{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,19]],"date-time":"2026-10-19T22:45:01Z","timestamp":1792449901369,"version":"4.5.0"},"reference-count":52,"publisher":"MDPI AG","issue":"9","license":[{"start":{"date-parts":[[2026,5,4]],"date-time":"2026-05-04T00:00:00Z","timestamp":1777852800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Background\/Objectives: Intentional insulin omission (IIO), commonly referred to as diabulimia, is a high-risk behavioural phenomenon observed mainly in adolescents and young adults with type 1 diabetes mellitus (T1D). Defined as the deliberate reduction or omission of insulin to influence body weight, IIO lies at the intersection of metabolic management and eating disorder psychopathology. Despite serious health risks, including diabetic ketoacidosis, microvascular complications, and increased mortality, it remains under-recognised due to stigma, diagnostic ambiguity, and overlap with routine diabetes self-management. This review aimed to examine the prevalence, psychological mechanisms, and clinical consequences of IIO. Methods: On 1 April 2026, we conducted a systematic search of PubMed, Scopus, APA PsycInfo\/PsycArticles and Cinahl for studies investigating intentional insulin omission and related metabolic and psychological outcomes in T1D. Clinical and epidemiological studies assessing prevalence, risk factors, and interventions were included. Results: Twenty-nine studies met the inclusion criteria. Prevalence estimates ranged from 20% to 45%, with higher risk among females, adolescents, and individuals experiencing diabetes-related distress or body dissatisfaction. Psychological factors\u2014including fear of weight gain, emotion dysregulation, depressive symptoms, and identity conflicts\u2014were associated with IIO onset and maintenance. IIO was consistently linked to poor glycaemic control, elevated HbA1c levels, and adverse metabolic and psychological outcomes. Screening tools such as the Diabetes Eating Problem Survey\u2013Revised (DEPS-R) may support early identification, while effective management requires integrated multidisciplinary care. Conclusions: Although IIO is not formally classified as an eating disorder in current diagnostic systems, it shares important psychopathological features with eating disorders and may represent a diabetes-specific disordered eating behaviour with life-threatening consequences.<\/jats:p>","DOI":"10.3390\/jcm15093518","type":"journal-article","created":{"date-parts":[[2026,5,5]],"date-time":"2026-05-05T07:57:29Z","timestamp":1777967849000},"page":"3518","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["Intentional Insulin Omission (Diabulimia) in Patients with Insulin-Dependent Diabetes: An Eating Disorder? A Systematic Review"],"prefix":"10.3390","volume":"15","author":[{"ORCID":"https:\/\/orcid.org\/0009-0005-5839-1301","authenticated-orcid":false,"given":"Maria Benedetta","family":"Anesini","sequence":"first","affiliation":[{"name":"Section of Psychiatry, Department of Neurosciences, Universit\u00e0 Cattolica del Sacro Cuore, 00168 Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8254-9299","authenticated-orcid":false,"given":"Mario","family":"Pinto","sequence":"additional","affiliation":[{"name":"Section of Psychiatry, Department of Neurosciences, Head-Neck and Chest, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0004-9963-7403","authenticated-orcid":false,"given":"Michela","family":"Bellezza","sequence":"additional","affiliation":[{"name":"Section of Psychiatry, Department of Neurosciences, Universit\u00e0 Cattolica del Sacro Cuore, 00168 Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0281-6324","authenticated-orcid":false,"given":"Georgios D.","family":"Kotzalidis","sequence":"additional","affiliation":[{"name":"Section of Psychiatry, Department of Neurosciences, Universit\u00e0 Cattolica del Sacro Cuore, 00168 Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6489-5331","authenticated-orcid":false,"given":"Tommaso","family":"Callovini","sequence":"additional","affiliation":[{"name":"Section of Psychiatry, Department of Neurosciences, Universit\u00e0 Cattolica del Sacro Cuore, 00168 Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Silvia","family":"Montanari","sequence":"additional","affiliation":[{"name":"Section of Psychiatry, Department of Neurosciences, Universit\u00e0 Cattolica del Sacro Cuore, 00168 Rome, Italy"},{"name":"Section of Psychiatry, Department of Neurosciences, Head-Neck and Chest, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0007-7289-3775","authenticated-orcid":false,"given":"Camilla","family":"Scialpi","sequence":"additional","affiliation":[{"name":"Section of Psychiatry, Department of Neurosciences, Universit\u00e0 Cattolica del Sacro Cuore, 00168 Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9767-8752","authenticated-orcid":false,"given":"Gabriele","family":"Sani","sequence":"additional","affiliation":[{"name":"Section of Psychiatry, Department of Neurosciences, Universit\u00e0 Cattolica del Sacro Cuore, 00168 Rome, Italy"},{"name":"Section of Psychiatry, Department of Neurosciences, Head-Neck and Chest, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lorenzo","family":"Moccia","sequence":"additional","affiliation":[{"name":"Section of Psychiatry, Department of Neurosciences, Universit\u00e0 Cattolica del Sacro Cuore, 00168 Rome, Italy"},{"name":"Section of Psychiatry, Department of Neurosciences, Head-Neck and Chest, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Delfina","family":"Janiri","sequence":"additional","affiliation":[{"name":"Section of Psychiatry, Department of Neurosciences, Universit\u00e0 Cattolica del Sacro Cuore, 00168 Rome, Italy"},{"name":"Section of Psychiatry, Department of Neurosciences, Head-Neck and Chest, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,5,4]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"113","DOI":"10.1089\/dia.2024.0267","article-title":"Glycemic Variability and disordered eating among adolescents and young adults with Type 1 Diabetes: The role of disinhibited eating","volume":"27","author":"Shalitin","year":"2025","journal-title":"Diabetes Technol. Ther."},{"key":"ref_2","first-page":"S131","article-title":"Factors associated with intentional insulin omission to lose weight in people living with type 1 diabetes: A BETTER registry analysis","volume":"39","author":"South","year":"2026","journal-title":"Can. J. Diabetes"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"909","DOI":"10.1007\/s11892-013-0418-4","article-title":"Eating disorders and disordered eating in type 1 diabetes: Prevalence, screening, and treatment options","volume":"13","author":"Hanlan","year":"2013","journal-title":"Curr. Diab. Rep."},{"key":"ref_4","doi-asserted-by":"crossref","unstructured":"Oikonomou, A., Christoforidis, A., Kotanidou, E.P., Giannopoulou, I., Paschalidou, E., Tsinopoulou, V.R., Sotiriou, G., Tsiroukidou, K., and Galli-Tsinopoulou, A. (2025). Detecting disordered eating behaviors in Greek youth with type 1 diabetes mellitus by using the Diabetes Eating Problem Survey-Revised (DEPS-R): Associations with insulin restriction, glycemic control, and anthropometric parameters. Children, 12.","DOI":"10.3390\/children12060795"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"36","DOI":"10.1007\/s40519-023-01559-y","article-title":"Diabetes-specific eating disorder and possible associated psychopathologies in adolescents with type 1 diabetes mellitus","volume":"28","author":"Akman","year":"2023","journal-title":"Eat. Weight Disord."},{"key":"ref_6","unstructured":"Brink, S.J. (1987). Pubertal and postpubertal diabetes (10- to 21-year olds). Pediatric and Adolescent Diabetes Mellitus, Year Book Medical Publishers."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"1638","DOI":"10.2337\/diacare.20.11.1638","article-title":"So what\u2019s the difference between teenage boys and girls, anyway?","volume":"20","author":"Brink","year":"1997","journal-title":"Diabetes Care"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"44","DOI":"10.1002\/pnp.782","article-title":"\u2018Diabulimia\u2019: Current insights into type 1 diabetes and bulimia nervosa","volume":"27","author":"Yahya","year":"2023","journal-title":"Prog. Neurol. Psychiatry"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"e15733998347278","DOI":"10.2174\/0115733998347278250309180707","article-title":"A review on diabulimia: Exploring the intersection of disordered eating, eating disorders, insulin dose manipulation, and type 1 diabetes","volume":"22","author":"Altabas","year":"2026","journal-title":"Curr. Diabetes Rev."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"n71","DOI":"10.1136\/bmj.n71","article-title":"The PRISMA 2020 statement: An updated guideline for reporting systematic reviews","volume":"372","author":"Page","year":"2021","journal-title":"BMJ"},{"key":"ref_11","unstructured":"Sterne, J., Brandt Mathur, M., Elbers, R., Hr\u00f3bjartsson, A., McAleenan, A., Reeves, B., Shrier, I., Tilling, K., Armstrong, R., and Berkman, N. (2025). The Risk of Bias in Non-Randomized Studies\u2014Of Interventions, Version 2 (ROBINS-I V2) Assessment Tool (for Follow-Up Studies), Cochrane Collaboration. Available online: https:\/\/docs.google.com\/document\/d\/1JPr8H33vSsAgzsQwpg6HU411i1MseAvy\/edit?pli=1."},{"key":"ref_12","first-page":"i4919","article-title":"ROBINS-I: A tool for assessing risk of bias in non-randomised studies of interventions","volume":"355","author":"Sterne","year":"2016","journal-title":"BMJ (Clin. Res. Ed.)"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"1178","DOI":"10.2337\/diacare.17.10.1178","article-title":"Insulin omission in women with IDDM","volume":"17","author":"Polonsky","year":"1994","journal-title":"Diabetes Care"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"343","DOI":"10.1111\/j.2044-8341.1996.tb01877.x","article-title":"Eating attitudes in young females with diabetes: Insulin omission identifies a vulnerable subgroup","volume":"69","author":"Khan","year":"1996","journal-title":"Br. J. Med. Psychol."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"221","DOI":"10.1016\/S0022-3999(99)00031-8","article-title":"Differences between bulimia nervosa and binge-eating disorder in females with type 1 diabetes: The important role of insulin omission","volume":"47","author":"Takii","year":"1999","journal-title":"J. Psychosom. Res."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"415","DOI":"10.2337\/dc07-2026","article-title":"Insulin restriction and associated morbidity and mortality in women with type 1 diabetes","volume":"31","author":"Fikkan","year":"2008","journal-title":"Diabetes Care"},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"259","DOI":"10.1002\/eat.20498","article-title":"The duration of severe insulin omission is the factor most closely associated with the microvascular complications of Type 1 diabetic females with clinical eating disorders","volume":"41","author":"Takii","year":"2008","journal-title":"Int. J. Eat. Disord."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"312","DOI":"10.1111\/j.1399-5448.2008.00392.x","article-title":"Disordered eating and body dissatisfaction in adolescents with type 1 diabetes and a population-based comparison sample: Comparative prevalence and clinical implications","volume":"9","author":"Ackard","year":"2008","journal-title":"Pediatr. Diabetes"},{"key":"ref_19","first-page":"163","article-title":"Factors contributing to nonadherence to oral hypoglycemic medications among ambulatory type 2 diabetes patients in Southwestern Nigeria","volume":"7","author":"Adisa","year":"2009","journal-title":"Pharm. Pract."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"240","DOI":"10.2337\/dc09-1348","article-title":"Correlates of insulin injection omission","volume":"33","author":"Peyrot","year":"2010","journal-title":"Diabetes Care"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"545","DOI":"10.2337\/dc10-1547","article-title":"Improvement and emergence of insulin restriction in women with type 1 diabetes","volume":"34","author":"Anderson","year":"2011","journal-title":"Diabetes Care"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"3382","DOI":"10.2337\/dc13-0431","article-title":"Disturbed eating behavior and omission of insulin in adolescents receiving intensified insulin treatment: A nationwide population-based study","volume":"36","author":"Wisting","year":"2013","journal-title":"Diabetes Care"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"819","DOI":"10.1002\/eat.22138","article-title":"Detecting intentional insulin omission for weight loss in girls with type 1 diabetes mellitus","volume":"46","author":"Hamiel","year":"2013","journal-title":"Int. J. Eat. Disord."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"2025","DOI":"10.2337\/dc15-0753","article-title":"Momentary predictors of insulin restriction among adults with type 1 diabetes and eating disorder symptomatology","volume":"38","author":"Merwin","year":"2015","journal-title":"Diabetes Care"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"191","DOI":"10.1002\/eat.22463","article-title":"Disordered eating and insulin restriction in youths receiving intensified insulin treatment: Results from a nationwide population-based study","volume":"49","author":"Rosenbauer","year":"2016","journal-title":"Int. J. Eat. Disord."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"2","DOI":"10.1186\/s40337-018-0232-0","article-title":"Psychometric properties and factor structure of the diabetes eating problem survey\u2014Revised (DEPS-R) among adult males and females with type 1 diabetes","volume":"7","author":"Wisting","year":"2019","journal-title":"J. Eat. Disord."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"207-OR","DOI":"10.2337\/db19-207-OR","article-title":"207-OR: Intentional insulin omission for weight loss and psychosocial outcomes among youth with type 1 diabetes: Findings from routine screening","volume":"68","author":"Papadakis","year":"2019","journal-title":"Diabetes"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"1637","DOI":"10.2337\/dc19-0445","article-title":"Disturbed eating behaviors in adolescents and emerging adults with type 1 diabetes: A one-year prospective study","volume":"42","author":"Luyckx","year":"2019","journal-title":"Diabetes Care"},{"key":"ref_29","doi-asserted-by":"crossref","unstructured":"Coleman, S.E., and Caswell, N. (2020). Diabetes and eating disorders: An exploration of \u2018Diabulimia\u2019. BMC Psychol., 8.","DOI":"10.1186\/s40359-020-00468-4"},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"1110","DOI":"10.1093\/jpepsy\/jsab042","article-title":"Insulin restriction, emotion dysregulation, and depressive symptoms in late adolescents with diabetes","volume":"46","author":"Beam","year":"2021","journal-title":"J. Pediatr. Psychol."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"281","DOI":"10.1016\/j.nupar.2021.05.002","article-title":"Determining the risk of diabulimia and its relationship with diet quality and nutritional status of adolescents with type 1 diabetes [D\u00e9terminer le risque de diaboulimie et sa relation avec la qualit\u00e9 de l\u2019alimentation et l\u2019\u00e9tat nutritionnel des adolescents atteints de diab\u00e8te de type 1]","volume":"35","author":"Keser","year":"2021","journal-title":"Nutr. Clin. M\u00e9tabolisme"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"388","DOI":"10.1016\/j.numecd.2022.11.017","article-title":"Associations of disordered eating with the intestinal microbiota and short-chain fatty acids among young adults with type 1 diabetes","volume":"33","author":"Igudesman","year":"2023","journal-title":"Nutr. Metab. Cardiovasc. Dis."},{"key":"ref_33","doi-asserted-by":"crossref","unstructured":"Yafei, S., Hummadi, A., Badedi, M., Darraj, H., Khawaji, A., Alzughbi, T., Abutaleb, R., Alhagawy, A.J., Alnami, A., and Kudam, B. (2023). Disordered eating behaviors and insulin restriction in Saudi adolescents and young adults with type 1 diabetes. Medicina, 59.","DOI":"10.3390\/medicina59020345"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"849","DOI":"10.1016\/j.eprac.2023.08.001","article-title":"Diabulimia: A risky trend among adults with type 1 diabetes mellitus","volume":"29","author":"Ip","year":"2023","journal-title":"Endocr. Pract."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"158","DOI":"10.1186\/s40337-023-00888-8","article-title":"Correlates of disordered eating and insulin restriction behavior and its association with psychological health in Taiwanese youths with diabetes mellitus","volume":"11","author":"Chou","year":"2023","journal-title":"J. Eat. Disord."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"1915","DOI":"10.1002\/eat.24490","article-title":"Disordered eating and intentional insulin restriction among young adults with type 1 diabetes: An examination of diabetes distress and appearance-related perceptions as correlates","volume":"58","author":"Hartlaub","year":"2025","journal-title":"Int. J. Eat. Disord."},{"key":"ref_37","doi-asserted-by":"crossref","unstructured":"Figueiredo, J.dC.M., Jo\u00e3o Pavin, E., Trevisan, T.L., and Vilela da Mota Silveira, M.S. (2026). Disordered eating behaviors in persons with type 1 diabetes: Frequency, risk factors, depressive and anxiety symptoms, and clinical outcomes. Eat. Disord., 1\u201316.","DOI":"10.1080\/10640266.2026.2618759"},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"e104542","DOI":"10.1136\/bmjopen-2025-104542","article-title":"Association of eating disorders and\/or insulin omission with impaired glycaemic control in persons living with type 1 diabetes: Cross-sectional analysis of the French SFDT1 study","volume":"16","author":"Ritz","year":"2026","journal-title":"BMJ Open"},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"e70022","DOI":"10.1111\/dme.70022","article-title":"Correspondence between the Diabetes Eating Problems Survey-Revised and eating disorder diagnosis: Examining the current cut-off for clinically significant eating disorder symptoms","volume":"42","author":"Moskovich","year":"2025","journal-title":"Diabet. Med."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"957","DOI":"10.1515\/jpem-2023-0330","article-title":"Depression, anxiety, eating problems, and diabulimia risk in adolescents with type 1 diabetes: A case-control study","volume":"36","author":"Kara","year":"2023","journal-title":"J. Pediatr. Endocrinol. Metab."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"213","DOI":"10.1186\/s40337-023-00924-7","article-title":"The role of diabetes distress in Diabulimia","volume":"11","author":"Poos","year":"2023","journal-title":"J. Eat. Disord."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"3946553","DOI":"10.1155\/2024\/3946553","article-title":"Understanding experiences of diabetes distress: A systematic review and thematic synthesis","volume":"2024","author":"Salifu","year":"2024","journal-title":"J. Diabetes Res."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"l982","DOI":"10.1136\/bmj.l982","article-title":"Diabulimia: The world\u2019s most dangerous eating disorder","volume":"364","author":"Torjesen","year":"2019","journal-title":"BMJ"},{"key":"ref_44","doi-asserted-by":"crossref","unstructured":"Campoverde, G., Sacaquir\u00edn, C., Quito-Calle, V., and Ram\u00edrez, A. (2025). Prevalence of diabulimia in adolescents with type 1 diabetes: A systematic review and meta-analysis in a psychiatric framework. Psychiatry Int., 6.","DOI":"10.20944\/preprints202506.1718.v1"},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"1281","DOI":"10.1177\/02601060241310639","article-title":"Unlocking the secrets: How well do nutrition and dietetics students understand diabulimia and health literacy?","volume":"31","author":"Bayram","year":"2025","journal-title":"Nutr. Health"},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"606","DOI":"10.1177\/13591045211026142","article-title":"A review of risk factors associated with insulin omission for weight loss in type 1 diabetes","volume":"26","author":"Hall","year":"2021","journal-title":"Clin. Child Psychol. Psychiatry"},{"key":"ref_47","doi-asserted-by":"crossref","unstructured":"American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), American Psychiatric Press.","DOI":"10.1176\/appi.books.9780890425596"},{"key":"ref_48","unstructured":"American Psychiatric Association (2022). Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition-Text Revision\u2122 (DSM-5-TR\u2122), American Psychiatric Press."},{"key":"ref_49","unstructured":"World Health Organization (WHO) (2018). International Classification of Diseases, 11th Edition (ICD-11), World Health Organization."},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"e473","DOI":"10.1002\/edm2.473","article-title":"Association between type 1 diabetes mellitus and eating disorders: A systematic review and meta-analysis","volume":"7","author":"Dean","year":"2024","journal-title":"Endocrinol. Diabetes Metab."},{"key":"ref_51","doi-asserted-by":"crossref","unstructured":"Dziewa, M., Ba\u0144ka, B., Herbet, M., and Pi\u0105tkowska-Chmiel, I. (2023). Eating disorders and diabetes: Facing the dual challenge. Nutrients, 15.","DOI":"10.3390\/nu15183955"},{"key":"ref_52","doi-asserted-by":"crossref","first-page":"10","DOI":"10.1186\/s40337-025-01188-z","article-title":"Assessment of diabetes-specific eating disorder risk in adult patients with diabetes","volume":"13","author":"Babayeva","year":"2025","journal-title":"J. Eat. Disord."}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/9\/3518\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,5,5]],"date-time":"2026-05-05T13:46:11Z","timestamp":1777988771000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/9\/3518"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,5,4]]},"references-count":52,"journal-issue":{"issue":"9","published-online":{"date-parts":[[2026,5]]}},"alternative-id":["jcm15093518"],"URL":"https:\/\/doi.org\/10.3390\/jcm15093518","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,5,4]]}}}