Predictors of weight loss after bariatric surgery—a cross-disciplinary approach combining physiological, social, and psychological measures
Background Bariatric surgery leads to a substantial weight loss (WL), however, a subset of patients undergoing surgery fails to achieve adequate WL. The reason for the individual variation in WL remains unexplained. Using an exploratory cross-disciplinary approach, we aimed to identify preoperative...
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| Veröffentlicht in: | International Journal of Obesity 2020-11, Vol.44 (11), p.2291-2302 |
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| creator | Nielsen, Mette S. Christensen, Bodil Just Schmidt, Julie Berg Tækker, Louise Holm, Lotte Lunn, Susanne Ritz, Christian Wewer Albrechtsen, Nicolai J. Holst, Jens Juul Schnurr, Theresia M. Hansen, Torben le Roux, Carel W. Lund, Thomas Bøker Floyd, Andrea Karen Sjödin, Anders |
| description | Background
Bariatric surgery leads to a substantial weight loss (WL), however, a subset of patients undergoing surgery fails to achieve adequate WL. The reason for the individual variation in WL remains unexplained. Using an exploratory cross-disciplinary approach, we aimed to identify preoperative and early postoperative factors explaining the variation in WL after bariatric surgery.
Methods
Sixty-one subjects were recruited. Eighteen subjects did not receive surgery and three subjects dropped out, leaving a total sample of 40 subjects. Physiological, social, and psychological data were collected before and 6 months after surgery. All variables were analyzed in combination using a least absolute shrinkage and selection operator (LASSO) regression to explain the variation in WL 18 months after Roux-en-Y gastric bypass (
n
= 30) and sleeve gastrectomy (
n
= 10).
Results
Mean WL was 31% (range: 10–52%). The following preoperative factors predicted 59% of the variation in WL: type of surgery (14%), diabetes status (12%), economic resources (9%), sex (7%), binge eating disorder (7%), degree of depression (5%), household type (3%), and physical activity (1%). Including information on early responses after surgery increased the ability to predict WL to 78% and was explained by early WL (47%), changes in energy density of food consumed from a buffet meal (9%), changes in glicentin (5%), degree of depression (5%), sex (5%), type of surgery (2%), economic resources (2%), and changes in drive for thinness (1%).
Conclusions
Using a cross-disciplinary approach, a substantial part of the individual variation in WL was explained by a combination of basic patient characteristics, psychological profile, and social conditions as well as physiological, psychological and behavioral responses to surgery. These results suggest that patient characteristics collected in a cross-disciplinary approach may help determine predictors for less successful WL after bariatric surgery. If verified in larger cohorts this may form the basis for individualized postoperative support to optimize WL outcome. |
| doi_str_mv | 10.1038/s41366-020-0576-9 |
| format | Article |
| fullrecord | <record><control><sourceid>gale_proqu</sourceid><recordid>TN_cdi_proquest_miscellaneous_2394885606</recordid><sourceformat>XML</sourceformat><sourcesystem>PC</sourcesystem><galeid>A639118042</galeid><sourcerecordid>A639118042</sourcerecordid><originalsourceid>FETCH-LOGICAL-c470t-69fd09747fbc2720047dc1c4ebba5b5b8c3484d14e34490c4d4d3ecfec9866643</originalsourceid><addsrcrecordid>eNp1ks9qFTEUxoMo9rb6AG4kIIgLp578n1mWolUo6ELXIZNk7qTMTMZkBrk7X8CdT-iTmOttrRUli4Sc3_dxDudD6AmBUwKsfpU5YVJWQKECoWTV3EMbwstD8EbdRxtgoEpFiiN0nPMVAAgB9CE6YpRRpSjdoG8fknfBLjFlHDv8xYdtv-Ah5oxNt_iEW5OCWVKwOK9p69Pux9fvBttUiMqFbMM8hMmkHTbznKKxPbZxbMMUpi2e-10OcYjbYM3wEudow_42k8Nz3tn-poRHb4q7z4_Qg84M2T--vk_QpzevP56_rS7fX7w7P7usLFewVLLpHDSKq661VFEArpwllvu2NaIVbW0Zr7kj3DPOG7Dccce87bxtaiklZyfoxcG3tPx59XnRYxnFD4OZfFyzpqzhdS0kyII--wu9imuaSneackUEgKTiltqaweswdXFJxu5N9ZlkDSE1cFqo039Q5Tg_Bhsn34Xyf0fw_A9B782w9DkO6xLilO-C5AD-WkzynZ5TGMtaNAG9z4o-ZEWXrOh9VnRTNE-vJ1vb0bvfiptwFIAegFxKU9n97ej_d_0JKh7K-A</addsrcrecordid><sourcetype>Aggregation Database</sourcetype><iscdi>true</iscdi><recordtype>article</recordtype><pqid>2471500625</pqid></control><display><type>article</type><title>Predictors of weight loss after bariatric surgery—a cross-disciplinary approach combining physiological, social, and psychological measures</title><source>MEDLINE</source><source>Nature Journals Online</source><source>SpringerLink Journals - AutoHoldings</source><creator>Nielsen, Mette S. ; Christensen, Bodil Just ; Schmidt, Julie Berg ; Tækker, Louise ; Holm, Lotte ; Lunn, Susanne ; Ritz, Christian ; Wewer Albrechtsen, Nicolai J. ; Holst, Jens Juul ; Schnurr, Theresia M. ; Hansen, Torben ; le Roux, Carel W. ; Lund, Thomas Bøker ; Floyd, Andrea Karen ; Sjödin, Anders</creator><creatorcontrib>Nielsen, Mette S. ; Christensen, Bodil Just ; Schmidt, Julie Berg ; Tækker, Louise ; Holm, Lotte ; Lunn, Susanne ; Ritz, Christian ; Wewer Albrechtsen, Nicolai J. ; Holst, Jens Juul ; Schnurr, Theresia M. ; Hansen, Torben ; le Roux, Carel W. ; Lund, Thomas Bøker ; Floyd, Andrea Karen ; Sjödin, Anders</creatorcontrib><description>Background
Bariatric surgery leads to a substantial weight loss (WL), however, a subset of patients undergoing surgery fails to achieve adequate WL. The reason for the individual variation in WL remains unexplained. Using an exploratory cross-disciplinary approach, we aimed to identify preoperative and early postoperative factors explaining the variation in WL after bariatric surgery.
Methods
Sixty-one subjects were recruited. Eighteen subjects did not receive surgery and three subjects dropped out, leaving a total sample of 40 subjects. Physiological, social, and psychological data were collected before and 6 months after surgery. All variables were analyzed in combination using a least absolute shrinkage and selection operator (LASSO) regression to explain the variation in WL 18 months after Roux-en-Y gastric bypass (
n
= 30) and sleeve gastrectomy (
n
= 10).
Results
Mean WL was 31% (range: 10–52%). The following preoperative factors predicted 59% of the variation in WL: type of surgery (14%), diabetes status (12%), economic resources (9%), sex (7%), binge eating disorder (7%), degree of depression (5%), household type (3%), and physical activity (1%). Including information on early responses after surgery increased the ability to predict WL to 78% and was explained by early WL (47%), changes in energy density of food consumed from a buffet meal (9%), changes in glicentin (5%), degree of depression (5%), sex (5%), type of surgery (2%), economic resources (2%), and changes in drive for thinness (1%).
Conclusions
Using a cross-disciplinary approach, a substantial part of the individual variation in WL was explained by a combination of basic patient characteristics, psychological profile, and social conditions as well as physiological, psychological and behavioral responses to surgery. These results suggest that patient characteristics collected in a cross-disciplinary approach may help determine predictors for less successful WL after bariatric surgery. If verified in larger cohorts this may form the basis for individualized postoperative support to optimize WL outcome.</description><identifier>ISSN: 0307-0565</identifier><identifier>EISSN: 1476-5497</identifier><identifier>DOI: 10.1038/s41366-020-0576-9</identifier><identifier>PMID: 32327722</identifier><language>eng</language><publisher>London: Nature Publishing Group UK</publisher><subject>692/499 ; 692/700/2817 ; Adult ; Analysis ; Bariatric Surgery ; Body weight loss ; Compulsive eating ; Denmark ; Diabetes mellitus ; Eating behavior ; Eating disorders ; Economics ; Epidemiology ; Exercise ; Female ; Flux density ; Forecasting ; Gastrectomy ; Gastric Bypass ; Gastrointestinal surgery ; Health Promotion and Disease Prevention ; Humans ; Interdisciplinary aspects ; Internal Medicine ; Male ; Medicine ; Medicine & Public Health ; Mental depression ; Mental Health ; Metabolic Diseases ; Middle Aged ; Obesity ; Obesity, Morbid - surgery ; Physical activity ; Physiological aspects ; Physiology ; Prospective Studies ; Public Health ; Regression analysis ; Sex ; Social conditions ; Social networks ; Socioeconomic Factors ; Surgery ; Treatment Outcome ; Type 2 diabetes ; Variation ; Weight Loss ; Weight loss measurement</subject><ispartof>International Journal of Obesity, 2020-11, Vol.44 (11), p.2291-2302</ispartof><rights>The Author(s), under exclusive licence to Springer Nature Limited 2020</rights><rights>COPYRIGHT 2020 Nature Publishing Group</rights><rights>The Author(s), under exclusive licence to Springer Nature Limited 2020.</rights><lds50>peer_reviewed</lds50><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-c470t-69fd09747fbc2720047dc1c4ebba5b5b8c3484d14e34490c4d4d3ecfec9866643</citedby><cites>FETCH-LOGICAL-c470t-69fd09747fbc2720047dc1c4ebba5b5b8c3484d14e34490c4d4d3ecfec9866643</cites><orcidid>0000-0003-0363-6090 ; 0000-0003-0667-7779 ; 0000-0002-5095-0624 ; 0000-0002-6812-1867 ; 0000-0001-5521-5445 ; 0000-0002-6573-4959 ; 0000-0001-7354-4648 ; 0000-0002-0299-7874 ; 0000-0001-6853-3805 ; 0000-0001-5282-1562 ; 0000-0001-8748-3831 ; 0000-0003-4230-5753</orcidid></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><linktopdf>$$Uhttps://link.springer.com/content/pdf/10.1038/s41366-020-0576-9$$EPDF$$P50$$Gspringer$$H</linktopdf><linktohtml>$$Uhttps://link.springer.com/10.1038/s41366-020-0576-9$$EHTML$$P50$$Gspringer$$H</linktohtml><link.rule.ids>314,778,782,27907,27908,41471,42540,51302</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/32327722$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>Nielsen, Mette S.</creatorcontrib><creatorcontrib>Christensen, Bodil Just</creatorcontrib><creatorcontrib>Schmidt, Julie Berg</creatorcontrib><creatorcontrib>Tækker, Louise</creatorcontrib><creatorcontrib>Holm, Lotte</creatorcontrib><creatorcontrib>Lunn, Susanne</creatorcontrib><creatorcontrib>Ritz, Christian</creatorcontrib><creatorcontrib>Wewer Albrechtsen, Nicolai J.</creatorcontrib><creatorcontrib>Holst, Jens Juul</creatorcontrib><creatorcontrib>Schnurr, Theresia M.</creatorcontrib><creatorcontrib>Hansen, Torben</creatorcontrib><creatorcontrib>le Roux, Carel W.</creatorcontrib><creatorcontrib>Lund, Thomas Bøker</creatorcontrib><creatorcontrib>Floyd, Andrea Karen</creatorcontrib><creatorcontrib>Sjödin, Anders</creatorcontrib><title>Predictors of weight loss after bariatric surgery—a cross-disciplinary approach combining physiological, social, and psychological measures</title><title>International Journal of Obesity</title><addtitle>Int J Obes</addtitle><addtitle>Int J Obes (Lond)</addtitle><description>Background
Bariatric surgery leads to a substantial weight loss (WL), however, a subset of patients undergoing surgery fails to achieve adequate WL. The reason for the individual variation in WL remains unexplained. Using an exploratory cross-disciplinary approach, we aimed to identify preoperative and early postoperative factors explaining the variation in WL after bariatric surgery.
Methods
Sixty-one subjects were recruited. Eighteen subjects did not receive surgery and three subjects dropped out, leaving a total sample of 40 subjects. Physiological, social, and psychological data were collected before and 6 months after surgery. All variables were analyzed in combination using a least absolute shrinkage and selection operator (LASSO) regression to explain the variation in WL 18 months after Roux-en-Y gastric bypass (
n
= 30) and sleeve gastrectomy (
n
= 10).
Results
Mean WL was 31% (range: 10–52%). The following preoperative factors predicted 59% of the variation in WL: type of surgery (14%), diabetes status (12%), economic resources (9%), sex (7%), binge eating disorder (7%), degree of depression (5%), household type (3%), and physical activity (1%). Including information on early responses after surgery increased the ability to predict WL to 78% and was explained by early WL (47%), changes in energy density of food consumed from a buffet meal (9%), changes in glicentin (5%), degree of depression (5%), sex (5%), type of surgery (2%), economic resources (2%), and changes in drive for thinness (1%).
Conclusions
Using a cross-disciplinary approach, a substantial part of the individual variation in WL was explained by a combination of basic patient characteristics, psychological profile, and social conditions as well as physiological, psychological and behavioral responses to surgery. These results suggest that patient characteristics collected in a cross-disciplinary approach may help determine predictors for less successful WL after bariatric surgery. If verified in larger cohorts this may form the basis for individualized postoperative support to optimize WL outcome.</description><subject>692/499</subject><subject>692/700/2817</subject><subject>Adult</subject><subject>Analysis</subject><subject>Bariatric Surgery</subject><subject>Body weight loss</subject><subject>Compulsive eating</subject><subject>Denmark</subject><subject>Diabetes mellitus</subject><subject>Eating behavior</subject><subject>Eating disorders</subject><subject>Economics</subject><subject>Epidemiology</subject><subject>Exercise</subject><subject>Female</subject><subject>Flux density</subject><subject>Forecasting</subject><subject>Gastrectomy</subject><subject>Gastric Bypass</subject><subject>Gastrointestinal surgery</subject><subject>Health Promotion and Disease Prevention</subject><subject>Humans</subject><subject>Interdisciplinary aspects</subject><subject>Internal Medicine</subject><subject>Male</subject><subject>Medicine</subject><subject>Medicine & Public Health</subject><subject>Mental depression</subject><subject>Mental Health</subject><subject>Metabolic Diseases</subject><subject>Middle Aged</subject><subject>Obesity</subject><subject>Obesity, Morbid - surgery</subject><subject>Physical activity</subject><subject>Physiological aspects</subject><subject>Physiology</subject><subject>Prospective Studies</subject><subject>Public Health</subject><subject>Regression analysis</subject><subject>Sex</subject><subject>Social conditions</subject><subject>Social networks</subject><subject>Socioeconomic Factors</subject><subject>Surgery</subject><subject>Treatment Outcome</subject><subject>Type 2 diabetes</subject><subject>Variation</subject><subject>Weight Loss</subject><subject>Weight loss 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of weight loss after bariatric surgery—a cross-disciplinary approach combining physiological, social, and psychological measures</title><author>Nielsen, Mette S. ; Christensen, Bodil Just ; Schmidt, Julie Berg ; Tækker, Louise ; Holm, Lotte ; Lunn, Susanne ; Ritz, Christian ; Wewer Albrechtsen, Nicolai J. ; Holst, Jens Juul ; Schnurr, Theresia M. ; Hansen, Torben ; le Roux, Carel W. ; Lund, Thomas Bøker ; Floyd, Andrea Karen ; Sjödin, Anders</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-c470t-69fd09747fbc2720047dc1c4ebba5b5b8c3484d14e34490c4d4d3ecfec9866643</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2020</creationdate><topic>692/499</topic><topic>692/700/2817</topic><topic>Adult</topic><topic>Analysis</topic><topic>Bariatric Surgery</topic><topic>Body weight loss</topic><topic>Compulsive eating</topic><topic>Denmark</topic><topic>Diabetes mellitus</topic><topic>Eating behavior</topic><topic>Eating disorders</topic><topic>Economics</topic><topic>Epidemiology</topic><topic>Exercise</topic><topic>Female</topic><topic>Flux density</topic><topic>Forecasting</topic><topic>Gastrectomy</topic><topic>Gastric Bypass</topic><topic>Gastrointestinal surgery</topic><topic>Health Promotion and Disease Prevention</topic><topic>Humans</topic><topic>Interdisciplinary aspects</topic><topic>Internal Medicine</topic><topic>Male</topic><topic>Medicine</topic><topic>Medicine & Public Health</topic><topic>Mental depression</topic><topic>Mental Health</topic><topic>Metabolic Diseases</topic><topic>Middle Aged</topic><topic>Obesity</topic><topic>Obesity, Morbid - surgery</topic><topic>Physical activity</topic><topic>Physiological aspects</topic><topic>Physiology</topic><topic>Prospective Studies</topic><topic>Public Health</topic><topic>Regression analysis</topic><topic>Sex</topic><topic>Social conditions</topic><topic>Social networks</topic><topic>Socioeconomic Factors</topic><topic>Surgery</topic><topic>Treatment Outcome</topic><topic>Type 2 diabetes</topic><topic>Variation</topic><topic>Weight Loss</topic><topic>Weight loss measurement</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>Nielsen, Mette S.</creatorcontrib><creatorcontrib>Christensen, Bodil Just</creatorcontrib><creatorcontrib>Schmidt, Julie Berg</creatorcontrib><creatorcontrib>Tækker, Louise</creatorcontrib><creatorcontrib>Holm, Lotte</creatorcontrib><creatorcontrib>Lunn, Susanne</creatorcontrib><creatorcontrib>Ritz, Christian</creatorcontrib><creatorcontrib>Wewer Albrechtsen, Nicolai J.</creatorcontrib><creatorcontrib>Holst, Jens Juul</creatorcontrib><creatorcontrib>Schnurr, Theresia M.</creatorcontrib><creatorcontrib>Hansen, Torben</creatorcontrib><creatorcontrib>le Roux, Carel W.</creatorcontrib><creatorcontrib>Lund, Thomas Bøker</creatorcontrib><creatorcontrib>Floyd, Andrea Karen</creatorcontrib><creatorcontrib>Sjödin, 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Louise</au><au>Holm, Lotte</au><au>Lunn, Susanne</au><au>Ritz, Christian</au><au>Wewer Albrechtsen, Nicolai J.</au><au>Holst, Jens Juul</au><au>Schnurr, Theresia M.</au><au>Hansen, Torben</au><au>le Roux, Carel W.</au><au>Lund, Thomas Bøker</au><au>Floyd, Andrea Karen</au><au>Sjödin, Anders</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Predictors of weight loss after bariatric surgery—a cross-disciplinary approach combining physiological, social, and psychological measures</atitle><jtitle>International Journal of Obesity</jtitle><stitle>Int J Obes</stitle><addtitle>Int J Obes (Lond)</addtitle><date>2020-11-01</date><risdate>2020</risdate><volume>44</volume><issue>11</issue><spage>2291</spage><epage>2302</epage><pages>2291-2302</pages><issn>0307-0565</issn><eissn>1476-5497</eissn><abstract>Background
Bariatric surgery leads to a substantial weight loss (WL), however, a subset of patients undergoing surgery fails to achieve adequate WL. The reason for the individual variation in WL remains unexplained. Using an exploratory cross-disciplinary approach, we aimed to identify preoperative and early postoperative factors explaining the variation in WL after bariatric surgery.
Methods
Sixty-one subjects were recruited. Eighteen subjects did not receive surgery and three subjects dropped out, leaving a total sample of 40 subjects. Physiological, social, and psychological data were collected before and 6 months after surgery. All variables were analyzed in combination using a least absolute shrinkage and selection operator (LASSO) regression to explain the variation in WL 18 months after Roux-en-Y gastric bypass (
n
= 30) and sleeve gastrectomy (
n
= 10).
Results
Mean WL was 31% (range: 10–52%). The following preoperative factors predicted 59% of the variation in WL: type of surgery (14%), diabetes status (12%), economic resources (9%), sex (7%), binge eating disorder (7%), degree of depression (5%), household type (3%), and physical activity (1%). Including information on early responses after surgery increased the ability to predict WL to 78% and was explained by early WL (47%), changes in energy density of food consumed from a buffet meal (9%), changes in glicentin (5%), degree of depression (5%), sex (5%), type of surgery (2%), economic resources (2%), and changes in drive for thinness (1%).
Conclusions
Using a cross-disciplinary approach, a substantial part of the individual variation in WL was explained by a combination of basic patient characteristics, psychological profile, and social conditions as well as physiological, psychological and behavioral responses to surgery. These results suggest that patient characteristics collected in a cross-disciplinary approach may help determine predictors for less successful WL after bariatric surgery. If verified in larger cohorts this may form the basis for individualized postoperative support to optimize WL outcome.</abstract><cop>London</cop><pub>Nature Publishing Group UK</pub><pmid>32327722</pmid><doi>10.1038/s41366-020-0576-9</doi><tpages>12</tpages><orcidid>https://orcid.org/0000-0003-0363-6090</orcidid><orcidid>https://orcid.org/0000-0003-0667-7779</orcidid><orcidid>https://orcid.org/0000-0002-5095-0624</orcidid><orcidid>https://orcid.org/0000-0002-6812-1867</orcidid><orcidid>https://orcid.org/0000-0001-5521-5445</orcidid><orcidid>https://orcid.org/0000-0002-6573-4959</orcidid><orcidid>https://orcid.org/0000-0001-7354-4648</orcidid><orcidid>https://orcid.org/0000-0002-0299-7874</orcidid><orcidid>https://orcid.org/0000-0001-6853-3805</orcidid><orcidid>https://orcid.org/0000-0001-5282-1562</orcidid><orcidid>https://orcid.org/0000-0001-8748-3831</orcidid><orcidid>https://orcid.org/0000-0003-4230-5753</orcidid></addata></record> |
| fulltext | fulltext |
| identifier | ISSN: 0307-0565 |
| ispartof | International Journal of Obesity, 2020-11, Vol.44 (11), p.2291-2302 |
| issn | 0307-0565 1476-5497 |
| language | eng |
| recordid | cdi_proquest_miscellaneous_2394885606 |
| source | MEDLINE; Nature Journals Online; SpringerLink Journals - AutoHoldings |
| subjects | 692/499 692/700/2817 Adult Analysis Bariatric Surgery Body weight loss Compulsive eating Denmark Diabetes mellitus Eating behavior Eating disorders Economics Epidemiology Exercise Female Flux density Forecasting Gastrectomy Gastric Bypass Gastrointestinal surgery Health Promotion and Disease Prevention Humans Interdisciplinary aspects Internal Medicine Male Medicine Medicine & Public Health Mental depression Mental Health Metabolic Diseases Middle Aged Obesity Obesity, Morbid - surgery Physical activity Physiological aspects Physiology Prospective Studies Public Health Regression analysis Sex Social conditions Social networks Socioeconomic Factors Surgery Treatment Outcome Type 2 diabetes Variation Weight Loss Weight loss measurement |
| title | Predictors of weight loss after bariatric surgery—a cross-disciplinary approach combining physiological, social, and psychological measures |
| url | https://sfx.bib-bvb.de/sfx_tum?ctx_ver=Z39.88-2004&ctx_enc=info:ofi/enc:UTF-8&ctx_tim=2025-01-16T21%3A25%3A04IST&url_ver=Z39.88-2004&url_ctx_fmt=infofi/fmt:kev:mtx:ctx&rfr_id=info:sid/primo.exlibrisgroup.com:primo3-Article-gale_proqu&rft_val_fmt=info:ofi/fmt:kev:mtx:journal&rft.genre=article&rft.atitle=Predictors%20of%20weight%20loss%20after%20bariatric%20surgery%E2%80%94a%20cross-disciplinary%20approach%20combining%20physiological,%20social,%20and%20psychological%20measures&rft.jtitle=International%20Journal%20of%20Obesity&rft.au=Nielsen,%20Mette%20S.&rft.date=2020-11-01&rft.volume=44&rft.issue=11&rft.spage=2291&rft.epage=2302&rft.pages=2291-2302&rft.issn=0307-0565&rft.eissn=1476-5497&rft_id=info:doi/10.1038/s41366-020-0576-9&rft_dat=%3Cgale_proqu%3EA639118042%3C/gale_proqu%3E%3Curl%3E%3C/url%3E&disable_directlink=true&sfx.directlink=off&sfx.report_link=0&rft_id=info:oai/&rft_pqid=2471500625&rft_id=info:pmid/32327722&rft_galeid=A639118042&rfr_iscdi=true |