Association Between Stress and Waist-To-Height Ratio Among Medical

ORIGINAL ARTICLE

Association between stress and waist-to-height ratio among medical students in a private university of Lima-Perú in 2018 Carolina Mendez-Guerra1,4, a, Andrés Quevedo-Ramirez1,4, a, Guillermo De la Borda-Prazak1,4,a, Claudia Silva-Pérez1,a, Mauricio Oscco-Tenorio1, a , Isabel Pinedo-Torres2,3, b

1. School of Medicine, Peruvian University of Applied Sciences, Lima, Peru. 2. Endocrinology Service, Department of Medicine and Office of Support for Teaching and Research (OADI), Hospital Daniel Alcides Carrión, Callao, Peru. 3. Red de Eficacia Clínica y Sanitaria (REDECS), Lima, Peru. 4. Scientific Society of Medical Students UPC (SOCIEMUPC), Lima, Peru. a. Human Medicine Student b. Endocrinologist

CIMEL 2020; 26(1): 15-21

ABSTRACT Objective: To determine the association between stress and waist-to-height ratio (WTHR) in medical students in a private university of Lima in 2018. Materials and Methods: An analytical cross-sectional study. The population in this study was comprised between 2nd and 5th year medical students in a private university in Lima. The main variables were stress and waist-to-height ratio. The data was submitted to STATA 14.0 where the frequency of categoric variables and measures of central tendency and dispersion of quantitative variables were calculated. Afterwards, a bivariate analysis was done, and finally a multivariate analysis was conducted, using a Poisson regression with robust variance. Results: A total of 234 persons were analyzed. No statistically significant association was found between stress and WTHR, in the crude analysis (p=0.93) nor when adjusted according to age, sex, academic year and physical activity. (p=0.43). Statistically association was found between sex and WTHR (p<0.00). Conclusions: No association was found between the WTHR and stress. Nevertheless, 46.58% of the population had an elevated WTHR and 29.06% had stress. Keywords: Self Stress, Psychological; Waist-Height Ratio; Students medical Please cite this article as: Mendez-Guerra C et al. Association between stress and waist-to-height ratio among medical students in a private university of Lima- Perú in 2018 . CIMEL 2020; 26(1): 15-21. DOI: https://doi.org/10.23961/cimel.v26i1.1360

INTRODUCTION distribution of body fat. Compared to the BMI and abdo- Obesity represents an important global public health pro- minal circumference, it is the best measure in the assessment blem. In recent years, there has been a significant increa- of metabolic syndrome (7,8). Due to this, WHtR has been sing trend of overweight and obesity in young adults (1). gaining relevance in the prediction of chronic diseases such Worldwide, in 2016, 40% of people over 18 years of age were as diabetes mellitus and arterial hypertension (9). The most overweight, from which 13% were obese (2). Similarly, the used cut-off point is 0.5, having been evaluated in popula- prevalence of overweight and obesity in university students tions from Cuba and Colombia (10,11). from 22 countries of low and middle socioeconomic class was 22% (3). There are various risk factors associated with excess weight, among them are: poor eating habits, sedentary lifestyles, According to studies in India, 28% of medical students were among others. Similarly, several studies mention stress as overweight, while 13% were obese (4). At the national level, an important risk factor in the development of overweight in 2016, 39.7% of young adults were overweight and 8.7% and obesity, since it influences diet, physical activity and use were obese (5). Evaluation of overweight and obesity can be of addictive substances (12). The prevalence of stress is high calculated through various anthropometric measures. The in university students, mostly in demanding careers such as body mass index (BMI) is widely used to assess nutritional Human Medicine. In India, 53% of medical students suffer a status and classify it within the parameters of: underweight, type of stress level (13). At the national level, in 2012, the estima- normal weight, overweight and obesity; however, this mea- ted prevalence of stress in medical students was 77.4% (14). surement does not allow for the estimation of visceral fat, a parameter that can be measured through the waist-to-height Studies revealed that stress increases serum cortisol levels, ge- ratio (6). nerating an increase in appetite and redistribution of fat pre- This is a simple and inexpensive anthropometric measure dominantly in the abdomen, which results in a high WHtR that allows the assessment of the nutritional status and the (15). Thus, in a cohort from Whitehall II, it was found that

CIMEL 2020, Volume 26, Number 1 ORIGINAL ARTICLE high levels of stress are associated with a high WHtR in both INSTRUMENTS AND DEFINITION OF VARIABLES genders (16), which is observed in the high levels of BMI re- gistered in medical students who undergo stress (17). Due Self-perception of stress: The Perceived Stress Scale 14 (PSS- to the aforementioned, the general objective of the present 14) was used. This one contains 7 positive items and 7 negati- study was to determine the association between stress and ve items, about the perceived feelings during the last month. WHtR in Human Medical students from a private university It displays questions such as: “In the last month, how often of Lima. have you felt like you couldn’t cope with all the things you had to do?” or “In the past month, how often have to suc- MATERIALS AND METHODS cessfully handled life’s irritating little problems?” Each item is measured on a scare from 0-4, with “0” equivalent to ne- Study design: An analytical cross-sectional study was carried ver and “4” to very often. The maximum score is 56 points out. (17). A score greater than 28 indicates a presence of stress, taking as a reference a study carried out in Chilean medical Location of study: Universidad Peruana de Ciencias Aplica- students, in which the cut-off point was used (18). das (UPC), an educational institution that has a Human Me- dicine degree. Waist-to-height ratio (WHtr): The WHtR is defined as the ratio between the abdominal circumference and the height. Study population: Made from medical students from 2nd The presence of WHtR at risk was defined as WHtR greater to 5th year in their career enrolled in the academic cycle than or equal to 0.5. 2018-02, of the UPC, based in Lima, Peru. Being a private university, a large part of its students come from families Physical activity: Physical activity was categorized as inactive, with a medium-high socioeconomic level. Likewise, those minimally active, or active. Said classification was based on students older than 18 years and with a BMI lower than 35 the IPAQ criteria, these being the number of times per week kg/m2 were considered as the unit of analysis. Those partici- that exercise was performed, the intensity and how many pants who suffered from an affective or eating disorder, prior MET-minutes were achieved per week. to the start of the race, or were UPC qualified athletes were excluded. The evaluation of the listed exclusion criteria was An inactive should not get a necessary score for the other 2 carried out through the questionnaire and was self-reported categories. In addition, the classification, minimally active, by the study subjects. must have 3 or more days of vigorous activity with a minimum of 20 minutes duration per day, 5 or more days of mo- The calculation of the sample size was carried out in the derate activity lasting minimum 30 minutes per day, or 5 or OpenEpi 3.01 program, based on a pilot study of 29 students more days of any type of activity mentioned in the question- where an increased WHtR was found in 56% of students not naire (vigorous, moderate or walking) with a total physical exposed to stress and in 77% of students exposed to stress. In activity of at least 600 MET- minutes/week. To calculate the addition, the ratio of exposed to not exposed was 1.23. Con- corresponding MET, formulas proposed in the scoring pro- sidering these values, a significance of 95% and a power of tocol of the questionnaire will be used. Similarly, the active 80%, a calculated same size of 160 study subjects is obtained, classification was considered as a vigorous activity of 3 days, according to the Fleiss method. On this value, a loss of 10% reaching a total physical activity of 1500 MET- minutes per of the collection records was considered due to incomplete week or 7 days of any activity mentioned in the questionnaire or inconsistent data. Therefore, 160 / (1-0.10)= 1160 / 0.9= with a minimum total physical activity of 3000 MET-minute 178 study subjects will need to be reviewed. per week. It should be noted that the variable was dichotomi- zed as inappropriate (inactive) or adequate (minimally active Legal aspects: The study was started after the approval from or active). the Ethics Committee at UPC and an informed consent was used, where there was a description of the procedures, the PROCEDURES benefits, and the risks; also, it was indicated that the participation was completely voluntarily. To ensure data confi- Information collection: Once the approval from the Ethics dentiality, these were recorded anonymously. Lastly, as it was Committee at UPC was obtained and the participation of an observational study, the subjects were not exposed to any the subjects was confirmed through the informed consent, risk. a recollection of data was carried out using a questionnaire,

CIMEL 2020, Volume 26, Number 1 ORIGINAL ARTICLE which included the evaluation of the exclusion criteria, ge- Data analysis: The analysis was carried out using the STA- neral epidemiological data, the independent variable (stress, TA 14.0 statistical program, a 95% confidence interval and measured with the PSS-14) and the physical activity variable a significance level of 0.05 were considered. In the univariate (measured by IPAQ). analysis, the absolute and relative frequencies were evaluated from the variables categorized, as stress and WHtR. Likewise, The questionnaire was applied in the morning hours and at the median and the interquartile range were determined for the end of classes, with previous coordination with the cour- the age variable. This was considered non-normal, through se teacher. In addition, it was taken into account that the co- the Shapiro Wilk test. In the bivariate analysis between the llection of data was carried out 2 weeks after the finalization dependent variable (WHtR at risk) and the independent of academic evaluations. Immediately after the application variable (stress), and the control variables, the chi-squared of the questionnaire, we proceeded with the measurement test was used. In the case of the numerical variable (age), the of height and abdominal circumference, necessary for the normality and homogeneity of variances were evaluated, fo- calculation of WHtR (dependent variable). Similarly, the te- llowed by the Mann Whitney test. To evaluate homogeneity chnical guide for the anthropometric nutritional assessment of variances, the Bartlett/Levene test was used. of the adult person of the MINSA of the year 2012 was used. In the multivariate analysis, the magnitude of association bet- The height measurement was carried out with a standardi- ween the dependent variable and the exposure variable was zed wooden height rod. The study subject was measured expressed as a prevalence ratio (PR). The PR was calculated with no shoes and no accessories that could difficult the in a crude way and adjusted using generalized linear models measurement. At the beginning the subject was asked to of the Poisson family with log link and robust variance. In position themselves at the center of the height rod, looking addition, it was adjusted with the variables age, sex, academic straight ahead, the upper extremities lateral to the body, the cycle and physical activity. palms resting on the thighs, the heels together, and the tips of the feet slightly apart. Next, we verified that the heels, calves, RESULTS butt, shoulders and back of the head were in contact with the height rod board. Subsequently, the correct position of the The present study had a total of 243 subjects (Figure 1). head was ensured in the “Frankfurt plane”. Finally, the measurement was obtained with a value in meters, centimeters and millimeters. It should be noted that the measurement was taken 3 times and the results were averaged. The measurement of the abdominal circumference was carried out with a flexible measuring tape. At the beginning, each subject was asked to remove any clothing that covered the abdomen or prevented the adequate measurement. Likewise, the subject was asked to maintain an upright position, with the arms relaxed and parallel to the abdomen, and the feet separated at a distance of 25 cm. Next, the measurement was carried out between the middle point of the last rib and the superior border of the iliac crest. The measuring tape was placed hori- zontally around the abdomen. Lastly, at the end of a normal exhale, the measurement was recorded in the point here the ends of the measuring tape overlapped. Three consecutive measurements were carried out and their average was recorded. The data collection was carried out within 14 days. Figure 1: Flowchart of enrollment of study subjects

Processing of the information: The data of the questionnaire The median age was 21±20-22 years. 58.55% of the subjects was entered to Microsoft Excel and twice the investigators in the study were female. The average of the PSS-14 score was recorded them. Next, the database were exported to the Stata 24.04 points ± 8.05 (DE), from which 29.06% (68), presented 14.0 program, and, finally, compared to identify errors. stress, obtaining a score greater than 28 points in the stress self-perception scale. The median waist-height ratio was 0.49

CIMEL 2020, Volume 26, Number 1 ORIGINAL ARTICLE

± 0.46-0.53 (IQR), from whcih 46.58% (109) were classified presented a WHtR at risk (Table 2). as having a WHtR at risk, presenting an index greater or equal to 0.5 Likewise, adequate physical activity was found in Table 2. Bivariate analysis between the waist-height ratio 62. 39% of the study subjects (Table 1). and the sociodemographic and clinical characteristics of the participants. Normal WHtR at risk Table 1. General characteristics of the population in the Variables p study. WHtR n(%) n(%) Variables n(%) Stress Gender Present 36 (52.94) 32 (47.06) 0.93* Female 137 (58.55%) Absente 89 (53.61) 77 (46.39) Male 97 (41.45%) Gender Age (p50 ± RIQ§) 21 ± 20-22 Female 88 (64.23) 49 (35.77) 0.00* Academic cycle Male 37 (38.14) 60 (61.86) (P50 ± RIQ†) 2nd 58 (24.79%) Age, years 21± 20-22 21± 20-22 0.27** 3rd 88 (37.61%) Academic cycle 4th 62 (26.50%) 2 and 3 year 87 (59.6) 59 (41.4) 0.08* 5tth 26 (11.11%) 4 and 5 year 38 (43.2) 50 (56.8) Inmigrant Physical activity Yes 94 (40.17%) Adequate 79 (54.11) 67 (45.89) 0.79* Score PSS-14* (media ± DE‡) 24.04 ± 8.05 Inadequate 46 (52.27) 42 (47.73) With estrés 166 (70.94%) Immigrant Without estrés 68 (29.06%) Yes 53 (56.38) 41 (43.62) 0.46* Waist-to-height ratio(p50 ± RIQ§) 0.49 ± 0.46-0.53 No 72 (51.43) 68 (48.57) WHtR in risk ** *Chi2 test ** U de Mann-Whitney test Absent 125 (53.42%) †interquantile range Present 109 (46.58%) Physical activity † Regarding the multivariate analysis of Poisson regression with robust variance, in the adjusted analysis, a Adequate 146 (62.39%) statistically significant association was not found bet- Moderate 87 (37.18%) ween WHtR at risk and stress (p= 0.43). High 59 (25.21%) Inadequate 88 (37.61%) Table 3. Association between WHtR at risk and stress: *The presence of stress was defined with a score > 28 on the perceived crude model and model adjusted for all variables. stress scale (PSS-14) Crude analysis Adjusted analysis ** WHtR at risk was defined as WHtR ≥ 0.5 Variables †The International Physical Activity Questionnaire (IPAQ) was used, RPc IC95% p RPa* IC95% p which takes into account the days, minutes and METs of different Stress levels of physical activity. . ‡Standard deviation Absent Ref. - - Ref. - - §Interquartile range Present 1.01 0.75-1.37 0.93 1.12 0.84-1.51 0.43 RPc= Crude prevalence ratio When evaluating the population according to the presence RPa= Adjusted prevalence ratio or absence of a WHtR in risk (≥0.5), no statisticaly significant *Adjusted for the variables age, sex, academic cycle and physical association was found between stress and WHtR (p= 0.93). activity DISCUSSION Likewise, despite the fact that no statistically significant association was found between the academic cycle and the A high or at risk WHtR had a frequency of close to 47% in WHtR (p=0.08), it is observed that, as the career years go our population, result that slightly differs from the results of by, the prevalence of WHtR at risk increases. In addition, a a study that found a 40% weight excess in medical students statistically significant association was reported between sex at Ica, Peru; it should be noted that this study used the body and WHtR (p=0.00), in such a way, 61.86% of male students mass index (BMI) as an anthropometric measure, which

CIMEL 2020, Volume 26, Number 1 ORIGINAL ARTICLE could explain the difference in results (19). Likewise in the is similar to the one found in a study carried out in students present study, 56.8% of the students in fourth and fifth year from the health sciences from Colombia, in which approxi- have a WHtR in risk, while students in second and third year, mately 58% carried out physical activity. It should be noted only had a 41.4%. This result agrees with a study carried out that this study used the same instrument to measure physical in Brazilian students, in which it is observed that the WHtR activity (27). increases as the years of study at the university progress (20). Among the limitations in our study, we can find that the va- This increase in the WHtR establishes itself as an important riable smoking was not included, through a validated ques- risk factor for the student population, since it is observed that tionnaire for university students, such as the Classification of WHtR is associated with cardiovascular risk factors such as Cigar Consumers (C4) (28); this was due to the length of our fasting glucose, cholesterol and LDL, as well as the develop- questionnaire. On the other hand, there is the impossibility ment of chronic kidney disease (21,22). of calculating the incidence of WHtR at risk, not being able to know the time of exposure to stress, as well as some bia- The prevalence of stress in our population was 29.06%. This ses at the time of filling the survey; however, we consider the result differs from the findings by Bedoya and collaborators, present investigation as novel and innovative, since few ori- who evidence a 77.54% of academical stress in medical stu- ginal articles evaluate the association between both variables. dents at the Universidad de Lima, Peru (14). This big diffe- It should be noted that despite having reached the calculated rence could be explained due to the fact that the mentioned sample size, we recommend an expansion of the sample size study used the SISCO instrument to measure stress in the to achieve statistical significance and also the performance of last semester, while in our study, the PSS-14 questionnaire a prospective study, which allows the evaluation of the tem- was used and it measured stress within this last month. In porality. addition, the application of our questionnaire was after the exam week, where a lower frequency of stress is expected, In conclusion, no significant association was found between taking into account that, in other publications, academic fac- stress and WHtR at risk in medical students from 2nd to 5th tors have been associated with stress in university students year at a private university in Lima in 2018. (23). On the other hand, in the present study, a PSS-14 score of 24.04 ± 8.05 was found, which is similar to the 25.64 ± 8.05 Conflict of interest: The authors declare that they have no con- found in medical students from a university in India (24). flict of interest.

Likewise, no statistically significant association was found Funding sources: No funding was received to carry out this between stress and WHtR at risk in our population. In con- article. trast, in India, a positive correlation was found between stress REFERENCES and BMI (Rho: 0.362, p<0.01) in males, with a variation of 11,8% of BMI attributed to stress. It should be noted that in 1. Poobalan A, Aucott L. Obesity Among Young Adults in Develo- this study, no statistically significant correlation was found ping Countries: A Systematic Overview. Curr Obes Rep. 2016;5:2-13. between stress and BMI in females, due to the reduced sam- 2. Obesity and overweight [Internet]. [citado 14 de septiembre de ple number (12). 2019]. Disponible en: https://www.who.int/news-room/fact-sheets/de- tail/obesity-and-overweight Similarly, a statistically significant association was found 3. Peltzer K, Pengpid S, Samuels TA, Özcan NK, Mantilla C, Raha- mefy OH, et al. Prevalence of Overweight/Obesity and Its Associated between gender and WHtR. A study carried out in univer- Factors among University Students from 22 Countries. Int J Environ Res sity students from Colombia observed that men had an in- Public Health. julio de 2014;11(7):7425-41. creased risk of developing metabolic syndrome (OR: 7.86, 4. Purohit G, Shah T, Harsoda JM. Prevalence of Obesity in Medi- IC95%=1.73-35.72) (25). No statistically significant associa- cal students and its correlation with cardiovascular risk factors: Emer- tion was found between physical activity and WHtR. Howe- gency Alarm for Today? Kathmandu Univ Med J KUMJ. diciembre de 2015;13(52):341-5. ver, in as study carried out in Korea, a protective OR of 0.76 5. Chávez V, E J. Prevalencia de sobrepeso y obesidad en el Perú. Rev (95% CI: 0.63-0.91; P<0.01) was found in the development of Peru Ginecol Obstet. octubre de 2017;63(4):593-8. obesity, measured by WHtR, when performing moderate to 6. Izze E, Ferreira L, Ana S, Priore SE. Waist circumference, waist/ active physical activity (26). Despite this, it should be empha- height ratio, and neck circumference as parameters of central obesity as- sized that approximately 62% of the studied population was sessment in children. Rev Paul Pediatr. 2014;32(3). 7. Knowles KM, Paiva LL, Sanchez SE, Revilla L, Lopez T, Yasuda MB, doing moderate to high intensity physical activity. This figure et al. Waist circumference, body mass index, and other measures of adi-

CIMEL 2020, Volume 26, Number 1 ORIGINAL ARTICLE posity in predicting cardiovascular disease risk factors among peruvian 24. Anuradha R, Dutta R, Raja JD, Sivaprakasam P, Patil AB. Stress and adults. Int J Hypertens. 2011;2011. Stressors among Medical Undergraduate Students: A Cross-sectional 8. Huamán J, Alvarez M, Gamboa L, Marino F. Índice cintura-esta- Study in a Private Medical College in Tamil Nadu. Indian J Community tura como prueba diagnóstica del Síndrome metabólico en adultos de Med Off Publ Indian Assoc Prev Soc Med. 2017;42(4):222-5. Trujillo. Rev Medica Hered. 2017;28(1):13. 25. Martinez-Torres J, Correa-bautista JE, Gonz K, Garc A, Ram R. 9. Hernández J, Duchi PN. Índice Cintura/Talla Y Su Utilidad Para A Cross-Sectional Study of the Prevalence of Metabolic Syndrome and Detectar Riesgo Cardiovascular Y Metabólico. Rev Cuba Endocrinol. Associated Factors in Colombian Collegiate Students : The FUPRECOL- 2015;2626(11):66-76. Adults Study. Int J Env Res Public Health. 2017;14(233). 10. Hernandez-Rodríguez J, Duchi-jimbo P, Dominguez-Alonso E, 26. Lee O, Lee DC, Lee S, Kim YS. Associations between physical acti- Diaz-Diaz O, Martinez-Montegro I, Bosch-Perez. Valor de corte del ín- vity and obesity defined by Waist-To-Height ratio and body mass index dice cintura / talla como predictor independiente de disglucemias. Rev in the Korean population. PLoS ONE. 2016;11(7):1-11. Cuba Endocrinol. 2017;28(2):1-15. 27. Moreno-bayona JA. Niveles de sedentarismo en estudiantes uni- 11. Martínez-Torres J, Correa-Bautista JE, González-Ruíz K, Vivas A, versitarios de pregrado en Colombia Sedentary lifestyles among Health Triana-Reina HR, Prieto-Benavidez DH, et al. A cross-sectional study Sciences undergraduate students of Colombia. Rev Cuba Salud Pública. of the prevalence of metabolic syndrome and associated factors in co- 2018;44(3):553-66. lombian collegiate students: The fuprecol-adults study. Int J Environ Res 28. Londoño Pérez C, Rodríguez Rodríguez I, Gantiva Díaz CA. Cues- Public Health. 2017;14(3). tionario para la clasificación de consumidores de cigarrillo (C4) para jó- 12. Gupta S, Ray T, Saha I. Overweight, obesity and influence of stress venes. Perspect Psicol. 2011;7(2). on body weight among undergraduate medical students. Indian J Com- munity Med. 2009;34(3):255. Correspondence: 13. Iqbal S, Gupta S, Venkatarao E. Stress , anxiety & depression among medical undergraduate students & their socio-demographic correlates. Carolina Mendez Guerra Indian J Med Res. 2014;19:19-22. 14. Bedoya-lau FN, Matos LJ, Zelaya EC. Niveles de estrés académico , Phone: +51 987737970 manifestaciones psicosomáticas y estrategias de afrontamiento en alum- E-mail: [email protected] nos de la facultad de medicina de una universidad privada de Lima en el año 2012 . Rev Neuropsiquiatr. 2014;77(4):262-70. Received: 16 /09/2019 15. Van der Valk ES, Savas M, van Rossum EFC. Stress and Obesity: Accepted: 05/05/2020 Are There More Susceptible Individuals? Curr Obes Rep. 2018;7(2):193- 203. 16. Kubera B, Leonhard C, Peters A. Stress-related changes in body form – Results from the Whitehall II study Britta. Obes Silver Spring. 2017;25(9):1625-32. 17. Rivzi M, Shaikh M, Ahmed A, Farooq S, Serafi A. Association of body mass index with perceived stress in male Saudi students. Int J Clin Exp Physio. 2015;2(4):214-9. 18. Meyer A, Ramírez L, Pérez C. Percepción de estrés en estudiantes chilenos de Medicina y Enfermería. Rev Educ Cienc Salud . 2013;10(2):79–85. 19. Torres-Roman JS, Helguero-Santín LM, Bazalar-Palacios J, Avilez JL, Dávila-Hernández CA. Sobrepeso y obesidad en estudiantes de medicina. ¿Un nuevo reto al sistema de salud peruano? Salud Publica Mex. 2017;59(3):207-9. 20. Vila Nova de Moraes JF, Sales M, Asano RY, Moreira SR, Carvalho FO, Campbell CSG. Semester and shift of study are associated with waist circumference, waist-to-height ratio, and body mass index in Brazilian college students. Int J Health Promot Educ. 4 de julio de 2014;52(4):200- 9. 21. Li W-C, Chen J-Y, Lee Y-Y, Weng Y-M, Hsiao C-T, Loke S-S. Asso- ciation between waist-to-height ratio and chronic kidney disease in the Taiwanese population. Intern Med J. julio de 2014;44(7):645-52. 22. Akhlaghi M, Kamali M, Dastsouz F, Sadeghi F, Amanat S. Increa- sed Waist-to-height Ratio May Contribute to Age-related Increase in Cardiovascular Risk Factors. Int J Prev Med [Internet]. 27 de abril de 2016 [citado 13 de julio de 2020];7. Disponible en: https://www.ncbi.nlm. nih.gov/pmc/articles/PMC4863399/ 23. Waghachavare VB, Dhumale GB, Kadam YR, Gore AD. A Study of Stress among Students of Professional Colleges from an Urban area in India. Clin Basic Res. 2013;13(August):429-36.

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