The Effects of Acceptance and Commitment Therapy (ACT) Intervention on Inflammation and Stress Biomarkers: a Randomized Controlled Trial

Elina Järvelä-Reijonen, Sampsa Puttonen, Leila Karhunen, Essi Sairanen, Jaana Laitinen, Mikko Kolehmainen, Jussi Pihlajamäki, Urho M Kujala, Riitta Korpela, Miikka Ermes, Raimo Lappalainen, Marjukka Kolehmainen, Elina Järvelä-Reijonen, Sampsa Puttonen, Leila Karhunen, Essi Sairanen, Jaana Laitinen, Mikko Kolehmainen, Jussi Pihlajamäki, Urho M Kujala, Riitta Korpela, Miikka Ermes, Raimo Lappalainen, Marjukka Kolehmainen

Abstract

Background: Psychological processes can be manifested in physiological health. We investigated whether acceptance and commitment therapy (ACT), targeted on psychological flexibility (PF), influences inflammation and stress biomarkers among working-age adults with psychological distress and overweight/obesity.

Method: Participants were randomized into three parallel groups: (1) ACT-based face-to-face (n = 65; six group sessions led by a psychologist), (2) ACT-based mobile (n = 73; one group session and mobile app), and (3) control (n = 66; only the measurements). Systemic inflammation and stress markers were analyzed at baseline, at 10 weeks after the baseline (post-intervention), and at 36 weeks after the baseline (follow-up). General PF and weight-related PF were measured with questionnaires (Acceptance and Action Questionnaire, Acceptance and Action Questionnaire for Weight-Related Difficulties).

Results: A group × time interaction (p = .012) was detected in the high-sensitivity C-reactive protein (hsCRP) level but not in other inflammation and stress biomarkers. hsCRP decreased significantly in the face-to-face group from week 0 to week 36, and at week 36, hsCRP was lower among the participants in the face-to-face group than in the mobile group (p = .035, post hoc test). Age and sex were stronger predictors of biomarker levels at follow-up than the post-intervention PF.

Conclusion: The results suggest that ACT delivered in group sessions may exert beneficial effects on low-grade systemic inflammation. More research is needed on how to best apply psychological interventions for the health of both mind and body among people with overweight/obesity and psychological distress.

Trial registration: ClinicalTrials.gov Identifier: NCT01738256, Registered 17 August, 2012.

Keywords: ACT; Low-grade inflammation; Mindfulness; Obesity; Psychological flexibility; Stress.

Conflict of interest statement

The authors declare that they have no conflict of interest.

Figures

Fig. 1
Fig. 1
The effects of ACT intervention on logarithmized hsCRP adjusted for study center and starting time of the study. The values are log-transformed estimated (adjusted for study center and starting time of the study) marginal means ± standard error (SE). The measurements were conducted before the intervention (baseline, study week 0), after the 8-week intervention period (study week 10), and 36 weeks after the baseline measurements (study week 36). The group × time interaction for the entire study period was significant (p = .012). The face-to-face and mobile groups had a significant difference at week 36 (p = .035, post hoc test, indicated with an asterisk). The decrease of hsCRP from week 0 to week 36 and from week 10 to week 36 was significant in the face-to-face group (p = .045 and p = .014, respectively)

References

    1. Antonelli M, Kushner I. It’s time to redefine inflammation. FASEB J. 2017;31(5):1787–1791.
    1. Hotamisligil GS. Inflammation and metabolic disorders. Nature. 2006;444(7121):860–867.
    1. Hotamisligil GS. Inflammation, metaflammation and immunometabolic disorders. Nature. 2017;542(7640):177–185.
    1. Calder PC, Ahluwalia N, Albers R, Bosco N, Bourdet-Sicard R, Haller D, Holgate ST, Jönsson LS, Latulippe ME, Marcos A, Moreines J, M'Rini C, Müller M, Pawelec G, van Neerven RJJ, Watzl B, Zhao J. A consideration of biomarkers to be used for evaluation of inflammation in human nutritional studies. Br J Nutr. 2013;109(Suppl 1):S1–34.
    1. Ahonen TM, Saltevo JT, Kautiainen HJ, Kumpusalo EA, Vanhala MJ. The association of adiponectin and low-grade inflammation with the course of metabolic syndrome. Nutr Metab Cardiovasc Dis. 2012;22(3):285–291.
    1. Wirtz PH, von Känel R. Psychological stress, inflammation, and coronary heart disease. Curr Cardiol Rep. 2017;19(11):111. doi: 10.1007/s11886-017-0919-x.
    1. Epel ES, Crosswell AD, Mayer SE, Prather AA, Slavich GM, Puterman E, Mendes WB. More than a feeling: a unified view of stress measurement for population science. Front Neuroendocrinol. 2018;49:146–169.
    1. Cohen S, Kessler R, Gordon U. Strategies for measuring stress in studies of psychiatric and physical disorders. In: Cohen S, Kessler R, Gordon U, editors. Measuring stress: a guide for health and social scientists. Oxford University Press; 1997. pp. 3–26.
    1. Cohen S, Gianaros PJ, Manuck SB. A stage model of stress and disease. Perspect Psychol Sci. 2016;11(4):456–463.
    1. Stratakis CA, Chrousos GP. Neuroendocrinology and pathophysiology of the stress system. Ann N Y Acad Sci. 1995;771:1–18.
    1. Miller GE, Chen E, Zhou ES. If it goes up, must it come down? Chronic stress and the hypothalamic-pituitary-adrenocortical axis in humans. Psychol Bull. 2007;133(1):25–45.
    1. Kamin HS, Kertes DA. Cortisol and DHEA in development and psychopathology. Horm Behav. 2017;89:69–85.
    1. Tomiyama AJ, Dallman MF, Epel ES. Comfort food is comforting to those most stressed: evidence of the chronic stress response network in high stress women. Psychoneuroendocrinology. 2011;36(10):1513–1519.
    1. Wolkowitz OM, Epel ES, Reus VI. Stress hormone-related psychopathology: pathophysiological and treatment implications. World J Biol Psychiatry. 2001;2(3):115–143.
    1. Adam EK, Quinn ME, Tavernier R, McQuillan MT, Dahlke KA, Gilbert KE. Diurnal cortisol slopes and mental and physical health outcomes: a systematic review and meta-analysis. Psychoneuroendocrinology. 2017;83:25–41.
    1. Maninger N, Wolkowitz OM, Reus VI, Epel ES, Mellon SH. Neurobiological and neuropsychiatric effects of dehydroepiandrosterone (DHEA) and DHEA sulfate (DHEAS) Front Neuroendocrinol. 2009;30(1):65–91.
    1. Traish AM, Kang HP, Saad F, Guay AT. Dehydroepiandrosterone (DHEA)--a precursor steroid or an active hormone in human physiology. J Sex Med. 2011;8(11):2960–2982.
    1. McEwen BS, Stellar E. Stress and the individual: mechanisms leading to disease. Arch Intern Med. 1993;153:2093–2101.
    1. McEwen BS. Protective and damaging effects of stress mediators. N Engl J Med. 1998;338(3):171–179.
    1. McEwen BS, Seeman T. Protective and damaging effects of mediators of stress. Elaborating and testing the concepts of allostasis and allostatic load. Ann N Y Acad Sci. 1999;896:30–47.
    1. McEwen BS. Biomarkers for assessing population and individual health and disease related to stress and adaptation. Metabolism. 2015;64(3 Suppl 1):S2–S10.
    1. Calder PC, Ahluwalia N, Brouns F, Buetler T, Clement K, Cunningham K, Esposito K, Jönsson LS, Kolb H, Lansink M, Marcos A, Margioris A, Matusheski N, Nordmann H, O'Brien J, Pugliese G, Rizkalla S, Schalkwijk C, Tuomilehto J, Wärnberg J, Watzl B, Winklhofer-Roob BM. Dietary factors and low-grade inflammation in relation to overweight and obesity. Br J Nutr. 2011;106(Suppl 3):S5–S78.
    1. Kanerva N, Kaartinen NE, Rissanen H, Knekt P, Eriksson JG, Sääksjärvi K, Sundvall J, Männistö S. Associations of the Baltic Sea diet with cardiometabolic risk factors--a meta-analysis of three Finnish studies. Br J Nutr. 2014;112(4):616–626.
    1. Kolehmainen M, Ulven SM, Paananen J, de Mello V, Schwab U, Carlberg C, Myhrstad M, Pihlajamäki J, Dungner E, Sjölin E, Gunnarsdottir I, Cloetens L, Landin-Olsson M, Akesson B, Rosqvist F, Hukkanen J, Herzig KH, Dragsted LO, Savolainen MJ, Brader L, Hermansen K, Risérus U, Thorsdottir I, Poutanen KS, Uusitupa M, Arner P, Dahlman I. Healthy Nordic diet downregulates the expression of genes involved in inflammation in subcutaneous adipose tissue in individuals with features of the metabolic syndrome. Am J Clin Nutr. 2015;101(1):228–239.
    1. Langeveld M, DeVries JH. The long-term effect of energy restricted diets for treating obesity. Obesity (Silver Spring) 2015;23(8):1529–1538.
    1. Kayman S, Bruvold W, Stern JS. Maintenance and relapse after weight loss in women: behavioral aspects. Am J Clin Nutr. 1990;52(5):800–807.
    1. Byrne S, Cooper Z, Fairburn C. Weight maintenance and relapse in obesity: a qualitative study. Int J Obes Relat Metab Disord. 2003;27(8):955–962.
    1. Byrne SM, Cooper Z, Fairburn CG. Psychological predictors of weight regain in obesity. Behav Res Ther. 2004;42(11):1341–1356.
    1. Hayes SC, Luoma JB, Bond FW, Masuda A, Lillis J. Acceptance and commitment therapy: model, processes and outcomes. Behav Res Ther. 2006;44(1):1–25.
    1. Kashdan TB, Rottenberg J. Psychological flexibility as a fundamental aspect of health. Clin Psychol Rev. 2010;30(7):865–878.
    1. Garland EL, Howard MO. A transdiagnostic perspective on cognitive, affective, and neurobiological processes underlying human suffering. Res Soc Work Pract. 2014;24(1):142–151.
    1. Nevanperä N, Lappalainen R, Kuosma E, Hopsu L, Uitti J, Laitinen J. Psychological flexibility, occupational burnout and eating behavior among working women. Open J Prev Med. 2013;3(4):355–361.
    1. de Lauzon B, Romon M, Deschamps V, Lafay L, Borys JM, Karlsson J, Ducimetière P, Charles MA, Fleurbaix Laventie Ville Sante Study Group The Three-Factor Eating Questionnaire-R18 is able to distinguish among different eating patterns in a general population. J Nutr. 2004;134(9):2372–2380.
    1. Keskitalo K, Tuorila H, Spector TD, Cherkas LF, Knaapila A, Kaprio J, Silventoinen K, Perola M. The Three-Factor Eating Questionnaire, body mass index, and responses to sweet and salty fatty foods: a twin study of genetic and environmental associations. Am J Clin Nutr. 2008;88(2):263–271.
    1. Nevanperä NJ, Hopsu L, Kuosma E, Ukkola O, Uitti J, Laitinen JH. Occupational burnout, eating behavior, and weight among working women. Am J Clin Nutr. 2012;95(4):934–943.
    1. Hayes SC, Hofmann SG. The third wave of cognitive behavioral therapy and the rise of process-based care. World Psychiatry. 2017;16(3):245–246.
    1. Gregg JA, Namekata MS, Louie WA, Chancellor-Freeland C. Impact of values clarification on cortisol reactivity to an acute stressor. J Contextual Behav Sci. 2014;3:299–304.
    1. Gloster AT, Klotsche J, Aggeler T, et al. Psychoneuroendocrine evaluation of an acceptance and commitment based stress management training. Psychother Res. 2017:1–11. 10.1080/10503307.2017.1380862.
    1. Dalen J, Smith BW, Shelley BM, Sloan AL, Leahigh L, Begay D. Pilot study: Mindful Eating and Living (MEAL): weight, eating behavior, and psychological outcomes associated with a mindfulness-based intervention for people with obesity. Complement Ther Med. 2010;18(6):260–264.
    1. Fang CY, Reibel DK, Longacre ML, Rosenzweig S, Campbell DE, Douglas SD. Enhanced psychosocial well-being following participation in a mindfulness-based stress reduction program is associated with increased natural killer cell activity. J Altern Complement Med. 2010;16(5):531–538.
    1. Jensen CG, Vangkilde S, Frokjaer V, Hasselbalch SG. Mindfulness training affects attention--or is it attentional effort? J Exp Psychol Gen. 2012;141(1):106–123.
    1. Bower JE, Irwin MR. Mind-body therapies and control of inflammatory biology: a descriptive review. Brain Behav Immun. 2016;51:1–11.
    1. Black DS, Slavich GM. Mindfulness meditation and the immune system: a systematic review of randomized controlled trials. Ann N Y Acad Sci. 2016;1373(1):13–24.
    1. Pascoe MC, Thompson DR, Jenkins ZM, Ski CF. Mindfulness mediates the physiological markers of stress: systematic review and meta-analysis. J Psychiatr Res. 2017;95:156–178.
    1. Lappalainen R, Sairanen E, Järvelä E, et al. The effectiveness and applicability of different lifestyle interventions for enhancing wellbeing: the study design for a randomized controlled trial for persons with metabolic syndrome risk factors and psychological distress. BMC Public Health. 2014;14:310. 10.1186/1471-2458-14-310.
    1. Goldberg D. The detection of psychiatric illness by questionnaire. Maudsley monograph no. 21. Oxford: Oxford University Press; 1972.
    1. Myers GL, Rifai N, Tracy RP, Roberts WL, Alexander RW, Biasucci LM, Catravas JD, Cole TG, Cooper GR, Khan BV, Kimberly MM, Stein EA, Taubert KA, Warnick GR, Waymack PP. CDC., AHA. CDC/AHA workshop on markers of inflammation and cardiovascular disease: application to clinical and public health practice: report from the laboratory science discussion group. Circulation. 2004;110(25):e545–e549.
    1. Järvelä-Reijonen E, Karhunen L, Sairanen E, et al. The effects of acceptance and commitment therapy on eating behavior and diet delivered through face-to-face contact and a mobile app: a randomized controlled trial. Int J Behav Nutr Phys Act. 2018;15:22. 10.1186/s12966-018-0654-8.
    1. Ahtinen A, Mattila E, Välkkynen P, et al. Mobile mental wellness training for stress management: feasibility and design implications based on a one-month field study. JMIR Mhealth Uhealth. 2013;1(2):e11. doi: 10.2196/mhealth.2596.
    1. Mattila E, Lappalainen R, Välkkynen P, et al. Usage and dose response of a mobile acceptance and commitment therapy app: secondary analysis of the intervention arm of a randomized controlled trial. JMIR Mhealth Uhealth. 2016;4:e90. 10.2196/mhealth.5241.
    1. Saltevo J, Vanhala M, Kautiainen H, Kumpusalo E, Laakso M. Association of C-reactive protein, interleukin-1 receptor antagonist and adiponectin with the metabolic syndrome. Mediators Inflamm. 2007;2007:93573. doi: 10.1155/2007/93573.
    1. Sollberger S, Ehlert U. How to use and interpret hormone ratios. Psychoneuroendocrinology. 2016;63:385–397.
    1. Bond FW, Hayes SC, Baer RA, Carpenter KM, Guenole N, Orcutt HK, Waltz T, Zettle RD. Preliminary psychometric properties of the Acceptance and Action Questionnaire-II: a revised measure of psychological inflexibility and experiential avoidance. Behav Ther. 2011;42(4):676–688.
    1. Lillis J, Hayes SC. Measuring avoidance and inflexibility in weight related problems. Int J Behav Consult Ther. 2008;4(4):348–354.
    1. Holi MM, Marttunen M, Aalberg V. Comparison of the GHQ-36, the GHQ-12 and the SCL-90 as psychiatric screening instruments in the Finnish population. Nord J Psychiatry. 2003;57(3):233–238.
    1. Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav. 1983;24(4):385–396.
    1. Lee EH. Review of the psychometric evidence of the perceived stress scale. Asian Nurs Res (Korean Soc Nurs Sci) 2012;6(4):121–127.
    1. Beck AT, Steer RA, Ball R, Ranieri W. Comparison of Beck Depression Inventories -IA and -II in psychiatric outpatients. J Pers Assess. 1996;67(3):588–597.
    1. Leppälä J, Lagström H, Kaljonen A, Laitinen K. Construction and evaluation of a self-contained index for assessment of diet quality. Scand J Public Health. 2010;38(8):794–802.
    1. Bush K, Kivlahan DR, McDonell MB, Fihn SD, Bradley KA. The AUDIT alcohol consumption questions (AUDIT-C): an effective brief screening test for problem drinking. Ambulatory Care Quality Improvement Project (ACQUIP). Alcohol Use Disorders Identification Test. Arch Intern Med. 1998;158(16):1789–1795.
    1. Helldán A, Raulio S, Kosola M, Tapanainen H, Ovaskainen M, Virtanen S. Finravinto 2012-tutkimus—the national FINDIET 2012 Survey. Helsinki: THL Report. 2013;16.
    1. Järvelä-Reijonen E, Karhunen L, Sairanen E, et al. High perceived stress is associated with unfavorable eating behavior in overweight and obese Finns of working age. Appetite. 2016;103:249–58.
    1. Kujala UM, Kaprio J, Sarna S, Koskenvuo M. Relationship of leisure-time physical activity and mortality: the Finnish twin cohort. JAMA. 1998;279(6):440–444.
    1. Waller K, Kaprio J, Kujala UM. Associations between long-term physical activity, waist circumference and weight gain: a 30-year longitudinal twin study. Int J Obes. 2008;32(2):353–361.
    1. Field A. Discovering statistics using IBM SPSS statistics: and sex and drugs and rock ‘n’ roll. 4th ed. Los Angeles; London: Sage cop.; 2013.
    1. Montanelli RG, Humphreys LG. Latent roots of random data correlation matrices with squared multiple correlations on the diagonal: a Monte Carlo study. Psychometrika. 1976;41(3):341–348.
    1. Lance CE, Butts MM, Michels LC. The sources of four commonly reported cutoff criteria: what did they really say? Organ Res Methods. 2006;9(2):202–220.
    1. Jolliffe IT. Principal component analysis. 2. New York: Springer; 2002.
    1. Pearson TA, Mensah GA, Alexander RW, Anderson JL, Cannon RO, III, Criqui M, Fadl YY, Fortmann SP, Hong Y, Myers GL, Rifai N, Smith SC, Jr, Taubert K, Tracy RP, Vinicor F. Markers of inflammation and cardiovascular disease: application to clinical and public health practice: a statement for healthcare professionals from the Centers for Disease Control and Prevention and the American Heart Association. Circulation. 2003;107(3):499–511.
    1. Sairanen E, Tolvanen A, Karhunen L, Kolehmainen M, Järvelä-Reijonen E, Lindroos S, Peuhkuri K, Korpela R, Ermes M, Mattila E, Lappalainen R. Psychological flexibility mediates change in intuitive eating regulation in acceptance and commitment therapy interventions. Public Health Nutr. 2017;20:1681–1691.
    1. Heckenberg RA, Eddy P, Kent S, Wright BJ. Do workplace-based mindfulness meditation programs improve physiological indices of stress? A systematic review and meta-analysis. J Psychosom Res. 2018;114:62–71.
    1. Ridker PM, Cook N. Clinical usefulness of very high and very low levels of C-reactive protein across the full range of Framingham risk scores. Circulation. 2004;109(16):1955–1959.
    1. Malarkey WB, Jarjoura D, Klatt M. Workplace based mindfulness practice and inflammation: a randomized trial. Brain Behav Immun. 2013;27(1):145–154.
    1. Daubenmier J, Moran PJ, Kristeller J, Acree M, Bacchetti P, Kemeny ME, Dallman M, Lustig RH, Grunfeld C, Nixon DF, Milush JM, Goldman V, Laraia B, Laugero KD, Woodhouse L, Epel ES, Hecht FM. Effects of a mindfulness-based weight loss intervention in adults with obesity: a randomized clinical trial. Obesity (Silver Spring) 2016;24(4):794–804.
    1. Creswell JD, Irwin MR, Burklund LJ, Lieberman MD, Arevalo JMG, Ma J, Breen EC, Cole SW. Mindfulness-based stress reduction training reduces loneliness and pro-inflammatory gene expression in older adults: a small randomized controlled trial. Brain Behav Immun. 2012;26(7):1095–1101.
    1. Uusitupa M, Schwab U. Diet, inflammation and prediabetes-impact of quality of diet. Can J Diabetes. 2013;37(5):327–331.
    1. Bjermo H, Iggman D, Kullberg J, Dahlman I, Johansson L, Persson L, Berglund J, Pulkki K, Basu S, Uusitupa M, Rudling M, Arner P, Cederholm T, Ahlström H, Risérus U. Effects of n-6 PUFAs compared with SFAs on liver fat, lipoproteins, and inflammation in abdominal obesity: a randomized controlled trial. Am J Clin Nutr. 2012;95(5):1003–1012.
    1. Uusitupa M, Hermansen K, Savolainen MJ, Schwab U, Kolehmainen M, Brader L, Mortensen LS, Cloetens L, Johansson-Persson A, Önning G, Landin-Olsson M, Herzig KH, Hukkanen J, Rosqvist F, Iggman D, Paananen J, Pulkki KJ, Siloaho M, Dragsted L, Barri T, Overvad K, Bach Knudsen KE, Hedemann MS, Arner P, Dahlman I, Borge GIA, Baardseth P, Ulven SM, Gunnarsdottir I, Jónsdóttir S, Thorsdottir I, Orešič M, Poutanen KS, Risérus U, Åkesson B. Effects of an isocaloric healthy Nordic diet on insulin sensitivity, lipid profile and inflammation markers in metabolic syndrome -- a randomized study (SYSDIET) J Intern Med. 2013;274(1):52–66.
    1. Chacko SA, Yeh GY, Davis RB, Wee CC. A mindfulness-based intervention to control weight after bariatric surgery: preliminary results from a randomized controlled pilot trial. Complement Ther Med. 2016;28:13–21.
    1. Daubenmier J, Kristeller J, Hecht FM, et al. Mindfulness intervention for stress eating to reduce cortisol and abdominal fat among overweight and obese women: an exploratory randomized controlled study. J Obes. 2011;2011:651936. doi: 10.1155/2011/651936.
    1. Basso JC, McHale A, Ende V, Oberlin DJ, Suzuki WA. Brief, daily meditation enhances attention, memory, mood, and emotional regulation in non-experienced meditators. Behav Brain Res. 2019;356:208–220.
    1. Roeser RW, Schonert-Reichl KA, Jha A, Cullen M, Wallace L, Wilensky R, Oberle E, Thomson K, Taylor C, Harrison J. Mindfulness training and reductions in teacher stress and burnout: results from two randomized, waitlist-control field trials. J Educ Psychol. 2013;105(3):787–804.
    1. Carlson LE, Speca M, Patel KD, Goodey E. Mindfulness-based stress reduction in relation to quality of life, mood, symptoms of stress and levels of cortisol, dehydroepiandrosterone sulfate (DHEAS) and melatonin in breast and prostate cancer outpatients. Psychoneuroendocrinology. 2004;29(4):448–474.
    1. Kroboth PD, Salek FS, Pittenger AL, Fabian TJ, Frye RF. DHEA and DHEA-S: a review. J Clin Pharmacol. 1999;39(4):327–348.
    1. Edwards S, Clow A, Evans P, Hucklebridge F. Exploration of the awakening cortisol response in relation to diurnal cortisol secretory activity. Life Sci. 2001;68(18):2093–2103.
    1. Golden SH, Wand GS, Malhotra S, Kamel I, Horton K. Reliability of hypothalamic-pituitary-adrenal axis assessment methods for use in population-based studies. Eur J Epidemiol. 2011;26(7):511–525.
    1. Wolgast M. What does the Acceptance and Action Questionnaire (AAQ-II) really measure? Behav Ther. 2014;45(6):831–839.
    1. Rochefort C, Baldwin AS, Chmielewski M. Experiential avoidance: an examination of the construct validity of the AAQ-II and MEAQ. Behav Ther. 2018;49(3):435–449.
    1. O'Connor MF, Bower JE, Cho HJ, et al. To assess, to control, to exclude: effects of biobehavioral factors on circulating inflammatory markers. Brain Behav Immun. 2009;23(7):887–897.
    1. MacIntyre UE, Wenhold FAM. Measuring dietary intake. In: Lanham-New SA, Hill TR, Gallagher AM, Vorster HH, editors. Introduction to human nutrition. 3. Hoboken: Wiley Blackwell; 2020. pp. 13–55.
    1. Hofmann SG, Hayes SC. The future of intervention science: process-based therapy. Clin Psychol Sci. 2018;7:1–14. doi: 10.1177/2167702618772296.
    1. Tomiyama AJ. Stress and obesity. Annu Rev Psychol. 2019;70:5.1–5.16. doi: 10.1146/annurev-psych-010418-102936.

Source: PubMed

Sponsoren und Mitarbeiter

Krankheiten

Drogeninterventionen

3
Abonnieren