Skip to main content
Top
Published in: Digestive Diseases and Sciences 2/2017

01-02-2017 | Original Article

Shiftwork Is Not Associated with Increased Risk of NAFLD: Findings from the National Health and Nutrition Examination Survey

Authors: Maya Balakrishnan, Hashem B. El-Serag, Fasiha Kanwal, Aaron P. Thrift

Published in: Digestive Diseases and Sciences | Issue 2/2017

Login to get access

Abstract

Aims

There is increased focus on the metabolic impact of shiftwork, especially given the significant number of employees who work nighttime or rotating shifts. Nonalcoholic fatty liver disease (NAFLD) is the hepatic manifestation of the metabolic syndrome. We conducted a cross-sectional study to examine the association between shiftwork and the risk of NAFLD.

Methods

We used aggregated data from the 2005–2006, 2007–2008, and 2009–2010 cycles of the National Health and Nutrition Examination Survey (NHANES). We defined NAFLD by elevated serum alanine aminotransferase (ALT) or aspartate aminotransferase (AST) levels (males: AST > 40 or ALT > 37; females: AST > 31 or ALT > 31) in the absence of excessive alcohol use and viral hepatitis. We defined shiftworkers as participants who self-reported currently working regular night shifts or rotating shifts. We calculated adjusted odds ratios (OR) and 95% confidence intervals (CI) using multivariable logistic regression.

Results

Overall, 8159 participants aged 20–79 years reported working at a job or business using the NHANES Occupation Questionnaire and were included in the analysis. Of these, 11.1% were classified as shiftworkers. Compared to non-shiftworkers, shiftworkers were younger, were less likely to be non-Hispanic White, and have health insurance or health care. The overall prevalence of NAFLD was 15.7%. NAFLD occurred more frequently in shiftworkers (17.0%) than non-shiftworkers (15.5%). However, in the overall multivariable analysis, shiftwork was not associated with the risk of NAFLD (OR 1.11, 95% CI 0.87–1.43).

Conclusions

The findings from this NHANES-based cross-sectional study do not support an association between shiftwork and increased risk of NAFLD.
Appendix
Available only for authorised users
Literature
1.
go back to reference Vernon G, Baranova A, Younossi ZM. Systematic review: the epidemiology and natural history of non-alcoholic fatty liver disease and non-alcoholic steatohepatitis in adults. Aliment Pharmacol Ther. 2011;34:274–285.CrossRefPubMed Vernon G, Baranova A, Younossi ZM. Systematic review: the epidemiology and natural history of non-alcoholic fatty liver disease and non-alcoholic steatohepatitis in adults. Aliment Pharmacol Ther. 2011;34:274–285.CrossRefPubMed
2.
go back to reference Ahmed A, Wong RJ, Harrison SA. Nonalcoholic fatty liver disease review: diagnosis, treatment, and outcomes. Clin Gastroenterol Hepatol. 2015;13:2062–2070.CrossRefPubMed Ahmed A, Wong RJ, Harrison SA. Nonalcoholic fatty liver disease review: diagnosis, treatment, and outcomes. Clin Gastroenterol Hepatol. 2015;13:2062–2070.CrossRefPubMed
3.
go back to reference Singh S, Allen AM, Wang Z, et al. Fibrosis progression in nonalcoholic fatty liver vs. nonalcoholic steatohepatitis: a systematic review and meta-analysis of paired-biopsy studies. Clin Gastroenterol Hepatol. 2015;13:643–654 e641–649; quiz e639–640. Singh S, Allen AM, Wang Z, et al. Fibrosis progression in nonalcoholic fatty liver vs. nonalcoholic steatohepatitis: a systematic review and meta-analysis of paired-biopsy studies. Clin Gastroenterol Hepatol. 2015;13:643–654 e641–649; quiz e639–640.
4.
go back to reference Younossi ZM, Stepanova M, Negro F, et al. Nonalcoholic fatty liver disease in lean individuals in the United States. Medicine (Baltimore). 2012;91:319–327.CrossRef Younossi ZM, Stepanova M, Negro F, et al. Nonalcoholic fatty liver disease in lean individuals in the United States. Medicine (Baltimore). 2012;91:319–327.CrossRef
5.
go back to reference Margariti E, Deutsch M, Manolakopoulos S, Papatheodoridis GV. Non-alcoholic fatty liver disease may develop in individuals with normal body mass index. Ann Gastroenterol. 2012;25:45–51.PubMedPubMedCentral Margariti E, Deutsch M, Manolakopoulos S, Papatheodoridis GV. Non-alcoholic fatty liver disease may develop in individuals with normal body mass index. Ann Gastroenterol. 2012;25:45–51.PubMedPubMedCentral
6.
go back to reference Kim HJ, Kim HJ, Lee KE, et al. Metabolic significance of nonalcoholic fatty liver disease in nonobese, nondiabetic adults. Arch Intern Med. 2004;164:2169–2175.CrossRefPubMed Kim HJ, Kim HJ, Lee KE, et al. Metabolic significance of nonalcoholic fatty liver disease in nonobese, nondiabetic adults. Arch Intern Med. 2004;164:2169–2175.CrossRefPubMed
7.
go back to reference Gutierrez-Repiso C, Soriguer F, Rubio-Martin E, et al. Night-time sleep duration and the incidence of obesity and type 2 diabetes. Findings from the prospective Pizarra study. Sleep Med. 2014;15:1398–1404.CrossRefPubMed Gutierrez-Repiso C, Soriguer F, Rubio-Martin E, et al. Night-time sleep duration and the incidence of obesity and type 2 diabetes. Findings from the prospective Pizarra study. Sleep Med. 2014;15:1398–1404.CrossRefPubMed
8.
go back to reference Donga E, van Dijk M, van Dijk JG, et al. A single night of partial sleep deprivation induces insulin resistance in multiple metabolic pathways in healthy subjects. J Clin Endocrinol Metab. 2010;95:2963–2968.CrossRefPubMed Donga E, van Dijk M, van Dijk JG, et al. A single night of partial sleep deprivation induces insulin resistance in multiple metabolic pathways in healthy subjects. J Clin Endocrinol Metab. 2010;95:2963–2968.CrossRefPubMed
9.
go back to reference Wong PM, Manuck SB, DiNardo MM, Korytkowski M, Muldoon MF. Shorter sleep duration is associated with decreased insulin sensitivity in healthy white men. Sleep. 2015;38:223–231.CrossRefPubMedPubMedCentral Wong PM, Manuck SB, DiNardo MM, Korytkowski M, Muldoon MF. Shorter sleep duration is associated with decreased insulin sensitivity in healthy white men. Sleep. 2015;38:223–231.CrossRefPubMedPubMedCentral
10.
go back to reference Cappuccio FP, D’Elia L, Strazzullo P, Miller MA. Quantity and quality of sleep and incidence of type 2 diabetes: a systematic review and meta-analysis. Diabetes Care. 2010;33:414–420.CrossRefPubMed Cappuccio FP, D’Elia L, Strazzullo P, Miller MA. Quantity and quality of sleep and incidence of type 2 diabetes: a systematic review and meta-analysis. Diabetes Care. 2010;33:414–420.CrossRefPubMed
11.
go back to reference Jackson CL, Redline S, Kawachi I, Hu FB. Association between sleep duration and diabetes in black and white adults. Diabetes Care. 2013;36:3557–3565.CrossRefPubMedPubMedCentral Jackson CL, Redline S, Kawachi I, Hu FB. Association between sleep duration and diabetes in black and white adults. Diabetes Care. 2013;36:3557–3565.CrossRefPubMedPubMedCentral
12.
go back to reference Kim CW, Yun KE, Jung HS, et al. Sleep duration and quality in relation to non-alcoholic fatty liver disease in middle-aged workers and their spouses. J Hepatol. 2013;59:351–357.CrossRefPubMed Kim CW, Yun KE, Jung HS, et al. Sleep duration and quality in relation to non-alcoholic fatty liver disease in middle-aged workers and their spouses. J Hepatol. 2013;59:351–357.CrossRefPubMed
13.
go back to reference Imaizumi H, Takahashi A, Tanji N, et al. The association between sleep duration and non-alcoholic fatty liver disease among Japanese men and women. Obes Facts. 2015;8:234–242.CrossRefPubMed Imaizumi H, Takahashi A, Tanji N, et al. The association between sleep duration and non-alcoholic fatty liver disease among Japanese men and women. Obes Facts. 2015;8:234–242.CrossRefPubMed
14.
go back to reference Miyake T, Kumagi T, Furukawa S, et al. Short sleep duration reduces the risk of nonalcoholic fatty liver disease onset in men: a community-based longitudinal cohort study. J Gastroenterol. 2015;50:583–589.CrossRefPubMed Miyake T, Kumagi T, Furukawa S, et al. Short sleep duration reduces the risk of nonalcoholic fatty liver disease onset in men: a community-based longitudinal cohort study. J Gastroenterol. 2015;50:583–589.CrossRefPubMed
15.
go back to reference Bureau of Labor Statistics. Workers on flexible and shift schedules in 2004 summary. In; 2005. Bureau of Labor Statistics. Workers on flexible and shift schedules in 2004 summary. In; 2005.
16.
17.
go back to reference Itani O, Kaneita Y, Murata A, Yokoyama E, Ohida T. Association of onset of obesity with sleep duration and shift work among Japanese adults. Sleep Med. 2011;12:341–345.CrossRefPubMed Itani O, Kaneita Y, Murata A, Yokoyama E, Ohida T. Association of onset of obesity with sleep duration and shift work among Japanese adults. Sleep Med. 2011;12:341–345.CrossRefPubMed
18.
go back to reference Di Lorenzo L, De Pergola G, Zocchetti C, et al. Effect of shift work on body mass index: results of a study performed in 319 glucose-tolerant men working in a Southern Italian industry. Int J Obes Relat Metab Disord. 2003;27:1353–1358.CrossRefPubMed Di Lorenzo L, De Pergola G, Zocchetti C, et al. Effect of shift work on body mass index: results of a study performed in 319 glucose-tolerant men working in a Southern Italian industry. Int J Obes Relat Metab Disord. 2003;27:1353–1358.CrossRefPubMed
19.
go back to reference Niedhammer I, Lert F, Marne MJ. Prevalence of overweight and weight gain in relation to night work in a nurses’ cohort. Int J Obes Relat Metab Disord. 1996;20:625–633.PubMed Niedhammer I, Lert F, Marne MJ. Prevalence of overweight and weight gain in relation to night work in a nurses’ cohort. Int J Obes Relat Metab Disord. 1996;20:625–633.PubMed
20.
go back to reference Dochi M, Suwazono Y, Sakata K, et al. Shift work is a risk factor for increased total cholesterol level: a 14-year prospective cohort study in 6886 male workers. Occup Environ Med. 2009;66:592–597.CrossRefPubMed Dochi M, Suwazono Y, Sakata K, et al. Shift work is a risk factor for increased total cholesterol level: a 14-year prospective cohort study in 6886 male workers. Occup Environ Med. 2009;66:592–597.CrossRefPubMed
21.
go back to reference Suwazono Y, Dochi M, Sakata K, et al. Shift work is a risk factor for increased blood pressure in Japanese men: a 14-year historical cohort study. Hypertension. 2008;52:581–586.CrossRefPubMed Suwazono Y, Dochi M, Sakata K, et al. Shift work is a risk factor for increased blood pressure in Japanese men: a 14-year historical cohort study. Hypertension. 2008;52:581–586.CrossRefPubMed
22.
go back to reference Karlsson B, Knutsson A, Lindahl B. Is there an association between shift work and having a metabolic syndrome? Results from a population based study of 27,485 people. Occup Environ Med. 2001;58:747–752.CrossRefPubMedPubMedCentral Karlsson B, Knutsson A, Lindahl B. Is there an association between shift work and having a metabolic syndrome? Results from a population based study of 27,485 people. Occup Environ Med. 2001;58:747–752.CrossRefPubMedPubMedCentral
23.
go back to reference De Bacquer D, Van Risseghem M, Clays E, Kittel F, De Backer G, Braeckman L. Rotating shift work and the metabolic syndrome: a prospective study. Int J Epidemiol. 2009;38:848–854.CrossRefPubMed De Bacquer D, Van Risseghem M, Clays E, Kittel F, De Backer G, Braeckman L. Rotating shift work and the metabolic syndrome: a prospective study. Int J Epidemiol. 2009;38:848–854.CrossRefPubMed
24.
go back to reference Gan Y, Yang C, Tong X, et al. Shift work and diabetes mellitus: a meta-analysis of observational studies. Occup Environ Med. 2015;72:72–78.CrossRefPubMed Gan Y, Yang C, Tong X, et al. Shift work and diabetes mellitus: a meta-analysis of observational studies. Occup Environ Med. 2015;72:72–78.CrossRefPubMed
25.
go back to reference Kallwitz ER, Daviglus ML, Allison MA, et al. Prevalence of suspected nonalcoholic fatty liver disease in Hispanic/Latino individuals differs by heritage. Clin Gastroenterol Hepatol. 2015;13:569–576.CrossRefPubMed Kallwitz ER, Daviglus ML, Allison MA, et al. Prevalence of suspected nonalcoholic fatty liver disease in Hispanic/Latino individuals differs by heritage. Clin Gastroenterol Hepatol. 2015;13:569–576.CrossRefPubMed
26.
go back to reference Clark JM, Brancati FL, Diehl AM. The prevalence and etiology of elevated aminotransferase levels in the United States. Am J Gastroenterol. 2003;98:960–967.CrossRefPubMed Clark JM, Brancati FL, Diehl AM. The prevalence and etiology of elevated aminotransferase levels in the United States. Am J Gastroenterol. 2003;98:960–967.CrossRefPubMed
27.
go back to reference Ong JP, Pitts A, Younossi ZM. Increased overall mortality and liver-related mortality in non-alcoholic fatty liver disease. J Hepatol. 2008;49:608–612.CrossRefPubMed Ong JP, Pitts A, Younossi ZM. Increased overall mortality and liver-related mortality in non-alcoholic fatty liver disease. J Hepatol. 2008;49:608–612.CrossRefPubMed
28.
go back to reference Younossi ZM, Stepanova M, Afendy M, et al. Changes in the prevalence of the most common causes of chronic liver diseases in the United States from 1988 to 2008. Clin Gastroenterol Hepatol. 2011;9:524–530 e521; quiz e560. Younossi ZM, Stepanova M, Afendy M, et al. Changes in the prevalence of the most common causes of chronic liver diseases in the United States from 1988 to 2008. Clin Gastroenterol Hepatol. 2011;9:524–530 e521; quiz e560.
29.
go back to reference U.S. Department of Health and Human Services. Analytic and Reporting Guidelines: The National Health and Nutrition Examination Survey (NHANES). National Center for Health Statistics, Centers for Disease Control and Prevention; 2005. U.S. Department of Health and Human Services. Analytic and Reporting Guidelines: The National Health and Nutrition Examination Survey (NHANES). National Center for Health Statistics, Centers for Disease Control and Prevention; 2005.
30.
go back to reference Parsons MJ, Moffitt TE, Gregory AM, et al. Social jetlag, obesity and metabolic disorder: investigation in a cohort study. Int J Obes (Lond). 2015;39:842–848.CrossRef Parsons MJ, Moffitt TE, Gregory AM, et al. Social jetlag, obesity and metabolic disorder: investigation in a cohort study. Int J Obes (Lond). 2015;39:842–848.CrossRef
31.
go back to reference Leproult R, Holmback U, Van Cauter E. Circadian misalignment augments markers of insulin resistance and inflammation, independently of sleep loss. Diabetes. 2014;63:1860–1869.CrossRefPubMedPubMedCentral Leproult R, Holmback U, Van Cauter E. Circadian misalignment augments markers of insulin resistance and inflammation, independently of sleep loss. Diabetes. 2014;63:1860–1869.CrossRefPubMedPubMedCentral
32.
go back to reference Buxton OM, Cain SW, O’Connor SP, et al. Adverse metabolic consequences in humans of prolonged sleep restriction combined with circadian disruption. Sci Transl Med. 2012;4:129ra143. Buxton OM, Cain SW, O’Connor SP, et al. Adverse metabolic consequences in humans of prolonged sleep restriction combined with circadian disruption. Sci Transl Med. 2012;4:129ra143.
33.
go back to reference Sahar S, Sassone-Corsi P. Regulation of metabolism: the circadian clock dictates the time. Trends Endocrinol Metab. 2012;23:1–8.CrossRefPubMed Sahar S, Sassone-Corsi P. Regulation of metabolism: the circadian clock dictates the time. Trends Endocrinol Metab. 2012;23:1–8.CrossRefPubMed
34.
go back to reference Tan E, Scott EM. Circadian rhythms, insulin action, and glucose homeostasis. Curr Opin Clin Nutr Metab Care. 2014;17:343–348.CrossRefPubMed Tan E, Scott EM. Circadian rhythms, insulin action, and glucose homeostasis. Curr Opin Clin Nutr Metab Care. 2014;17:343–348.CrossRefPubMed
36.
go back to reference Rao MN, Neylan TC, Grunfeld C, Mulligan K, Schambelan M, Schwarz JM. Subchronic sleep restriction causes tissue-specific insulin resistance. J Clin Endocrinol Metab. 2015;100:1664–1671.CrossRefPubMedPubMedCentral Rao MN, Neylan TC, Grunfeld C, Mulligan K, Schambelan M, Schwarz JM. Subchronic sleep restriction causes tissue-specific insulin resistance. J Clin Endocrinol Metab. 2015;100:1664–1671.CrossRefPubMedPubMedCentral
37.
go back to reference Spiegel K, Leproult R, Van Cauter E. Impact of sleep debt on metabolic and endocrine function. Lancet. 1999;354:1435–1439.CrossRefPubMed Spiegel K, Leproult R, Van Cauter E. Impact of sleep debt on metabolic and endocrine function. Lancet. 1999;354:1435–1439.CrossRefPubMed
38.
go back to reference Spiegel K, Tasali E, Penev P, Van Cauter E. Brief communication: Sleep curtailment in healthy young men is associated with decreased leptin levels, elevated ghrelin levels, and increased hunger and appetite. Ann Intern Med. 2004;141:846–850.CrossRefPubMed Spiegel K, Tasali E, Penev P, Van Cauter E. Brief communication: Sleep curtailment in healthy young men is associated with decreased leptin levels, elevated ghrelin levels, and increased hunger and appetite. Ann Intern Med. 2004;141:846–850.CrossRefPubMed
39.
go back to reference Hemio K, Puttonen S, Viitasalo K, Harma M, Peltonen M, Lindstrom J. Food and nutrient intake among workers with different shift systems. Occup Environ Med. 2015;72:513–520.CrossRefPubMed Hemio K, Puttonen S, Viitasalo K, Harma M, Peltonen M, Lindstrom J. Food and nutrient intake among workers with different shift systems. Occup Environ Med. 2015;72:513–520.CrossRefPubMed
40.
go back to reference Al-Naimi S, Hampton SM, Richard P, Tzung C, Morgan LM. Postprandial metabolic profiles following meals and snacks eaten during simulated night and day shift work. Chronobiol Int. 2004;21:937–947.CrossRefPubMed Al-Naimi S, Hampton SM, Richard P, Tzung C, Morgan LM. Postprandial metabolic profiles following meals and snacks eaten during simulated night and day shift work. Chronobiol Int. 2004;21:937–947.CrossRefPubMed
41.
go back to reference Peplonska B, Burdelak W, Krysicka J, et al. Night shift work and modifiable lifestyle factors. Int J Occup Med Environ Health. 2014;27:693–706.CrossRefPubMed Peplonska B, Burdelak W, Krysicka J, et al. Night shift work and modifiable lifestyle factors. Int J Occup Med Environ Health. 2014;27:693–706.CrossRefPubMed
42.
go back to reference Gan Y, Yang C, Tong X, et al. Shift work and diabetes mellitus: a meta-analysis of observational studies. Occup Environ Med. 2014:oemed-2014-102150. Gan Y, Yang C, Tong X, et al. Shift work and diabetes mellitus: a meta-analysis of observational studies. Occup Environ Med. 2014:oemed-2014-102150.
43.
go back to reference Santhanam P, Driscoll HK, Gress TW, Khthir R. Metabolic disease and shift work: is there an association? An analysis of NHANES data for 2007–2008. Occup Environ Med. 2014;71:661–662.CrossRefPubMed Santhanam P, Driscoll HK, Gress TW, Khthir R. Metabolic disease and shift work: is there an association? An analysis of NHANES data for 2007–2008. Occup Environ Med. 2014;71:661–662.CrossRefPubMed
44.
go back to reference Givens ML, Malecki KC, Peppard PE, et al. Shiftwork, sleep habits, and metabolic disparities: results from the survey of the health of Wisconsin. Sleep Health. 2015;1:115–120.CrossRefPubMedPubMedCentral Givens ML, Malecki KC, Peppard PE, et al. Shiftwork, sleep habits, and metabolic disparities: results from the survey of the health of Wisconsin. Sleep Health. 2015;1:115–120.CrossRefPubMedPubMedCentral
45.
go back to reference Knutsson A, Kempe A. Shift work and diabetes—a systematic review. Chronobiol Int. 2014;31:1146–1151.CrossRefPubMed Knutsson A, Kempe A. Shift work and diabetes—a systematic review. Chronobiol Int. 2014;31:1146–1151.CrossRefPubMed
46.
go back to reference Tucker P, Marquie JC, Folkard S, Ansiau D, Esquirol Y. Shiftwork and metabolic dysfunction. Chronobiol Int. 2012;29:549–555.CrossRefPubMed Tucker P, Marquie JC, Folkard S, Ansiau D, Esquirol Y. Shiftwork and metabolic dysfunction. Chronobiol Int. 2012;29:549–555.CrossRefPubMed
47.
go back to reference Pietroiusti A, Neri A, Somma G, et al. Incidence of metabolic syndrome among night-shift healthcare workers. Occup Environ Med. 2010;67:54–57.CrossRefPubMed Pietroiusti A, Neri A, Somma G, et al. Incidence of metabolic syndrome among night-shift healthcare workers. Occup Environ Med. 2010;67:54–57.CrossRefPubMed
48.
go back to reference Pan A, Schernhammer ES, Sun Q, Hu FB. Rotating night shift work and risk of type 2 diabetes: two prospective cohort studies in women. PLoS Med. 2011;8:e1001141.CrossRefPubMedPubMedCentral Pan A, Schernhammer ES, Sun Q, Hu FB. Rotating night shift work and risk of type 2 diabetes: two prospective cohort studies in women. PLoS Med. 2011;8:e1001141.CrossRefPubMedPubMedCentral
49.
go back to reference Suwazono Y, Sakata K, Okubo Y, et al. Long-term longitudinal study on the relationship between alternating shift work and the onset of diabetes mellitus in male Japanese workers. J Occup Environ Med. 2006;48:455–461.CrossRefPubMed Suwazono Y, Sakata K, Okubo Y, et al. Long-term longitudinal study on the relationship between alternating shift work and the onset of diabetes mellitus in male Japanese workers. J Occup Environ Med. 2006;48:455–461.CrossRefPubMed
50.
go back to reference Morikawa Y, Nakagawa H, Miura K, et al. Shift work and the risk of diabetes mellitus among Japanese male factory workers. Scand J Work Environ Health. 2005;31:179–183.CrossRefPubMed Morikawa Y, Nakagawa H, Miura K, et al. Shift work and the risk of diabetes mellitus among Japanese male factory workers. Scand J Work Environ Health. 2005;31:179–183.CrossRefPubMed
51.
go back to reference van Amelsvoort LG, Schouten EG, Kok FJ. Duration of shiftwork related to body mass index and waist to hip ratio. Int J Obes Relat Metab Disord. 1999;23:973–978.CrossRefPubMed van Amelsvoort LG, Schouten EG, Kok FJ. Duration of shiftwork related to body mass index and waist to hip ratio. Int J Obes Relat Metab Disord. 1999;23:973–978.CrossRefPubMed
52.
go back to reference Bertolotti M, Lonardo A, Mussi C, et al. Nonalcoholic fatty liver disease and aging: epidemiology to management. World J Gastroenterol WJG. 2014;20:14185–14204.CrossRefPubMed Bertolotti M, Lonardo A, Mussi C, et al. Nonalcoholic fatty liver disease and aging: epidemiology to management. World J Gastroenterol WJG. 2014;20:14185–14204.CrossRefPubMed
Metadata
Title
Shiftwork Is Not Associated with Increased Risk of NAFLD: Findings from the National Health and Nutrition Examination Survey
Authors
Maya Balakrishnan
Hashem B. El-Serag
Fasiha Kanwal
Aaron P. Thrift
Publication date
01-02-2017
Publisher
Springer US
Published in
Digestive Diseases and Sciences / Issue 2/2017
Print ISSN: 0163-2116
Electronic ISSN: 1573-2568
DOI
https://doi.org/10.1007/s10620-016-4401-1

Other articles of this Issue 2/2017

Digestive Diseases and Sciences 2/2017 Go to the issue