{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,7]],"date-time":"2026-07-07T05:03:40Z","timestamp":1783400620799,"version":"3.54.6"},"reference-count":56,"publisher":"MDPI AG","issue":"19","license":[{"start":{"date-parts":[[2020,10,3]],"date-time":"2020-10-03T00:00:00Z","timestamp":1601683200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["IJERPH"],"abstract":"<jats:p>Obesity is becoming a pandemic and percutaneous electrical stimulation (PENS) of dermatome T6 has been demonstrated to reduce stomach motility and appetite, allowing greater weight loss than isolated hypocaloric diets. However, modulation of intestinal microbiota could improve this effect and control cardiovascular risk factors. Our objective was to test whether addition of probiotics could improve weight loss and cardiovascular risk factors in obese subjects after PENS and a hypocaloric diet. A pilot prospective study was performed in patients (n = 20) with a body mass index (BMI) &gt; 30 kg\/m2. Half of them underwent ten weeks of PENS in conjunction with a hypocaloric diet (PENS-Diet), and the other half was treated with a PENS-Diet plus multistrain probiotics (L. plantarum LP115, B. brevis B3, and L. acidophilus LA14) administration. Fecal samples were obtained before and after interventions. The weight loss and changes in blood pressure, glycemic and lipid profile, and in gut microbiota were investigated. Weight loss was significantly higher (16.2 vs. 11.1 kg, p = 0.022), whereas glycated hemoglobin and triglycerides were lower (\u22120.46 vs. \u22120.05%, p = 0.032, and \u221247.0 vs. \u22128.5 mg\/dL, p = 0.002, respectively) in patients receiving PENS-Diet + probiotics compared with those with a PENS-Diet. Moreover, an enrichment of anti-obesogenic bacteria, including Bifidobacterium spp, Akkermansia spp, Prevotella spp, and the attenuation of the Firmicutes\/Bacteroidetes ratio were noted in fecal samples after probiotics administration. In obese patients, the addition of probiotics to a PENS intervention under a hypocaloric diet could further improve weight loss and glycemic and lipid profile in parallel to the amelioration of gut dysbiosis.<\/jats:p>","DOI":"10.3390\/ijerph17197239","type":"journal-article","created":{"date-parts":[[2020,10,5]],"date-time":"2020-10-05T08:35:57Z","timestamp":1601886957000},"page":"7239","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":10,"title":["Addition of Probiotics to Anti-Obesity Therapy by Percutaneous Electrical Stimulation of Dermatome T6. A Pilot Study"],"prefix":"10.3390","volume":"17","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-5515-6078","authenticated-orcid":false,"given":"Oscar","family":"Lorenzo","sequence":"first","affiliation":[{"name":"Laboratory of Diabetes and Vascular Pathology, Instituto de Investigaciones Sanitarias-Fundaci\u00f3n Jim\u00e9nez D\u00edaz, Universidad Aut\u00f3noma, 28040 Madrid, Spain"},{"name":"Spanish Biomedical Research Centre on Diabetes and Associated Metabolic Disorders (CIBERDEM) Network, 28040 Madrid, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Marta","family":"Crespo-Yanguas","sequence":"additional","affiliation":[{"name":"Laboratory of Diabetes and Vascular Pathology, Instituto de Investigaciones Sanitarias-Fundaci\u00f3n Jim\u00e9nez D\u00edaz, Universidad Aut\u00f3noma, 28040 Madrid, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3670-837X","authenticated-orcid":false,"given":"Tianyu","family":"Hang","sequence":"additional","affiliation":[{"name":"Laboratory of Diabetes and Vascular Pathology, Instituto de Investigaciones Sanitarias-Fundaci\u00f3n Jim\u00e9nez D\u00edaz, Universidad Aut\u00f3noma, 28040 Madrid, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3458-0328","authenticated-orcid":false,"given":"Jairo","family":"Lumpuy-Castillo","sequence":"additional","affiliation":[{"name":"Laboratory of Diabetes and Vascular Pathology, Instituto de Investigaciones Sanitarias-Fundaci\u00f3n Jim\u00e9nez D\u00edaz, Universidad Aut\u00f3noma, 28040 Madrid, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Artur M.","family":"Hern\u00e1ndez","sequence":"additional","affiliation":[{"name":"Department of Sport Sciences, Universidad Europea de Madrid, 28670 Villaviciosa de Od\u00f3n-Madrid, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Carolina","family":"Llavero","sequence":"additional","affiliation":[{"name":"Obesity Unit, Clinica Garcilaso, 28010 Madrid, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"MLuisa","family":"Garc\u00eda-Alonso","sequence":"additional","affiliation":[{"name":"Laboratory of Diabetes and Vascular Pathology, Instituto de Investigaciones Sanitarias-Fundaci\u00f3n Jim\u00e9nez D\u00edaz, Universidad Aut\u00f3noma, 28040 Madrid, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8505-2605","authenticated-orcid":false,"given":"Jaime","family":"Ruiz-Tovar","sequence":"additional","affiliation":[{"name":"Obesity Unit, Clinica Garcilaso, 28010 Madrid, Spain"},{"name":"Department of Health Sciences, Universidad Rey Juan Carlos, 28933 Mostoles-Madrid, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2020,10,3]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"6","DOI":"10.1016\/j.metabol.2018.09.005","article-title":"The epidemiology of obesity","volume":"92","author":"Chooi","year":"2019","journal-title":"Metab. Clin. Exp."},{"key":"ref_2","unstructured":"World Health Organization (2000). Obesity: Preventing and Managing the Global Epidemic, World Health Organization. Report of a WHO consultation."},{"key":"ref_3","doi-asserted-by":"crossref","unstructured":"Su, X., and Peng, D. (2020). Emerging functions of adipokines in linking the development of obesity and cardiovascular diseases. Mol. Biol. Rep.","DOI":"10.1007\/s11033-020-05732-9"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"1590","DOI":"10.1161\/CIRCRESAHA.120.316203","article-title":"Leukocyte heterogeneity in adipose tissue, including in obesity","volume":"126","author":"Weinstock","year":"2020","journal-title":"Circ. Res."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"511","DOI":"10.1016\/j.ecl.2016.04.004","article-title":"Regarding obesity as a disease: Evolving policies and their implications","volume":"45","author":"Kyle","year":"2016","journal-title":"Endocrinol. Metab. Clin. N. Am."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"537","DOI":"10.1016\/j.pcl.2020.02.008","article-title":"Behavioral approaches to weight management for health and wellness","volume":"67","author":"Normand","year":"2020","journal-title":"Pediatr. Clin. N. Am."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"547","DOI":"10.1111\/j.1464-410X.2006.06055.x","article-title":"Percutaneous tibial nerve stimulation in the treatment of refractory overactive bladder syndrome: Is maintenance treatment necessary?","volume":"97","author":"Heesakkers","year":"2006","journal-title":"BJU Int."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"212","DOI":"10.1097\/SLE.0000000000000271","article-title":"Long-term effect of percutaneous electrical neurostimulation of dermatome T6 for Appetite reduction and weight loss in obese patients","volume":"26","author":"Llavero","year":"2016","journal-title":"Surg. Laparosc. Endosc. Percutaneous Tech."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"241","DOI":"10.1097\/SLE.0000000000000437","article-title":"Percutaneous electrical neurostimulation of dermatome T6 for short-term weight loss in overweight and obese patients: Effect on ghrelin levels, glucose, lipid, and hormonal profile","volume":"27","author":"Llavero","year":"2017","journal-title":"Surg. Laparosc. Endosc. Percutaneous Tech."},{"key":"ref_10","first-page":"205","article-title":"Percutaneous electrical neurostimulation of dermatome T6 for appetite reduction and weight loss in morbidly obese patients","volume":"24","author":"Oller","year":"2013","journal-title":"Obes. Surg."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"3","DOI":"10.1093\/gastro\/goy052","article-title":"Fight them or feed them: How the intestinal mucus layer manages the gut microbiota","volume":"7","author":"Schroeder","year":"2019","journal-title":"Gastroenterol. Rep. (Oxf.)"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"220","DOI":"10.1038\/nature11550","article-title":"Diversity, stability and resilience of the human gut microbiota","volume":"489","author":"Lozupone","year":"2012","journal-title":"Nature"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"1823","DOI":"10.1042\/BCJ20160510","article-title":"Introduction to the human gut microbiota","volume":"474","author":"Thursby","year":"2017","journal-title":"Biochem. J."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"397","DOI":"10.1007\/s13238-018-0546-3","article-title":"Insights into the role of gut microbiota in obesity: Pathogenesis, mechanisms, and therapeutic perspectives","volume":"9","author":"Sun","year":"2018","journal-title":"Protein Cell"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"1476","DOI":"10.1053\/j.gastro.2009.03.030","article-title":"Obesity and the Microbiota","volume":"136","author":"Tilg","year":"2009","journal-title":"Gastroenterology"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"1720","DOI":"10.1038\/ijo.2008.155","article-title":"Human colonic microbiota associated with diet, obesity and weight loss","volume":"32","author":"Duncan","year":"2008","journal-title":"Int. J. Obes. (Lond.)"},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"58","DOI":"10.3945\/ajcn.110.010132","article-title":"Energy-balance studies reveal associations between gut microbes, caloric load, and nutrient absorption in humans","volume":"94","author":"Jumpertz","year":"2011","journal-title":"Am. J. Clin. Nutr."},{"key":"ref_18","unstructured":"Cerd\u00f3, T., Garc\u00eda-Santos, J.A., Berm\u00fadez, M.G., and Campoy, C. (2020, February 14). The Role of Probiotics and Prebiotics in the Prevention and Treatment of Obesity, Available online: https:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC6470608\/."},{"key":"ref_19","first-page":"3862971","article-title":"The potential role of probiotics in controlling overweight\/obesity and associated metabolic parameters in adults: A systematic review and meta-analysis","volume":"2019","author":"Wang","year":"2019","journal-title":"Evid. Based Complement. Altern. Med."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"505","DOI":"10.3945\/ajcn.112.042457","article-title":"Systematic review and meta-analysis of different dietary approaches to the management of type 2 diabetes","volume":"97","author":"Ajala","year":"2013","journal-title":"Am. J. Clin. Nutr."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"389","DOI":"10.1123\/jpah.2016-0064","article-title":"The influence of age, sex and body mass index on the effectiveness of brisk walking for obesity management in adults: A systematic review and meta-analysis","volume":"14","author":"Mabire","year":"2017","journal-title":"J. Phys. Act. Health"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"16350","DOI":"10.1038\/srep16350","article-title":"Sample storage conditions significantly influence faecal microbiome profiles","volume":"5","author":"Choo","year":"2015","journal-title":"Sci. Rep."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"12","DOI":"10.1186\/s12933-017-0643-2","article-title":"\u00c1ngel; Lorenzo, O. Sitagliptin improved glucose assimilation in detriment of fatty-acid utilization in experimental type-II diabetes: Role of GLP-1 isoforms in Glut4 receptor trafficking","volume":"17","author":"Picatoste","year":"2018","journal-title":"Cardiovasc. Diabetol."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"1647","DOI":"10.1126\/science.1155725","article-title":"Evolution of mammals and their gut microbes","volume":"320","author":"Ley","year":"2008","journal-title":"Science"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"D294","DOI":"10.1093\/nar\/gki038","article-title":"The Ribosomal Database Project (RDP-II): Sequences and tools for high-throughput rRNA analysis","volume":"33","author":"Cole","year":"2004","journal-title":"Nucleic Acids Res."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"3021","DOI":"10.1093\/eurheartj\/ehy339","article-title":"2018 ESC\/ESH Guidelines for the management of arterial hypertension","volume":"39","author":"Williams","year":"2018","journal-title":"Eur. Heart J."},{"key":"ref_27","doi-asserted-by":"crossref","unstructured":"American Diabetes Association (2018). Glycemic targets: Standards of medical care in diabetes. Diabetes Care, 41, S55\u2013S64.","DOI":"10.2337\/dc18-S006"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"2999","DOI":"10.1093\/eurheartj\/ehw272","article-title":"2016 ESC\/EAS guidelines for the management of dyslipidaemias","volume":"37","author":"Catapano","year":"2016","journal-title":"Eur. Heart J."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"90","DOI":"10.3945\/an.115.010587","article-title":"Can we prevent obesity-related metabolic diseases by dietary modulation of the gut microbiota?","volume":"7","author":"Brahe","year":"2016","journal-title":"Adv. Nutr."},{"key":"ref_30","unstructured":"CDC (2020, February 05). Adult Overweight and Obesity, Available online: https:\/\/www.cdc.gov\/obesity\/adult\/index.html."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"71","DOI":"10.1001\/jama.2012.113905","article-title":"Association of all-cause mortality with overweight and obesity using standard body mass index categories: A systematic review and meta-analysis","volume":"309","author":"Flegal","year":"2013","journal-title":"JAMA"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"2899","DOI":"10.1007\/s11695-016-2214-0","article-title":"Percutaneous Electrical Neurostimulation (PENS) of dermatome t6 with an ambulatory self-applied patch vs PENS of dermatome T6 with conventional procedure: Effect on appetite and weight loss in moderately obese patients","volume":"26","year":"2016","journal-title":"Obes. Surg."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1186\/s12967-019-1810-x","article-title":"Emerging trends and research foci in gastrointestinal microbiome","volume":"17","author":"Huang","year":"2019","journal-title":"J. Transl. Med."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"206","DOI":"10.4183\/aeb.2016.206","article-title":"Implication of gut microbiota in diabetes mellitus and obesity","volume":"12","author":"Grigorescu","year":"2016","journal-title":"Acta Endocrinol. (Buchar.)"},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"25","DOI":"10.1186\/s12263-017-0583-1","article-title":"Impact of supplementation with a food-derived microbial community on obesity-associated inflammation and gut microbiota composition","volume":"12","author":"Roselli","year":"2017","journal-title":"Genes Nutr."},{"key":"ref_36","doi-asserted-by":"crossref","unstructured":"Montandon, S.A., and Jornayvaz, F.R. (2017). Effects of antidiabetic drugs on gut microbiota composition. Genes, 8.","DOI":"10.3390\/genes8100250"},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"971","DOI":"10.1016\/j.cmet.2015.10.001","article-title":"Dietary fiber-induced improvement in glucose metabolism is associated with increased abundance of prevotella","volume":"22","author":"Nilsson","year":"2015","journal-title":"Cell Metab."},{"key":"ref_38","doi-asserted-by":"crossref","unstructured":"Huang, W.-C., Lee, M.-C., Lee, C.-C., Ng, K.-S., Hsu, Y.-J., Tsai, T.-Y., Young, S.-L., Lin, J.-S., and Huang, C.-C. (2019). Effect of lactobacillus plantarum TWK10 on exercise physiological adaptation, performance, and body composition in healthy humans. Nutrients, 11.","DOI":"10.3390\/nu11112836"},{"key":"ref_39","doi-asserted-by":"crossref","unstructured":"Chen, Y.-M., Wei, L., Chiu, Y.-S., Hsu, Y.-J., Tsai, T.-Y., Wang, M.-F., and Huang, C.-C. (2016). Lactobacillus plantarum TWK10 supplementation improves exercise performance and increases muscle mass in mice. Nutrients, 8.","DOI":"10.3390\/nu8040205"},{"key":"ref_40","doi-asserted-by":"crossref","unstructured":"Lee, E., Jung, S.-R., Lee, S.-Y., Lee, N.-K., Paik, H.-D., and Lim, S. (2018). Lactobacillus plantarum strain Ln4 attenuates diet-induced obesity, insulin resistance, and changes in hepatic mRNA levels associated with glucose and lipid metabolism. Nutrients, 10.","DOI":"10.3390\/nu10050643"},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"1607","DOI":"10.1038\/ijo.2017.161","article-title":"Effect of Lactobacillus on body weight and body fat in overweight subjects: A systematic review of randomized controlled clinical trials","volume":"41","author":"Crovesy","year":"2017","journal-title":"Int. J. Obes. (Lond.)"},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"3556","DOI":"10.1039\/C9FO00205G","article-title":"Mechanism analysis of improved glucose homeostasis and cholesterol metabolism in high-fat-induced obese mice treated with La-SJLH001 via transcriptomics and culturomics","volume":"10","author":"Sun","year":"2019","journal-title":"Food Funct."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"67","DOI":"10.12938\/bmfh.18-001","article-title":"Effects of Bifidobacterium breve B-3 on body fat reductions in pre-obese adults: A randomized, double-blind, placebo-controlled trial","volume":"37","author":"Minami","year":"2018","journal-title":"Biosci. Microbiota Food Health"},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"1656","DOI":"10.1271\/bbb.100267","article-title":"Antiobesity effects ofBifidobacterium breveStrain B-3 Supplementation in a mouse model with high-fat diet-induced obesity","volume":"74","author":"Kondo","year":"2010","journal-title":"Biosci. Biotechnol. Biochem."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"1035","DOI":"10.1067\/mai.2002.124894","article-title":"Intestinal Bifidobacterium species induce varying cytokine production","volume":"109","author":"He","year":"2002","journal-title":"J. Allergy Clin. Immunol."},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"1091","DOI":"10.1136\/gut.2008.165886","article-title":"Changes in gut microbiota control inflammation in obese mice through a mechanism involving GLP-2-driven improvement of gut permeability","volume":"58","author":"Cani","year":"2009","journal-title":"Gut"},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"357","DOI":"10.1007\/s13167-017-0117-3","article-title":"Comparative study of probiotic effects of Lactobacillus and Bifidobacteria strains on cholesterol levels, liver morphology and the gut microbiota in obese mice","volume":"8","author":"Bubnov","year":"2017","journal-title":"EPMA J."},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"2897","DOI":"10.3389\/fmicb.2018.02897","article-title":"Comparative Microbiome signatures and short-chain fatty acids in mouse, rat, non-human primate, and human feces","volume":"9","author":"Nagpal","year":"2018","journal-title":"Front. Microbiol."},{"key":"ref_49","doi-asserted-by":"crossref","unstructured":"Lin, H.V., Frassetto, A., Kowalik, E.J., Nawrocki, A.R., Lu, M.M., Kosinski, J.R., Hubert, J.A., Szeto, D., Yao, X., and Forrest, G. (2012). Butyrate and propionate protect against diet-induced obesity and regulate gut hormones via free fatty acid receptor 3-independent mechanisms. PLoS ONE, 7.","DOI":"10.1371\/journal.pone.0035240"},{"key":"ref_50","doi-asserted-by":"crossref","unstructured":"Geerlings, S.Y., Kostopoulos, I., De Vos, W.M., and Belzer, C. (2018). Akkermansia muciniphila in the human gastrointestinal tract: When, where, and how?. Microorganisms, 6.","DOI":"10.3390\/microorganisms6030075"},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"9066","DOI":"10.1073\/pnas.1219451110","article-title":"Cross-talk between Akkermansia muciniphila and intestinal epithelium controls diet-induced obesity","volume":"110","author":"Everard","year":"2013","journal-title":"Proc. Natl. Acad. Sci. USA"},{"key":"ref_52","doi-asserted-by":"crossref","first-page":"727","DOI":"10.1136\/gutjnl-2012-303839","article-title":"An increase in theAkkermansiaspp. population induced by metformin treatment improves glucose homeostasis in diet-induced obese mice","volume":"63","author":"Shin","year":"2013","journal-title":"Gut"},{"key":"ref_53","doi-asserted-by":"crossref","first-page":"2434","DOI":"10.1161\/CIRCULATIONAHA.115.019645","article-title":"Akkermansia muciniphila protects against atherosclerosis by preventing metabolic endotoxemia-induced inflammation in Apoe-\/- Mice","volume":"133","author":"Li","year":"2016","journal-title":"Circulation"},{"key":"ref_54","doi-asserted-by":"crossref","first-page":"100309","DOI":"10.1016\/j.conctc.2018.100309","article-title":"Comparing different ways of calculating sample size for two independent means: A worked example","volume":"13","author":"Clifton","year":"2018","journal-title":"Contemp. Clin. Trials Commun."},{"key":"ref_55","first-page":"179","article-title":"Plasma ghrelin levels after percutaneous electrical nerve stimulation of dermatome T6 for the treatment of obesity","volume":"67","author":"Violeta","year":"2020","journal-title":"Endocrinol. Diabetes Nutr."},{"key":"ref_56","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1155\/2016\/8341487","article-title":"Overweight and general and abdominal obesity in a representative sample of Spanish adults: Findings from the ANIBES study","volume":"2016","author":"Sobaler","year":"2016","journal-title":"BioMed Res. Int."}],"container-title":["International Journal of Environmental Research and Public Health"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1660-4601\/17\/19\/7239\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,11]],"date-time":"2025-10-11T10:16:23Z","timestamp":1760177783000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1660-4601\/17\/19\/7239"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2020,10,3]]},"references-count":56,"journal-issue":{"issue":"19","published-online":{"date-parts":[[2020,10]]}},"alternative-id":["ijerph17197239"],"URL":"https:\/\/doi.org\/10.3390\/ijerph17197239","relation":{},"ISSN":["1660-4601"],"issn-type":[{"value":"1660-4601","type":"electronic"}],"subject":[],"published":{"date-parts":[[2020,10,3]]}}}