Introduction: Body size underestimation in patients with obesity may be associated with long-term weight increase. In the current report, we analyse changes in body size perception in patients with obesity undergoing either bariatric surgery or usual obesity care, and in subgroups of patients who gain weight or maintain their body weight over 10 years. Materials and Methods: A total of 2,504 patients with obesity from the prospective, controlled Swedish Obese Subjects (SOS) intervention study were included in this report, 1,370 patients underwent bariatric surgery and 1,134 patients were usual care controls. Weight was measured and body size was self-estimated using the Stunkard’s figure rating scale at baseline and after 0.5, 1, 2, 3, 4, 6, 8 and 10 years of follow-up. A body perception index (BPI) was calculated as estimated/measured BMI. Weight (re)gain was defined as ≥10% increase between 1 and 10 years of follow-up. Results: Body size was underestimated by 12% in the surgery and 14% in the control group (i.e., >5 BMI units) at baseline and underestimation largely persisted over 10 years in both intervention groups. When stratified by long-term weight development, weight regainers from the surgery group underestimated their body size to a larger degree compared to weight maintainers (12 vs. 9%, p < 0.001) after 10 years. Likewise weight gainers in the control group also underestimated their body size to a larger degree (17% vs. 13%, p < 0.001). In both groups, the change in BPI was significantly different between weight regainers and maintainers during follow-up (time-BPI interactions both p < 0.001). Conclusion: Patients with obesity underestimate their body size and this underestimation remains long-term even after major weight loss induced by bariatric surgery. In patients with obesity who maintain their weight, regardless of treatment, underestimation of body size persists but body size perception is slightly more accurate compared to patients who gain or regain weight long-term.

The interaction between lifestyle, genetic and environmental factors is generally considered to be a central aspect of the development of obesity [1]. However, body size perception, i.e., an individual’s estimation of their own body size, might also be relevant in the context of body weight regulation. Indeed, distorted body size perception, the failure of estimating one’s own body size accurately [2], and in particular, body size underestimation has been found to be present in patients with obesity [3, 4]. In addition, more accurate body size perception in people with obesity, especially in women, was associated with better weight control [5]. It has been hypothesized that perceiving one’s own body size as obese may result in behavioural changes favouring better weight control [5].

At the moment, bariatric surgery is the only available treatment resulting in significant and long-lasting weight loss [6] along with amelioration of a wide range of comorbidities [7‒11]. Unfortunately, weight regain occurs in about 20–25% of patients after bariatric surgery [12]. Previous studies have reported that after bariatric surgery, patients thought about themselves and behaved as though they still had obesity [13, 14] and that body image concerns were associated with significant weight gain after bariatric surgery [15].

In the present report, the perceived body size of participants from the Swedish Obese Subjects (SOS) study, before and after bariatric surgery or usual obesity care, was self-estimated by Stunkard’s figure rating scale [16‒18]. Up to now, long-term changes in body size perception and possible associations with weight regain after bariatric surgery as compared with controls receiving conventional treatment for obesity have not been investigated. Previous studies have examined body size perception only in small cohorts over short periods of time, without investigating the impact on long-term weight management [19‒21]. Therefore, in this report we analysed the accuracy of perceived body size in patients with obesity treated by ususal care and patients treated with bariatric surgery over 10 years of follow-up in a very large sample size. In addition, we investigated whether perceived body size differs between patients with weight (re)gain and those who maintain weight long-term.

Study Design and Participants

The SOS study is a prospective, matched intervention trial investigating the long-term effects of bariatric surgery [22, 23]. After recruitment campaigns in the mass media and at 480 primary health-care centres, a matching examination was completed by 6,905 patients, 5,335 of which were eligible. Among them, 2010 individuals electing surgery formed the surgery group, and a matched control group of 2,037 individuals was contemporaneously created using 18 matching variables (Fig. 1). Patients were included between years 1987 and 2001.

Fig. 1.

Flowchart for the Swedish Obese Subjects (SOS) study describing the subjects included in this report and the subgroups used in the analyses.

Fig. 1.

Flowchart for the Swedish Obese Subjects (SOS) study describing the subjects included in this report and the subgroups used in the analyses.

Close modal

The two study groups had identical inclusion and exclusion criteria, and all controls were eligible for surgery. The inclusion criteria were age 37–60 years of age and BMI ≥34 kg/m2 for men and ≥38 kg/m2 for women before or at a matching examination. The exclusion criteria were previous surgery for gastric or duodenal ulcer, previous bariatric surgery, gastric ulcer during the past 6 months, ongoing malignancy, active malignancy during the past 5 years, myocardial infarction during the past 6 months, bulimic eating pattern, drug or alcohol abuse, psychiatric or cooperation problems contraindicating bariatric surgery and other contraindicating conditions (such as chronic glucocorticoid or anti-inflammatory treatment). The 18 matching variables included gender, age, weight, height, waist and hip circumferences, systolic blood pressure, serum cholesterol and triglyceride levels, smoking status, diabetes, menopausal status, four psychosocial variables with documented associations with the risk of death and two personality traits related to treatment preferences [23].

The control group received the conventional treatment for obesity (usual care) at their primary health-care centre. This care was not predefined and ranged from advanced lifestyle advice to basically no professional treatment at all. Participants in the surgery group underwent either gastric bypass, vertical-banded gastroplasty or gastric banding.

Measurements

Study participants were examined at baseline and 0.5, 1, 2, 3, 4, 6, 8, and 10 years after undergoing bariatric surgery or initiation of conventional treatment, respectively. The participants’ weight and height were measured and their BMI was calculated. At the same time, questionnaires were administered where participants were asked to estimate their body figure by using Stunkard’s figure rating scale [24]. This scale consists of nine male and female body figures that increase gradually in body size [24]. Estimated body size was derived from the BMI-adjusted Stunkard’s figure rating scale based on data from the SOS reference study [25]. In this scale, a mean BMI value based on measured weight and height data from the SOS reference cohort was assigned to each male and female silhouette of the Stunkard’s figure rating scale. A body perception index (BPI) was calculated by dividing estimated body size with measured BMI for intelligible interpretation. A BPI of 100% indicates accurate body size perception, whereas a lower BPI indicates an underestimation of body size.

Weight (re)gain was defined as weight increase of ≥10% after 10 years of follow-up compared to measured weight 1 year after surgery in the bariatric surgery group and 1 year after initiation of conventional obesity treatment in the control group. Weight maintenance was defined as <10% of weight increase after 10 years of follow-up compared to measured weight 1 year after surgery in the bariatric surgery group and 1 year after initiation of conventional obesity treatment in the control group.

Statistics

Means and standard deviations were used to describe the baseline characteristics. Differences between the surgery and the control group as well as between weight (re)gainers and maintainers within both of these two groups were tested with a t test for continuous and Fisher’s exact test for dichotomous variables. Means and 95% confidence intervals derived from mixed model analyses adjusted for sex and age were used to illustrate changes over time. Tests for time-BPI interaction were conducted to evaluate between-group differences in changes.

Body size perception was compared between weight (re)gainers and maintainers in both groups. Underestimation of body size is calculated as the difference between estimated and measured BMI. In a sensitivity analysis, we compared our results with previously published BMI-adjusted Stunkard’s figure rating scales [26, 27] to assess whether our results were valid regardless of the BMI-adjusted figure rating scale that is used for the calculation of the estimated BMI.

Pearson’s coefficient (r) was used to test associations between the BMI and the degree of distortion of perceived body size, i.e., BPI, both in the surgery and in the control group. Participants were excluded if Stunkard’s figure rating scale estimation of body size, or if an observed BMI at the 1-year or 10-year follow-up was missing. Participants were also excluded as per protocol censoring, if any bariatric surgery was performed in the control group or there was a change in or removal of the bariatric surgical procedure in the surgery group. All p values are two-sided and p < 0.05 was considered as statistically significant. The STATA statistical package (version 15.1) was used to perform the statistical analyses.

Baseline Characteristics and Overall Weight Changes

In the current report, a total of 2,504 subjects with obesity from the SOS intervention study with available data at baseline, 1 and 10 years were included (Fig. 1; Table 1). The bariatric surgery group included 1,370 subjects (28.7% men, age = 47.3 ± 5.9 years). Subjects underwent vertical-banded gastroplasty (n = 952 [69.5%]), gastric bypass (n = 174 [12.7%]) or gastric banding (n = 244 [17.8%]). The control group included 1,134 subjects (30.6% men, age 48.8 ± 6.1 years). The average BMI at baseline was higher in the surgery group compared to the control group (42.1 ± 4.3 and 39.7 ± 4.5 kg/m2, respectively), but as expected, substantially lower in the surgery group by year 1 (31.3 ± 4.4 and 38.7 ± 4.7 kg/m2, respectively). At 10 years, BMI remained substantially lower in the surgery group compared with usual care controls (34.9 ± 5.5 and 40.7 ± 5.7 kg/m2, respectively) (Table 1).

Table 1.

Baseline characteristics, measured BMI and estimated BMI values at baseline and during follow-up

Full cohortControl groupSurgery group
surgery control p valueweight gainer weight maintainer p valueweight regainer weight maintainer p value
(n = 1,370)(n = 1,134)(n = 372)(n = 762)(n = 747)(n = 623)
Baseline data 
 Male, sex, n (%) 393 (28.7) 347 (30.6) 0.312 121 (32.5) 226 (29.7) 0.337 227 (30.4) 166 (26.6) 0.126 
 Age, years 47.3±5.9 48.8±6.1 <0.001 47.7±5.9 49.3±6.2 <0.001 47.1±5.7 47.6±6.1 0.081 
 Weight, kg 120.1±16.2 113.5±15.9 <0.001 112.6±17.4 113.9±15.1 0.187 119.5±16.1 120.8±16.4 0.159 
 Measured BMI, kg/m2 42.1±4.3 39.7±4.5 <0.001 39.1±5.2 40.0±4.1 0.005 42.0±4.2 42.3±4.4 0.216 
 Estimated BMI, kg/m2 36.9±4.2 34.1±4.5 <0.001 33.5±4.8 34.4±4.3 0.005 36.9±4.2 37.0±4.2 0.421 
 Estimated − measured BMI −5.2±4.6 −5.6±4.2 0.016 −5.6±4.2 −5.6±4.2 0.895 −5.1±4.6 −5.2±4.6 0.639 
 Body size perception, %* 88±10 86±10 <0.001 86±10 86±10 0.837 88±10 88±10 0.716 
1-year data (nadir) 
 Measured BMI, kg/m2 31.3±4.4 38.7±4.7 <0.001 37.2±5.4 39.4±4.1 <0.001 30.3±4.1 32.5±4.4 <0.001 
10-year data 
 Measured BMI, kg/m2 34.9±5.5 40.7±5.7 <0.001 44.2±5.7 39.0±4.9 <0.001 37.2±4.9 32.1±4.9 <0.001 
 Estimated BMI, kg/m2 30.9±5.0 34.5±4.7 <0.001 36.2±4.6 33.7±4.6 <0.001 32.6±4.7 29.0±4.6 <0.001 
 Estimated − measured BMI −4.0±4.2 −6.2±4.8 <0.001 −8.0±5.3 −5.3±4.2 <0.001 −4.6±4.4 −3.2±3.7 <0.001 
 Body size perception, %* 89±11 86±11 <0.001 83±11 87±10 <0.001 88±11 91±11 <0.001 
Full cohortControl groupSurgery group
surgery control p valueweight gainer weight maintainer p valueweight regainer weight maintainer p value
(n = 1,370)(n = 1,134)(n = 372)(n = 762)(n = 747)(n = 623)
Baseline data 
 Male, sex, n (%) 393 (28.7) 347 (30.6) 0.312 121 (32.5) 226 (29.7) 0.337 227 (30.4) 166 (26.6) 0.126 
 Age, years 47.3±5.9 48.8±6.1 <0.001 47.7±5.9 49.3±6.2 <0.001 47.1±5.7 47.6±6.1 0.081 
 Weight, kg 120.1±16.2 113.5±15.9 <0.001 112.6±17.4 113.9±15.1 0.187 119.5±16.1 120.8±16.4 0.159 
 Measured BMI, kg/m2 42.1±4.3 39.7±4.5 <0.001 39.1±5.2 40.0±4.1 0.005 42.0±4.2 42.3±4.4 0.216 
 Estimated BMI, kg/m2 36.9±4.2 34.1±4.5 <0.001 33.5±4.8 34.4±4.3 0.005 36.9±4.2 37.0±4.2 0.421 
 Estimated − measured BMI −5.2±4.6 −5.6±4.2 0.016 −5.6±4.2 −5.6±4.2 0.895 −5.1±4.6 −5.2±4.6 0.639 
 Body size perception, %* 88±10 86±10 <0.001 86±10 86±10 0.837 88±10 88±10 0.716 
1-year data (nadir) 
 Measured BMI, kg/m2 31.3±4.4 38.7±4.7 <0.001 37.2±5.4 39.4±4.1 <0.001 30.3±4.1 32.5±4.4 <0.001 
10-year data 
 Measured BMI, kg/m2 34.9±5.5 40.7±5.7 <0.001 44.2±5.7 39.0±4.9 <0.001 37.2±4.9 32.1±4.9 <0.001 
 Estimated BMI, kg/m2 30.9±5.0 34.5±4.7 <0.001 36.2±4.6 33.7±4.6 <0.001 32.6±4.7 29.0±4.6 <0.001 
 Estimated − measured BMI −4.0±4.2 −6.2±4.8 <0.001 −8.0±5.3 −5.3±4.2 <0.001 −4.6±4.4 −3.2±3.7 <0.001 
 Body size perception, %* 89±11 86±11 <0.001 83±11 87±10 <0.001 88±11 91±11 <0.001 

*Body size perception calculated as (estimated BMI/measured BMI) ×100, i.e., values indicate perceived percent of actual body size. Data are mean ± SD unless otherwise indicated.

Estimation of Body Size in Surgery and Control Groups

At baseline, a higher BMI was associated with a less accurate perceived body size, i.e., lower BPI, both in the bariatric surgery group (r = −0.428, p < 0.001) and in the control group (r = −0.323, p < 0.001). At baseline, BPI was 0.88 ± 0.10 in surgery patients and 0.86 ± 0.10 in usual care controls. Hence, surgery patients and ususal care controls on average underestimated their body size by 12% and 14%, respectively, corresponding to a >5 BMI units underestimation in both groups (Table 1; Fig. 2a, b).

Fig. 2.

Body size perception in patients treated with bariatric surgery or usual obesity care. Measured and estimated BMI in patients treated with bariatric surgery (a) and usual care controls (b). Body size perception (body size underestimation) in patients treated with bariatric surgery and usual care controls (c). Lines are estimated means from a mixed model with adjustment for sex and age.

Fig. 2.

Body size perception in patients treated with bariatric surgery or usual obesity care. Measured and estimated BMI in patients treated with bariatric surgery (a) and usual care controls (b). Body size perception (body size underestimation) in patients treated with bariatric surgery and usual care controls (c). Lines are estimated means from a mixed model with adjustment for sex and age.

Close modal

Body size underestimation largely persisted over 10 years in both surgery patients and usual care controls (Fig. 2c). At the 10-year follow-up, BPI was 0.89 ± 0.11 in surgery patients and 0.86 ± 0.11 in controls corresponding to an average underestimation of perceived body size by 11% and 14%, respectively.

Estimation of Body Size in Groups Stratified by Weight Development during Follow-Up

In a further step, we stratified the bariatric surgery group, and control group according to weight development between 1 and 10 years (maintainers or regainers/gainers). In the surgery group, baseline BMI was similar in weight regainers (n = 747) and weight maintainers (n = 623; p = 0.216) (Table 1). In the control group, BMI at baseline was slightly lower in weight gainers (n = 372) compared with weight maintainers (n = 762; p = 0.005) (Table 1). Importantly, at baseline, a similar degree of distortion of perceived body size (12% underestimation) was observed in weight regainers and maintainers in both the bariatric group (BPI = 0.88 ± 0.10 and 0.88 ± 0.10, p = 0.716), and gainers and maintainers (14% underestimation) in the control group (BPI = 0.86 ± 0.10 and 0.86 ± 0.10, p = 0.837) (Table 1).

Measured and estimated BMI values in weight (re)gainers and maintainers are shown in Figure 3a, b. At baseline, all groups underestimated their body size by on average more than 5 BMI units, and no significant differences between weight (re)gainers and maintainers were observed within the surgery and the control groups (Table 1; Fig. 3a, b). After 10 years, body size underestimation was significantly larger in (re)gainers compared to maintainers in both the surgery (−4.6 vs. −3.2 BMI units, p < 0.001) and the control group (−8.0 vs. −5.3 BMI units, p < 0.001) (Table 1; Fig. 3a, b). Thus, at 10 years, weight maintainers in the surgery group presented with the least underestimation of their body size (−3.2 BMI units).

Fig. 3.

Body size perception in patients treated with bariatric surgery or usual obesity care, stratified by long-term weight change. Measured and estimated BMI in weight (re)gainers and weight maintainers in the bariatric surgery group (a) and control group (b). Body size perception (body size underestimation) in weight (re)gainers and weight maintainers in the bariatric surgery group (c) and control group (d). Lines are estimated means from a mixed model with adjustment for sex and age.

Fig. 3.

Body size perception in patients treated with bariatric surgery or usual obesity care, stratified by long-term weight change. Measured and estimated BMI in weight (re)gainers and weight maintainers in the bariatric surgery group (a) and control group (b). Body size perception (body size underestimation) in weight (re)gainers and weight maintainers in the bariatric surgery group (c) and control group (d). Lines are estimated means from a mixed model with adjustment for sex and age.

Close modal

A comparison of the accuracy of perceived body size between weight (re)gainers and maintainers in the surgery and control groups at different points of follow-up is shown in Figure 3c and d, respectively. In both the surgery and control groups, the change in BPI was significantly different between weight regainers and maintainers during follow-up (time-BPI interactions both p < 0.001).

At 10 years, accuracy of perceived body size was significantly lower in (re)gainers compared to maintainers in both the surgery (0.88 ± 0.11 and 0.91 ± 0.11, p < 0.001) and control group 0.83 ± 0.11 and 0.87 ± 0.10, p < 0.001) (Table 1). Thus, in both the surgery and control group, weight maintainers (9 and 13% underestimation, respectively) had a more accurate body size perception compared to the (re)gainers (12 and 17% underestimation, respectively).

Sensitivity Analysis

In a sensitivity analysis, we then tested whether the results differed depending on the BMI-adjusted scale used to calculate estimated BMI. We thus compared our results, derived from the BMI-adjusted Stunkard’s figure rating scale based on data from the SOS reference cohort [25], with the previously published BMI-adjusted Stunkard’s figure rating scales (Wesnes and Bulik scales) [26, 27]. Importantly, these analyses produced similar results (data not shown).

Bariatric surgery is known to improve many obesity-related comorbidities and affects various aspects of the patients’ life [23, 28, 29], but effect of surgical treatment on body size perception long-term has not been extensively researched. Our results, from the prospective, controlled SOS intervention study show that patients with obesity underestimate their body size by approximately 5 BMI units. Moreover, this underestimation persists even after major weight loss induced by bariatric surgery, but body size perception seems slightly more accurate in patients who are able to maintain their body weight long-term.

Body size perception is influenced by neurophysiological, socio-cultural, cognitive [30] and psychological factors [31] and body size distortion differs depending on weight class. When asked to estimate their own body size by Stunkard’s figure rating scale, 39.8% of people with normal weight rated themselves as having underweight, 13.7% as having overweight and 0.7% as having obesity [32]. In the same study, 53% of people with obesity underestimated and 9.5% of people with underweight overestimated their body size [32]. However, our results show that although body weight and body size perception are changed after surgery, patients still underestimated their body size. This failure in updating the body size perception might be explained by the “allocentric lock hypothesis” postulated by Riva et al. [33] He suggested that patients with distorted body size perception are locked to an allocentric representation of their body that is stored in long-term memory and which is not adequately updated with real-time perceptive inputs even after a significant weight loss. The allocentric lock may be induced by psychological stress mechanisms influencing brain areas involved in the integration of perceptive input [33].

Previous studies show that a higher BMI is associated with a higher degree of body size underestimation [4, 5]. This was confirmed by our results, showing that body size underestimation was present in both intervention groups at baseline. For example, patients who underwent bariatric surgery underestimated their body size by approximately 5 BMI units at baseline. Previous, short-term studies indicate that, after bariatric surgery, a considerable proportion of patients still suffer from distortion of perceived body size despite weight loss [19‒21]. We now extend these findings by showing that patients undergoing bariatric surgery underestimated their body size by at least 9% even after 10 years of follow-up. These findings support the allocentric lock hypothesis by showing that distortion of perceived body size remains over time but also adds a new aspect to the hypothesis by showing that the body size perception is updated by real-time perceptive input but only to a very limited extent. However, it is possible that this discrepancy is partly due to the fact that, even after successful weight loss in bariatric surgery patients, most patients still have overweight or obesity [34].

Weight (re)gain is a major challenge for people living with obesity. Body dissatisfaction in people with obesity is common and could result in additional weight loss attempts and better weight control [5, 32, 35, 36]. Our results show that weight regainers in the surgery group displayed a higher degree of body size underestimation compared to weight maintainers after 10 years. A similar pattern was observed also for usual care controls. These results together with previous reports [5, 32, 35, 36] support the tight association between body weight and accuracy of body size perception. The underestimation of body size in people with obesity might have several health implications. For example, if one fails to identify themselves as a person with obesity, it might be unlikely that medical help will be sought [32]. On the other hand, perceiving oneself as a person with obesity might be psychologically stressful. However, our study has shown that a more accurate body size perception was associated with weight maintenance.

Important strengths of our study are the very large sample size and extended follow-up. Furthermore, the BMI-adjusted Stunkard’s figure rating scale used in this report is based on data from the SOS reference cohort, which was originally designed to be a reference cohort for the SOS intervention study [25]. However, some limitations of the current analyses need to be considered. The Stunkard’s figure rating scale has been criticised for the limited number of presented figures resulting in reduced data resolution and that the silhouette range does not cover extreme obesity [37, 38]. Moreover, our data were collected in a Caucasian sample and it is known that body satisfaction and body size perception differ among different cultures [39]. It also needs to be mentioned that participants were not asked about their ideal body size or body size dissatisfaction and hence, we cannot investigate a potential association between these factors and weight development. Finally, there is no consensus in the literature regarding the definition of weight regain and a wide variety of definitions of weight regain exist [12], including the one used in our study [40].

In conclusion, patients with obesity underestimate their body size and this distorted body size perception persists long-term, even after major weight loss induced by bariatric surgery. Furthermore, in patients with obesity who maintain their weight, regardless of treatment, underestimation persists but is slightly less pronounced compared to patients who fail to maintain their weight long-term. Further research is needed to determine to what extent lower accuracy in body size perception affects obesity development and/or long-term weight management and to unravel the underlying mechanisms.

The authors thank the staff members at 480 primary health-care centres and 25 surgical departments in Sweden who participated in the SOS study.

Seven regional Ethics Review Boards (Gothenburg, Lund, Linköping, Örebro, Karolinska Institute, Uppsala, Umeå) approved the study (reference numbers 184-90 och T508-17), and written or verbal informed consent was obtained from all participants. This consent procedure was reviewed and approved by all seven review boards, approval number 184-90, date of decision June 6, 1990. The study has been registered at ClinicalTrials.gov (NCT01479452).

V.P., M.P., P.-A.S., and K.S. have no conflicts of interest to declare. M.T. holds stocks in Umecrine AB and has a patent licensed to Umecrine AB. B. Ludvik received grant support and honoraria for research projects and advice from Eli Lilly, Novo Nordisk, Sanofi, Boehringer Ingelheim, Astra Zeneca, Bayer, and Amgen. B.L. is an associate editor in the journal Obesity Facts. J.M.B. received honoraria from Astra Zeneca, Boehringer Ingelheim, Eli Lilly, MSD, Novo Nordisk, and Sanofi Aventis.

The research reported in this article was supported by the Swedish Research Council (2020-01303), the Swedish state under the agreement between the Swedish government and the county councils, the ALF agreement (ALFGBG-965046, and ALFGBG-966076), the Swedish Diabetes foundation (2019-417) and the Adlerbert research foundation.

Verena Parzer, Magdalena Taube, Bernhard Ludvik, Markku Peltonen, Per-Arne Svensson, Johanna Maria Brix, and Kajsa Sjöholm were involved in the design of the study and responsible for interpretation of the results. Per-Arne Svensson, Magdalena Taube, Markku Peltonen, and Kajsa Sjöholm were responsible for acquisition and integrity of the data. Verena Parzer and Markku Peltonen were responsible for the statistical data analysis. Verena Parzer drafted the manuscript. All authors participated in critical revision of the manuscript and provided intellectual input. Per-Arne Svensson and Kajsa Sjöholm were involved in fundraising. All authors approved the final version and agreed to be accountable for all aspects of the work.

Additional Information

Johanna Maria Brix and Kajsa Sjöholm contributed equally and should both be considered last authors.

The information is subject to legal restrictions according to national legislation. Confidentiality regarding personal information in studies is regulated in the Public Access to Information and Secrecy Act (SFS 2009:400), OSL. A request to get access to public documents can be rejected or granted with reservations by the University of Gothenburg. If the University of Gothenburg refuses to disclose the documents, the applicant is entitled to get a written decision that can be appealed to the administrative court of appeal. Further enquiries can be directed to the corresponding author.

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