Consensus document
Prevention, diagnosis, and treatment of obesity. 2016 position statement of the Spanish Society for the Study of Obesity
Prevención, diagnóstico y tratamiento de la obesidad. Posicionamiento de la Sociedad Española para el Estudio de la Obesidad de 2016
Albert Lecubea,1,
Susana Monereob,1Miguel Ángel RubiocPurificación Martínez-de-IcayadAmelia MartíeJavier SalvadorfLluís MasmiquelgAlberto GodayhDiego BellidoiEmpar LurbejJosé Manuel García-AlmeidakFrancisco José TinahoneslPedro Pablo García-LunamEnrique PalacionManuel GargalloñIrene BretónbSalvador Morales-CondeoAssumpta CaixàspEdelmiro MenéndezqManel Puig-DomingorFelipe F. Casanuevas
Corresponding author
a Servicio de Endocrinología y Nutrición, Unidad de Obesidad, Hospital Universitari Arnau de Vilanova de Lleida, Institut de Recerca Biomèdica de Lleida, CIBERDEM (CIBER de Diabetes y Enfermedades Metabólicas Asociadas, ISCIII), Universitat de Lleida, Lleida, Spain
b Servicio de Endocrinología y Nutrición, Hospital General Universitario Gregorio Marañón, Madrid, Spain
c Servicio de Endocrinología y Nutrición, Hospital Clínico San Carlos, Madrid, Spain
d Sección de Endocrinología y Nurición, Hospital Universitario Severo Ochoa de Leganés, Madrid, Spain
e Departamento de Ciencias de la Alimentación y Fisiología, Universidad de Navarra, CIBERobn (CIBER de Fisiopatología de la Obesidad y Nutrición, ISCIII), Instituto de Investigación Sanitaria de Navarra (Idisna), Pamplona, Spain
f Departamento de Endocrinología y Nutrición, Clínica Universidad de Navarra, CIBERobn (CIBER de Fisiopatología de la Obesidad y Nutrición, ISCIII), Instituto de Investigación Sanitaria de Navarra (Idisna), Pamplona, Spain
g Servicio de Endocrinología y Nutrición, Unidad de Obesidad, Hospital de Son Llàtzer, Institut Universitari d’Investigació en Ciències de la Salut (IUNICS-IdISPa), Universitat de les Illes Balears, Palma de Mallorca, Spain
h Hospital del Mar, Institut Hospital del Mar d’Investigacions Mèdiques (IMIM), CIBERobn (CIBER de Fisiopatología de la Obesidad y Nutrición, ISCIII), Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
i Servicio Endocrinología y Nutrición, Complejo Hospitalario Universitario de Ferrol (CHUF), SERGAS, Ferrol, A Coruña, Spain
j Departamento de Pediatría, Consorcio Hospital General. CIBERobn (CIBER de Fisiopatología de la Obesidad y Nutrición, ISCIII), Universidad de Valencia, Valencia, Spain
k Complejo Hospitalario de Málaga (Virgen de la Victoria), Hospital Quirón-Salud Málaga, Universidad de Málaga, Málaga, Spain
l Unidad de Gestión Clínica de Endocrinología y Nutrición, Instituto de Investigación Biomédica de Málaga (IBIMA), Hospital Clínico Virgen de la Victoria, CIBERobn (CIBER de Fisiopatología de la Obesidad y Nutrición, ISCIII), Universidad de Málaga, Málaga, Spain
m Unidad de Nutrición Clínica y Dietética, Servicio de Endocrinología y Nutrición, Hospital Universitario Virgen del Rocío, Sevilla, Spain
n Servicio de Endocrinología y Nutrición, Hospital Universitario Nuestra Señora de Candelaria (HUNSC), Santa Cruz de Tenerife, Spain
ñ Servicio de Endocrinología y Nutrición, Hospital Virgen de la Torre, Madrid, Spain
o Unidad de Innovación Cirugía Mínima Invasiva, Servicio de Cirugía General y Digestiva, Hospital Universitario Virgen del Rocío, Sevilla, Spain
p Servicio de Endocrinología y Nutrición, Hospital Universitari Parc Taulí de Sabadell, Corporació Sanitària Parc Taulí, Institut de Recerca I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain
q Servicio de Endocrinología y Nutrición, Hospital Universitario Central de Asturias (HUCA). Departamento de Medicina, Universidad de Oviedo, Oviedo, Spain
r Servicio de Endocrinología y Nutrición, Hospital Germans Trias i Pujol, Badalona, Departamento de Medicina, Universidad Autónoma de Barcelona, Barcelona, Spain
s Departamento de Medicina, Universidad de Santiago, Compejo Hospitalario Universitario de Santiago (CHUS), CIBERobn (CIBER de Fisiopatología de la Obesidad y Nutrición, ISCIII), Santiago de Compostela, Spain
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"apellidos" => "Casanueva" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">s</span>" "identificador" => "aff0100" ] ] ] ] "afiliaciones" => array:20 [ 0 => array:3 [ "entidad" => "Servicio de Endocrinología y Nutrición, Unidad de Obesidad, Hospital Universitari Arnau de Vilanova de Lleida, Institut de Recerca Biomèdica de Lleida, CIBERDEM (CIBER de Diabetes y Enfermedades Metabólicas Asociadas, ISCIII), Universitat de Lleida, Lleida, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Endocrinología y Nutrición, Hospital General Universitario Gregorio Marañón, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Endocrinología y Nutrición, Hospital Clínico San Carlos, Madrid, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Sección de Endocrinología y Nurición, Hospital Universitario Severo Ochoa de Leganés, Madrid, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Departamento de Ciencias de la Alimentación y Fisiología, Universidad de Navarra, CIBERobn (CIBER de Fisiopatología de la Obesidad y Nutrición, ISCIII), Instituto de Investigación Sanitaria de Navarra (Idisna), Pamplona, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Departamento de Endocrinología y Nutrición, Clínica Universidad de Navarra, CIBERobn (CIBER de Fisiopatología de la Obesidad y Nutrición, ISCIII), Instituto de Investigación Sanitaria de Navarra (Idisna), Pamplona, Spain" "etiqueta" => "f" "identificador" => "aff0030" ] 6 => array:3 [ "entidad" => "Servicio de Endocrinología y Nutrición, Unidad de Obesidad, Hospital de Son Llàtzer, Institut Universitari d’Investigació en Ciències de la Salut (IUNICS-IdISPa), Universitat de les Illes Balears, Palma de Mallorca, Spain" "etiqueta" => "g" "identificador" => "aff0035" ] 7 => array:3 [ "entidad" => "Hospital del Mar, Institut Hospital del Mar d’Investigacions Mèdiques (IMIM), CIBERobn (CIBER de Fisiopatología de la Obesidad y Nutrición, ISCIII), Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain" "etiqueta" => "h" "identificador" => "aff0040" ] 8 => array:3 [ "entidad" => "Servicio Endocrinología y Nutrición, Complejo Hospitalario Universitario de Ferrol (CHUF), SERGAS, Ferrol, A Coruña, Spain" "etiqueta" => "i" "identificador" => "aff0045" ] 9 => array:3 [ "entidad" => "Departamento de Pediatría, Consorcio Hospital General. CIBERobn (CIBER de Fisiopatología de la Obesidad y Nutrición, ISCIII), Universidad de Valencia, Valencia, Spain" "etiqueta" => "j" "identificador" => "aff0050" ] 10 => array:3 [ "entidad" => "Complejo Hospitalario de Málaga (Virgen de la Victoria), Hospital Quirón-Salud Málaga, Universidad de Málaga, Málaga, Spain" "etiqueta" => "k" "identificador" => "aff0055" ] 11 => array:3 [ "entidad" => "Unidad de Gestión Clínica de Endocrinología y Nutrición, Instituto de Investigación Biomédica de Málaga (IBIMA), Hospital Clínico Virgen de la Victoria, CIBERobn (CIBER de Fisiopatología de la Obesidad y Nutrición, ISCIII), Universidad de Málaga, Málaga, Spain" "etiqueta" => "l" "identificador" => "aff0060" ] 12 => array:3 [ "entidad" => "Unidad de Nutrición Clínica y Dietética, Servicio de Endocrinología y Nutrición, Hospital Universitario Virgen del Rocío, Sevilla, Spain" "etiqueta" => "m" "identificador" => "aff0065" ] 13 => array:3 [ "entidad" => "Servicio de Endocrinología y Nutrición, Hospital Universitario Nuestra Señora de Candelaria (HUNSC), Santa Cruz de Tenerife, Spain" "etiqueta" => "n" "identificador" => "aff0070" ] 14 => array:3 [ "entidad" => "Servicio de Endocrinología y Nutrición, Hospital Virgen de la Torre, Madrid, Spain" "etiqueta" => "ñ" "identificador" => "aff0075" ] 15 => array:3 [ "entidad" => "Unidad de Innovación Cirugía Mínima Invasiva, Servicio de Cirugía General y Digestiva, Hospital Universitario Virgen del Rocío, Sevilla, Spain" "etiqueta" => "o" "identificador" => "aff0080" ] 16 => array:3 [ "entidad" => "Servicio de Endocrinología y Nutrición, Hospital Universitari Parc Taulí de Sabadell, Corporació Sanitària Parc Taulí, Institut de Recerca I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain" "etiqueta" => "p" "identificador" => "aff0085" ] 17 => array:3 [ "entidad" => "Servicio de Endocrinología y Nutrición, Hospital Universitario Central de Asturias (HUCA). Departamento de Medicina, Universidad de Oviedo, Oviedo, Spain" "etiqueta" => "q" "identificador" => "aff0090" ] 18 => array:3 [ "entidad" => "Servicio de Endocrinología y Nutrición, Hospital Germans Trias i Pujol, Badalona, Departamento de Medicina, Universidad Autónoma de Barcelona, Barcelona, Spain" "etiqueta" => "r" "identificador" => "aff0095" ] 19 => array:3 [ "entidad" => "Departamento de Medicina, Universidad de Santiago, Compejo Hospitalario Universitario de Santiago (CHUS), CIBERobn (CIBER de Fisiopatología de la Obesidad y Nutrición, ISCIII), Santiago de Compostela, Spain" "etiqueta" => "s" "identificador" => "aff0100" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Prevención, diagnóstico y tratamiento de la obesidad. Posicionamiento de la Sociedad Española para el Estudio de la Obesidad de 2016" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1094 "Ancho" => 1330 "Tamanyo" => 99450 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Obesity as multifactorial disease.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">This position statement is intended to clearly establish obesity as a disease, one of the most prevalent and underestimated (and less diagnosed and treated) diseases in history.<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">1</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Etiopathogenesis: classical and new elements</span><p id="par0010" class="elsevierStylePara elsevierViewall">Classical elements include age (sarcopenia and greater fat mass in subjects over 65 years of age), sex (decline in levels of anabolic hormones and estrogens after menopause), genetics (multiple gene variants involved, but with an isolated influence), sedentary lifestyle, nutritional behavior (interaction of biological and emotional factors), certain drugs (antidiabetics, contraceptives, antihistamines, and psychotropics), hypothalamic-pituitary dysfunction, and some endocrine diseases<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">2–5</span></a> (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The complexity of the disease is also shown by participation in its development of chronodisruption (circadian desynchrony, changes in the sleep-wake cycle, and sleep deprivation), epigenetics and fetal programming (malnutrition and maternal overfeeding, even before conception), psychiatric disease (irrespective of treatment), stress (both chronic and uncontrolled), intestinal microbiota (predominance of <span class="elsevierStyleItalic">firmicutes</span> over <span class="elsevierStyleItalic">bacteroidetes</span>, a poorly diverse microbiota), endocrine disruptors (bisphenol A, phthalates, pesticides, and insecticides), feeding pattern (excess fat and refined sugars, inadequate fruit and vegetable consumption), an undeprivileged socioeconomic status, and an obesogenic environment (urban dispersion, food availability…).<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">6–9</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">How and when is obesity diagnosed?</span><p id="par0020" class="elsevierStylePara elsevierViewall">Obesity is defined as a proportion of fat mass (FM) greater than 25% in males and 33% in females. When FM cannot be measured, BMI (mild of class I obesity [30–34.9<span class="elsevierStyleHsp" style=""></span>kg/m<span class="elsevierStyleSup">2</span>], moderate or class II obesity [35–39.9<span class="elsevierStyleHsp" style=""></span>kg/m<span class="elsevierStyleSup">2</span>], and severe, morbid, or class III obesity [≥40<span class="elsevierStyleHsp" style=""></span>kg/m<span class="elsevierStyleSup">2</span>]) or waist circumference (WC) (abdominal obesity [≥102<span class="elsevierStyleHsp" style=""></span>cm in males, ≥88<span class="elsevierStyleHsp" style=""></span>cm in females while standing and on the iliac crest]) are used. BMI does not inform about body fat distribution, does not differentiate between lean mass (LM) and FM, and is a poor indicator in subjects of short stature or advanced age, with great muscle mass and water and salt retention, or pregnant.<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">10</span></a> Measurement of WC is not considered useful when BMI is ≥35<span class="elsevierStyleHsp" style=""></span>kg/m<span class="elsevierStyleSup">2</span>.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The SEEDO promotes use of classifications of obesity that combine anthropometric and clinical descriptors,<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">11</span></a> as well as mathematical formulas developed in the Spanish population to estimate percent FM (Clínica Universidad de Navarra-<span class="elsevierStyleItalic">Body Adiposity Estimator</span>).<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">12</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Epidemiology in Spain</span><p id="par0030" class="elsevierStylePara elsevierViewall">Based on BMI, prevalence is 21.6% (22.8% in males, 20.5% in females), increases with age, and is greater in females from 50 years of age. It is greater in Asturias (25.7%) and lower in the Balearic Islands (10.5%).<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">13</span></a> According to WC values, the abdominal obesity rate is 36%, and increases up to 62% in subjects over 65 years of age.<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">14</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Use of technology</span><p id="par0035" class="elsevierStylePara elsevierViewall">Body composition analysis should be used for diagnosis, clinical evaluation, and monitoring of obesity Bioelectrical impedance is simple and noninvasive, and estimates fat-free mass and, indirectly, total body fat. There is no adequate validation with BMI values >35<span class="elsevierStyleHsp" style=""></span>kg/m<span class="elsevierStyleSup">2</span>. Dual-energy X-ray densitometry is the gold standard for assessing total body fat and regional fat distribution.<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">15</span></a> Both computerized tomography and magnetic resonance imaging are standard procedures to estimate the visceral and subcutaneous fat area at L4-L5, and intrahepatic fat at T12-L1.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Classical comorbidities, what's new?</span><p id="par0040" class="elsevierStylePara elsevierViewall">The high prevalence of metabolic syndrome in obesity suggests that the different components share lipotoxicity as etiopathogenic mechanism. High blood pressure (HBP) is 25–40% more common in the obese than in the general population, implicating in its development the greater sympathetic activation and activation of the renin-angiotensin-aldosterone system. Obesity accounts for 44% of the burden of type 2 diabetes mellitus (T2DM), in which obesity is two times more prevalent than in the general population.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Obesity and new comorbidities</span><p id="par0045" class="elsevierStylePara elsevierViewall">Obesity is a preventable cause of colorectal cancer, breast cancer in postmenopausal women, and endometrial, kidney, esophagus, and pancreatic tumors.<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">16</span></a> It is the main risk factor for sleep apnea-hypopnea syndrome. In addition, obesity increases the chance of mood disorders and anxiety by 25%. Prevalence of non-alcoholic fat liver disease reaches 100% in subjects with morbid obesity.<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">17</span></a> Obesity is also associated to osteoarthritis of the hip and knee, but also in non-weight-bearing joints such as the hands.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Benefits of weight loss</span><p id="par0050" class="elsevierStylePara elsevierViewall">When combined with lifestyle changes, a 5–10% weight loss decreases by up to 1.0% HbA1c levels and drug requirements for diabetes, as well as systolic and diastolic blood pressure and use of antihypertensive treatment.<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">18</span></a> Increases the feeling of well-being and functional capacity. Moderate 3–5% weight loss will already have benefits. Losing from 2.5 to 5.5<span class="elsevierStyleHsp" style=""></span>kg of weight after 2 years decreases risk of T2DM by 30–60%.</p><p id="par0055" class="elsevierStylePara elsevierViewall">After bariatric surgery, a decrease occurs in fatal and non-fatal cardiovascular events, with favorable effects on overall mortality, diabetes, cardiovascular risk factors, cancer, sleep apnea-hypopnea syndrome, joint pain, and quality of life.<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">19</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Risk associated to obesity</span><p id="par0060" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> lists the minimal data to be recorded in the clinical history of subjects with obesity. The Edmonton classification system used 5 categories based on morbidity and risk profile of the disease, and is able to predict increased mortality.<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">20</span></a> Although no healthy obesity exists, subjects who have one or no cardiometabolic abnormality associated to obesity are defined as metabolically healthy.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Every 5<span class="elsevierStyleHsp" style=""></span>kg/m<span class="elsevierStyleSup">2</span> increase in BMI significantly increases mortality of T2DM (HR 2.16), chronic kidney disease (HR 1.59), ischemic heart disease (HR 1.39), stroke (HR 1.39), respiratory disease (HR 1.20), and cancer (HR 1.10).<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">21</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Modest weight increases (≥5<span class="elsevierStyleHsp" style=""></span>kg) after 18 years in females (after 20 years in males) increase the risk of heat disease and T2DM, regardless of initial BMI.</p><p id="par0075" class="elsevierStylePara elsevierViewall">In older obese subjects, comorbidity is more prevalent and sever, although BMI is associated to lower relative mortality.<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">22</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Obese child, obese adult?</span><p id="par0080" class="elsevierStylePara elsevierViewall">In childhood, diagnosis is made based on BMI percentiles. In children aged 6–9 years, prevalence in Spain is 18.3% (our country ranks second in boys and third in girls in Europe).<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">23</span></a> Prevalence of comorbidities is lower than in adults, and if projected to older ages, with critical times in its development: the first year of life, the period from 4 to 6 years, and adolescence.<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">24</span></a> Treatment is based on three mainstays: reorganization of dietary habits, promotion of physical activity, and child motivation with the help of the family and social environment.</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Dietary plan</span><p id="par0085" class="elsevierStylePara elsevierViewall">Obesity prevention and treatment require achievement and maintenance of a healthy lifestyle (diet, exercise, social, geopolitical, and environmental determinants). Includes both quantitative (decreased portions and energy provision) and qualitative changes (varying the proportion of different nutrients).</p><p id="par0090" class="elsevierStylePara elsevierViewall">A healthy pattern includes greater vegetable and fruit consumption followed, although with a lower grade of evidence, by whole grain cereals, low fat dairy products, fish, pulses, and nuts. A decreased meat intake, including processed meat and sugary foods, is also characteristic of this pattern.<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">25</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">The low-calorie Mediterranean diet is the model supported by the SEEDO because it best represents this balanced and healthy approach, with low intake of saturated and trans fatty acids and added sugars, and high intake of vegetable fiber and monounsaturated fatty acids. Its benefits on health, including mortality, have been clearly established.<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">26</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">As regards modified macronutrient diets, no studies showing its advantages are available. Because of this, together with their widespread use, lack of strict medical control, and presence of commercial interests, the SEEDO does not recommend their use. Use of functional foods is not supported by scientific evidence either.</p><p id="par0105" class="elsevierStylePara elsevierViewall">The risks of an inadequate diet include malnutrition or micronutrient deficiency, worsening of cardiovascular risk, promotion of eating disorders, transmission of wrong nutritional concepts, or promotion of a feeling of frustration.</p><p id="par0110" class="elsevierStylePara elsevierViewall">The SEEDO stands against any diet with no scientific support. It is essential to emphasize the need for a varied, healthy, and balanced diet in the context of the Mediterranean diet, and for regular physical exercise.</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Physical activity: Not everything is the same</span><p id="par0115" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Physical activity</span> (PA) represents daily muscle movement. <span class="elsevierStyleItalic">Physical exercise</span> (PE) is structured, planned, and repetitive PA. <span class="elsevierStyleItalic">Sports activity</span> is PE practiced according to some rules, usually with competitive purposes. <span class="elsevierStyleItalic">Fitness</span> is the set of benefits achieved from the practice of PE.</p><p id="par0120" class="elsevierStylePara elsevierViewall">PA is measured using the resting metabolic rate (MET), corresponding to 3.5<span class="elsevierStyleHsp" style=""></span>mL O<span class="elsevierStyleInf">2</span>/kg/min, the minimum oxygen consumption to maintain vital signs. Reading, driving, work in a sitting position, and house chores spend 1–3 METs. Moderate PA (brisk walking, quiet cycling) is performed at 3–6 METs, and intense PA (running, jumping, aerobic exercise) from 6 METs.</p><p id="par0125" class="elsevierStylePara elsevierViewall">Weight loss is not clinically relevant when PE is only performed, although there is a great individual variability. However, a PE program is important, almost indispensable, to prevent recovery of the weight lost.<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">27</span></a> The psychological improvement provided by exercise contributes to decrease energy intake for emotional reasons, and is most useful in people with stress hyperphagia.</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">How should a physical exercise program be prescribed?</span><p id="par0130" class="elsevierStylePara elsevierViewall">At least 30<span class="elsevierStyleHsp" style=""></span>min daily of moderate or intense exercise five or more days per week (150<span class="elsevierStyleHsp" style=""></span>min/week; 300<span class="elsevierStyleHsp" style=""></span>min/week to prevent weight gain) and restriction of physical inactivity are recommended.<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">28</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">Combined aerobic (walking, jogging, dancing, skiing, pedaling, etc.) and anaerobic PE achieves better results than either PE alone.<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">29</span></a> Because of its effect on muscle mass, anaerobic exercise is particularly indicated for elderly people.</p><p id="par0140" class="elsevierStylePara elsevierViewall">Exercise prescription should be personalized, considering the preferences and skills, physical condition, cardiorespiratory and orthopedic status, medication, and disabilities of each person (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). Adverse effects to be considered include overload of weight-bearing joints and respiratory compromise.</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Present and future of drug treatment</span><p id="par0145" class="elsevierStylePara elsevierViewall">Drugs must be used in subjects with BMI >30<span class="elsevierStyleHsp" style=""></span>kg/m<span class="elsevierStyleSup">2</span>, or >27<span class="elsevierStyleHsp" style=""></span>kg/m<span class="elsevierStyleSup">2</span> associated to major comorbidities, when they do not lose >5% of initial weight after 3–6 months in a structured program. If program is well tolerated and weight loss is greater than 5% of initial weight, program should be continued while the indication persists.</p><p id="par0150" class="elsevierStylePara elsevierViewall">After orlistat, the European Medicines Agency approved in 2015 two new drugs: liraglutide 3.0<span class="elsevierStyleHsp" style=""></span>mg (Saxenda<span class="elsevierStyleSup">®</span>) and the combination of bupropion (360<span class="elsevierStyleHsp" style=""></span>mg) and naltrexone (16 or 32<span class="elsevierStyleHsp" style=""></span>mg) (Mysimba<span class="elsevierStyleSup">®</span>). Liraglutide is a GLP-1 receptor agonists for daily subcutaneous administration. After 56 weeks of treatment, liraglutide decreases weight by 8.0<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>6.7% (8.4<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>7.3<span class="elsevierStyleHsp" style=""></span>kg).<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">30</span></a> Bupropion/naltrexone is administered orally, and achieves weight losses of 5.4–8.1%. This combination may be useful in patients with depressive symptoms.<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">31</span></a> Side effects include nausea and vomiting with liraglutide, and headache, dry mouth, nausea, and dizziness with bupropion-naltrexone. Both drug treatments are contraindicated in pregnancy. Side effects are transient and are not a major cause of discontinuation.</p><p id="par0155" class="elsevierStylePara elsevierViewall">Liraglutide contributes to decrease blood pressure and improve cardiovascular risk parameters, and decreases cardiovascular mortality. It is the drug of choice in patients with T2DM or prediabetes.<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">32</span></a> Bupropion/naltrexone improves blood pressure and lipid profile.</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Prevention of obesity</span><p id="par0160" class="elsevierStylePara elsevierViewall">The goal is to decrease development of overweight and obesity in subjects with normal weight and overweight respectively by preventing weight recovery. We recommend identification of and action on the groups at greater risk (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>).<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">33</span></a></p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0165" class="elsevierStylePara elsevierViewall">Implication should be sought of the food industry (nutritional quality and labeling), communication media (true, verified information), legislative power and authorities (regulatory and coercive measures for industry, economic incentives to use of some food items), local administration (town planning), educational institutions (school canteens, restriction of vending machines with sugary drinks), workplaces (remove lifts and mechanical means, provide leisure areas), and scientific societies. These should lead the fight against obesity, warn of its consequences, and foster prevention strategies.</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Treatment of “diabesity”, is there anything new?</span><p id="par0170" class="elsevierStylePara elsevierViewall">Weight reduction is the first step, and is an essential part of all phases of treatment, together with exercise.<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">34</span></a> The time of diagnosis is critical to prescribe weight loss.</p><p id="par0175" class="elsevierStylePara elsevierViewall">Drug treatment for diabetes is conditioned by the weight gain associated to sulfonylureas, thiazolidinediones, and insulin. However, GLP-1 receptor agonists are associated to 2.9<span class="elsevierStyleHsp" style=""></span>kg weight reductions as compared to placebo, oral antidiabetics, or insulin.<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">35</span></a> Similarly, SGLT2 inhibitors have been reported to cause weight losses ranging from 1.8 to 2.3<span class="elsevierStyleHsp" style=""></span>kg versus placebo.<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">36</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">T2DM remission rate after gastrointestinal surgery is 72% at two years and 30.4% at 15 years.<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">37</span></a> A reduction has also been reported in the incidence of microvascular and macrovascular complications, and better metabolic control is achieved as compared to standard treatment.<a class="elsevierStyleCrossRefs" href="#bib0420"><span class="elsevierStyleSup">38,39</span></a> Prognostic factors associated to remission include younger age, shorter disease duration, lower HbA1c values, higher C-peptide levels, and no need for insulin therapy.<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">40</span></a> In Spain, the indication for subjects with BMI <35<span class="elsevierStyleHsp" style=""></span>kg/m<span class="elsevierStyleSup">2</span> only applies to participation in clinical trials.</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Bariatric surgery</span><p id="par0185" class="elsevierStylePara elsevierViewall">This is indicated for subjects with BMI<span class="elsevierStyleHsp" style=""></span>≥<span class="elsevierStyleHsp" style=""></span>40<span class="elsevierStyleHsp" style=""></span>kg/m<span class="elsevierStyleSup">2</span>, or less severe forms of obesity (BMI 35–40<span class="elsevierStyleHsp" style=""></span>kg/m<span class="elsevierStyleSup">2</span>) with severe associated comorbidities, aged 18–60 years (individualizing adolescents and elderly subjects). Dietary pattern, BMI, associated comorbidities, and surgical should be considered when a surgical procedure is decided.</p><p id="par0190" class="elsevierStylePara elsevierViewall">Patient expectations should be modulated before surgery. The goal of surgery is to achieve a weight loss that improves comorbid conditions and quality of life. Although Roux-en-Y gastric bypass (RYGBP) is considered as the reference procedure, vertical sleeve gastrectomy is increasingly used because of its simplicity and effectiveness.<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">41</span></a> Several studies have reported an initial weight loss similar to that achieved by RYGBP, but long-term results should be assessed.<a class="elsevierStyleCrossRef" href="#bib0440"><span class="elsevierStyleSup">42</span></a> A laparoscopic approach should be used, and intraoperative mortality should be <0.5%. The main complications include infection, bleeding, and suture failures.<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">41</span></a></p><p id="par0195" class="elsevierStylePara elsevierViewall">Long-term multidisciplinary follow-up is required to ensure adequate weight loss and adherence to healthy lifestyles. It should not be forgotten that surgery may modify absorption and bioavailability of some drugs.<a class="elsevierStyleCrossRef" href="#bib0445"><span class="elsevierStyleSup">43</span></a></p><p id="par0200" class="elsevierStylePara elsevierViewall">While modification of the gastrointestinal tract may be a therapeutic alternative for the components of metabolic syndrome, generalized use of metabolic surgery cannot be recommended.<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">44</span></a></p><p id="par0205" class="elsevierStylePara elsevierViewall">After surgery, effective contraceptive methods not dependent on intestinal absorption should be used, and pregnancy should be avoided until 12–18 months have elapsed.<a class="elsevierStyleCrossRef" href="#bib0455"><span class="elsevierStyleSup">45</span></a></p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Where should obese patients be treated?</span><p id="par0210" class="elsevierStylePara elsevierViewall">A single protocol for assessment and treatment of obesity, stating the criteria for referral between the primary and specialized care settings should be prepared, and communication between professionals should be facilitated. Continued training activities and coordinated development of research lines should be a constant.<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">46</span></a></p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Funding</span><p id="par0215" class="elsevierStylePara elsevierViewall">Novo Nordisk and AstraZeneca provided unconditioned support to the Spanish Society for the Study of Obesity (SEEDO).</p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conflicts of interest</span><p id="par0220" class="elsevierStylePara elsevierViewall">A. Lecube received honoraria as scientific advisor (Novo Nordisk, AstraZeneca, Janssen) and for sponsored lectures (Novo Nordisk, AstraZeneca, Sanofi, Boehringher-Lilly). D. Bellido received honoraria as scientific advisor (Novo Nordisk, Boehringher-Lilly, Sanofi) and for sponsored lectures (Novo Nordisk, Boehringher-Lilly, Sanofi, AstraZeneca, Janssen, Almirall, Novartis, MSD). P.P. García-Luna received honoraria as scientific advisor (Novo Nordisk, Vegenat) and for sponsored lectures (Novo Nordisk, Vegenat, Nestlé, MSD, Janssen). F.F. Casanueva received research grants and fees for consultancy or lectures from Novo Nordisk, Lilly, Pfizer, AstraZeneca, Boheringer Manheim, Novartis y Janssen.</p><p id="par0225" class="elsevierStylePara elsevierViewall">S. Monereo, M.A. Rubio, P. Martínez-de-Icaya, A. Martí, J. Salvador, L. Masmiquel, A. Goday, E. Lurbe, J.M. García-Almeida, F.J. Tinahones, E. Palacio, M. Gargallo, I. Bretón, S. Morales-Conde, A. Caixàs, E. Menéndez, and M. Puig-Domingo have no conflicts of interest related to their participation in this study.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:22 [ 0 => array:2 [ "identificador" => "xpalclavsec830707" "titulo" => "Palabras clave" ] 1 => array:2 [ "identificador" => "xpalclavsec830708" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "sec0005" "titulo" => "Etiopathogenesis: classical and new elements" ] 3 => array:2 [ "identificador" => "sec0010" "titulo" => "How and when is obesity diagnosed?" ] 4 => array:2 [ "identificador" => "sec0015" "titulo" => "Epidemiology in Spain" ] 5 => array:2 [ "identificador" => "sec0020" "titulo" => "Use of technology" ] 6 => array:2 [ "identificador" => "sec0025" "titulo" => "Classical comorbidities, what's new?" ] 7 => array:2 [ "identificador" => "sec0030" "titulo" => "Obesity and new comorbidities" ] 8 => array:2 [ "identificador" => "sec0035" "titulo" => "Benefits of weight loss" ] 9 => array:2 [ "identificador" => "sec0040" "titulo" => "Risk associated to obesity" ] 10 => array:2 [ "identificador" => "sec0045" "titulo" => "Obese child, obese adult?" ] 11 => array:2 [ "identificador" => "sec0050" "titulo" => "Dietary plan" ] 12 => array:2 [ "identificador" => "sec0055" "titulo" => "Physical activity: Not everything is the same" ] 13 => array:2 [ "identificador" => "sec0060" "titulo" => "How should a physical exercise program be prescribed?" ] 14 => array:2 [ "identificador" => "sec0065" "titulo" => "Present and future of drug treatment" ] 15 => array:2 [ "identificador" => "sec0070" "titulo" => "Prevention of obesity" ] 16 => array:2 [ "identificador" => "sec0075" "titulo" => "Treatment of “diabesity”, is there anything new?" ] 17 => array:2 [ "identificador" => "sec0080" "titulo" => "Bariatric surgery" ] 18 => array:2 [ "identificador" => "sec0085" "titulo" => "Where should obese patients be treated?" ] 19 => array:2 [ "identificador" => "sec0090" "titulo" => "Funding" ] 20 => array:2 [ "identificador" => "sec0095" "titulo" => "Conflicts of interest" ] 21 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "PalabrasClave" => array:1 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec830708" "palabras" => array:6 [ 0 => "Obesity" 1 => "Prevention" 2 => "Treatment" 3 => "Diagnosis" 4 => "Comorbidities" 5 => "Spanish Society for the Study of Obesity" ] ] ] ] "NotaPie" => array:3 [ 0 => array:3 [ "etiqueta" => "1" "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Equal first authors.</p>" "identificador" => "fn0005" ] 1 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Lecube A, Monereo S, Rubio MÁ, Martínez-de-Icaya P, Martí A, Salvador J, et al. Prevención, diagnóstico y tratamiento de la obesidad. Posicionamiento de la Sociedad Española para el Estudio de la Obesidad de 2016. Endocrinol Nutr. 2017;64:15–22.</p>" ] 2 => array:2 [ "etiqueta" => "☆☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">This document has been approved by the board of directors of the Spanish Society of Endocrinology and Nutrition and the Spanish Diabetes Society. The complete version may be found in the web site of both societies (<span class="elsevierStyleInterRef" id="intr0010" href="http://www.see.es/">www.see.es</span>; <span class="elsevierStyleInterRef" id="intr0015" href="http://www.sediabetes.org/">www.sediabetes.org</span>), an in the web site of the Spanish Society for the Study of Obesity (<span class="elsevierStyleInterRef" id="intr0020" href="http://www.seedo.es/">www.seedo.es</span>).</p>" ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1094 "Ancho" => 1330 "Tamanyo" => 99450 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Obesity as multifactorial disease.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">ALT, alanine aminotransferase; AST, aspartate aminotransferase; HDL, high density lipoprotein cholesterol; HOMA, homeostasis model assessment; HBP, high blood pressure; LDL, low density lipoprotein cholesterol; GER, gastroesophageal reflux.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Weight (kg) and height (cm) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Body mass index (kg/m<span class="elsevierStyleSup">2</span>) and waist circumference (cm) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Systolic and diastolic blood pressure (mmHg) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Fasting triglycerides (mg/dL or mmol/L) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">HDL and LDL cholesterol (mg/dL or mmol/L) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Fasting glucose (mg/dL or mmol/L) and HbA1c (% or mmol/mol). Estimation of insulin resistance (HOMA) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Thyroid-stimulating hormone (TSH) and liver enzyme (ALT and AST) levels \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">High-sensitivity C-reactive protein \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Are there symptoms of sleep apnea? \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Coronary artery disease \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Any medication promoting weight gain? \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Regular physical activity? \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Other etiological factors \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Other comorbidities? HBP, dyslipidemia, impaired blood glucose (prediabetes, diabetes), osteoarthritis, cholelithiasis, GERa, menstrual irregularities, infertility, depression, and quality of life impairment \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Eating disorders (snacks, compulsions, binge eating disorder, bulimia nervosa)? \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1407691.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">What are the minimal clinical and laboratory data required for adequate assessment of patients with obesity?</p>" ] ] 2 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Advice 1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Measure the activity/inactivity level. A podometer may be used to classify obese subjects as sedentary (<5000<span class="elsevierStyleHsp" style=""></span>steps/day), moderately active (5000–10,000 steps/day), or active and healthy (>10,000<span class="elsevierStyleHsp" style=""></span>steps/day). An alternative is the short version of the International Physical Activity Questionnaire (PAQ), validated in Spanish, which classifies physical activity level as low (not done), moderate, or intense \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Advice 2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Establish as a goal to change and increase activity level depending on the condition of each person \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Advice 3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Perform at least 30<span class="elsevierStyleHsp" style=""></span>min daily of moderate to highly intense exercise 5 or more days per week (150<span class="elsevierStyleHsp" style=""></span>min/week); all weekly exercise may be concentrated in only 2 sessions. Choose any activity that is pleasant, accepted by the patient, and easy to do. They may be daily activities (such as walking or cycling), supervised programmed exercises (such as classes at a gym), or other activities such as swimming, climbing stairs, etc. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Advice 4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Prior warm-up, including joint movement, for approximately 10<span class="elsevierStyleHsp" style=""></span>min is advisable to prevent muscle lesions \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Advice 5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Indicate frequency and intensity with the greatest possible flexibility, using both variables to achieve the same goal. Increases in intensity of the activity provide improvements in fitness. A training modality of high intensity and short duration is high intensive interval training, which achieves cardiorespiratory improvements \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Advice 6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Contact with some friend or perform in group. Use music to set the pace \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Advice 7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Maintain adequate hydration, drinking approximately 1.5<span class="elsevierStyleHsp" style=""></span>L of water before, during, and after exercise. Avoid drinking more than 200<span class="elsevierStyleHsp" style=""></span>mL/15<span class="elsevierStyleHsp" style=""></span>min (maximum bowel absorption rate), because it would cause intestinal discomfort (the typical flank pain) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Advice 8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Wearing adequate clothes and shoes makes exercise more pleasant and prevents injuries \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Advice 9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">After exercise, cool down for some 5<span class="elsevierStyleHsp" style=""></span>min (for example, walking slowly) to allow for disappearance of muscle lactate \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1407690.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Advice to start prescription of a physical exercise program in standard clinical practice.</p>" ] ] 3 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Overweight subjects \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Central body fat distribution \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Obese people who have lost weight \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cyclical weight changes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Diseases predisposing to obesity (genetic, orthopedic, endocrine, etc.) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Patients receiving certain treatments (corticoids, antihistamines, anxiolytics) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Familial predisposition to obesity and sedentary lifestyles \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Environmental risk factors (low sociocultural level, fruit and vegetables not available) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Inadequate dietary habits (increased intake of calorie and fat, high-calorie foods and sugary drinks, etc.) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Life periods critical for obesity (pregnancy, from 5 to 7 years, adolescence, and menopause) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Former smokers \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Subjects highly motivated to prevent weight increase \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1407692.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Risk groups that should be identified to apply selective prevention measures intended to avoid weight gain.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:46 [ 0 => array:3 [ "identificador" => "bib0235" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Consenso SEEDO 2007 para la evaluación del sobrepeso y la obesidad y el establecimiento de criterios de intervención terapéutica" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M.A. Rubio" 1 => "J. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 7 | 1 | 8 |
| 2024 October | 88 | 13 | 101 |
| 2024 September | 117 | 19 | 136 |
| 2024 August | 70 | 16 | 86 |
| 2024 July | 53 | 10 | 63 |
| 2024 June | 52 | 8 | 60 |
| 2024 May | 53 | 8 | 61 |
| 2024 April | 76 | 18 | 94 |
| 2024 March | 109 | 11 | 120 |
| 2024 February | 243 | 12 | 255 |
| 2024 January | 61 | 9 | 70 |
| 2023 December | 55 | 5 | 60 |
| 2023 November | 83 | 12 | 95 |
| 2023 October | 93 | 5 | 98 |
| 2023 September | 65 | 6 | 71 |
| 2023 August | 21 | 5 | 26 |
| 2023 July | 52 | 4 | 56 |
| 2023 June | 58 | 6 | 64 |
| 2023 May | 118 | 14 | 132 |
| 2023 April | 102 | 4 | 106 |
| 2023 March | 82 | 4 | 86 |
| 2023 February | 86 | 19 | 105 |
| 2023 January | 73 | 4 | 77 |
| 2022 December | 61 | 13 | 74 |
| 2022 November | 75 | 24 | 99 |
| 2022 October | 86 | 32 | 118 |
| 2022 September | 137 | 27 | 164 |
| 2022 August | 66 | 21 | 87 |
| 2022 July | 76 | 20 | 96 |
| 2022 June | 55 | 9 | 64 |
| 2022 May | 65 | 19 | 84 |
| 2022 April | 83 | 23 | 106 |
| 2022 March | 100 | 20 | 120 |
| 2022 February | 74 | 21 | 95 |
| 2022 January | 84 | 11 | 95 |
| 2021 December | 92 | 36 | 128 |
| 2021 November | 114 | 28 | 142 |
| 2021 October | 127 | 36 | 163 |
| 2021 September | 111 | 38 | 149 |
| 2021 August | 70 | 28 | 98 |
| 2021 July | 60 | 24 | 84 |
| 2021 June | 110 | 29 | 139 |
| 2021 May | 133 | 54 | 187 |
| 2021 April | 275 | 53 | 328 |
| 2021 March | 156 | 51 | 207 |
| 2021 February | 126 | 26 | 152 |
| 2021 January | 163 | 44 | 207 |
| 2020 December | 115 | 32 | 147 |
| 2020 November | 155 | 32 | 187 |
| 2020 October | 139 | 24 | 163 |
| 2020 September | 157 | 51 | 208 |
| 2020 August | 182 | 40 | 222 |
| 2020 July | 10124 | 31 | 10155 |
| 2020 June | 213 | 48 | 261 |
| 2020 May | 401 | 48 | 449 |
| 2020 April | 153 | 50 | 203 |
| 2020 March | 176 | 22 | 198 |
| 2020 February | 173 | 38 | 211 |
| 2020 January | 116 | 25 | 141 |
| 2019 December | 100 | 14 | 114 |
| 2019 November | 104 | 36 | 140 |
| 2019 October | 100 | 21 | 121 |
| 2019 September | 93 | 7 | 100 |
| 2019 August | 57 | 8 | 65 |
| 2019 July | 74 | 28 | 102 |
| 2019 June | 104 | 42 | 146 |
| 2019 May | 197 | 35 | 232 |
| 2019 April | 97 | 34 | 131 |
| 2019 March | 31 | 18 | 49 |
| 2019 February | 30 | 5 | 35 |
| 2019 January | 27 | 10 | 37 |
| 2018 December | 12 | 5 | 17 |
| 2018 November | 30 | 11 | 41 |
| 2018 October | 43 | 6 | 49 |
| 2018 September | 31 | 8 | 39 |
| 2018 August | 14 | 7 | 21 |
| 2018 July | 13 | 5 | 18 |
| 2018 June | 15 | 1 | 16 |
| 2018 May | 12 | 5 | 17 |
| 2018 April | 6 | 3 | 9 |
| 2018 March | 8 | 1 | 9 |
| 2018 February | 7 | 1 | 8 |
| 2018 January | 5 | 0 | 5 |
| 2017 December | 7 | 1 | 8 |
| 2017 November | 4 | 3 | 7 |
| 2017 October | 8 | 0 | 8 |
| 2017 September | 5 | 0 | 5 |
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