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Clinical Sciences
A Higher Meal Frequency May be Associated with Diminished Weight Loss after Bariatric Surgery
Angela Gadelha RibeiroI, Maria José de Carvalho CostaI, Joel FaintuchII, Maria Carolina Gonçalves DiasIII
I School of Nutrition, University of Paraíba (UFPB) - João Pessoa/PB, Brazil
II Department of Gastroenterology, Faculdade de Medicina da Universidade de Sao Paulo - São Paulo/SP, Brazil
III Nutrition Team (EMTN) , Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo - São Paulo/SP, Brazil. Tel: 55 83 3216.7417 / 3235.3353
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="cesec10" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle60">INTRODUCTION</span><p id="para10" class="elsevierStylePara elsevierViewall">The incidence of obesity in the U&#46;S&#46; has exponentially increased to epidemic proportions&#44; increasing by more than 75&#37; over the last 25 years&#46; This fact allows obesity to currently be considered a major public health issue&#46; The most recent NHANES data &#40;1999&#8211;2004&#41; estimate that among adults in the U&#46;S&#46;&#44; 66&#46;3&#37; are overweight or obese&#44; 32&#46;4&#37; are obese and 4&#46;8&#37; are extremely obese&#46;<a class="elsevierStyleCrossRef" href="#bib1">1</a></p><p id="para20" class="elsevierStylePara elsevierViewall">Diverse intervention strategies are being applied&#44; and Roux-en-Y gastric bypass &#40;RYGB&#41;<a class="elsevierStyleCrossRef" href="#bib2">2</a> is a prominent technique among them&#46; It is an effective and relatively low-risk procedure to provide weight loss&#44; which can generally be controlled on a short- or long-term basis&#46;<a class="elsevierStyleCrossRef" href="#bib3">3</a></p><p id="para30" class="elsevierStylePara elsevierViewall">Although the number of surgeries and the number of published essays<a class="elsevierStyleCrossRef" href="#bib4">4</a>&#8211;<a class="elsevierStyleCrossRef" href="#bib7">7</a> on this matter increase each year&#44; the influences of postoperative food programs on weight loss have not been thoroughly investigated&#46; This is especially true when it comes to meal frequency&#46;</p><p id="para40" class="elsevierStylePara elsevierViewall">Some authors have suggested that a higher fractionation of meals would induce more weight loss&#46;<a class="elsevierStyleCrossRef" href="#bib8">8</a>&#8211;<a class="elsevierStyleCrossRef" href="#bib11">11</a> The mechanisms that explain such a relationship&#44; however&#44; are obscure and even paradoxical&#44;<a class="elsevierStyleCrossRef" href="#bib12">12</a>&#8211;<a class="elsevierStyleCrossRef" href="#bib14">14</a> raising doubts about the true advantage of multiple meals&#46; Vomiting is not uncommon in this setting&#44; and small amounts of food divided throughout the day may alleviate discomfort&#46;<a class="elsevierStyleCrossRef" href="#bib2">2</a>&#44; <a class="elsevierStyleCrossRef" href="#bib4">4</a>&#8211; <a class="elsevierStyleCrossRef" href="#bib7">7</a></p><p id="para50" class="elsevierStylePara elsevierViewall">The present study was designed to investigate the interactions between consumed meals&#44; vomiting episodes and weight loss in bariatric patients up to 9 months after RYGB&#46;</p></span><span id="cesec20" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle70">METHODS</span><span id="cesec30" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle80">Population</span><p id="para60" class="elsevierStylePara elsevierViewall">Morbidly obese female patients &#40;n &#61; 80&#41; who had been submitted to RYGB were nutritionally followed over a 9-month period after surgery&#46; Women were selected because they represent the majority of surgical candidates and because they allow us to obtain a homogeneous analysis of the results&#46;</p><p id="para70" class="elsevierStylePara elsevierViewall">Surgical indication followed the accepted rules&#44; namely&#44; a body mass index &#40;BMI&#41; &#62; 40 kg&#47;m2 independent of comorbidities or &#62; 35 kg&#47;m2 in the presence of significant associated diseases&#46; The prevalence of comorbidities was not targeted by the protocol&#44; but results were not substantially different from those previously published &#40;diabetes mellitus&#44; 24&#37;&#59; dyslipidemia&#44; 52&#37;&#59; arterial hypertension&#44; 72&#37;&#59; metabolic syndrome&#44; 59&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib15">15</a></p><p id="para80" class="elsevierStylePara elsevierViewall">Inclusion criteria were&#58; age of 18&#8211;65 years&#44; elective intervention and informed consent&#46; Exclusion criteria were&#58; sepsis&#44; shock&#44; coma&#44; hospitalization or reoperation during the study period or refusal to participate in the study&#46;</p></span><span id="cesec40" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle90">Study design</span><p id="para90" class="elsevierStylePara elsevierViewall">This study employed a prospective observational clinical protocol with outpatient subjects&#46; Patients were interviewed at 3-month intervals between the 3<span class="elsevierStyleSup">rd</span> and 9<span class="elsevierStyleSup">th</span> postoperative months by a trained dietitian&#46; General information was collected from hospital records and was confirmed during scheduled visits&#46;</p></span><span id="cesec50" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle100">Exclusions</span><p id="para100" class="elsevierStylePara elsevierViewall">The study began with 160 subjects with a planned duration of 12 months&#46; At the end of the study&#44; only 80 were included&#44; and only the first 9 months were analyzed because returns sharply diminished after this time&#46;</p></span><span id="cesec60" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle110">Surgical technique</span><p id="para110" class="elsevierStylePara elsevierViewall">The open RYGBP involved the creation of a vertical gastric pouch of approximately 30 ml&#44; a Roux-en-Y jejunal limb of 100 cm and a biliopancreatic limb of 60&#8211;80 cm&#46; The gastric reservoir had a length of 8&#8211;10 cm and a volume of 30&#8211;50 ml&#44; and a silastic ring &#40;6&#46;3 cm in circumference&#41; was inserted around the pouch 3 cm proximal to the end-to-side gastrojejunal anastomosis to prevent future dilatation&#46;</p></span><span id="cesec70" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle120">Anthropometric variables</span><p id="para120" class="elsevierStylePara elsevierViewall">Body weight&#44; height&#44; BMI and weight loss were recorded at each visit&#46; Weight loss &#40;absolute or as a percentage&#41; was based on the following equation&#58; Weight loss &#61; Usual weight &#8211; Present weight&#46;</p></span><span id="cesec80" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle130">Dietetic methods</span><p id="para130" class="elsevierStylePara elsevierViewall">Diet fractionation considered all options adopted by the patients&#44; from just one or two meals&#47;day up to more than six meals&#47;day&#46; Vomiting episodes were numerically registered&#44; irrespective of the severity of the event&#46; Dietary recall &#40;24 h&#41; was analyzed using the Virtual Nutri software package &#40;S&#227;o Paulo&#44; SP&#44; Brazil&#41;&#44; which has been programmed for Brazilian foods and meal sizes&#46;</p><p id="para140" class="elsevierStylePara elsevierViewall">Recall was performed at three different occasions at the end of each quarter&#44; including one weekend&#44; and the median score was used to evaluate macronutrients&#46;</p><p id="para150" class="elsevierStylePara elsevierViewall">Interviews were conducted by an experienced dietitian&#46; Patients who stated that they were ill or&#44; for some other reason&#44; had changed their diet within the last 48 hours were scheduled for another date&#46; All consumed foods and drinks were recorded&#44; and details regarding the ingredients and preparation technique&#44; or food brand in the case of industrialized items&#44; were collected&#46; Standard cups&#44; dishware and food portions were described&#44; and more information was requested from the patient in case of doubt before registering the questionnaire&#46;</p><p id="para160" class="elsevierStylePara elsevierViewall">Final verification emphasized forgotten items&#44; such as occasional cookies&#44; sugar- or alcohol-containing drinks&#44; as well as midnight snacks&#46;</p></span><span id="cesec90" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle140">Ethical considerations</span><p id="para170" class="elsevierStylePara elsevierViewall">Informed consent was obtained from all subjects&#44; and the protocol was approved by the ethical committees of the two involved institutions&#46;</p></span><span id="cesec100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle150">Statistical analysis</span><p id="para180" class="elsevierStylePara elsevierViewall">Values are presented as means &#177; SD&#46; An analysis of variance &#40;ANOVA&#41; was used to compare numerical variables &#40;anthropometry and calories&#41; after confirmation of normality by the Kolmogorov-Smirnov test&#46; A comparison of diet fractionation means &#40;organized into six categories&#41; was performed using the Tukey test&#46; Qualitative data &#40;vomiting&#41; was examined by chi-squared analysis or a Fisher&#8217;s exact test&#46; Pearson&#8217;s correlation analysis was used to evaluate the variables of weight loss&#44; diet fractionation&#44; vomiting episodes and calories&#46; A significance level of 5&#37; &#40;P &#60; 0&#46;05&#41; was adopted in all circumstances&#46;</p></span></span><span id="cesec110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle160">RESULTS</span><p id="para190" class="elsevierStylePara elsevierViewall">The general findings of the population are organized in <a class="elsevierStyleCrossRef" href="#t1-cln64_11p1053">Table 1</a>&#46; Maximum weight loss&#44; at least in absolute values&#44; occurred in the first quarter&#46; The rate of absolute weight loss decreased at the later time points&#46; Dietary intake gradually increased&#44; although always remaining well below the recommended allowances&#46; Vomiting episodes increased and peaked at 6 months&#44; but were at common levels by 9 months&#46;</p><elsevierMultimedia ident="t1-cln64_11p1053"></elsevierMultimedia><p id="para200" class="elsevierStylePara elsevierViewall">The number of meals did not influence the BMI&#44; weight loss or food intake up to 6 months&#46; Nevertheless&#44; when the entire study period was considered&#44; diet fractionation had an impact on weight loss &#40;<a class="elsevierStyleCrossRef" href="#t2-cln64_11p1053">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="t2-cln64_11p1053"></elsevierMultimedia><p id="para210" class="elsevierStylePara elsevierViewall">In the first 6 months&#44; no differences in BMI or dietary choleric intake could be attributed to diet fractionation&#46; Analysis of the entire 9 months&#44; however&#44; revealed that a three-meals&#47;day regimen was associated with the highest weight loss&#44; as compared to that obtained with a larger number of meals &#40;<a class="elsevierStyleCrossRef" href="#t3-cln64_11p1053">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="t3-cln64_11p1053"></elsevierMultimedia><p id="para220" class="elsevierStylePara elsevierViewall">A Pearson correlation confirmed that diet fractionation&#44; vomiting episodes and choleric intake did not interfere with the outcome at 3 months&#46; By 9 months&#44; however&#44; there was a significant negative correlation with a 1&#37; probability &#40;P &#60; 0&#46;01&#41; between weight loss and diet fractionation&#44; indicating that a greater number of meals&#47;day was associated with less weight loss&#46; Conversely&#44; vomiting improved with more meals by 6 months &#40;<a class="elsevierStyleCrossRef" href="#t4-cln64_11p1053">Table 4</a>&#41;&#46;</p><elsevierMultimedia ident="t4-cln64_11p1053"></elsevierMultimedia><p id="para230" class="elsevierStylePara elsevierViewall">Although weight loss was influenced by the frequency of meals&#44; the effect was not significant&#46; This tended to be analogously associated with energy intake&#44; especially at 3 months &#40;P &#61; 0&#46;063&#44; NS&#41; and at 9 months &#40;P &#61; 0&#46;051&#44; NS&#41;&#46;</p></span><span id="cesec120" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle170">DISCUSSION</span><p id="para240" class="elsevierStylePara elsevierViewall">Gastric bypass is not the only bariatric technique available&#46; There are a variety of modalities for weight loss available around the world&#46; It is&#44; however&#44; still respected as the gold standard and the benchmark to which other approaches have been compared&#46;<a class="elsevierStyleCrossRefs" href="#bib2">2&#44;4&#44;6&#44;15</a></p><p id="para250" class="elsevierStylePara elsevierViewall">The pre-bariatric weight in this series was 129&#46;1 &#177; 27&#46;1 kg&#44; a value almost identical to that observed in the study of Ocon et al&#46;<a class="elsevierStyleCrossRef" href="#bib16">16</a> &#40;129&#46;7 &#177; 25&#46;6 kg&#41;&#46; Weight curves during the postoperative period are more variable&#44; as they suffer from the impact of previous weight&#44; dietary pattern&#44; comorbidities and complications&#46; According to Crookes et al&#46; and others&#44;<a class="elsevierStyleCrossRef" href="#bib16">16</a>&#8211; <a class="elsevierStyleCrossRef" href="#bib19">19</a> patients are expected to lose 25&#8211;32&#37; of body weight during the first 6&#8211;12 months&#44; which is roughly the range observed in this study&#46;</p><p id="para260" class="elsevierStylePara elsevierViewall">Vomiting is a recognized side effect due to the narrowed gastric outlet&#44; especially if patients eat rapidly or swallow large chunks of food without chewing&#44; and may affect 8&#8211;49&#37; of subjects&#46;<a class="elsevierStyleCrossRef" href="#bib6">6</a>&#46;<a class="elsevierStyleCrossRef" href="#bib19">19</a>&#8211;<a class="elsevierStyleCrossRef" href="#bib21">21</a> When persistent&#44; it may precipitate protein-calorie malnutrition as well as Wernicke&#8217;s encephalopathy&#46;<a class="elsevierStyleCrossRefs" href="#bib22">22&#44;23</a> In the current series&#44; somewhat higher than average values were found&#44; with an increasing tendency up to 6 months&#46; These values&#44; however&#44; decreased around 9 months&#46; Multiple meals were beneficial to alleviating this complication&#44; as observed at 6 months &#40;<a class="elsevierStyleCrossRef" href="#t4-cln64_11p1053">Table 4</a>&#59; P &#61; 0&#46;038&#41;&#46;</p><p id="para270" class="elsevierStylePara elsevierViewall">Meal frequency following RYGB or gastric banding was documented by Ward&#233;-Kamar et al&#46;<a class="elsevierStyleCrossRef" href="#bib24">24</a> and Restuccia et al&#46;<a class="elsevierStyleCrossRef" href="#bib25">25</a> Moreover&#44; Ward&#233;-Kamar et al&#46;<a class="elsevierStyleCrossRef" href="#bib24">24</a> reported that after 30 months&#44; energy intake was 1733 &#177; 630 Kcal&#47;day&#46; Patients fed themselves six times a day&#44; a routine that was not criticized because the weight loss was quite adequate &#40;58 &#177; 17&#37;&#41;&#46;</p><p id="para280" class="elsevierStylePara elsevierViewall">Restuccia et al&#46;<a class="elsevierStyleCrossRef" href="#bib25">25</a> showed an association between weight loss and diet pattern&#44; but only after 18 months following RYGB&#46; Nevertheless&#44; in non-operated children and adolescents&#44; it is well established that a greater number of snacks and&#44; particularly&#44; a greater of meals in the absence of hunger result in increased body weight&#46;<a class="elsevierStyleCrossRef" href="#bib26">26</a> After bariatric intervention&#44; it was recently shown that snack-eating&#44; and multiple meals in general&#44; are deleterious for BMI normalization&#46;<a class="elsevierStyleCrossRef" href="#bib27">27</a></p><p id="para290" class="elsevierStylePara elsevierViewall">Total ingestion should not be overlooked&#44; and the results reported here were globally low &#40;536 &#177; 295&#46;7 Kcal&#47;day by 3 months and 829&#46;0 &#177; 398&#46;2 Kcal&#47;day at 9 months&#41;&#46; These data are consistent with the case-report of undernutrition by Kushner&#44;<a class="elsevierStyleCrossRef" href="#bib28">28</a> but not with the conventional experience reported by Skroubis et al&#46;<a class="elsevierStyleCrossRef" href="#bib29">29</a> and Bobbioni et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib30">30</a> who noted more substantial values &#40;900&#8211;1000 Kcal&#47;day and 1140 &#177; 420 Kcal&#47;day during the 6 first months&#44; respectively&#41;&#46; Such a downward trend in food ingestion appears to be typical of public hospitals in Brazil and has already been reported by Dias et al&#46;<a class="elsevierStyleCrossRef" href="#bib6">6</a></p><p id="para300" class="elsevierStylePara elsevierViewall">In the initial 3 months&#44; more calories were consumed by our patients who ate six times per day than by those that had only three meals &#40;<a class="elsevierStyleCrossRef" href="#t3-cln64_11p1053">Table 3</a>&#41;&#46; The impact on weight loss was not evident at this point&#44; likely because the total daily volume at this stage was extremely low &#40;slightly above 500 Kcal&#47;day&#41;&#46; Nonetheless&#44; weight loss tended to correlate with dietary energy both at 3 and 9 months &#40;P &#61; 0&#46;063 and P &#61; 0&#46;051&#44; respectively&#59; <a class="elsevierStyleCrossRef" href="#t4-cln64_11p1053">Table 4</a>&#41;&#46;</p><p id="para310" class="elsevierStylePara elsevierViewall">In light of the present observations&#44; which are consistent with those of Leite-Faria et al&#46; under similar conditions&#44;<a class="elsevierStyleCrossRef" href="#bib27">27</a> a standard regimen of three meals&#47;day appears to be an option to be considered against insufficient weight loss&#46;</p><p id="para320" class="elsevierStylePara elsevierViewall">More divided meals should only be planned in specific settings&#44; such as those involving patients with limited food tolerance and frequent vomiting&#44; those that are addicted to or unable to change an all-day-grazing routine due to social or psychological reasons or when it is believed that numerous scheduled meals will inhibit consumption of even more damaging calorie-dense snacks&#46;</p><p id="para330" class="elsevierStylePara elsevierViewall">The impact of comorbidities on weight loss was not addressed in this protocol&#46; In a recent article with a comparable population&#44; it was noted that diabetics tended to lose less weight than non-diabetics&#44; particularly in the first two years&#46;<a class="elsevierStyleCrossRef" href="#bib31">31</a></p><p id="para340" class="elsevierStylePara elsevierViewall">Our study suffers from the weaknesses intrinsic in any observational protocol&#46; There was no intervention concerning the frequency of meals or choleric consumption&#44; and the distribution was not previously determined&#46; The outcome depended on the spontaneous decisions of the patients or the eventual recommendations of their surgeon&#46; As a consequence&#44; the numbers were occasionally skewed&#44; and statistical significance could only be achieved at certain points&#46;</p><p id="para350" class="elsevierStylePara elsevierViewall">Physical exercise was also not evaluated in this study&#46; Although patients were mostly sedentary housewives&#44; in rare circumstances&#44; vigorous exercising can introduce a bias in weight loss findings&#46;</p><p id="para360" class="elsevierStylePara elsevierViewall">Additional investigations are needed to better elucidate the various factors interfering with diet&#44; vomiting and weight loss in individuals with bariatric devices&#46;</p></span><span id="cesec130" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle180">CONCLUSIONS</span><p id="para370" class="elsevierStylePara elsevierViewall">1&#41; Frequent small meals were associated with reduced weight loss after gastric bypass and with decreased vomiting episodes at 6 months&#44; and 2&#41; vomiting did not interfere with nutritional outcome&#46; Unless required due to vomiting or other reasons&#44; multiple small meals may not be advantageous after bariatric intervention&#46;</p></span></span>"
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        1 => array:2 [
          "identificador" => "cesec10"
          "titulo" => "INTRODUCTION"
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        2 => array:3 [
          "identificador" => "cesec20"
          "titulo" => "METHODS"
          "secciones" => array:8 [
            0 => array:2 [
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              "titulo" => "Population"
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            1 => array:2 [
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              "titulo" => "Surgical technique"
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            4 => array:2 [
              "identificador" => "cesec70"
              "titulo" => "Anthropometric variables"
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            5 => array:2 [
              "identificador" => "cesec80"
              "titulo" => "Dietetic methods"
            ]
            6 => array:2 [
              "identificador" => "cesec90"
              "titulo" => "Ethical considerations"
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            7 => array:2 [
              "identificador" => "cesec100"
              "titulo" => "Statistical analysis"
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          ]
        ]
        3 => array:2 [
          "identificador" => "cesec110"
          "titulo" => "RESULTS"
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        4 => array:2 [
          "identificador" => "cesec120"
          "titulo" => "DISCUSSION"
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        5 => array:2 [
          "identificador" => "cesec130"
          "titulo" => "CONCLUSIONS"
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        6 => array:1 [
          "titulo" => "REFERENCES"
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      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2009-06-09"
    "fechaAceptado" => "2009-07-27"
    "PalabrasClave" => array:1 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "KEYWORDS&#58;"
          "identificador" => "xpalclavsec1585070"
          "palabras" => array:5 [
            0 => "Roux-en-Y gastric bypass"
            1 => "Bariatric surgery"
            2 => "Morbid obesity"
            3 => "Calorie ingestion"
            4 => "Diet"
          ]
        ]
      ]
    ]
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    "resumen" => array:1 [
      "en" => array:2 [
        "resumen" => "<span id="ceabs10" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle10">OBJECTIVE</span><p id="spara80" class="elsevierStyleSimplePara elsevierViewall">This study aimed to investigate the relationship between meal frequency&#44; the occurrence of vomiting and weight loss among patients submitted to Roux-en-Y gastric bypass up to 9 months after surgery&#46;</p></span> <span id="ceabs20" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle20">METHODS</span><p id="spara90" class="elsevierStyleSimplePara elsevierViewall">Female patients &#40;n &#61; 80&#41; were followed at 3-month intervals for 9 months&#46; Weight&#44; BMI&#44; 24-hour dietary recall&#44; drug consumption and vomiting episodes were recorded and compared with nutritional outcome&#46;</p></span> <span id="ceabs30" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle30">RESULTS</span><p id="spara100" class="elsevierStyleSimplePara elsevierViewall">The BMI values at 3&#44; 6 and 9 months were 45&#46;1 &#177; 9&#46;7&#44; 39&#46;9 &#177; 7&#46;6 and 35&#46;4 &#177; 8&#46;2 kg&#47;m<span class="elsevierStyleSup">2</span>&#44; respectively&#46; The corresponding choleric intakes were 535&#46;6 &#177; 295&#46;7&#44; 677&#46;1 &#177; 314&#46;7 and 828&#46;6 &#177; 398&#46;2 kcal&#47;day&#44; and the numbers of daily meals were 5&#46;0 &#177; 2&#46;5&#44; 4&#46;7 &#177; 1&#46;8 and 4&#46;9 &#177; 1&#46;0&#44; respectively&#46; The peak of vomiting episodes occurred within 6 months&#59; however&#44; patients tolerated this complication despite its high prevalence&#46; A significant negative correlation between weight loss and diet fractioning&#44; but not vomiting&#44; was observed throughout the entire postoperative period &#40;P &#61; 0&#46;001&#41;&#46;</p></span> <span id="ceabs40" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle40">CONCLUSIONS</span><p id="spara110" class="elsevierStyleSimplePara elsevierViewall">1&#41; Frequent small meals were associated with a reduction in weight loss after gastric bypass and a decrease in vomiting episodes at 6 months&#44; and 2&#41; vomiting did not interfere with nutritional outcome&#46; Unless required because of vomiting or other reasons&#44; multiple small meals may not be advantageous after such intervention&#46;</p></span>"
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            "titulo" => "METHODS"
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          2 => array:2 [
            "identificador" => "ceabs30"
            "titulo" => "RESULTS"
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          3 => array:2 [
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            "titulo" => "CONCLUSIONS"
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        "identificador" => "t1-cln64_11p1053"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
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        "tabla" => array:2 [
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Variables&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Preoperative&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">3 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">6 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">9 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Weight &#40;kg&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">129&#46;1 &#177; 27&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">113&#46;4 &#177; 25&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">99&#46;9 &#177; 19&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">88&#46;0 &#177; 21&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">BMI &#40;kg&#47;m<span class="elsevierStyleSup">2</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">53&#46;5 &#177; 10&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">45&#46;1 &#177; 9&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">39&#46;9 &#177; 7&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">35&#46;4 &#177; 8&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Weight loss &#40;kg&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15&#46;7 &#177; 7&#46;3 <a class="elsevierStyleCrossRef" href="#tfn1-cln64_11p1053">&#42;</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&#46;3 &#177; 4&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&#46;5 &#177; 12&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Weight loss &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&#46;2 &#177; 4&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&#46;3 &#177; 4&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13&#46;5 &#177; 8&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Calories &#40;Kcal&#47;day&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">535&#46;6 &#177; 295&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">677&#46;1 &#177; 314&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">828&#46;6&#177; 398&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Vomiting &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">31&#46;3 &#40;25&#47;80&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">50&#46;0 &#40;40&#47;80&#41;<a class="elsevierStyleCrossRef" href="#tfn2-cln64_11p1053">&#42;&#42;</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">43&#46;8 &#40;35&#47;80&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Number of meals&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">5&#46;0 &#177; 2&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">4&#46;7 &#177; 1&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">4&#46;9 &#177; 1&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
            ]
          ]
          "notaPie" => array:2 [
            0 => array:3 [
              "identificador" => "tfn1-cln64_11p1053"
              "etiqueta" => "&#40;&#42;&#41;"
              "nota" => "<p class="elsevierStyleNotepara" id="cenpara10">P &#61; 0&#46;044 &#40;ANOVA&#41;&#59;</p>"
            ]
            1 => array:3 [
              "identificador" => "tfn2-cln64_11p1053"
              "etiqueta" => "&#40;&#42;&#42;&#41;"
              "nota" => "<p class="elsevierStyleNotepara" id="cenpara20">P &#61; 0&#46;47 &#40;chi-square analysis&#41;</p>"
            ]
          ]
        ]
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          "en" => "<p id="spara10" class="elsevierStyleSimplePara elsevierViewall">General population profile</p>"
        ]
      ]
      1 => array:7 [
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        "etiqueta" => "Table 2"
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          "leyenda" => "<p id="spara30" class="elsevierStyleSimplePara elsevierViewall">NS &#61; Not significant</p>"
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            0 => array:1 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Period&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">BMI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Weight loss&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Calories&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">F &#61; 1&#46;28 NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">F &#61; 0&#46;28 NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">F &#61; 2&#46;89 P &#60; 0&#46;05</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">F &#61; 0&#46;13 NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">F &#61; 0&#46;35 NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;88 NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">9 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">F &#61; 0&#46;51 NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black"><span class="elsevierStyleBold">F &#61; 12&#44;57 P &#60; 0&#46;01</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">0&#46;93 NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spara20" class="elsevierStyleSimplePara elsevierViewall">Nutritional impact of daily meal frequency &#40;ANOVA &#8220;F&#8221; test&#41;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "t3-cln64_11p1053"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:3 [
          "leyenda" => "<p id="spara50" class="elsevierStyleSimplePara elsevierViewall">Categories with less than five patients were eliminated&#59;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:1 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Postop period&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Fractionation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">BMI &#40;kg&#47;m<span class="elsevierStyleSup">2</span>&#41; <a class="elsevierStyleCrossRef" href="#tfn5-cln64_11p1053">&#42;</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Weight loss &#40;kg&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Calories &#40;Kcal&#47;day&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 times &#40;n&#61;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">42&#46;6 &#177; 8&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18&#46;2 &#177; 11&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">290&#46;5 &#177; 181&#46;5<a class="elsevierStyleCrossRef" href="#tfn7-cln64_11p1053">&#42;&#42;&#42;</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4 times &#40;n&#61;26&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">44&#46;8 &#177; 10&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14&#46;9&#177; 6&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">523&#46;5 &#177; 272&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 times &#40;n&#61;27&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">45&#46;1 &#177; 8&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16&#46;9 &#177; 8&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">572&#46;8 &#177; 265&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6 times &#40; n&#61;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">52&#46;4 &#177; 13&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14&#46;6 &#177; 2&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">814&#46;2 &#177; 466&#46;5 <a class="elsevierStyleCrossRef" href="#tfn8-cln64_11p1053">&#42;&#42;&#42;&#42;</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">More than 6 times &#40;n&#61;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">41&#46;2 &#177; 8&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15&#46;4 &#177; 3&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">494&#46;2 &#177; 241&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Once or twice &#40;n&#61;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">39&#46;5 &#177; 12&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&#46;5 &#177; 1&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">312&#46;9 &#177; 182&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 times &#40;n&#61;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">39&#46;5 &#177; 7&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14&#46;0 &#177; 1&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">683&#46;1 &#177; 128&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4 times &#40;n&#61;25&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">39&#46;7 &#177; 10&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&#46;9 &#177; 5&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">661&#46;8 &#177; 257&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 times &#40;n&#61;24&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">41&#46;1 &#177; 6&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&#46;9 &#177; 4&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">753&#46;1 &#177; 362&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6 times &#40;n&#61;16&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">38&#46;9 &#177; 5&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&#46;8 &#177; 4&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">665&#46;20 &#177; 352&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 times &#40;n&#61;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">30&#46;4 &#177; 11&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">36&#46;4 &#177; 16&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">534&#46;5 &#177; 414&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4 times &#40;n&#61;17&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">33&#46;0 &#177; 6&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14&#46;5 &#177; 12&#46;0 <a class="elsevierStyleCrossRef" href="#tfn6-cln64_11p1053">&#42;&#42;</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">852&#46;0 &#177; 536&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 times &#40;n&#61;28&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">35&#46;9 &#177; 8&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&#46;9 &#177; 5&#46;1 <a class="elsevierStyleCrossRef" href="#tfn6-cln64_11p1053">&#42;&#42;</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">862&#46;7 &#177; 371&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">6 times &#40;n&#61; 18&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">35&#46;4 &#177; 10&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">12&#46;4 &#177; 4&#46;5 <a class="elsevierStyleCrossRef" href="#tfn6-cln64_11p1053">&#42;&#42;</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">741&#46;0 &#177; 257&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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          "notaPie" => array:4 [
            0 => array:3 [
              "identificador" => "tfn5-cln64_11p1053"
              "etiqueta" => "&#40;&#42;&#41;"
              "nota" => "<p class="elsevierStyleNotepara" id="cenpara30">No significant difference at any time&#59;</p>"
            ]
            1 => array:3 [
              "identificador" => "tfn6-cln64_11p1053"
              "etiqueta" => "&#40;&#42;&#42;&#41;"
              "nota" => "<p class="elsevierStyleNotepara" id="cenpara40">Three-fold reduction in comparison during the same period &#40;P &#60; 0&#46;05&#41;&#59;</p>"
            ]
            2 => array:3 [
              "identificador" => "tfn7-cln64_11p1053"
              "etiqueta" => "&#40;&#42;&#42;&#42;&#41;"
              "nota" => "<p class="elsevierStyleNotepara" id="cenpara50">Reduced for the period&#44; P &#60; 0&#46;05&#59;</p>"
            ]
            3 => array:3 [
              "identificador" => "tfn8-cln64_11p1053"
              "etiqueta" => "&#40;&#42;&#42;&#42;&#42;&#41;"
              "nota" => "<p class="elsevierStyleNotepara" id="cenpara60">Increased for the period&#44; P &#60; 0&#46;05</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spara40" class="elsevierStyleSimplePara elsevierViewall">Nutritional course and diet fractionation</p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "t4-cln64_11p1053"
        "etiqueta" => "Table 4"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
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        "tabla" => array:2 [
          "leyenda" => "<p id="spara70" class="elsevierStyleSimplePara elsevierViewall">DF&#58; Diet fractionation&#59; Vomiting&#58; Number of vomiting episodes&#59; Cal&#58; Calorie intake&#59; P-values&#58; Significant results are shown in bold&#46;</p>"
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            0 => array:1 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Postoperative period&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Variables&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">P&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Weight loss x DF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;609&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Weight loss x Vomiting&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;593&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Weight loss x Cal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;063&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">DF x Vomiting&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;127&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">DF x Calories&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;677&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Vomiting x calories&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;689&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Weight loss x DF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;854&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Weight loss x Vomiting&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;760&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Weight loss x Cal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;264&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">DF x Vomiting&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">0&#46;038 &#40;r &#61; &#8722;0&#46;261&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">DF x Calories&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;332&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Vomiting x Calories&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;937&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Weight loss x DF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">0&#46;001 &#40;r &#61; &#8722;0&#46;404&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Weight loss x Vomiting&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;308&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Weight loss x Cal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;051&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">DF x Vomiting&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;264&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">DF x Calories&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;271&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Vomiting x Calories&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">0&#46;516&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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        "descripcion" => array:1 [
          "en" => "<p id="spara60" class="elsevierStyleSimplePara elsevierViewall">Correlation between weight loss&#44; diet fractionation and vomiting episodes</p>"
        ]
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      "titulo" => "REFERENCES"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "cebibsec10"
          "bibliografiaReferencia" => array:31 [
            0 => array:3 [
              "identificador" => "bib1"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The obesity epidemic in the United States&#8211;gender&#44; age&#44; socioeconomic&#44; racial&#47;ethnic&#44; and geographic characteristics&#58; a systematic review and meta-regression analysis"
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                        0 => array:2 [
                          "etal" => false
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                      "doi" => "10.1093/epirev/mxm007"
                      "Revista" => array:6 [
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            1 => array:3 [
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                      "autores" => array:1 [
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                          "etal" => false
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                        "tituloSerie" => "Obes Surg"
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            2 => array:3 [
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                  "contribucion" => array:1 [
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                      "titulo" => "Gastric bypass surgery causes body weight loss without reducing food intake in rats"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
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                      "Revista" => array:6 [
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            3 => array:3 [
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                  "contribucion" => array:1 [
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                      "titulo" => "Weight Loss and health outcomes in African Americans and white after gastric bypass surgery"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
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                          "etal" => true
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                  "contribucion" => array:1 [
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            8 => array:3 [
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              "referencia" => array:1 [
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                  "contribucion" => array:1 [
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                      "autores" => array:1 [
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Article information
ISSN: 18075932
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos