs far as Infliximab (IFX) is concerned, research studies suggest that IFX treatment in CD patients increased the N-terminal telopeptide of type I collagen . HoweverThe use of monoclonal antibodies in osteoporosis associated with IBD is the subject of several studies. Bone metabolism at the osteoclast/osteoblast level is regulated by the following factors belonging to the tumour necrosis factor superfamily: receptor activator of nuclear factor kappa B , its ligand , and osteoprotegerin (RANKL/RANK/OPG). Krela-Kaźmierczak I. et al. showed that low OPG levels may be associated with osteoporosis in UC. Nevertheless, in CD patients increased RANKL levels were observed ,21. InteDiet and nutritional status constitute risk factors in the development of osteoporosis. Micro and macronutrients, vitamins, and mineral components intake is often below the recommended values, particularly when the disease is active. Hence, malnutrition and deficiency in nutrients essential to bone mineralization can affect patients with inflammatory bowel diseases .The European Society for Clinical Nutrition and Metabolism (ESPEN) recommends supplying 1.2–1.5 g protein/kg body weight in active IBD. Patients in remission should consume 1 g protein/kg body weight. Improper diet and the loss of nutrients in the gastrointestinal tract leads to an increase in fat mass, as well as a decrease in free fat mass in patients suffering from IBD. On the basis of these guidelines, there is no special diet in the remission period . The recProtein provides about 50% of bone volume, 1/3 of bone mass and forms the bone matrix, therefore its supply determines the maintenance of bone mass in adults . On the Moderate or severe hypoalbuminemia was diagnosed in 17% and 24% of IBD patients, respectively. In patients with albumin deficiency following surgical procedures, mortality within 30 days was higher than in patients with normal albumin levels . ProteinOne of the research studies showed a statistically significant difference in protein intake between men over 63 years old with and without a femur fracture. Every 3% increase in protein daily intake caused a 20% decreased risk of femur fractures . What isThere was no statistically significant differences in the intake of total fat, saturated fat, and mono–and poly–unsaturated fat between healthy individuals and CU patients . The EurThe development of osteoporosis was correlated with the type of fatty acids. In fact, the risk of fractures was increased by n-3 and saturated fatty acid intake and it was decreased by monounsaturated and n-6 fatty acids. Dong et al. demonstrated that the supplementation of eicosapentaenoic and docosahexaenoic acid (1.2 g per day) did not result in statistically significant differences in osteocalcin and bone-specific alkaline phosphatase . FurtherCarbohydrates supply energy for host cells and the intestinal microbiome. Fermentable carbohydrates  and fibre constitute important factors in inflammatory bowel diseases .A meta-analysis demonstrated that a low-FODMAP diet  decreased the incidence of abdominal pain, nausea, weakness, and flatulence, although no change in the rate of constipation was observed . PatientOn the other hand, the fructose content in breast milk triggered an increased BMC  in a 6-month-old infant compared to the first month of the baby’s life. Nevertheless, lactose and glucose did not cause changes in BMC . AnotherVitamin D comprises a group of chemical compounds such as ergocalciferol (vitamin D2) and cholecalciferol (vitamin D3). The active forms of vitamin D are 1.25(OH)2D and 24.25(OH)2D. Vitamin D acts directly and indirectly on the bone , regulatIBD patients are a group presenting a higher risk of vitamin deficiency and, therefore, should control their 25(OH)D serum level. The recommended vitamin D supplementation for healthy adults is 800–2000 IU from September to April . AccordiAlthough the supplementation of vitamin D decreased the risk of fractures in general as well as the risk of femoral neck fractures, it did not alter the risk of osteoporosis . In eldeBone tissue is 90% made of collagen, and vitamin C is a necessary antioxidant for its synthesis . MoreoveSince patients with IBD fear the symptoms of the disease, they often eliminate vegetables and fruits from their diets. This, in turn, may lead to an insufficient vitamin C intake and to the deterioration of the patients’ health. Children, the elderly, and patients with the malabsorption syndrome are particularly exposed to this deficiency. Ascorbic acid can be found in citrus fruits, potatoes, parsley, and berries without seeds; thus, their consumption should be encouraged in this patient group . In factSahni et al. estimated vitamin C intake on the basis of the Food Frequency Questionnaire. Following a 17-year-long observation period, subjects who consumed the highest amount of vitamin C suffered femoral neck and non-spine fractures less frequently than individuals reporting the lowest intake. The authors suggested that vitamin C intake in the elderly can be beneficial to bone health . AdditioVitamins B9 (folic acid) and B12  are water-soluble vitamins. Folic acid is necessary for DNA methylation, whereas cobalamin is a coenzyme found in many biochemical reactions in the human body, e.g., in the metabolization of folic acid, or DNA synthesis. Their deficiency causes megaloblastic anaemia as well as nervous system disorders . VitaminA meta-analysis showed that the serum folic acid level was lower in IBD patients than in healthy individuals. This could be accounted for by an insufficient intake, higher utilization, or taking medications. The authors recommended the routine supplementation of folic acid for colorectal cancer prevention. However, the study did not demonstrate a significant difference in serum B12 levels between the patients and the control group .Kim et al. pointed out a negative correlation between the serum homocysteine level and BMD in women under 50 years of age . Women wHyperhomocysteinemia (diagnosed in 60% of patients) was associated with osteoporosis and low BMD in CD patients, whereas bone disorders affected 90% of the subjects .Vitamin A is vital for growth; vision; and osteoclastogenesis stimulation, which further influences BMD. A total of 16% of non-adult patients with IBD presented vitamin A deficiency .There was no statistically significant difference in vitamin A intake between men suffering form UC and the control group . In factThe enzyme participating in the synthesis of glutamic acid (Gla) found in osteocalcin created in osteoblast and in the matrix bone protein is vitamin K. It occurs in two forms: K1 (phylloquinone) and K2  .The study, conducted among postmenopausal Japanese women with osteoporosis, indicated that the administration of risedronic acid with vitamin K (45 g/day) was not more beneficial than administration without vitamin K supplementation. In fact, there was no statistically significant difference in fractures within the studied group . AnotherCalcium (Ca) is responsible for proper BMD, blood coagulation, and the proper functioning of the cardiovascular system. In the human body, more than 99% of Ca is stored in bones. Therefore, a decreased serum calcium level leads to its release from bones and causes bone tissue resorption . FurtherThe insufficient intake of calcium was estimated in 80–86% of IBD patients, who avoid milk and dairy products due to lactose intolerance . PatientAnother cause of calcium malabsorption is the use of steroids as well as the occurrence of diarrhoea. The supplementation of calcium in a 1000–1500 mg/day dose is recommended for most patients with inflammatory bowel diseases. Furthermore, patients treated with steroids require calcium and vitamin D supplementation . CalciumMagnesium (Mg) is absorbed in the small intestine, and its absorption ranges from 30% to 80%. Bones store about 60% of the total body magnesium. The main sources of Mg are legumes, seeds, nuts, almonds, spinach, and buckwheat. Not only is this element responsible for the stability and permeability of cell membranes but it also maintains the DNA double helix integrity and regulates the activity of about 300 enzymes . On the Patients with UC and CD consumed a lower amount of Mg than healthy adults. CD patients consumed 60–63% of the daily magnesium requirement ,100. MagThe absorption of water and electrolytes, including sodium (Na), takes place in the colon. The lymphatic function of the large intestine can be impaired in the course of the mucosal inflammation .+ level is 135–145 mmol, both too high and too low Na concentration levels constitute a threat to health and life. In fact, hypernatremia causes weakness, headache, vomiting, loss of appetite, weak nerve reflexes, and cardiac disorders. On the other hand, hyponatremia induces neuromuscular excitability, confusion, and cardiac arrest.In spite of the fact that the human body contains as much as 105 g of sodium, the intake of Na in the population is still too high, with some people consuming 9–12 g salt per day, which results in numerous disorders and also affects bones ; it is uPatients with UC in remission consumed non-significantly lower sodium amounts than healthy individuals . The sodThe Korea National Health and Nutrition Examination Survey indicated that osteoporosis was observed more frequently in postmenopausal women consuming ≥ 4001 mg of salt per day than in those consuming ≤ 2000 mg/day. A salt intake of ≥ 5001 mg was associated with a higher risk of osteoporosis in the femoral neck compared to the consumption of ≤ 2000 mg/day . A sodiuA low sodium diet  for 6 months decreased calcium excretion with urine in patients who consumed 3.4 g or more salt per day and reduced the concentration of P1NP (propeptide of type 1 collagen). There was no significant change in the serum NTX level.On the other hand, a low-sodium diet  of 6-month duration in persons consuming 3.4 g or more salt per day increased the amount of excreted calcium and the serum P1NP level. The authors did not observe any changes in the serum NTX level .Zinc (Zn) catalyses about 100 enzymes, which makes it an indispensable element for the proper functioning of the immune system as well as for protein and DNA synthesis . Zinc paAbout 15% of patients with UC or CD exhibited zinc deficiency. In diarrhoea, which often affects IBD patients, Zn demand in the body increases, and its supplementation is essential .The serum zinc level of postmenopausal women with osteoporosis was lower than that of the control group, suggesting the influence of Zn on bone mineralization . Zinc inThe human body contains about 80–150 mg copper (Cu), stored mainly in the muscles, bones, brain, and liver. Cu is absorbed in the small intestine and constitutes a cofactor for many enzymes, such as lysyl oxidase, participating also in collagen synthesis . Thus, cAlthough women with IBD did not consume enough copper , NangliyThe serum Cu level was statistically lower in postmenopausal women with osteoporosis than in the group without bone disorders. The administration of calcitonin to women with osteoporosis caused an increase in the serum Cu level. Hence, the results suggested that Cu impacts the development of osteoporosis . In contSelenium (Se) is an antioxidant and a cofactor for numerous enzymes in the human body. Additionally, it decreases inflammation and inactivates osteoclasts, thus influencing BMD . FurtherIt was observed that the serum selenium level was lower in CD patients than in healthy adults. In men with UC, the selenium concentration depended on the location of the inflammatory lesions .A study showed a negative correlation between the amount of selenium intake and osteoporosis . On the The demand for selected vitamins and minerals for adults is presented in Polyphenols are bioactivity chemical compounds which occur in plants, primarily in fruits, vegetables, coffee, tea, cocoa, herbs, and spices . They arIn addition, it is crucial to acknowledge the importance of green tea polyphenols. They decrease the TNF-α level and increase COX-2 (cyclooxygenase-2) synthesis. .A study based on animal models showed that green tea polyphenols increase antioxidants levels, reduce serum TNF-α and Il-6, and decrease intestinal inflammation. . Rezaei Another study presented no association between the total polyphenol intake and CD or UC, but polyphenols and resveratrol may protect against the development of Crohn’s disease . MoreoveWhat is more, polyphenols are vital elements in the prevention of osteoporosis. The consumption of products with high amounts of polyphenols  probably protects against osteoporosis development. However, the mechanism of action is not well understood . A higheThe diet of IBD patients often proves to be inadequate, which affects the peak bone mass, thus leading to osteopenia, osteoporosis, and fractures. Nutrition guidelines for IBD patients should include osteoporosis prevention.The vitamin D concentration in patients with IBD should be examined routinely, since IBD constitutes a risk factor of vitamin D deficiency. Individual doses of vitamin D are recommended.Most IBD patients require calcium supplementation (1000–1500 mg/day).We recommend the assessment of the fruit and vegetable intake in IBD patients. In patients with low BMD and a simultaneous inadequate consumption of fruits and vegetables, vitamin C supplementation may be considered.Vitamin B12 and folic acid supplementation may be introduced in patients with hyperhomocysteinemia, since a high level of homocysteine correlates with a low bone mineral density.Vitamin A supplementation is not recommended. A high level of this vitamin may have a negative influence on bone health.There are no sufficient data to recommend the supplementation of vitamin K, magnesium, zinc, copper, and selenium in IBD patients for the prevention of osteoporosis.IBD patients consume less sodium than the rest of the population, in particular the malnourished patients. On the other hand, sodium intake in developed countries is higher than recommended, and a high dose of Na correlates with a low BMD. Therefore, it is not necessary to encourage patients to use more salt.Polyphenols may be beneficial for patients’ health; thus, they should be included in the diet in the form of herbs, fruits, or vegetables.In conclusion, it is worth emphasizing that:The importance of diet in the prevention of osteoporosis in the group of patients with IBD is indisputable. Hence, it is vital to adhere to the recommendations of a clinical dietitian, as an important member of the coordinated IBD patient care team.


The stress that arises from workplace discrimination can have a large impact on an employee’s work attitude, their work and life satisfaction, and oftentimes whether or not they stay in a job. Workplace discrimination can also have a considerable influence on employees’ short- and long-term health. However, less is known about the factors that might mitigate or exacerbate the effects of discrimination on health. The current study focused not only on the links between workplace discrimination and health, and but also on the effects of potential moderators of the discrimination-health link . People with high neuroticism, high extraversion and high agreeableness were more negatively affected by workplace discrimination than those low on neuroticism, extraversion, and agreeableness. Perceived control was found to be a protective factor, such that those high in perceived control had fewer chronic illnesses in the context of high levels of workplace discrimination. Employees can face workplace discrimination from a variety of factors, such as their age, gender, and race. The stress that arises from workplace discrimination can have a large impact on an employee’s work attitude, their work and life satisfaction, and oftentimes whether or not they stay in a job. Workplace discrimination can also have a considerable influence on employees’ short-term and long-term health. However, less is known about the factors that might mitigate or exacerbate the effects of discrimination on health. The current study focused not only on the links between workplace discrimination and health, and but also on the effects of potential moderators of the discrimination-health link .Although overt, explicit display of discrimination in today’s society are rare, there are still a lot of subtle ways in which vulnerable groups are discriminated against . Perceivincreased according to some scholars  and focus on constructs less theoretically linked to perceived discrimination and health , agreeableness (traits like helpful and sympathetic), conscientiousness (traits like responsible and hardworking), neuroticism (traits like sensitive and moody) and openness to experience (traits like curious and imaginative)  . Perceivinative) . This stinative) . People inative) .Personality not only affects stress-coping mechanisms, but also influences the appraisal of situations in everyday life . ResearcOptimism is the general expectation that good things will happen in one’s life. Optimism is negatively associated with depressive symptoms and positively associated with life satisfaction . In a stAside from its role in influencing health, optimism also affects workplace outcomes. Optimism is a large determinant of happiness, sense of purpose, and relationships with other people at work . OptimisPerceived control is a belief in one’s capability of accomplishing or succeeding in a specific situation. Judgement of one’s efficacy determines how much effort an individual would exert when faced with challenges, and how long they persist in the face of hardships . PerceivPeople with high perceived control are not only more likely to take a proactive approach toward stressful situations at work, but they are also more likely to cope with illness and regulate health-related behaviors . For exaCoworker and supervisor support are considered forms of organizational and social support. Coworkers and supervisors provide both emotional and instrumental support. Coworkers and supervisors listen sympathetically and acknowledge other people’s feelings . Coworkers and supervisors also provide physical aid and tangible assistance by giving advice and knowledge for solving problems . In the current study, we examined the moderating effects of Big Five personality traits, perceived control, optimism, and coworker and supervisor support on the relationship between workplace discrimination and health over time. Specifically, we examined how discrimination affects depression, self-rated health, and the incidence of chronic illnesses in over 5,000 people followed over a six-year period from the Health and Retirement Study.Mage = 60.15, SD = 8.19; 56.1% were women) from the Health and Retirement Study (HRS). The HRS is a nationally representative and prospective panel study that has surveyed more than 22,000 Americans aged 50 +  every two years (SD = 2.77) years of education. The average tenure at their current job was 12.67 years (SD = 11.60). The most common occupations were office/admin support (16.9%), sales (10.4%), and management (10.2%). The most common industries were health care and social assistance (17.4%), education (11.1%), and manufacturing (10.7%).The study sample consisted of 5,023 working participants  and 2010 . Thus, two distinct cohorts were formed that had multiple assessments of health and depression, albeit technically at different waves . The cohorts were combined into one sample for the present analyses to increase statistical power and precision . At the d = 1.18), had more education (d = 0.41), had more perceived control (d = 0.27), were more extraverted (d = 0.16), more agreeable (d = 0.07), more conscientious (d = 0.27), less neurotic (d = 0.06), more open to experience (d = 0.26), more optimistic (d = 0.20), reported more coworker support (d = 0.51), more supervisor support (d = 0.29), were healthier (d = 0.49), had fewer chronic conditions (d = 0.69), and had lower depression (d = 0.28).The current study’s sample differed in many ways from the broader HRS sample. Compared to everyone who was excluded for not currently working or had missing data on health and depression at wave 1, participants in the current study were younger .never) to 6. Responses were averaged such that higher scores indicated more frequent workplace discrimination (α = 0.83).Perceived work discrimination was assessed with six items adapted from a number of measures of perceived discrimination e.g., . Particistrongly disagree; 6 = strongly agree) and averaged such that higher scores indicated higher perceived control (α = 0.89).Perceived control was assessed using five items from not at all) to 4(a lot). Extraversion was measured with five items ; agreeableness was measured with five items ; neuroticism was measured with four items  conscientiousness was measured with five items ; openness to experience was measured with seven items .Big Five personality traits were measured using the MIDI personality scales , which istrongly disagree) to 6 (strongly agree). In total, six items were used to assess optimism (α = 0.75).Optimism was measured using the Life Orientation Test-Revised (LOT-R). Studies have shown that the LOT-R has good reliability and validity . A samplstrongly disagree) to 4(strongly agree) (strongly disagree) to 4(strongly agree) (Coworker support was assessed with a three-item measure with responses ranging from 1(y agree) . A samply agree) . Responspoor) to 5(excellent). Self-rated health is a strong predictor of mortality  was computed at each wave. Participants were asked to report if he or she was diagnosed (yes/no) by a physician with any of the following: (1) high blood pressure, (2) diabetes, (3) cancer or a malignant tumor of any kind, (4) lung disease, (5) coronary heart disease including heart attacks, angina, and congestive heart failure, (6) emotional, nervous, or psychiatric problems, (7) arthritis or rheumatism, and (8) stroke. Chronic illnesses were summed so higher values reflected more health problems.Depressive symptoms were measured at all waves with a modified eight-item version of the Center for Epidemiological Studies Depression Scale CES-D; . ParticiTo examine longitudinal changes in health, chronic illnesses, and depression, and whether these changes were moderated by workplace discrimination and personality characteristics, three multilevel models were constructed . Specifically, we employed moderated growth curve models. Multilevel modeling allows for the analysis of the entire sample, whereas traditional regression approaches utilize listwise deletion of subjects who do not have complete data on all measures. Thus, if an individual had missing data on optimism, the effect is only estimated among people with data on this variable. Health, chronic illnesses, and depression at each wave were treated as within-subjects variables that varied over time. The linear effect of time was modeled on these within-subject observations. Workplace discrimination, perceived control, Big Five characteristics, optimism, coworker support, and supervisor support were entered as time-invariant predictors of health, chronic illnesses, and depression. Interactions between the individual and situational factors and workplace discrimination were also modeled . All of these variables were grand-mean centered before inclusion in the model. Betas from the model represent the effects of a one-unit increase in a continuous variable  on the outcome of interest. Partial correlations are reported as a standardized effect size for each individual estimate.Further, supplementary analyses tested interactions between workplace discrimination, coworker/supervisor support, and each of the personality traits and time to test whether the associations with health became stronger, weaker, or stayed the same over time in older adulthood. Participant gender , race, age (at Wave 1), and education (at Wave 1) were included as covariates.Correlations and descriptive statistics are presented in R2 for the health (0.28), chronic illness (0.26), and depression models (0.33) suggested good model fit  were associated with perceiving less workplace discrimination. A number of our hypotheses were supported—extraversion, conscientiousness, optimism, perceived control , and coworker support  were associated with better health and well-being; perceived workplace discrimination and neuroticism were associated with worse health and well-being. Agreeableness, openness to experience, and supervisor support were either unrelated or related in the opposite way to what was hypothesized. These variables occasionally moderated associations between perceived discrimination and each outcome. This study not only confirms a number of results of previous studies but constituted an exhaustive examination of several moderating variables. It also provides insights into how workers and organizations can prevent, adjust, and react to perceived workplace discrimination.The results of the current study align well with previous research and theory on coping in the face of discrimination and stigma . As PascThe current study also found that people with high perceived control were less negatively affected by workplace discrimination when reporting on their overall health. These findings align with previous studies showing that people high in control were more likely to take on adaptive coping strategies and take a proactive approach toward navigating difficulty situations at work . People One surprising finding from the current study was that agreeableness was associated with worse health, more chronic illnesses, and greater depression. These results may have arisen from two sources. First, it could be that agreeableness is not a protective factor (and may even be a risk factor) in the context of stressful situations, like perceived discrimination. For example, agreeable individuals report more distress in response to interpersonal conflict than others . This miBased off the findings of the present study, combined with previous research, perceived workplace discrimination is directly associated with worse health and well-being. The significant moderation effects of extraversion, neuroticism, and perceived control on the link between perceived workplace discrimination and health have great significance for organizations that struggle with the effects of incivility. Maintaining a diverse and open-minded culture likely helps with lowering the prevalence of discrimination at work . Based oThe study had many strengths. We used a large sample of workers who completed measures of mental and physical health at multiple time points over a six-year period. Our study was also one of the most comprehensive examinations of possible moderators to date—simultaneously considering nine different buffering effects of personality and workplace environment constructs.Mage = 60.15). This limited range of age excludes younger workers and the negative effects that discrimination might have on their lives. Future research should include a wider range of participants to examine the effects of discrimination on health and whether the moderators of this link also vary by age. Further, only 27.9% of the sample was non-white. The lack of representation from people of color might have affected the results as racial discrimination may have been a major source of discrimination for these participants. Related, we hope that researchers will also employ multi-informant reports and other measures of discrimination in the future. In the current study, we focused on perceived discrimination from the perspective of the aggrieved party. Of course, from one perspective, it is possible that perceiving discrimination (even when no ill-intent was present) is likely more closely related to mental and physical health outcomes than discrimination measured a different way . However, having more nuanced and multi-faceted assessments of workplace environments (particularly with respect to discrimination) would help elucidate the effects of discrimination on health and well-being over time. Future research should try to achieve a better balance of race/ethnicity when examining questions related to discrimination.Nevertheless, the study had limitations that are worth noting. First, participants were older adults  which might be affecting health in indirect ways. It is important that future research investigate the exact pathways through which individual difference characteristics put people at heightened risk (or resilience) when experiencing workplace discrimination.Additionally, the current study examined a specific set of variables—Big Five personality traits, optimism, perceived control, and workplace social support. However, less is known about The current study examined the link between perceived workplace discrimination and health, along with several moderators of this link . Workplace discrimination was associated with worse health, more chronic illness, and higher depression. Extraversion, agreeableness, perceived control, and neuroticism were all implicated in either amplifying or suppressing the negative effects of discrimination on mental and physical health. The current study provides a valuable step in examining the individual and workplace characteristics that put individuals at greater risk of experiencing negative outcomes in response to workplace discrimination. Although the current study provided a descriptive account of moderators of the discrimination-health link, future applied researchers can look for actionable ways to reduce workplace discrimination and the particularly negative effects that it has on certain people.https://hrs.isr.umich.edu/.Data from the Health and Retirement Study is publicly available for researchers. The study can be accessed via The studies involving human participants were reviewed and approved by the Michigan State Institutional Review Board. The patients/participants provided their written informed consent to participate in this study.YX and WC conceived of this study. WC analyzed the data, created tables and figures, and provided the critical edition. YX drafted the initial manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Since walkability plays an important role in active commuting, several cities are actively promoting its integration into urban and environmental planning policies. This study examined the association between walkability and active commuting in Seoul, Korea. A multilevel logistic regression model was used to examine the correlation between Walkability Score and the probability of active commuting after controlling for individual variables. The analysis used 129,044 individual samples nested within 424 administrative districts (dongs). In this study, three models were tested: Model 1 contained only individual variables, Model 2 contained individual variables and Walkability Score, and Model 3 included neighborhood-level variables in addition to the variables of Model 2. The results showed that the Walkability Score was significantly correlated with the odds of active commuting. Specifically, every additional one-point increase in Walkability Score was associated with 0.3% higher odds of active commuting (Model 2: odds ratio (OR) = 1.003, 95% confidence interval (CI) = 1.001–1.005; Model 3: OR = 1.003, 95% CI = 1.001–1.006). Additionally, public transportation density was also positively correlated with the odds of active commuting. The odds of active commuting were positively correlated with younger age, female, lower-income, and having no car. Based on the findings, policy recommendations in urban planning and design, transport engineering, and environmental planning are provided. Active commuting  has numerous advantages. It is a cost-effective transportation mode, being an affordable means of transportation with little maintenance required . ReducedSeveral studies have used health outcome variables rather than mental health measures as health indicators. Celis-Morales et al. examined the relationship between active commuting and cardiovascular disease, cancer, and all-cause mortality. They used data from UK Biobank, which was recruited from 22 sites across the UK. They found that active commuting was associated with a lower risk of cardiovascular diseases, cancer, and mortality . Blond aMeanwhile, there have been studies that calculated the benefits of active commuting in monetary values. One report from Public Health England estimated that the economic cost of physical inactivity to the National Health Service in England is more than ₤450 million (approximately US $586 million) a year . The BriSeoul is the most urbanized city in Korea. It has chronic urban problems typical of several megacities, such as long commuting distance and times, heavy traffic congestion, and severe air pollution, which are mainly caused by high levels of car dependence. The active commuting  of Seoul was 28.0% in 2015 of the total commuting trip ,19, whicIt is often said that the neighborhood environment is important for promoting active commuting. Some evidence suggests that the built environment is associated with walking and cycling for transportation. A higher level of active commuting is associated with higher levels of street connectivity, population density, mixed land use, and public transportation density ,24,25,26Numerous studies have focused on the measurement of environmental walkability, using objectively measured indices in particular ,34,35,36One such index, Walk Score, is a popular measure which several empirical studies have used ,38,39,40A growing body of literature has found that Walk Score had positive associations with walking in communities ,46,47,48Areas with more walkable environments have correlation with higher odds of walking and cycling to work and school  than areas with less walkable environments.As in the empirical studies of the United States, Canada, and Germany ,46,47,482) in Korea [Seoul is the capital of Korea, located in the northwest of the country. It has the highest population density This study used the ‘travel mode to work and school’ data from the 2016 Household Travel Diary Survey of the Korea Transport Database as its dependent variable (Table 2). This mode includes commuting transport and is extracted by home-based origin or destination . The Hou● Socioeconomic statusIndividual variables included were age, gender , income level, and car ownership (no/yes), also sourced from the 2016 Household Travel Diary Survey . The mea● Walkability Score (key independent variable)This study used the Walkability Score from Kim et al.  as an inSeoul consists of 424 administrative districts (“dong” in Korean), which are used as the neighborhood-level units in this study. The Walkability Score, measured at the grid point-level , was then aggregated at the dong level (N = 424) for analysis . The mea● Additional neighborhood environmental factorsAdditional environmental variables analyzed include land use mix, residential density, and public transport density. Some studies have found that land-use mix is significantly associated with walking for transport ,67. Thert-test was employed for comparison of travel mode types and urban forms between areas with higher walkability and areas with lower walkability. A multilevel logistic model was used to examine the probability of non-motorized commuting transport  by considering both individual-level and neighborhood-level (dong-level) variables. The analysis includes 129,044 individual commuters nested within 424 dongs using a two-level structure . Two-level logistic regression analysis was performed using R (version 3.6.1).Bivariate analysis was used to compare the differences between variables at the individual level and neighborhood level by Walkability Score. Specifically, the Conversely, As shown in To do so, we classified the entirety of Seoul as either more walkable or less walkable. More walkable areas were those with a Walkability Score ≥ 50 ; less walkable areas were those with a Walkability Score < 50 . We then calculated the mean value for each dong. Of the 424 dongs, 395 had a mean Walkability Score of 50 or more, and 29 dongs had a mean Walkability Score of less than 50. t-test between the two groups . There were significantly more walking trips for commuting purposes in the more walkable areas (55.4%) than those with a less walkable environment (50.5%) at the 0.05 significance level. However, the other three travel modes  had no statistical mean differences between areas with high and low Walkability Scores. Urban form variables of residential density and public transport density in the areas with a more walkable environment  were significantly higher than those with a less walkable environment . This is consistent with the results of previous studies ,69,70,71To investigate the role of the walkable environment on the incidence of active commuting trips, we employed a multilevel logistic regression model using two levels of data: individual commuter (level 1) and dong (level 2). A total of 129,044 individuals nested within 424 dongs were used. Individuals living in the same area (dong) share the same environmental conditions. The results of the multilevel logistic regression model for the odds of non-motorized  commuting are presented in The findings of the analyses are three-fold. First, the neighborhood-level Walkability Score had a significantly positive relationship with the individual-level odds of non-motorized trips at the 0.01 significance level. People who lived in areas (dongs) with a higher Walkability Score were much more likely to undertake walking and cycling trips for commuting purposes. Specifically, every additional one-point increase in Walkability Score was associated with 0.3% higher odds of walking and cycling trips for commuting purposes from both Model 2 and Model 3 (Model 2: odds ratio (OR) = 1.003, 95% confidence interval (CI) = 1.001–1.005; Model 3: OR = 1.003, 95% CI = 1.001–1.006). This result empirically supports the hypothesis that areas with more walkable environments have correlation with higher odds of walking and cycling to work and school  more than areas with a less walkable environment.Second, public transport density was positively correlated with the odds of non-motorized trips at the 0.05 significance level . This result is similar to that of previous studies, which found that access to public transportation was positively correlated with walking and cycling ,27,28. OThird, the effects of all individual variables are fairly consistent across all models. The odds of non-motorized transport were positively correlated with the female gender , while it was negatively associated with age, level of income, and car ownership (reference group: no). Thus, those who were female, younger, on a lower income, and had no car were more likely to walk and bike for commuting purposes.Encouraging active commuting is one of the most important agendas in the fields of urban planning and design, transportation planning and engineering, environmental planning, and even public health. Several studies have identified individual health benefits of active commuting ,13,14,15The quality of the environment is one of the most important factors influencing the level of walking and cycling taking place in a city. Therefore, this study examined the role of environmental walkability on active commuting. Specifically, it tested the hypothesis that areas with more walkable environments have correlation with higher odds of walking and cycling to work and school  more than areas with less walkable environments. In this study, we found that the level of walkability was positively correlated with the probability of walking and cycling for commuting purposes in Seoul. This finding supports the hypothesis that the walkable environment has a strong role in the incidence of active commuting. Second, public transportation density had a significantly positive relationship with the probability of walking and cycling. This indicates that public transportation destinations, including subway stations and bus stops, encourages walking and cycling. As discussed earlier, some studies have shown that easy access to public transportation leads people to walk and bike to public transport facilities ,27,28. IBased on the findings of this study, some suggestions for future policymaking can be made. First, creating walkable environments could be considered a measure for sustainable development indicators within local and national urban and environmental policies. Policy actions to promote active commuting will directly contribute to achieving the third goal of the United Nations 2030 Sustainable Development Goals (SDGs), i.e., good health and well-being . CreatinThis study has several limitations, and directions for future study to address them are as follows. First, although this study could examine the overall correlation between walkability and active commuting throughout the entire Seoul, it could not include different characteristics by sub-regions. In further research, the areas with low levels of walkability and/or active commuting in particular should be examined. Second, this study dichotomized travel purpose into motorized and non-motorized transport for the use of a multilevel logistic model. For this reason, it was somewhat difficult to find and discuss the results for each transportation purpose. In a future study, it may be necessary to use a multilevel analysis for categorical outcomes. Third, the study only examined the correlation between walkability and active commuting. Further research could go beyond active commuting to empirically analyze how environmental walkability plays a role in reducing diseases  and in improving health conditions . Fourth, the Walkability Score used was adapted from the popular Walk Score index; however, walkability level using another objectively measured index can be considered. According to previous empirical literature on Seoul, other indices such as Walkability Index, Pedshed, and Moveability Index could be examined . Lastly,Despite these limitations, this study has the following implications. First, we used a relatively large amount of data including 129,044 covering all administrative units (N = 424) in Seoul. Therefore, the study was able to meaningfully look at the overall associations between active commuting and environmental walkability in Seoul. Second, we employed an objectively measured environmental walkability index, which can more reliably stand for environmental walkability, and thus be more useful for policy purposes, than a subjective index. Third, because the correlation of environmental walkability and active commuting was analyzed using a multilevel logistic model, factors from both individual and neighborhood levels could be taken into account. Furthermore, because individual-level variables were nested within the neighborhood, the multilevel analysis allowed the impact of multilevel factors on the dependent variable (active commuting) to be examined. Lastly, this study empirically investigated the relationship between environmental walkability and active commuting in Seoul. Although it has been several years since the city of Seoul implemented the “Walkable City, Seoul” project, no studies have examined how the creation of walkable environment correlates with walking and cycling. In this aspect, we believe this study is significant in that we explored the relationship between the level of neighborhood walking environment and walking and cycling in Seoul.This study found a positive correlation between objectively-measured environmental walkability and active commuting outcomes using a multilevel logistic regression model in a Korean context. In general, personal behavior variables such as walking and cycling are highly influenced by individual characteristics . Nevertheless, this study found a significant correlation between Walkability Score and the odds of active commuting. Based on the results of this study, we can expect several related policies to promote active commuting in the fields of urban regeneration, environmental planning, and transportation engineering. Furthermore, it is expected that health-promotion policies would benefit from the encouragement of active commuting.


This study draws on previous studies to develop the Social Networking Sites Use Multi-Motive Grid Questionnaire (SNSU-MMG) and test its reliability and validity. The results show that social networking sites use motivation includes four factors: cognitive motivation, emotional motivation, leisure motivation and herding motivation. Confirmatory factor analysis, reliability and validity tests show that the questionnaire has good structural validity, internal consistency and split-half reliability. The SNSU-MMG can be used as a measurement tool for users' social networking sites use implicit motivation. Research from Global Web Index indicates global Internet users spend 60 percent more time on social media over the past seven years, China spent an average of 139 minutes a day on social media in 2019, an increase of 19 minutes over 2018.SNS have become increasingly common in recent years. SNS have been integrated into people's daily lives and have a significant impact on people’s behaviors.According to the 44SNS are defined as web-based services that allow individuals to construct a public or semi-public profile and share connections with a certain list of other users . The rapIn recent years, Weibo has launched functions such as shopping, payment and entertainment. WeChat has also integrated various commercial, entertainment and lifestyle service functions. Many other SNS are also moving towards the “hypermedia” ecosystem .Many researchers have done an in-depth study on seeking the main motivations to use SNS. Several studies on WeChat found that the main motivations for college students to use WeChat are seeking information and entertainment ,7. EmotiIn addition, some researchers have mentioned a herd motivation, which is characterized by following trends and being consistent with friends . StudiesSome Researches on users’ motivation of SNS is based on the technology acceptance model, expectation-conformation and the information system success model –22. HoweThe uses and gratifications theory divides the needs of the mass networking sites into five categories: cognitive needs, such as access to information, knowledge and understanding; emotional needs, such as emotional, pleasant or aesthetic experiences; individual integrated needs, such as strengthening confidence and consolidating status; comprehensive social needs, such as strengthening contact with family members, and friends; and releasing stress demands, such as escaping or diverting attention . TherefoCurrently, measuring SNS use motivation is limited to using self-assessment questionnaire to measure explicit motivation. In addition, there are few tools that are used to measure implicit motivation. Although the questionnaire technique has many advantages, some criticisms warrant consideration. For instance, Shweder and D’Andrade  have argIn order to make up for the deficiency of explicit measurements, researchers began paying attention to implicit measurements. Wilson et al.  proposedIn 1976, Schmalt developed a grid technique that combines the Thematic Aptitude Test (TAT) and questionnaire measurement methods . SimilarLater, three types of grids have been developed in German thus far: the Achievement-Motive Grid , the AffIn 2000, Sokolowski and others combined three motivational grids to form the MMG, which can measure the three motivations with respect to its approach and avoidance—-its hopes and fears . This toThe idea of separating the implicit and explicit modes of information processing, as well as the debate on this separation, has always been a hot topic. It is ubiquitous in many areas such as cognition (such as memory), personality, attitude, self-esteem, interpersonal relationship, imprinting, self-concept, behavior and behavior control . During In motivational research, McClelland et al.  pointed However, the current domestic methods of measuring users' explicit motivation of users of SNS are limited to using self-assessment questionnaire. Very few methods for measuring implicit motivation are used to measure SNS use motivation. The development of measurement tools for the use of implicit motivation in SNS is essential for future research. Some researchers have used Multi-Motive Grid to measure the implicit motivation of users . TherefoThe number of Internet users using mobile phones accounts for 97.5% of the total number of Internet users. It can be seen that the mobile phone with its portable, flexible, easy-to-get characteristics, the use of the population continues to expand. Therefore, this study chose the use of SNS via mobile phones as the main picture stimulus and the use of SNS via computers as the secondary stimulus, so as to arouse the motivation of the subjects to use SNS. Referring to the MMG paradigm of the three major motivations of previous studies, 15 fuzzy images were drawn. Each picture is a simple line of strokes containing at least two people using a mobile phone or a computer, assuming that they are using SNS such as WeChat, Weibo or Renren. When drawing, we balanced the gender of the characters in the picture, and covered a wide range of situations where the college students appear frequently. Since Sokolowski used 14 images in the MMG experiment to measure the three major motivations, this experiment deleted a picture of repeated scenes according to previous studies . The remaining 14 images were scrambled to form a formal questionnaire see .The choice of the SNSU-MMG sentences refers to the five needs proposed by the theory of use and satisfaction: cognitive needs, emotional needs, personal comprehensive needs, social comprehensive needs and entertainment needs . CombineM = 21.11, SD = 1.68).For college students nationwide, the participants were recruited offline, 253 questionnaires were distributed, and 203 valid questionnaires were collected, including 68 males, 135 females, 197 undergraduates and 6 graduate students. The age range of the participants was 17–28 years, of which 1 person was 17 years old (n = 203) was used for exploratory factor analysis of the SNSU-MMG.The sample of this survey . Therefore, we obtained the same consent from this participant as those above 18 years old, which was also approved by the Human Research Ethics Committee of Anhui University.p<0.01).First, we ranked the participants in descending order of the total score of the questionnaire. The first 27% of the subjects were recorded as high group, and the least 27% were recorded as low group. Then, an independent sample t-test was performed on the scores of the two groups of subjects on each item. The results showed that the scores of the high and low scores on all items reached a significant level (p<0.01). This meant that the data was suitable for exploratory factors analysis. Subsequently, principal component analysis and orthogonal rotation were used. According to the gravel map, determine the extraction of 4 factors.Second, we performed exploratory factor analysis on the initial data (n = 203). Bartlett spherical test and KMO measurement found that the Bartlett spherical test value was 3635.255 and the KMO measure was 0.929  of the 14 images was 0.938. The reliability test of the initial questionnaire showed that the score of the questionnaire was 0.857, and the internal consistency (Cronbach's α coefficient) of the four subtests of emotional motivation, cognitive motivation, leisure motivation and herd motivation were 0.899, 0.851, 0.890, 0.839 respectively.p< 0.01). Another correlation analysis between each item and the total score showed that items significantly correlated with the total score (p<0.01), and the correlation coefficient was 0.465~0.838. In addition, the correlation coefficient between the questionnaire scores of the SNSU-MMG and the total score of the SNSU-MMG was between 0.651 and 0.879; and correlation coefficient reached a significant level (p<0.01).Finally, we performed a correlation test between each picture and the total score is between 0.555 and 0.827, and both were found to be significantly correlated . Among them, 382 were male and 405 were female.872 questionnaires were distributed online and offline. Online questionnaires were distributed through Questionnaire star. For the offline method, the questionnaire was distributed to the surrounding areas and student groups of a public university in China, and finally 787 valid questionnaires were collected. The age range of the participants was 17–25 years, of which 6 persons were 17 years old (n = 787) was used for confirmatory factor analysis and correlation analysis.The sample of this survey . The results showed that the overall fit indicators and the fit indices were within a reasonable range: χ2/df = 3.89, CFI = 0.99, TLI = 0.97, AGFI = 0.94, NFI = 0.98, IFI = 0.99, RFI = 0.95, GFI = 0.98, RMSEA = 0.06. The results of the confirmatory factor analysis supported the rationality of the SNSU-MMG model initially constructed in this study. p>0.01), or significantly correlated but the correlation coefficient values were less than 0.2. The study found that below 0.2 was considered to be zero- or weakly correlated [We performed a correlation test between the motivational questionnaire for SNS and MMG. Results showed that SNSU-MMG scored were not significantly correlated with the motivation scores of the explicit questionnaire . Following the procedure of cross-validation, a confirmatory factor analysis was carried out after the formal questionnaire was re-sampled. Results showed the 4-factor structural model of the SNSU-MMG had better fit the observation data and supported results of exploratory factor analysis. At the same time, this study examined the sub-confidence of the questionnaire and the internal consistency of each factor, all of which met psychometric values.Through correlation analysis between various factors and total scores, results showed that the correlation coefficient between each factor and the total score is between 0.56 and 0.91, and both reach a significant level . Future research can further improve and revise the MMG pictures and statements in this study to make it more externally valid and can be extended to non-college students. At present, there are few empirical studies measuring the use of implicit motivation in SNS. Most studies choose to use questionnaires to measure explicit motivation. Therefore, in the future, we can pay more attention to implicit motivation, and use the experimental methods such as IAT and MMG to compare the implicit motivation with the explicit motivation.S1 Data(DS_STORE)Click here for additional data file.S1 File(DOCX)Click here for additional data file.S2 File(DOCX)Click here for additional data file.S3 File(DOCX)Click here for additional data file.S4 File(DOCX)Click here for additional data file.


Human Immunodeficiency Virus (HIV) infection remains prevalent co-morbidity, and among fracture patients. Few studies have investigated the role of exercise interventions in preventing bone demineralization in people who have fractures and HIV. If exercise exposed, HIV-infected individuals may experience improved bone health outcomes (BMD), function, quality of life (QoL). The study will aim to assess the impact of home based exercises on bone mineral density, functional capacity, QoL, and some serological markers of health in HIV infection among Nigerians and South Africans.The study is an assessor-blinded randomized controlled trial. Patients managed with internal and external fixation for femoral shaft fracture at the study sites will be recruited to participate in the study. The participants will be recruited 2 weeks post-discharge at the follow-up clinic with the orthopaedic surgeon. The study population will consist of all persons with femoral fracture and HIV-positive and negative  aged 18 to 60 years attending the above-named health facilities. For the HIV-positive participants, a documented positive HIV result, as well as a history of being followed-up at the HIV treatment and care center. A developed home based exercise programme will be implemented in the experimental group while the control group continues with the usual rehabilitation programme. The primary outcome measures will be function, gait, bone mineral density, physical activity, and QoL.The proposed trial will compare the effect of a home-based physical exercise-training programme in the management of femoral fracture to the usual physiotherapy management programmes with specific outcomes of bone mineral density, function, and inflammatory markers.https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=9425).The study was prospectively registered with the Pan African Clinical Trials Registry (Reference number – PACTR201910562118957) on October 21, 2019. ( According to the UNAIDS  report, South Africa has an estimated 7.5 million people living with HIV, with 200,000 new infections and 72,000 HIV-related deaths. Currently, South Africa has the most extensive antiretroviral treatment (ART) programme globally, with over 3 million HIV-infected persons. HIV programmes in SA are estimated to cost $1.34 billion annually. Similar to South Africa, Nigeria, with an estimated population of 161.7 million by 2015, has about 3.2 million people living with HIV. Currently, Nigeria records about 180, 000 HIV-related deaths, 227, 000 new HIV cases with the highest incidence occurring in the productive age group (15–49 years). In Nigeria, 51% of adults with HIV are placed on antiretroviral therapy (ART). Highly active antiretroviral therapy (HAART) has significantly increased life expectancy.,8 With increased longevity and side effects of HAART, the prevalence of chronic and non-communicable diseases among people living with HIV as part of the ageing process, has been evident.South Africa, with an estimated population of 56.5 million in 2017–12 HIV was shown to increase the risk of osteoporosis by 3.7, and the long-term use of HAART further increases the risk by 1.6 when the prevalence of osteoporosis was compared between HIV-positive and HIV-negative individuals. Although, the loss of bone mineral density associated with the use of HAART usually stabilizes after one year, and there is no further HAART related bone loss.Reduced bone mineral density is a common associated with HIV, and their relationship is multi-factorial. The major related pathogenesis is that HIV infection alters bone metabolism, and this is further compounded with long-term use of HAART. showed that there is a significant reduction in bone mineral density in patients immobilized using cast compared to healthy controls. The difference in bone mineral density ranged from −5.8% to −31.7% at the hip, greater trochanter, calcaneus, and total lower limb. Also, the consequent immobilization of the affected individuals should translate to loss of independence in activities of daily living, limited functional capacity, loss of economic independence and poor quality of life (QoL). These challenges could minimize functional mobility with an adverse impact on socialization resulting in restricted social participation. The net effect from a population-based national outlook suggests a substantial loss of productive workforce, decline in the overall national productivity, economic development, gross domestic product, and QoL with a predictable negative impact on poverty level.,18 Therefore, any interventions that could prevent/ameliorate or reverse the adverse effects of HIV and HAART-related bone demineralization should be of socio-economic significance.Apart from HIV and several other risk factors for reduced bone mineral density, immobilization as a result of fracture is also a predisposing factor. A study by Ceroni et al,,20 Not only does exercise improve health, it also increases muscle strength, coordination, balance, flexibility, and leads to overall health, which may enhance functional capacity in activities of daily living and thus, QoL. Available evidence suggests that exercise is a safe and relevant therapy in HIV/AIDS management, but its safety and relevance have not been fully investigated or exploited to the benefit of the patients.–23 The decision on whether to use physical exercises to address the issues related to bone health in HIV conditions should be guided by objective clinical markers. In recent years, biochemical markers  have enabled the detection of changes of bone turnover in response to biological , biomechanical, and other variables.,25 This trend is useful and may guide therapeutic/clinical decisions for the benefit of clients.Physical exercise can be defined as  planned, structured and repetitive bodily movement, performed with the goal of improving or maintaining physical fitness. The Chetty model promotes greater integration and collaboration between hospitals and communities. The HBR programme in KwaZulu-Natal was able to apply several principles such as evidence-based practice, task shifting to lay personnel, enabling patient-centered care and maximising function and independence of People Living with HIV/AIDS (PLWHA). Other elements, such as the adoption of a multidisciplinary approach, training on the use of disability screening tools and the use of evidence to influence policy development were more challenging to implement. However, our findings suggest that it is possible to implement elements of the integrated model of care. The lessons we learned from our KwaZulu-Natal study, and the Nigeria-HIV BMD study, have been explored to determine how the home-based exercise programmes can be deployed to address bone health issues and other contextual disabilities arising from HIV that may be amenable to physical exercises. Also, the small sample studies already cited have demonstrated efficacy and relevance of physical exercises in ameliorating/preventing HIV/HAART-related bone demineralization, while boosting immune function, and serves as an orientation towards a population-based study.–29 We will also exploit the opportunity to explore various coping mechanisms of people living with HIV using an adaptation of the COPE questionnaire, which may have implications for QoL. The objective of this article is to describe the protocol of a study, which is aimed at determining the effects of exercise on bone mineral density and other health outcomes. The proposed study design is randomized controlled trial, as outlined in Figure We previously described a home-based rehabilitation (HBR) programme we developed in KwaZulu-Natal, South Africa, which adhered to the fundamental principles of a theoretical model of integrated care, that is, the Chetty model, and is also home-based.2The study will aim to determine the effectiveness of a home-based exercise programme in the management of femoral fracture. The specific objectives of the study will be to:1.To develop an evidence-based exercise intervention programme, based on evidence from the literature for improved: BMD, immune and inflammatory markers, BMI, function capacity and HRQOL2.To determine the effects of physical exercises on BMD, immune and inflammatory markers and functional capacity in adults living with HIV in Nigeria & South Africa with femoral shaft fracture.3It is hypothesized that:1.4+ count) in HAART-experienced HIV-infected adults compared to controls in both Nigeria and South Africa.Home based exercise programme will significantly influence muscle strength, gait output/speed, BMD, functional capacity, body composition  and immune function , Johannesburg, South Africa, which is a multidisciplinary teaching hospital for the University of the Witwatersrand, Faculty of Health Sciences. Gauteng, with an estimated population of 14.3 million, is one of the nine provinces of South Africa, with Johannesburg as its biggest city with 4.4 million inhabitants.Site 2: This is primarily at the Enugu State University Teaching Hospital, Parklane and the University of Nigeria Teaching Hospital, Enugu State, Nigeria. Enugu State, with an estimated population of 3.8 million, is one of the 36 states of Nigeria. The state has an HIV prevalence of 1.3% . There are 20,297 people living with HIV on treatment in 21 treatment facilities. HIV services are offered in 318 centers. The state benefits from the expanded access to ART instituted in Nigeria in 1999 from a national coverage for 359,181 people in 2010 to 747,382 in 2014. Since then, the prevalence of HIV/AIDS in Enugu has risen from 1.3% in 1992, to 5.2% in 2001, and 6.5% in 2005, but declined remarkably to 1.3% in 2012 suggesting that HIV transmission has not shown a stable pattern of decline over the past decades.,335.4The study population will consist of all persons with femoral fracture and HIV-positive and negative  aged 18 to 60 years attending the above-named health facilities. For the HIV-positive participants, a documented positive HIV result, as well as a history of being followed-up at the HIV treatment and care center.Inclusion criteriaOnly patients between 18 and 60 years at the last birthday and not more than 60 years at the next birthday.For HIV-negative participants, willingness to accept HIV testing.All patients on ART therapy with femoral shaft fracture will be recruited.All patients with lower limb fractures (femur) will be recruited.All patients must be ambulant.Exclusion criteriaSeverely ill persons based on investigator judgment.Presence of any bone or rheumatic disorder.Fracture of the femoral neck.Interventions: The intervention programme will be a home-based exercise programme targeted at improving bone mineral density, function, gait, QoL, and physical activity. The intervention programme aims to improve the joint range of motion, gait training, muscle strengthening, and balance. The participants in the intervention group will be followed up weekly via phone calls to monitor the intervention and ensure adherence to the programme.Control group: The control group will continue with their usual rehabilitation programme as conducted by the various clinics.5.5Table 5.6Sampling and sample size: Consecutive sampling will be used to recruit the participants. Using the statistical superiority sample size design, a sample of size of 36 participants per group will be sufficient to show a statistical difference in the bone mineral density between the control and the experimental group. For this study, the groups are divided into four which are the experimental group (HIV+ and HIV−) and the control group (HIV+ and HIV−), therefore, at least a total of 144 patients per study site will be recruited to participate in the study. The sample size will be calculated using Equation 1:Z1−α/2 = 1.96, Z1−β = 0.845, d2 = 0.1 and pooled standard deviation = 0.093.where N = total sample size per group, 5.7Patients managed with internal and external fixation for femoral shaft fracture at the study sites will be recruited to participate in the study. The participants will be recruited 2 weeks post-discharge at the follow-up clinic with the orthopaedic surgeon. Consenting participants will be assessed for eligibility and eligible participants will be allocated into the intervention or control group.5.8Blocked allocation will be used to allocate the participants into groups. Random numbers will be generated to allocate the patients into intervention and control groups in blocks . There will be two blocks namely1.HIV-positive and2.HIV-negative blocks.The number allocation will be done by independent research support. Opaque envelopes will be used to conceal the allocation.5.9The assessors and the data analysts will be blinded to the participant's assigned groups.5.10Baseline and follow up assessment will be conducted by a qualified physiotherapist (Research assistant) who will be blinded to the study.5.115.11.1A pilot randomized controlled trials will be conducted to evaluate the feasibility of the study procedure and prepare for unforeseen logistical circumstances. The recruitment process, randomization, intervention protocol, and assessment using the outcome measures exactly as proposed will be tested. A sample of eight participants per group, which is ∼10% of the estimated sample size will be recruited for the pilot trial. After recruitment, baseline (2-weeks post-surgery) assessment of the variables will be measured, followed by a 6-week (post-surgery). The control group will continue with their usual treatment programme. Participants in the experimental and control groups will be re-assessed at the end of the 4-week intervention programme. If there were no changes to the study procedure, the pilot participants would be included in the main study. If there are amendments to the protocol, the changes will be communicated to the relevant bodies.5.12The research will recruit patients with femoral fracture being managed at the orthopaedic department at CHBAH, and the following process will be used as a guide for the recruitment, blinding, and allocation. The main study procedure will follow the recruitment, allocation, blinding and intervention guidelines as presented. The CONSORT diagram below in Figure 5.13All physical measurements, as well as clinical and laboratory data, are will be entered into a case record form (CRF) that is developed prior to the commencement of the study. Instructions on how to complete the relevant forms and how to carry out the various physical, laboratory and radiological measurements are to be provided in appropriate standard operating procedures. The questionnaires and the CRFs will be checked for completeness.Subjects’ data will be stored on a server located in Berlin, Germany. There will be ongoing data cleaning and verification. The computerized handling of the data by the study team conducting the research after receipt of the data may generate additional requests to which the study sites are obliged to respond by confirming.The original hard copies of the questionnaires, CRFs, and related documents will be stored securely  in lockable filing cabinets with restricted access, both during and after the completion of the study. The entire study documentation will be stored for a minimum of 5 years after the publication of the primary data.5.14Reports of health deterioration warranting hospitalization or resulting in the death of any participant will be reported to the PI within 24 h. All participants must be informed of such developments within 72 h and be required to re-consent to continue with the trials.5.15T-test (parametric) and Mann–Whitney U test (non-parametric). Intention to treat analysis method will be used for this study. Alpha shall be set at P < .05 (two-tailed). All analyses will be intent-to-treat and missing data will be treated as missing.Data to be collected shall include discrete and normally distributed continuous variables. The normal distribution of the continuous variables will be tested using the Shapiro–Wilk test, and depending on the outcome, parametric or non-parametric statistics will be used to analyze the data. The change in the categorical outcomes across the time points will be measured using the McNemar's test. The difference in the continuous outcomes between the groups will be measured using the independent 6,53 as demonstrated in studies involving non-HIV infected individuals. There are possible translational benefits for people living with HIV. Exercise interventions may improve function, livelihood and QoL, as well as contribute to reducing hospital costs, enhancing return to work and local and national productivity. Available evidence suggests that co-morbidities associated with degeneration in HIV conditions are worsened by a lack of physical exercise and restriction in social participation leading to multi-system  impairments, which are amenable to physical exercise modalities. The impact of the home-based exercise programme on bone mineral density may reduce the risk of osteoporosis. Previous studies have demonstrated this prospect but are yet to be explored in a large randomized controlled trial. As it is, most of the studies on bone disease and physical exercises in HIV condition have been done outside Africa, which by far has the highest prevalence of HIV infection globally. There are contextual, racial, and gender differences that may influence the outcomes of an exercise intervention on BMD. Such differences can alter the interventions needed, including exercise. For this reason, it is prudent to research to test the impact of an exercise intervention on BMD in HIV positive patients in an African context.Physical exercise could influence bone metabolism and bone healing,6.1The benefits of exercise interventions in HIV and HAART-related bone demineralization should be explored in a randomized controlled trial. Moreover, limitations in availability, affordability and accessibility of most HIV patients to clinics where gymnasiums are available, may limit compliance to the use and prescription of relevant exercise modalities. Therefore, we consider implementing evidence-based functional-based oriented, simplified, cost-free and innovative home-based exercises and which need to be tested for efficacy in achieving the desired therapeutic goals of improved physical functioning and BMD in HIV management. A home-based rehabilitation approach under an integrated healthcare model, which we developed in a semi-rural poor resource setting of KwaZulu–Natal, was therefore proposed as the most viable option. South Africa and Nigeria are multi-cultural societies and appear as ideal settings for such studies to enable easy recruitment of participants who are exposed to similar environmental variables that may influence bone metabolism other than genetic differences. The net effect of delayed lower limb fracture healing in HIV condition, from a population-based national outlook, suggests a substantial loss of productive manpower, decline in the overall national productivity, economic development, gross domestic product, and QoL with a predictable negative impact on the poverty level. Therefore, any interventions that could prevent/ameliorate/reverse the adverse effects of HIV and HAART-related bone demineralization should be of socio-economic significance.6.2The results from this study will be communicated to health professionals via publications and presentation at conferences and seminars and to the participants via health promotion programmes.We would like to acknowledge the support of the Chris Hani Baragwanath Hospital, Johannesburg, South Africa and the University Teaching Hospital Enugu, Nigeria.Conceptualization: Adedayo Tunde Ajidahun, Hellen Myezwa, Sam Chidi Ibeneme, Sebastian Magobotha, Gerhard Fortwengel, Maxwell Jingo, Brenda Milner, Sadiya Ravat, Ifeoma Okoye, Edward Schnaid, Faith Bischoff.Funding acquisition: Adedayo Tunde Ajidahun, Hellen Myezwa, Sebastian Magobotha.Investigation: Sebastian Magobotha.Methodology: Adedayo Tunde Ajidahun, Hellen Myezwa, Sam Chidi Ibeneme, Sebastian Magobotha, Gerhard Fortwengel, Maxwell Jingo, Brenda Milner, Sadiya Ravat, Ifeoma Okoye, Edward Schnaid, Faith Bischoff.Project administration: Adedayo Tunde Ajidahun, Hellen Myezwa, Gerhard Fortwengel, Maxwell Jingo, Brenda Milner.Supervision: Hellen Myezwa, Sam Chidi Ibeneme, Sebastian Magobotha, Gerhard Fortwengel.Writing – original draft: Adedayo Tunde Ajidahun, Hellen Myezwa, Sam Chidi Ibeneme, Sebastian Magobotha, Gerhard Fortwengel, Faith Bischoff.Writing – review & editing: Adedayo Tunde Ajidahun, Hellen Myezwa, Sam Chidi Ibeneme, Sebastian Magobotha, Gerhard Fortwengel, Maxwell Jingo, Brenda Milner, Sadiya Ravat, Ifeoma Okoye, Edward Schnaid.


Chrysanthemum morifolium Ramat.) is an economically important ornamental plant species grown worldwide. However, the origin of the genus Chrysanthemum remains unclear. This study was conducted in the Hengduan Mountains, Yunnan Province. We took advantage of a special geographic region where the southernmost species of Ajania and the highest altitude population of Chrysanthemum indicum coexist to investigate their evolutionary origins. Diversity analysis of 9 populations of 5 species that came from 3 genera was carried out based on morphological traits and SRAP markers. Furthermore, topographical and ecological analyses and surveys of the vegetation communities in the plots were carried out for correlation analysis, and past data were used to reconstruct the ancient topography and vegetation to estimate the migration path and divergence time. We found that Chrysanthemum and Ajania were closely related based on the smooth transition states among marginal female florets and their common pollination system. The genetic relationship between Phaeostigma and Chrysanthemum was relatively distant, and Ajania was between them. Low light intensity and relatively humid habitats may be driving the elongation and evolution of marginal female florets. We found that Chrysanthemum and related genera were largely restricted to stony topographies at an altitude of ~3000 m.a.s.l. and in specialized alpine coniferous (Pinus) and broad-leaved (Quercus) mixed forest marginal communities. These stony topographies have become ecological islands of refuge for these species in the current interglacial period. The Hengduan Mountains play a key role in the evolution, divergence, and survival of Chrysanthemum and its allies.Cultivated chrysanthemum ( Chrysanthemum morifolium Ramat.), as one of the most economically important ornamental plants grown worldwide1, has been popular among horticulturists and botanists for a long time2. Most research on cultivated chrysanthemum has focused on breeding, disease control, regulation of horticultural characteristics, and their molecular mechanisms9. There are relatively few studies on the evolutionary relationships between the genus Chrysanthemum and its wild relatives, especially with regard to biogeography and ecology, for which the origin of chrysanthemums would be useful information.Cultivated chrysanthemum  and eastern Europe10. There are approximately 21 species distributed in most parts of China, except Tibet and Northwest China, and most of these species grow in humid areas at low and medium altitudes.Ajania Poljakov  is a sister group closely related to Chrysanthemum that can be distinguished by its disciform capitula; Chrysanthemum, on the other hand, has radiate capitula11. Phaeostigma established by Muldashev13 was a genus circumscribing the Chinese endemic species formerly described under Ajania based on palynology and morphology14, and this view was supported by molecular phylogeny15. Ajania and Chrysanthemum are not easy to distinguish clearly based on the nuclear ribosomal ITS, chloroplast DNA sequences or single-copy nuclear genes17. Hybrids between these taxa are easy to obtain, and their chromosomes are similar to each other. Ohashi and Yonekura18 included Ajania in Chrysanthemum. However, the results of phylogenetic comparisons among different samples and gene sequences are divergent19. The characteristics of marginal female tubular florets in Ajania can be significantly different from those of ray florets in Chrysanthemum, and more importantly, the geographical distributions of the genera Chrysanthemum and Ajania in China have obvious differences20. According to the records of the Flora of China and the Chinese Virtual Herbarium, Chrysanthemum is usually distributed to the south of China’s 500-mm isoline, whereas Ajania is mainly distributed to the north of China’s 800-mm isoline, and both are distributed between the two isolines. In addition, Chrysanthemum is usually distributed below 3000 m.a.s.l. Hence, the evolutionary relationship and origin of the two genera are still unclear. In particular, the ancestral floret characteristics being the same as those of marginal female florets, either tubular florets or ray florets, is a critical issue.21, phytogeographical22, ecological24, and other evidence to obtain reasonable and accurate results. In these aspects, there is a paucity of research on Chrysanthemum, Ajania, and their allies , especially on the phytogeography and ecology within their areas.The evolution of species is driven by the environment. To explore the key issues of evolutionary history, such as the region of origin, divergence time, radiation path, and distribution range, it is necessary to combine fossil26. Mountain regions are unusually biodiverse, with rich aggregations of small-ranged species that form centers of endemism27. Owing to the diversification of habitats and climates, mountains have become refuges and centers of diversity for many species31. The Hengduan Mountains, located in southwest China, are a hotspot of biodiversity32. The Hengduan Mountains are home to many temperate plant species and are a center of distribution and speciation for many alpine taxa35.Mountains contribute disproportionately to the terrestrial biodiversity of EarthAjania sericea (A. sericea) is the southernmost recorded species of the genus Ajania in China at present, residing to the south of China’s 800 mm isoline. This special geographical distribution has important significance for the study of biogeography and evolution. However, only one specimen has been collected worldwide, in the collections of Harvard University Herbaria and Libraries, since it was discovered by J. M. Delavay in Yan-in-chan in 1887, and there is a paucity of research on this species. In addition, we found several populations of Chrysanthemum distributed at altitudes over 3000 m.a.s.l. here.The research site of this study was in the Erhai Lake Range, Dali, Yunnan Province, which is located in the southern margin of the Hengduan Mountains. The latitude here is between N25.482° and N26.543°, and the lake-level elevation is 1972 m.a.s.l., whereas the surrounding mountains are almost more than 3000 m.a.s.l. (the highest elevation is more than 4000 m.a.s.l.), which is a typical low-latitude and high-altitude area. As an endemic species of this area, Chrysanthemum and its allies (including A. sericea) were collected along with geomorphologic and geographic information on their habitats. In addition, we surveyed the plant community of the habitats for ecological analysis. Morphological diversity and genetic diversity were analyzed based on traits and sequence-related amplified polymorphism (SRAP) markers, respectively, and the special geographical distribution was documented using geographic information systems (GIS); correlation analysis was performed by combining topography and ecology. Last, the paleogeomorphology, paleovegetation and paleoclimate36 during the upper Eocene and the last glacial of the Quaternary in this study area were reconstructed based on previous studies of paleopalynology and geology to deduce the potential evolutionary relationship and history of the two genera. Our results will provide a new research methodology and perspective for the study of the evolutionary history and origin of Chrysanthemum and its allies through the in-depth study of biogeography and ecology.In this study, the main ranges around the Erhai Lake Basin were surveyed comprehensively in different periods for 3 years (2016–2018), and samples of Chrysanthemum and its allies throughout the study area to obtain comprehensive distribution data. Moreover, the main vegetation types in this study area were recorded to understand vegetation characteristics at different altitudes. Furthermore, for each plot in which target species were found, plant community and topography data were collected in plots for correlation analysis.The research area was the mountains, river valleys, and basins around Erhai Lake, from N25.482° to N26.543° and E99.895° to E100.524°, within a rectangular range of approximately 120 × 65 km in Dali, Yunnan Province, China. Fieldwork analysis was conducted during May–December of 2016–2018; we searched for the species of the genus 37, and each replicate plot was spaced 10–50 m apart38. The number of target plants in each plot was recorded as the abundance (AB). The species richness of the tree layer , shrub layer , and herb layer  and the total richness  were separately recorded within each plot. TS was determined to the species level because of the significance that presenting detailed descriptions of tree species composition would have for this study, and SS and HS were identified to the genus level. Photos were taken for comparison with herbarium specimens if a species could not be identified in the field39 or had great significance to this study. The percentage cover41 of the tree layer (TLC), shrub layer (SLC), and herb layer (HLC) were estimated based on the surface area. The surface rock coverage (SRC) as a topographical factor in this study was estimated by the following formula:Three replicate plots (10 × 10 m) were randomly established within each plotL(m): maximum length of rock; W (m): maximum width of rock; 0.7: correction factor based on the empirical value obtained after 20 different measurements; p: plot area (100 m2)). method. The SRAP method followed the protocol described by Zhang et al.44, and analysis was performed as described by Li and Quiros45. Analysis of genetic relationships was performed with NTSYS-pc 2.1 based on UPGMA (unweighted pair-group method with arithmetic means). The sequences of the forward and reverse SRAP primers used in this study are shown in Table To assess the genetic diversity, based on SRAP markers, genomic DNA was extracted from the leaves of each species using a slightly modified version52, the ancient topography and vegetation communities were reconstructed based on time nodes. These data were used to deduce the potential evolutionary relationship and estimate the divergence time between Chrysanthemum and its allies via comparison with the current situation.We determined geographical coordinates and altitude (m.a.s.l.) of each sampling area by GPS. To understand the pollination traits, we recorded the florescence and took photos of the pollinating insects of each target population as evidence. The current main vegetation types of the study area were recorded within altitude gradient intervals; according to the previous data of paleopalynological and geological research53, and topographic position index for GIS analysis54. To more intuitively and accurately show topographic features, we made DEM profiles for each population. Since most of the mountains in this area are north-south oriented, we adopted east-west cross sections that were parallel to the latitude. In addition to the coefficient of variation (CV), the Shannon-Weaver diversity index (H’)55 was calculated based on qualitative traits using the following formula:The digital elevation model (DEM) was based on the Shuttle Radar Topography Mission  data. We used ArcMap10.5 (Esri USA) to extract the aspect, slopeP: populations = 9, Xi: the number of code values within the ith level for a qualitative trait. Level: the average value (A) and standard deviation (S) of all codes of a certain trait were calculated and then divided into 10 levels, from the first level (X < A–2S) to the tenth level (X > A + 2S), where each 0.5S is a level) in Origin 2019 . To account for potential correlations between the target species abundance, plant community structure and topography that could explain differences in the distribution patterns of Chrysanthemum and its allies, a correlation matrix56 was established using R 3.6.1 .The differences between two populations of the species that live in two different plots, based on 11 quantitative morphological indexes, can be assessed by Chrysanthemum, one species of Ajania, and one species of Phaeostigma were found in nine independent small-scale alpine areas  ; in particular, this trait was reported for the first time for A. sericea, Chrysanthemum glabriusculum, and Chrysanthemum lavandulifolium var. tomentellum. Notably, A. sericea exhibited morphological characteristics that suggested that it has very high drought tolerance in comparison to other species. These characteristics included densely packed trichomes all over the plant, completely subdivided leaves, and narrowly elliptical ultimate segments.Although the altitude and topography were similar, the 9 populations showed high morphological diversity based on the 44 qualitative traits Table . The qua = 1.58) . Subsequ = 1.58) , Fig. S1Phaeostigma quercifolium was significantly different from other species, exhibiting qualitative traits that were different from those noted in previous studies, such as a subshrub posture, the presence of cicatricles, lateral expansion of the petiole base, yellow-white tubular florets, an absence of rhizomes, and annular lobules at the petiole   . The main significant differences came from the PH. However, the RFL of the Cg-N population was significantly higher than that of Cg population  were polymorphic Table , Fig. S5ult Fig.  based onChrysanthemum species or their allies distributed in the valleys and basins that are found in low-altitude regions  and HLC  and was negatively related to TLC  and TS   Fig. . These fChrysanthemum is generally distributed in the middle-low altitude and middle-low-latitude humid areas of the subtropical and temperate zones of Asia, and a few grow in the high-latitude frigid zones of Russia (Far East) and North America. For C. indicum, the distribution area is relatively wide, but there are few high-altitude populations25. Ajania is usually distributed in mid-latitude arid and semiarid areas, and the altitude is higher than that of Chrysanthemum, with the highest altitude being 5300 m.a.s.l. (A. khartensis). Ci was the highest population of Chrysanthemum indicum (3210 m.a.s.l.) reported in China, with an altitude higher than that of Ajania in this area. This may be mainly due to the relatively warm climate of the low latitudes. In addition, this area is located in the southernmost margin of the Hengduan Mountain Range, which blocks the cold current from the north. The warm and wet current from the south59 easily forms rain and fog at the top of the mountains, which makes the small area relatively warm and humid even in the high-altitude areas above 3000 m.a.s.l., allowing C. indicum to survive. In addition, these particular stony small areas with long light hours and a relatively dry microclimate allowed Ajania to exist in the low-latitude area with 1000 mm annual average precipitation. However, the differences in light hours caused by aspect and vegetation community led to the discrepant florescence of Chrysanthemum in this area. Even for the same species, the florescence of the Cg–N population on the northern aspect occurred earlier than that of the Cg population on the eastern aspect 71 and the last Quaternary glaciation (~70–10 Ka BP)73 for these two types of mountains  areas  to date. Hence, we estimated that the divergence of the two genera occurred along with the uplift of the Hengduan Mountains and Quaternary glacial-interglacial cycles, from approximately the late Miocene to the late Pleistocene (8–0.1 Ma).By the last Quaternary glaciation (~70–10 ka BP), the Qinghai–Tibetan Plateau and Hengduan Mountains had been uplifted, and the landform of this area was basically the same as it is now. Affected by glaciation, the climate had become cold and dry, the area above 3900 m.a.s.l. was covered by glaciers all year round, and the lake level had reduced. The climate in the low-altitude basin area was relatively warm and became that of a temperate coniferous–broad-leaved mixed forest dominated by 13 separated Phaeostigma from Ajania. However, there were also brownish style branches in A. sericea, whereas the browning degree was relatively lower than that in P. quercifolium. Two different pollen exine ornamentations have been confirmed for the tribe Anthemideae, namely, the Anthemis-type  and the Artemisia-type 78. The former was more likely to be related to entomophily, while the latter was more likely to be related to anemophily79. Chrysanthemum and most Ajania species Anthemis-type species, while Phaeostigma species were Artemisia-type species78, and there was no relevant research on A. sericea. In our study, although pollen morphology was not involved, P. quercifolium was more likely related to anemophily, and the other four species, including A. sericea, were more likely related to entomophily based on the pollinators recorded through our long-term field work  and Ajania (tubular florets) discovered in the Cg–N population (C. glabriusculum) and the fact that they use the same entomophily pollination system. This assumption is also supported by previous molecular biology results17, and our dendrogram showed that the genetic distance between Chrysanthemum and Ajania was closer than that between Chrysanthemum and Phaeostigma  grains preserved in dinosaur-bearing deposits from the Late Cretaceous (~76–66 Ma) in Antarctica drastically pushes back the timing of assumed origin of Asteraceae65. Therefore, at the family and angiosperm levels, we speculate that the groups that were likely related to anemophily with short spinule pollens were the more ancient and primitive ancestors. Hence, tubular florets corresponding to anemophily may be the ancestral characteristics of marginal female florets. The results of our PCA and qualitative trait analysis indicated that Chrysanthemum had a more significant inflorescence to attract pollinators; in contrast, P. quercifolium was unattractive, with erect whitish corollas, and A. sericea was in the middle of the two. P. quercifolium may be a relic species of Artemisiinae that benefited from the diverse topographies and climate of the Hengduan Mountains, which was a refuge for this species, as it survived through several global climate changes in the Late Tertiary and Quaternary.However, there is a key problem: what were the ancestral characteristics of the marginal female florets, the tubular florets, or ray florets? Previous studies have shown that Artemisia groups (tubular florets) were considered to have evolved secondarily by loss of ray floretsChrysanthemum and its related genera were highly dependent on small-scale special stony topographies and specialized communities in the study area and that the northern aspect (16.28), with less light, may be the key factor for the elongation and evolution of marginal female florets. The uplift of the Hengduan Mountains played a key role in the evolution, divergence, and survival of Chrysanthemum and its allies.Owing to the limitations of species samples, in this study, we were unable to perform a comprehensive analysis of the evolution of the three genera. However, we highlight that Table S1Table S2Table S3Tabla S4Table S5Table S6Fig.S1(a)Fig.S1(b)Fig.S1(c)Fig.S1(d)Fig.S2Fig.S3Fig.S4Fig. S5