The implications of chronic psychological stress in the development of diabetes mellitus type 2
DOI:
https://doi.org/10.13129/2282-1619/mjcp-3544Abstract
Indroduction:Diabetes mellitus type 2 is a systemic disease with major negative effects on every organ and this is why the risk factors should be known and limited. In the past, in the majority perception, diabetes was associated especially with dietary factors, but psychological stress seems to be a factor incriminated in diabetes mellitus developement, too.Material and Method: During the writing of this review, there were used materials selected through search engines such as Pubmed, Web of Science, and Scopus, inserting formula: (diabetes*) AND (type 2 OR type two) AND (stress). The search included articles published in last 20 years with full text in english.
Results and discussions: The complexity of the human body is distinguished through the fact that is biochemically prepared for defying every danger or risk factor by using two major physiological pathways: the sympathetic nervous system and the hypothalamic-pituitary-adrenal axis (HPA)
Even if proinflammatory cytokines are usually synthesized as a response of the human body to a certain disease, they can also be increased when a stressor occurs, a fact previously demonstrated. Another cytokine involved in diabetes pathogeny is IL-6 of which contribution to insulin secretion has been intensely researched. Cortisol has a major impact on the stress response, a fact previously demonstrated, but is also a considerable factor in glucose metabolism: it is a hyperglycemic hormone because has a stimulating action on gluconeogenesis and glycogenolysis. Another factor that contributes to diabetes mellitus type 2 pathogeny is the higher level of homocysteine found among people who have suffered chronic psychological stress
Conclusions: The evolution of diabetes mellitus type 2 is severely affected by chronic psychological stress through modifications that occur in normal physiology, such as activation of the sympathetic nervous system, inhibition of the cholinergic pathway, synthesis of proinflammatory cytokines, or hyperproduction of homocysteine. These changes lead to hyperglycemia and insulin resistance, but they can be prevented by stress management procedures and treatment the stress-related diseases.References
Aguilera, G., & Liu, Y. (2012). The Molecular Physiology of CRH neurons. Frontiers in Neuroendocrinology, 33(1), 67. https://doi.org/10.1016/J.YFRNE.2011.08.002
Akbari, M., & Hassan-Zadeh, V. (2018). IL-6 signalling pathways and the development of type 2 diabetes. Inflammopharmacology, 26(3), 685–698. https://doi.org/10.1007/S10787-018-0458-0
Anagnostis, P., Athyros, V. G., Tziomalos, K., Karagiannis, A., & Mikhailidis, D. P. (2009). The Pathogenetic Role of Cortisol in the Metabolic Syndrome: A Hypothesis. The Journal of Clinical Endocrinology & Metabolism, 94(8), 2692–2701. https://doi.org/10.1210/JC.2009-0370
Anderson, E., & Durstine, J. L. (2019). Physical activity, exercise, and chronic diseases: A brief review. Sports Medicine and Health Science, 1(1), 3-10. https://doi.org/10.1016/j.smhs.2019.08.006
Anisman, H., Gibb, J., & Hayley, S. (2008). Influence of continuous infusion of interleukin-1β on depression-related processes in mice: corticosterone, circulating cytokines, brain monoamines, and cytokine mRNA expression. Psychopharmacology, 199:2, 199(2), 231–244. http s://doi.org/10.1007/S00213-008-1166-Z
Ardeleanu, V., Toma, A., Pafili, K., Papanas, N., Motofei, I., Diaconu, C.C., Rizzo, M. & Pantea Stoian, A.(2020). Current Pharmacological Treatment of Painful Diabetic Neuropathy: A Narrative Review. Medicina, 56(1),25. https://doi.org/10.3390/medicina56010025
Bale, T. L., Picetti, R., Contarino, A., Koob, G. F., Vale, W. W., & Lee, K. F. (2002). Mice Deficient for Both Corticotropin-Releasing Factor Receptor 1 (CRFR1) and CRFR2 Have an Impaired Stress Response and Display Sexually Dichotomous Anxiety-Like Behavior. The Journal of Neuroscience, 22(1), 193. https://doi.org/10.1523/JNEUROSCI.22-01-00193.2002
Barchetta, S., Martino, G., Craparo, G., Salehinejad, M. A., Nitsche, M. A., & Vicario, C. M. (2021). Alexithymia is linked with a negative bias for past and current events in healthy humans. International Journal of Environmental Research and Public Health, 18(13), 6696. https://doi.org/10.3390/ijerph18136696
Barone, M., Savarese, L., & Freda, M. F. (2019). Living with a chronic disease: the role of maternal mediation in the meaning-making process of their children’s Type 1 Diabetes. Mediterranean Journal of Clinical Psychology, 7(3). https://doi.org/10.6092/2282-1619/2019.7.2187
Bierhaus, A., Wolf, J., Andrassy, M., Rohleder, N., Humpert, P. M., Petrov, D., Ferstl, R., von Eynatten, M., Wendt, T., Rudofsky, G., Joswig, M., Morcos, M., Schwaninger, M., McEwen, B., Kirschbaum, C., & Nawroth, P. P. (2003). A mechanism converting psychosocial stress into mononuclear cell activation. Proceedings of the National Academy of Sciences of the United States of America, 100(4), 1920–1925. https://doi.org/10.1073/PNAS.0438019100
Borovikova, L. v., Ivanova, S., Zhang, M., Yang, H., Botchkina, G. I., Watkins, L. R., Wang, H., Abumrad, N., Eaton, J. W., & Tracey, K. J. (2000). Vagus nerve stimulation attenuates the systemic inflammatory response to endotoxin. Nature, 405(6785), 458–462. https://doi.org/10.1038/35013070
Busnatu, S.S., Salmen, T., Pana, M.A., Rizzo, M., Stallone, T., Papanas, N., Popovic, D., Tanasescu, D., Serban, D., Stoian, A.P. (2022). The Role of Fructose as a Cardiovascular Risk Factor: An Update. Metabolites. 12, 12(1), 67. https://doi.org/10.3390/metabo12010067
Cuzzocrea, F., Costa, S., Barberis, N., & Castiglione, C. (2018). Parent–child interaction: A comparative analysis of the parents of children with diabetes and asthma and of nonchronically ill children. Mediterranean Journal of Clinical Psychology, 6(2). https://doi.org/10.6092/2282-1619/2018.6.1825
Dascalu, A.M., Stoian, A.P., Cherecheanu, A.P., Serban, D., Costea, D.O., Tudosie, M.S., Stana, D., Tanasescu, D., Sabau, A.D., Gangura, G.A., Costea, A.C., Nicolae, V.A., Smarandache, C.G. (2021). Outcomes of Diabetic Retinopathy Post-Bariatric Surgery in Patients with Type 2 Diabetes Mellitus. J Clin Med. 22, 10(16), 3736. https://doi.org/10.3390/jcm10163736
de Weerth, C., Zijl, R. H., & Buitelaar, J. K. (2003). Development of cortisol circadian rhythm in infancy. Early Human Development, 73(1–2), 39–52. https://doi.org/10.1016/S0378-3782(03)00074-4
Demorrow, S. (2018). Role of the Hypothalamic–Pituitary–Adrenal Axis in Health and Disease. International Journal of Molecular Sciences, 19(4). https://doi.org/10.3390/IJMS19040986
Devrajani, B., Davidovic, S., & Sakac, V. (n.d.). Plasma Homocysteine Level in Patients with Diabetes mellitus. World Applied Sciences Journal, 16 (9): 1269-1273, 2012.
Di Giacomo, D., Ranieri, J., Nasta, L., Moscato, S., Guerra, F., & Passafiume, D. (2019). Psychological distress in Interstitial Cystitis/Bladder Pain Syndrome: A cross-sectional study on emotional patterns. Mediterranean Journal of Clinical Psychology, 7(2). https://doi.org/10.6092/2282-1619/2019.7.2135
Dickerson, S. S., Gable, S. L., Irwin, M. R., Aziz, N., & Kemeny, M. E. (2009). Social-evaluative threat and proinflammatory cytokine regulation: an experimental laboratory investigation. Psychological Science, 20(10), 1237–1244. https://doi.org/10.1111/J.1467-9280.2009.02437.X
Dimova, E. D., Ward, A., Swanson, V., & Evans, J. M. (2019). Patients' illness perceptions of type 2 diabetes: a scoping review. Current diabetes reviews, 15(1), 15-30. https://doi.org/10.2174/1573399814666171227214845
Donath, M. Y., Schumann, D. M., Faulenbach, M., Ellingsgaard, H., Perren, A., & Ehses, J. A. (2008). Islet Inflammation in Type 2 Diabetes. Diabetes Care, 31(Supplement 2), S161–S164. https://doi.org/10.2337/DC08-S243
Eisenberger, N. I., & Cole, S. W. (2012). Social neuroscience and health: neurophysiological mechanisms linking social ties with physical health. Nature Neuroscience, 15(5), 669–674. https://doi.org/10.1038/NN.3086
Evans, S. W., & Whicher, J. T. (1993). The Cytokines: Physiological and Pathophysiological Aspects. Advances in Clinical Chemistry, 30(C), 1–88. https://doi.org/10.1016/S0065-2423(08)60194-8
Gabry, K. E., Gold, P. W., & Chrousos, G. P. (2002). Hypothalamic-Pituitary-Adrenal Axis: Introduction to Physiology and Pathophysiology. Hormones, Brain and Behavior, 841–866. https://doi.org/10.1016/B978-012532104-4/50083-4
Garay‐Sevilla, M. E., Malacara, J. M., Gutiérrez‐Roa, A., & Gonzalez, E. (1999). Denial of disease in Type 2 diabetes mellitus: its influence on metabolic control and associated factors. Diabetic medicine, 16(3), 238-244. https://doi.org/10.1046/j.1464-5491.1999.00033.x
Goldbeck, R. (1997). Denial in physical illness. Journal of psychosomatic research, 43(6), 575-593. https://doi.org/10.1016/S0022-3999(97)00168-2
Gragnoli, C. (2012). Depression and type 2 diabetes: Cortisol pathway implication and investigational needs. Journal of Cellular Physiology, 227(6), 2318–2322. https://doi.org/10.1002/JCP.23012
Guze, S. B. (2006). Diagnostic and Statistical Manual of Mental Disorders, 4th ed., 152(8), 1228–1228. https://doi.org/10.1176/AJP.152.8.1228
Hajat, C., & Stein, E. (2018). The global burden of multiple chronic conditions: a narrative review. Preventive medicine reports, 12, 284-293. https://doi.org/10.1016/j.pmedr.2018.10.008
Huang, T., Ren, J. J., Huang, J., & Li, D. (2013). Association of homocysteine with type 2 diabetes: a meta-analysis implementing Mendelian randomization approach. BMC Genomics, 14(1), 867. https://doi.org/10.1186/1471-2164-14-867
Irwin, M. R., & Cole, S. W. (2011). Reciprocal regulation of the neural and innate immune systems. Nature Reviews. Immunology, 11(9), 625. https://doi.org/10.1038/NRI3042
Johnson, R. J., Sánchez-Lozada, L. G., Andrews, P., & Lanaspa, M. A. (2017). Perspective: A Historical and Scientific Perspective of Sugar and Its Relation with Obesity and Diabetes. Advances in Nutrition (Bethesda, Md.), 8(3), 412–422. https://doi.org/10.3945/AN.116.014654
Johnston, G. R., & Webster, N. R. (2009). Cytokines and the immunomodulatory function of the vagus nerve. British Journal of Anaesthesia, 102(4), 453–462. https://doi.org/10.1093/BJA/AEP037
Katon, W., Maj, M., & Sartorius, N. (n.d.). Depression and Diabetes (World Psychiatric Association).
Kolb, H., & Martin, S. (2017). Environmental/lifestyle factors in the pathogenesis and prevention of type 2 diabetes. BMC Medicine, 15(1). https://doi.org/10.1186/S12916-017-0901-X
Kontoangelos, K., Papageorgiou, C. C., Raptis, A. E., Tsiotra, P., Lambadiari, V., Papadimitriou, G. N., Rabavilas, A. D., Dimitriadis, G., & Raptis, S. A. (2015). Homocysteine, cortisol, diabetes mellitus, and psychopathology. Journal of Diabetes Research, 2015. https://doi.org/10.1155/2015/354923
Lambillotte, C., Gilon, P., & Henquin, J. C. (1997). Direct glucocorticoid inhibition of insulin secretion. An in vitro study of dexamethasone effects in mouse islets. The Journal of Clinical Investigation, 99(3), 414–423. https://doi.org/10.1172/JCI119175
Lloyd, C. E., Nouwen, A., Sartorius, N., Ahmed, H. U., Alvarez, A., Bahendeka, S., Basangwa, D., Bobrov, A. E., Boden, S., Bulgari, V., Burti, L., Chaturvedi, S. K., Cimino, L. C., Gaebel, W., de Girolamo, G., Gondek, T. M., de Braude, M. G., Guntupalli, A., Heinze, M. G., … Xin, Y. (2018). Prevalence and correlates of depressive disorders in people with Type 2 diabetes: results from the International Prevalence and Treatment of Diabetes and Depression study, a collaborative study carried out in 14 countries. Diabetic Medicine : A Journal of the British Diabetic Association, 35(6), 760–769. https://doi.org/10.1111/DME.13611
Lockwood, K. G., Marsland, A. L., Cohen, S., & Gianaros, P. J. (2016). Sex differences in the association between stressor-evoked interleukin-6 reactivity and C-reactive protein. Brain, Behavior, and Immunity, 58, 173–180. https://doi.org/10.1016/J.BBI.2016.07.001
Lustman, P. J., & Clouse, R. E. (2002). Treatment of depression in diabetes: impact on mood and medical outcome. Journal of Psychosomatic Research, 53(4), 917–924. https://doi.org/10.1016/S0022-3999(02)00416-6
Marchini, F., Langher, V., Napoli, A., Balonan, J. T., Fedele, F., Martino, G., ... & Caputo, A. (2021). Unconscious loss processing in diabetes: associations with medication adherence and quality of care. Psychoanalytic Psychotherapy, 35(1), 5-23. https://doi.org/10.1080/02668734.2021.1922492
Martino, G., Bellone, F., Langher, V., Caputo, A., Catalano, A., Quattropani, M. C., & Morabito, N. (2019). Alexithymia and psychological distress affect perceived quality of life in patients with type 2 diabetes mellitus. Mediterranean Journal of Clinical Psychology, 7(3). https://doi.org/10.6092/2282-1619/2019.7.2328
Martino, G., Caputo, A., Vicario, C. M., Feldt-Rasmussen, U., Watt, T., Vita, R., ... & Benvenga, S. (2021a). Interrelations between mental health, generic and thyroid-related quality of life in patients with Hashimoto’s thyroiditis receiving levothyroxine replacement. Mediterranean Journal of Clinical Psychology, 9(2). https://doi.org/10.13129/2282-1619/mjcp-3072
Martino, G., Caputo, A., Vicario, C. M., Feldt-Rasmussen, U., Watt, T., Quattropani, M. C., ... & Vita, R. (2021a). Alexithymia, emotional distress, and perceived quality of life in patients with hashimoto’s thyroiditis. Frontiers in psychology, 12, 667237. https://doi.org/10.3389/fpsyg.2021.667237
McGinnis, R. A., McGrady, A., Cox, S. A., & Grower-Dowling, K. A. (2005). Biofeedback-assisted relaxation in type 2 diabetes. Diabetes Care, 28(9), 2145–2149. https://doi.org/10.2337/DIACARE.28.9.2145
Mezuk, B., Eaton, W. W., Albrecht, S., & Golden, S. H. (2008). Depression and Type 2 Diabetes Over the Lifespan: A meta-analysis. Diabetes Care, 31(12), 2383. https://doi.org/10.2337/DC08-0985
Moroianu, L. A., Motofei, I. G., Cecilia, C., Barbu, R. E., & Toma, A. (2020). The impact of anxiety and depression on the pediatric patients with diabetes. Mediterranean Journal of Clinical Psychology, 8(2). https://doi.org/10.6092/2282-1619/mjcp-2435
Novak, M., Björck, L., Giang, K. W., Heden-Ståhl, C., Wilhelmsen, L., & Rosengren, A. (2013). Perceived stress and incidence of Type 2 diabetes: A 35-year follow-up study of middle-aged Swedish men. Diabetic Medicine, 30(1). https://doi.org/10.1111/DME.12037
Packard, C. J. (2006). Small dense low-density lipoprotein and its role as an independent predictor of cardiovascular disease. Current Opinion in Lipidology, 17(4), 412–417. https://doi.org/10.1097/01.MOL.0000236367.42755.C1
Panagiotakos, D. B., Pitsavos, C., Chrysohoou, C., Tsetsekou, E., Papageorgiou, C., Christodoulou, G., & Stefanadis, C. (n.d.). Increased plasma homocysteine concentrations in healthy people with hostile behavior: the ATTICA study. http://www.MedSciMonit.com/pub/vol_10/no_8/4326.pdf
Pandey, A., Chawla, S., & Guchhait, P. (2015). Type-2 diabetes: Current understanding and future perspectives. IUBMB Life, 67(7), 506–513. https://doi.org/10.1002/IUB.1396
Pantea Stoian, A. Pituru, S.M., Hainarosie, R., Andronache, L.F., Ginghina, O. &. Serafinceanu, C. (2018). Testosterone therapy, new opportunities in diabetes mellitus, Farmacia, 66(1),1-7.
Papanicolaou, D. A., Wilder, R. L., Manolagas, S. C., & Chrousos, G. P. (1998). The pathophysiologic roles of interleukin-6 in human disease. Annals of Internal Medicine, 128(2), 127–137. https://doi.org/10.7326/0003-4819-128-2-199801150-00009
Péres, D. S., Santos, M. A. D., Zanetti, M. L., & Ferronato, A. A. (2007). Difficulties of diabetic patients in the illness control: feelings and behaviors. Revista Latino-americana de Enfermagem, 15, 1105-1112. https://doi.org/10.1590/S0104-11692007000600008
Rehman, K., Akash, M. S. H., Liaqat, A., Kamal, S., Qadir, M. I., & Rasul, A. (2017). Role of Interleukin-6 in Development of Insulin Resistance and Type 2 Diabetes Mellitus. Critical Reviews in Eukaryotic Gene Expression, 27(3), 229–236. https://doi.org/10.1615/CRITREVEUKARYOTGENEEXPR.2017019712
Rehman, T., Shabbir, M. A., Inam-Ur-Raheem, M., Manzoor, M. F., Ahmad, N., Liu, Z. W., Ahmad, M. H., Siddeeg, A., Abid, M., & Aadil, R. M. (2020). Cysteine and homocysteine as biomarker of various diseases. Food Science & Nutrition, 8(9), 4696–4707. https://doi.org/10.1002/FSN3.1818
Saltiel, A. R. (2000). Series Introduction: The molecular and physiological basis of insulin resistance: emerging implications for metabolic and cardiovascular diseases. The Journal of Clinical Investigation, 106(2), 163–164. https://doi.org/10.1172/JCI10533
Scherrer, J. F., & Lustman, P. J. (2019). Posttraumatic Stress Disorder and Incident Type 2 Diabetes: Is Obesity to Blame? Chronic Stress, 3. https://doi.org/10.1177/2470547019863415
Scherrer, J. F., Salas, J., Norman, S. B., Schnurr, P. P., Chard, K. M., Tuerk, P., Schneider, F. D., van den Berk-Clark, C., Cohen, B. E., Friedman, M. J., & Lustman, P. J. (2019). Association Between Clinically Meaningful Posttraumatic Stress Disorder Improvement and Risk of Type 2 Diabetes. JAMA Psychiatry, 76(11), 1159–1166. https://doi.org/10.1001/JAMAPSYCHIATRY.2019.2096
Senn, J. J., Klover, P. J., Nowak, I. A., & Mooney, R. A. (2002). Interleukin-6 Induces Cellular Insulin Resistance in Hepatocytes. Diabetes, 51(12), 3391–3399. https://doi.org/10.2337/DIABETES.51.12.3391
Serban, D., Papanas, N., Dascalu, A.M., Kempler, P., Raz, I., Rizvi, A.A., Rizzo, M., Tudor, C., Tudosie, M., S., Tanasescu, D., Pantea Stoian, A., Gouveri, E., Costea, D.O. (2021). Significance of Neutrophil to Lymphocyte Ratio (NLR) and Platelet Lymphocyte Ratio (PLR) in Diabetic Foot Ulcer and Potential New Therapeutic Targets. Int J Low Extrem Wounds. 18, 15347346211057742. https://doi.org/10.1177/15347346211057742
Serván, P. R. (2013). Obesity and diabetes. Nutricion Hospitalaria, 28, Suppl 5, 138–143. https://doi.org/10.3305/NH.2013.28.SUP5.6929
Sheikh, S., Dahiya, S., Ansari, A. H., & Kumar, M. M. (2019). The association of quality of life between anxiety and depression in patients with chronic rheumatic heart disease. Mediterranean Journal of Clinical Psychology, 7(2). https://doi.org/10.6092/2282-1619/2019.7.2164
Silva, J. A. D., Souza, E. C. F. D., Echazú Böschemeier, A. G., Costa, C. C. M. D., Bezerra, H. S., & Feitosa, E. E. L. C. (2018). Diagnosis of diabetes mellitus and living with a chronic condition: participatory study. BMC Public Health, 18(1), 1-8. https://doi.org/10.1186/s12889-018-5637-9
Soo, H., & Lam, S. (2009). Stress management training in diabetes mellitus. Journal of Health Psychology, 14(7), 933–943. https://doi.org/10.1177/1359105309341146
Starkebaum, G., & Harlan, J. M. (1986). Endothelial cell injury due to copper-catalyzed hydrogen peroxide generation from homocysteine. The Journal of Clinical Investigation, 77(4), 1370–1376. https://doi.org/10.1172/JCI112442
Suceveanu, A.I., Mazilu, L., Katsiki, N., Parepa, I., Voinea, F., Pantea-Stoian, A., Rizzo, M., Botea, F., Herlea, V., Serban, D., Suceveanu, A.P. (2020). NLRP3 Inflammasome Biomarker-Could Be the New Tool for Improved Cardiometabolic Syndrome Outcome. Metabolites. 6, 10(11), 448. https://doi.org/10.3390/metabo10110448
Suceveanu,A.I., Pantea Stoian,A., Parepa,I., Voinea,C., Hainarosie,R., Manuc,D., Nitipir,C., Mazilu,L. & Suceveanu,A.P.(2018).Gut microbiota patterns in obese and type 2 diabetes (t2d)patients from romanian black sea coast region, Rev Chim.(Bucharest),69(8),2260-2267.
Suzuki, T., Imai, J., Yamada, T., Ishigaki, Y., Kaneko, K., Uno, K., Hasegawa, Y., Ishihara, H., Oka, Y., & Katagiri, H. (2011). Interleukin-6 enhances glucose-stimulated insulin secretion from pancreatic beta-cells: potential involvement of the PLC-IP3-dependent pathway. Diabetes, 60(2), 537–547. https://doi.org/10.2337/DB10-0796
Tang, J., & Gao, L. (2020). Illness perceptions among patients with type 2 diabetes mellitus: A cross‐sectional study. International journal of nursing practice, 26(5), e12801. https://doi.org/10.1111/ijn.12801
van der Feltz-Cornelis, C., Allen, S. F., Holt, R. I. G., Roberts, R., Nouwen, A., & Sartorius, N. (2021). Treatment for comorbid depressive disorder or subthreshold depression in diabetes mellitus: Systematic review and meta‐analysis. Brain and Behavior, 11(2). https://doi.org/10.1002/BRB3.1981
van der Horst, K., Bucher, T., Duncanson, K., Murawski, B., & Labbe, D. (2019). Dietary Intake and Type 2. Diabetes. Nutrients, 11(9). https://doi.org/10.3390/NU11092177
Vargatu, I. (2016). William textbook of endocrinology. Acta Endocrinologica (Bucharest), 12(1), 113. https://doi.org/10.4183/AEB.2016.113
Vicario, C. M., Nitsche, M. A., Salehinejad, M. A., Avanzino, L., & Martino, G. (2020). Time processing, interoception, and insula activation: a mini-review on clinical disorders. Frontiers in psychology, 11, 1893. https://doi.org/10.3389/fpsyg.2020.01893
Vita, R., Caputo, A., Quattropani, M. C., Watt, T., Feldt-Rasmussen, U., Puleio, P., ... & Martino, G. (2020). Quality of life in patients with hyperthyroidism: where do we stand?. Mediterranean Journal of Clinical Psychology, 8(2). https://doi.org/10.6092/2282-1619/mjcp-2521
Welch, G. N., & Loscalzo, J. (2009). Homocysteine and Atherothrombosis, New England Journal of Medicine, 338(15), 1042–1050. https://doi.org/10.1056/NEJM199804093381507
Zugravu, C.,.Baciu, A., Patrascu, D., Tarcea, M. & Stoian, A.(2012).Depression and diabetes:are there any consequences on self-care?, The European Journal of Public Health, Oxford Academic.22(suppl.2),272.
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