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Endocrinología, Diabetes y Nutrición (English ed.)
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Original Article
Feeding behavior pattern and glycosylated hemoglobin in people with type 2 diabetes at the beginning and end of an educational intervention
Comportamiento del patrón de alimentación y de la hemoglobina glicosilada en personas con diabetes tipo 2, al inicio y final de una intervención educativa
Marlene Roselló Araya
Corresponding author
mrosello@inciensa.sa.cr

Corresponding author.
, Sonia Guzmán Padilla
Unidad de Salud y Nutrición, Instituto Costarricense de Investigación y Enseñanza en Nutrición y Salud (INCIENSA), Tres Ríos, Cartago, Costa Rica
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Type 2 diabetes mellitus &#40;T2DM&#41; is a metabolic disorder arising from multiple factors&#44; and constitutes a non-transmissible chronic disease&#46; The worldwide prevalence of T2DM is on the rise&#44; and its complications imply important economic costs for people who suffer the disease&#44; their families and healthcare systems&#44; as a result of direct medical costs&#44; and loss of work and wages&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">1</span></a> According to the cardiovascular risk factor monitoring survey&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">2</span></a> in 2014 the prevalence of T2DM in Costa Rica was 12&#46;8&#37;&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The causes related to this disease are complex and its complications can be prevented through healthy eating&#44; normal blood glucose values&#44; adequate body weight and physical activity&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">3</span></a> This represents one of the greatest challenges for healthcare professionals&#44; since people with diabetes are characterized by such risky behavior as having unhealthy eating habits and&#47;or leading a sedentary lifestyle&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Glycosylated hemoglobin &#40;HbA<span class="elsevierStyleInf">1c</span>&#41; reflects mean glycemia and is used as a risk marker&#46; It is considered the gold standard for assessing glycemic control in this population&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">5&#8211;7</span></a> The American Diabetes Association &#40;ADA&#41; has established HbA<span class="elsevierStyleInf">1c</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>7&#37; as the target for good control in most diabetic individuals&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">3&#44;8</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">One of the key elements for improving glycemic control is nutritional therapy&#44; since several studies have shown that it can reduce HbA<span class="elsevierStyleInf">1c</span> levels by 1&#46;0&#8211;2&#46;0&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">9</span></a> Dietary prescription should consider individual needs&#44; the health condition&#44; eating habits&#44; the availability of food&#44; and personal preferences&#44; among other factors&#46; It is also important to accompany nutritional therapy with an educational intervention in order for nutritional learning to have the expected effect upon metabolic control and the prevention of complications&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">10</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Therapeutic education is considered a prevention and treatment strategy for providing diabetic individuals with the necessary tools to cope with lifestyle changes and to achieve self-control of the disease through knowledge and the acquisition of skills&#44; while also modifying attitudes and behavior patterns in order to facilitate the active participation of patients in the control and management of their disease&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">11</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The Nutritional Intervention in Chronic Diseases Program &#40;<span class="elsevierStyleItalic">Programa de Intervenci&#243;n Nutricional en Enfermedades Cr&#243;nicas</span> &#91;PINEC&#93;&#41; was designed on the basis of this approach&#46; Its therapeutic education methodology is group oriented&#44; based on skills &#40;learn to know&#44; learn to do and learn to be&#41; and focuses on promoting the capacity of patients to take control and responsibility of their own lives with regard to the disease&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">12</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The PINEC is an innovative group education strategy&#44; integrated within the medical management of diabetes&#44; which promotes the capacity of patients to take control of and responsibility for their own lives with regard to the disease&#46; It also allows for improving and unifying care in nutrition&#44; by assessing the impact of the therapeutic intervention and&#44; above all&#44; improving metabolic control in patients with diabetes&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The program was designed to meet the standards for the development of Education Programs for People with Diabetes in the Americas in relation to the 7 diabetes behavior patterns defined by the ADA&#44;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">3</span></a> within the context of therapeutic education&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">It comprises 6 face-to-face group sessions held over a period of 11 months&#44; in which active and participatory educational activities are conducted in small groups of 8&#8211;10 people with diabetes&#44; and includes relatives as a support network for the patient&#44; and thus also for the prevention of chronic diseases&#46; In addition&#44; before the educational intervention&#44; the supervising professional conducts a reminder of the usual diet for each patient and prepares an individualized food plan in the nutrition clinic&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The sessions are organized in two blocks&#58; a basic intensive block of three consecutive sessions &#40;one a week&#41; during the first month&#44; and a maintenance block of three sessions held 2&#44; 4 and 6 months after the start of the program&#44; in which topics are dealt with corresponding to general aspects of the disease&#44; such as food intake&#44; drug treatment&#44; cardiovascular health&#44; body weight control and self-care&#46; In addition&#44; a series of teaching techniques are used such as demonstrations and dance exercises&#44; and teaching material is used in a simple and clear manner suited to the patient and to the topic contents&#46; In each session&#44; a summary of the topic is provided as reinforcing material for consultation by the patient at home&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">In this program&#44; the nutrition professional has the task of guiding the diabetic subjects in relation to aspects such as the food groups that supply carbohydrates&#44; serving sizes&#44; meal times&#44; and their effects upon disease control&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">13</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">According to the recommendations of the ADA&#44;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">3</span></a> the educational sessions should emphasize&#44; explain and adjust the eating plan to the needs of the diabetic subject&#44; in order to adopt a balanced diet in terms of carbohydrates&#44; fruit&#44; vegetables and protein consumption&#44; with a view to achieving or maintaining good metabolic control&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The central element of the PINEC is the nutritional aspect&#44; with the adoption of an integral approach to treatment&#44; prevention and the management of other disorders such as obesity&#44; arterial hypertension and dyslipidemia&#46; Accordingly&#44; the objective of the present study was to determine the behavior of eating habits and HbA<span class="elsevierStyleInf">1c</span> levels in people with type 2 diabetes&#44; both at the start and at the end of the PINEC educational intervention&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><p id="par0070" class="elsevierStylePara elsevierViewall">A prospective descriptive study was carried out&#46; The inclusion criteria were people over 18 years of age&#44; males and females diagnosed with T2DM&#44; seen at the nutrition clinics of the health centers of the Costa Rican Social Security system &#40;<span class="elsevierStyleItalic">Caja Costarricense de Seguro Social</span> &#91;CCSS&#93;&#41; during the period 2012&#8211;2016&#44; agreement to participate in the educational intervention&#44; and completion of the 6 sessions&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">The following variables were recorded from the clinical records in order to characterize the study population&#58; gender&#44; age&#44; personal disease history&#44; the time of diagnosis of the disease&#44; and the treatment prescribed&#46; The body mass index &#40;BMI&#41;&#44; fasting glycemia and HbA<span class="elsevierStyleInf">1c</span> were recorded at the first and sixth sessions&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The hexokinase method was used to determine glycemia after an 8-h fasting period&#46; Glycosylated hemoglobin was determined based on chromatographic separation in an ion exchange cartridge&#46; Separation was optimized to minimize interference from hemoglobin variants&#44; labile fraction and carbamylated hemoglobin&#46; Both parameters were obtained in the clinical laboratories of the CCSS using an automated analyzer &#40;AU680 Beckman Coulter&#41;&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">The educational sessions were held at different times depending on each health center&#44; either in the morning at 8&#58;00 a&#46;m&#46; or in the afternoon at 2&#58;00 p&#46;m&#46; In these sessions&#44; the participants measured their postprandial glucose levels two hours after the last meal &#40;breakfast or lunch&#44; depending on the time of the session&#41;&#44; in order to promote self-monitoring&#44; which was done using an Accu-Chek&#174; Performa glucometer distributed in Costa Rica by the drug company Roche&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">For the analysis of the glycemic parameters of the study population&#44; we used the criteria of the guide for the care of people with type 2 diabetes of Costa Rica<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">14</span></a>&#59; for fasting glycemia&#58; good &#8804;120<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; regular 120 to &#8804;140<span class="elsevierStyleHsp" style=""></span>mg&#47;dl and poor &#62;140<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#59; for postprandial glycemia&#58; good &#8804;140<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; regular 140 to &#60;180<span class="elsevierStyleHsp" style=""></span>mg&#47;dl and poor &#62;180<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#59; and for HbA<span class="elsevierStyleInf">1c</span>&#58; good &#8804;7&#37;&#44; regular 7&#46;1&#8211;8&#37; and poor &#62;8&#37;&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">The usual daily diet was assessed using the consumption pattern developed for the PINEC&#46; This comprises 11 healthy eating criteria<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">13</span></a> &#40;breads&#44; biscuits&#44; legumes&#44; milk&#47;yoghurt&#44; fruit&#44; sugar source foods&#44; vegetables&#44; protein&#44; lipid spreads&#44; fries and packaged foods&#41;&#46; For the purposes of this study&#44; the investigators scored eating pattern as follows&#58; poor compliance 0&#8211;3&#44; regular compliance 4&#8211;7&#44; and good compliance 8&#8211;11&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">The CCSS protocols on patient data disclosure were followed in order to maintain participant confidentiality&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">The study data were analyzed using the SPSS&#174; version 16 statistical package&#46; Descriptive statistics were used&#44; with the determination of absolute and relative frequencies for qualitative variables&#44; while the arithmetic mean and standard deviation &#40;SD&#41; were calculated for quantitative variables&#46; The comparison of quantitative variables between baseline and the end of the intervention was made using the Student <span class="elsevierStyleItalic">t</span>-test for paired data&#44; with a significance level of 5&#37;&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">In order to assess the success of the educational intervention&#44; an additional metabolic control category was generated &#40;good &#8804;7&#37; and poor &#62;7&#37;&#41;&#44; and the food consumption pattern was analyzed with the three above established categories&#46; The statistical analysis was performed using the McNemar test&#44; with a significance level of 5&#37; for hypothesis testing&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0115" class="elsevierStylePara elsevierViewall">The mean age of the 702 people included in the study was 54&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&#46;6 years&#44; and 73&#46;8&#37; were women&#46; A total of 41&#46;9&#37; controlled the disease with mixed treatment &#40;oral antidiabetic drugs plus insulin&#41;&#44; 40&#46;2&#37; with oral antidiabetic drugs&#44; 15&#46;8&#37; with insulin&#44; and only 2&#46;1&#37; with diet&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">From the perspective of T2DM and its comorbidities&#44; the mean duration of the disease was 10&#46;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>7&#46;9 years &#40;range 1&#8211;40 years&#41;&#46; Three-quarters of the participants were diagnosed with arterial hypertension&#44; and 58&#37; had dyslipidemia&#59; all were receiving drug treatment to control these conditions&#46; The mean baseline BMI was 33&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&#46;9<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span>&#59; 91&#46;6&#37; were overweight or obese &#40;24&#46;4&#37; and 67&#46;2&#37; respectively&#41;&#46; At the end of the educational intervention&#44; the BMI was 34&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>17&#46;1<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span>&#44; with no significant differences versus baseline &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;219&#41;&#46; Body weight loss was 0&#46;3<span class="elsevierStyleHsp" style=""></span>kg&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the baseline and final values of the blood glucose parameters&#59; a statistically significant decrease was observed at the end of the intervention &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;000&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0130" class="elsevierStylePara elsevierViewall">With regard to HbA<span class="elsevierStyleInf">1c</span>&#44; at baseline&#44; 23&#46;9&#37; of the participants showed good metabolic control &#40;&#8804;7&#37;&#41;&#44; versus 41&#46;3&#37; at the end of the intervention &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; The cases of regular and poor control were seen to decrease by 0&#46;2&#37; and 1&#46;6&#37;&#44; respectively&#46; This parameter showed statistically significant differences among the three groups at both baseline and the end of the study &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;000&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0135" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the mean HbA<span class="elsevierStyleInf">1c</span> values according to the type of treatment used by the participants for diabetes control&#46; Regarding the mean scores of this glycemic parameter&#44; significant differences were observed among the four groups at both baseline &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;009&#41; and the end of the intervention &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;005&#41;&#46; Statistically significant reductions were observed only in the &#8220;antidiabetic drugs alone&#8221; and &#8220;insulin alone&#8221; treatment groups &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001 and <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#44; respectively&#41;&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">With regard to the pattern of food intake&#44; the mean number of criteria met was 6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3 at baseline&#44; versus 9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2 at the end of the intervention&#44; the difference being statistically significant &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;000&#41;&#46; At baseline&#44; 2&#46;3&#37; of the people did not meet any criterion&#59; 2&#46;3&#37; met only one criterion&#59; and only 10&#37; met more than 10 criteria&#46; At the end of the educational intervention&#44; the food consumption pattern was modified&#44; with the total population meeting at least two criteria&#44; while 36&#46;6&#37; met more than 10 criteria &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0145" class="elsevierStylePara elsevierViewall">Regarding compliance with the food consumption pattern &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#44; 16&#37; of the participating subjects showed poor compliance &#40;3 or fewer criteria&#41; at baseline&#46; This percentage had decreased to 3&#46;5&#37; at the end of the intervention&#46; On the other hand&#44; the percentage of subjects showing good compliance increased from 33&#46;5&#37; to 75&#46;6&#37;&#46; On relating the pattern of food intake to HbA<span class="elsevierStyleInf">1c</span>&#44; the three food consumption patterns showed similar behavior at baseline&#44; with poor metabolic control &#40;&#8805;8&#37;&#41;&#46; The change in HbA<span class="elsevierStyleInf">1c</span> in the poor and regular compliance categories proved statistically significant &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;022 and <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;000&#44; respectively&#41;&#44; though statistical significance was not reached in the good compliance category &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;065&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0150" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a> shows that less than 30&#37; of the participants in the three consumption pattern categories had good metabolic control at baseline &#40;HbA<span class="elsevierStyleInf">1c</span><span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>7&#37;&#41;&#46; Of the participants with poor adherence to the consumption pattern at baseline&#44; 51&#46;8&#37; presented HbA<span class="elsevierStyleInf">1c</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>8&#37;&#46; However&#44; metabolic control improved in the good and regular compliance categories&#59; at the end of the intervention the number of subjects with poor metabolic control was seen to have decreased&#44; at the expense of an increase in the number of individuals with regular and good metabolic control&#46; These data are reinforced by the McNemar test findings&#44; which proved statistically significant &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; for both metabolic control and for the food consumption pattern &#40;<a class="elsevierStyleCrossRefs" href="#tbl0020">Tables 4 and 5</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><elsevierMultimedia ident="tbl0025"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0155" class="elsevierStylePara elsevierViewall">The objective of the present study was to determine the behavior of the pattern of food intake and HbA<span class="elsevierStyleInf">1c</span> in people with diabetes who participated in the PINEC&#46; The data show that an educational intervention focused on self-care had a positive impact upon these two variables&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Programmed feeding is one of the cornerstones in the management of T2DM&#59; adequate metabolic control is difficult to achieve without it&#44; even when antidiabetic medication is used&#46; In many cases&#44; it is the only adopted therapeutic measure&#44; along with physical exercise&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">15</span></a> Scientific evidence suggests that there is no &#8220;ideal&#8221; eating pattern capable of benefiting all diabetic individuals&#46; Emphasis is therefore placed on the need for an individualized nutritional strategy with no discrimination regarding the culture or the social situation of the patient&#46; The strategy should be based on local habits and should seek to achieve healthier eating patterns&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">16</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">These aspects were considered in the PINEC&#46; At the start&#44; the individualized feeding plan was designed for the participants&#44; being adjusted to their needs and habits&#46; This contributed to making the eating pattern more consistent with the international recommendations for people with diabetes&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">3</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">In our study&#44; the participants had a poor food consumption pattern at baseline&#44; with a mean compliance of 6 of the 11 established healthy eating criteria&#46; According to the data&#44; this population had been diagnosed with the disease for several years &#40;10&#46;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>7&#46;9 years on average&#41;&#44; and in one way or another had received nutritional orientation within the public healthcare system&#44; but no changes had been made in their eating habits&#46; This emphasizes the fact that adherence to dietary-nutritional treatment is a complex&#44; slow and difficult process&#44; because it involves a change in eating habits &#40;these being strongly rooted in people with diabetes&#41; that requires the incorporation of new feeding regimens which need to be systematically maintained for life&#46;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">16&#44;17</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">Since the PINEC involved group therapy where knowledge was incorporated through active-participatory educational activities&#44; it allowed people with diabetes to make lifestyle changes&#44; particularly in relation to diet&#46; At the end of the program 75&#46;6&#37; of the participants met more than 9 healthy eating criteria&#44; i&#46;e&#46;&#44; they showed good compliance with the food consumption pattern&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Education is crucial in any action seeking to improve adherence to nutritional therapy in people with diabetes&#44; particularly when it comes to changes in lifestyle&#46; According to some studies&#44; in structured therapeutic education programs using group methodology based on self-care and the empowerment of individuals&#44; the metabolic changes achieved can be sustained or improved over the short term&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">12&#44;18&#44;19</span></a></p><p id="par0185" class="elsevierStylePara elsevierViewall">Group interventions where education is patient-centered and not disease-centered have been shown to make a greater impact than traditional interventions&#44; because interactive participation allows for the exchange of experiences&#44; and the recommendations and treatments are not imposed but serve to reinforce empowerment&#44; participation&#44; the understanding of information&#44; and personal satisfaction&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">20</span></a> In 2003&#44; Ram&#237;rez-Sanabria et al&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">21</span></a> assessed the degree of satisfaction of participants in the PINEC&#46; The active-participatory group methodology allowed the participants to change their attitude from a passive role to being responsible for their own disease through new knowledge &#40;learn to know&#44; learn to do and learn to be&#41;&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Guzm&#225;n-Padilla et al&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">22</span></a> in turn carried out a qualitative evaluation of the educational methodology of the PINEC&#46; In their study&#44; the participants described education as being a key element for the management of diabetes&#44; and the topics developed in the educational interventions were perceived as allowing them to become better informed&#44; whereas individual consultation never allowed enough time for effective education&#46; What pleased the participants most was the group methodology&#44; since it allowed them to share and learn from others through the exchange of experiences and the questions and doubts of their companions&#44; and the integration of accompanying persons &#40;particularly relatives&#41; in the sessions&#44; so converting the educational intervention into a support system&#46; Another key aspect in this intervention was the perception of the facilitators as role models&#44; generating a positive and significant influence through kindness&#44; understanding&#44; empathy&#44; confidence and the concern shown to the participants&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">Furthermore&#44; Rosell&#243; et al&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">13</span></a> found that group educational intervention increased the consumption of legumes&#44; fruits&#44; vegetables and protein foods&#44; and that a group of patients optimized their metabolic control by decreasing HbA<span class="elsevierStyleInf">1c</span>&#46; Trento et al&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">23</span></a> showed that group intervention exerted a greater effect in terms of the acquisition of new knowledge when the process was adapted to the needs and characteristics of the patient&#44; independently of schooling and age&#46; Finally&#44; group sessions were shown to be more effective with regard to metabolic control&#44; particularly in relation to HbA<span class="elsevierStyleInf">1c</span>&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">The effects of the PINEC are consistent with the results of a number of studies demonstrating the benefits of such educational interventions&#44; showing reductions in fasting glycemia&#44; postprandial glycemia&#44; HbA<span class="elsevierStyleInf">1c</span> and the body mass index&#44; among other factors&#44; thus confirming that these strategies are favorable for metabolic control in people with diabetes&#46;<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">21&#8211;28</span></a></p><p id="par0205" class="elsevierStylePara elsevierViewall">In the study carried out by Carral et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">16</span></a> on measuring adherence to the Mediterranean diet using a 14-item questionnaire&#44; the mean score was found to be 9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2 points&#44; and 59&#37; of the patients had a score of 9 points or less&#46; In other words&#44; most patients showed a low adherence to the traditional Mediterranean diet&#46; Bl&#225;zquez et al&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">29</span></a> documented poor compliance with the recommendations referring to the daily intake of foods at the base of the diet pyramid&#46; This is in contrast to the results of our study&#44; where 16&#37; of the subjects showed non-compliance with the food consumption pattern at baseline&#44; followed by a decrease in this percentage at the end of the intervention&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">As mentioned above&#44; HbA<span class="elsevierStyleInf">1c</span> concentration has been the gold standard for assessing glycemic control and treatment efficacy&#46; The relationship between HbA<span class="elsevierStyleInf">1c</span> and the complications of diabetes is continuous&#59; accordingly&#44; a decrease in HbA<span class="elsevierStyleInf">1c</span> is likely to reduce the risk of complications&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">30</span></a> The mean HbA value<span class="elsevierStyleInf">1c</span> of our study at baseline was 8&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;1&#37;&#46; At the end of the intervention&#44; this parameter showed a statistically significant decrease of 1&#37;&#44; which is consistent with the data of other studies<a class="elsevierStyleCrossRefs" href="#bib0320"><span class="elsevierStyleSup">31&#44;32</span></a> where individuals underwent educational processes and achieved an HbA<span class="elsevierStyleInf">1c</span> reduction of up to 0&#46;44&#37; at 6 months&#44; like that described by Steinsbekk et al&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">33</span></a> However&#44; these results show that the improvements achieved in interventions are only short-term &#40;not exceeding 12 months&#41;&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">In our study&#44; a significant decrease was observed in fasting and postprandial glycemia at the end of the intervention&#44; thus meeting the objectives of T2DM therapy according to the international standards<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">3</span></a> and the PINEC&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">However&#44; 38&#46;5&#37; of the subjects maintained HbA<span class="elsevierStyleInf">1c</span> values &#62;8&#37;&#59; this may be because initially the values of this parameter were three times greater than the desired level according to the ADA&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">3</span></a> It is important to take into account that the progressive nature of T2DM makes it difficult to maintain metabolic control over time in many patients&#44; despite lifestyle interventions and drug treatment&#46; Further changes are required in these cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">8&#44;16</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conclusions</span><p id="par0225" class="elsevierStylePara elsevierViewall">The educational intervention had a positive impact upon the food consumption patterns and HbA<span class="elsevierStyleInf">1c</span> levels of the participants&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">Regardless of whether people with diabetes have a good or poor food consumption pattern&#44; there always will be patients with HbA<span class="elsevierStyleInf">1c</span> outside the desired ranges&#46;</p><p id="par0235" class="elsevierStylePara elsevierViewall">It is important to carry out studies to identify the factors that have the greatest impact upon this parameter&#44; in order to develop strategies aimed at improving compliance with the therapeutic objectives&#46;</p><p id="par0240" class="elsevierStylePara elsevierViewall">As a structured program&#44; the PINEC represents a redefining of functions and procedures in the context of the transition from individual to group care in the nutrition clinic&#46;</p><p id="par0245" class="elsevierStylePara elsevierViewall">The PINEC provides a comprehensive response to the needs of people with diabetes in the public health system of Costa Rica&#44; beyond medical consultation&#46; For this reason&#44; it was taken as a basis for care and education in non-transmissible chronic diseases in the CCSS&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Financial support</span><p id="par0250" class="elsevierStylePara elsevierViewall">This study received public funding from the Government of Costa Rica&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Authorship</span><p id="par0255" class="elsevierStylePara elsevierViewall">The authors declare that they have all fully contributed to the preparation of the present article&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conflicts of interest</span><p id="par0260" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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          "titulo" => "Abstract"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To assess the changes in food consumption pattern and glycosylated hemoglobin levels in patients with type 2 diabetes after an educational intervention&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Materials and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A descriptive study in people over 18 years of age with type 2 diabetes receiving the educational intervention provided by the health facilities of the Costa Rican Social Security&#46; Sociodemographic&#44; biochemical&#44; and anthropometric variables were collected&#46; Glycemic control was classified as good &#40;&#8804;7&#37;&#41;&#44; fair &#40;7&#46;1&#8211;8&#37;&#41;&#44; and poor &#40;&#62;8&#37;&#41;&#46; The usual daily diet record was used to assess the food consumption pattern based on the 11 criteria&#44; divided into the following categories&#58; poor compliance &#40;0&#8211;3 criteria&#41;&#44; fair compliance &#40;4&#8211;7 criteria&#41;&#44; and good compliance &#40;8&#8211;11 criteria&#41;&#46; Data collected were processed using SPSS version 16 software&#46; A Student&#39;s t test was used for dependent samples&#46; The impact of the educational intervention on metabolic control and food consumption pattern was determined using a McNemar test with a level of significance of 5&#37; for hypothesis testing&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The study sample consisted of 702 patients with a mean age of 54&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&#46;6 years&#44; 73&#46;8&#37; females&#46; Mean initial glycosylated hemoglobin level was 8&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;14&#37;&#44; while final level was 7&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;78&#37; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; Glycosylated hemoglobin levels less than 7&#37; were found in 23&#46;9&#37; of the population at study start and in 41&#46;3&#37; at study end&#46; As regard the food consumption pattern&#44; the mean number of criteria met was 6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3 at study start and 9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2 at study end &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;000&#41;&#46; Mean glycosylated hemoglobin level showed at the start of intervention a similar behavior in all 3 categories of the food consumption pattern&#44; and at the end the changes in glycosylated hemoglobin in the poor and fair compliance categories were statistically significant &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;022 and <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;000 respectively&#41;&#44; unlike in the good compliance category &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;065&#41;&#46; At the end of the intervention&#44; of the 75&#46;6&#37; of the population with good compliance&#44; 41&#46;3&#37; had good metabolic control &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;0001&#41;&#46; The educational intervention was significant &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;000&#41; using the McNemar test&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The educational intervention approach to nutritional therapy had a positive impact on the food consumption pattern and glycosylated hemoglobin levels&#44; showing that therapeutic education is part of the treatment of diabetes to achieve the objectives&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Determinar el comportamiento del patr&#243;n de consumo de alimentos y de la hemoglobina glicosilada en personas con diabetes tipo 2&#44; despu&#233;s de una intervenci&#243;n educativa&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Materiales y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio descriptivo en personas mayores de 18 a&#241;os&#44; con diabetes tipo 2&#44; participantes en la intervenci&#243;n educativa brindada en los establecimientos de salud de la Caja Costarricense de Seguro Social&#46; Se recogieron variables sociodemogr&#225;ficas&#44; bioqu&#237;micas y antropom&#233;tricas&#46; La hemoglobina glicosilada fue clasificada en buen control &#40;&#8804;7&#37;&#41;&#44; regular control &#40;de 7&#44;1 a 8&#37;&#41; y mal control &#40;&#62;8&#37;&#41;&#46; Por medio del registro de dieta usual diaria se evalu&#243; el patr&#243;n de consumo de alimentos&#44; que contiene 11 criterios divididos en las siguientes categor&#237;as&#58; mal cumplimiento &#40;0-3 criterios&#41;&#44; regular cumplimiento &#40;4-7 criterios&#41; y buen cumplimiento &#40;8-11 criterios&#41;&#46; Los datos obtenidos se procesaron en el programa SPSS versi&#243;n 16&#46; Se utiliz&#243; la prueba t de Student para muestras dependientes&#46; El efecto de la intervenci&#243;n educativa en el control metab&#243;lico y en el patr&#243;n de consumo de alimentos se midi&#243; por medio de la prueba de McNemar con un nivel de significaci&#243;n del 5&#37; para las pruebas de hip&#243;tesis&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Participaron 702 pacientes&#44; con una edad promedio de 54&#44;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&#44;6 a&#241;os&#44; el 73&#44;8&#37; mujeres&#46; La media de hemoglobina glicosilada inicial fue de 8&#44;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#44;14&#37; y al finalizar&#44; de 7&#44;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#44;78&#37;&#44; &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41;&#46; Al inicio&#44; el 23&#44;9&#37; de la poblaci&#243;n present&#243; hemoglobina glicosilada menor de 7&#37;&#59; al finalizar&#44; aument&#243; esta proporci&#243;n al 41&#44;3&#37;&#46; Respecto al patr&#243;n de consumo de alimentos&#44; la media de criterios cumplidos fue 6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#44; el cual aument&#243; a 9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2 &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;000&#41;&#46; El promedio de la hemoglobina glicosilada mostr&#243; al inicio de la intervenci&#243;n un comportamiento similar en las 3 categor&#237;as del patr&#243;n de consumo de alimentos&#44; al finalizar el cambio de la hemoglobina glicosilada en la categor&#237;a de mal y regular cumplimiento fue estad&#237;sticamente significativo &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;022 y p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;000&#44; respectivamente&#41;&#44; no as&#237; en la categor&#237;a de buen cumplimiento &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;065&#41;&#46; Al finalizar la intervenci&#243;n&#44; del 75&#44;6&#37; de la poblaci&#243;n ubicada en buen cumplimiento&#44; el 41&#44;3&#37; present&#243; buen control metab&#243;lico &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;0001&#41;&#46; Por lo tanto&#44; mediante la prueba de McNemar se determin&#243; que el control metab&#243;lico y el patr&#243;n de consumo de alimentos se modificaron por efecto de la intervenci&#243;n educativa &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;000&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusi&#243;n</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La intervenci&#243;n educativa tuvo un impacto positivo sobre el patr&#243;n de consumo de alimentos y el nivel de hemoglobina glicosilada&#44; demostrando que la educaci&#243;n terap&#233;utica forma parte del tratamiento de la diabetes para alcanzar los objetivos&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Rosell&#243; Araya M&#44; Guzm&#225;n Padilla S&#46; Comportamiento del patr&#243;n de alimentaci&#243;n y de la hemoglobina glicosilada en personas con diabetes tipo 2&#44; al inicio y final de una intervenci&#243;n educativa&#46; Endocrinol Diabetes Nutr&#46; 2020&#59;67&#58;155&#8211;163&#46;</p>"
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            0 => array:2 [
              "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-with-role" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Hemoglobin classification&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  " colspan="3" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Start</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="3" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">End</th><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"><span class="elsevierStyleItalic">p</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">n</span>&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&#37;&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">HbA<span class="elsevierStyleInf">1c</span>&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">n</span>&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&#37;&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">HbA<span class="elsevierStyleInf">1c</span>&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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&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-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Good control &#40;&#8804;7&#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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">168&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">23&#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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;54&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">290&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">41&#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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;12&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Regular control &#40;7&#46;1&#8211;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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">117&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16&#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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;30&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">142&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">20&#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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;28&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Poor control &#40;&#62;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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">417&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">59&#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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&#46;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">270&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">38&#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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;75&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;02&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab2302087.png"
              ]
            ]
            1 => array:2 [
              "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  " colspan="8" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Type of treatment</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Diet alone&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;01&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#46;0<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;83&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;73&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Antidiabetic drugs&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">282&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">40&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#46;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;06&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">282&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">40&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#46;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;49&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;000&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Insulin&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">110&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;33&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">110&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;93&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Antidiabetic drugs<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>insulin&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">295&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">41&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;81<span class="elsevierStyleItalic">F</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>32&#46;9<span class="elsevierStyleItalic">df</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>3<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;009&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">295&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
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                  \t\t\t\t">41&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;72<span class="elsevierStyleItalic">F</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>32&#46;8<span class="elsevierStyleItalic">df</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>3<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;005&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Mean HbA<span class="elsevierStyleInf">1c</span> levels according to the classification and type of treatment at baseline and the end of the intervention&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Consumption pattern categories&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">HbA<span class="elsevierStyleInf">1c</span> start</th><th class="td" title="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Range&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">Good compliance&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">235&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">8&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;99&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">531&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">7&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;80&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;065&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">355&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">50&#46;6&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">8&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;26&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">4&#46;7&#8211;19&#46;8&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">146&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">20&#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
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                  \t\t\t\t">7&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;75&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&#46;000&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">112&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="char" valign="\n
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                  \t\t\t\t">16&#46;0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;06&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="char" valign="\n
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                  \t\t\t\t">5&#46;2&#8211;15&#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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">25&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;73&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="char" valign="\n
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                  \t\t\t\t">5&#46;4&#8211;11&#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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;022&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Total&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">702&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">100&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="char" valign="\n
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                  \t\t\t\t">8&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;14&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">4&#46;7&#8211;19&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">702&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="char" valign="\n
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                  \t\t\t\t">100&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
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                  \t\t\t\t">7&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;78&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">4&#46;4&#8211;14&#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="char" valign="\n
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                  """
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          "tablatextoimagen" => array:1 [
            0 => array:2 [
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                0 => """
                  <table border="0" frame="\n
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Glycosylated hemoglobin&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  " colspan="4" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">After the intervention</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="2" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Total</th></tr><tr title="table-row"><th class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="2" align="center" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&#8804;7&#37;</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="2" align="center" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&#62;7&#37;</th><th class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&#37;&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">n</span>&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&#37;&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="" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&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="" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&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  " colspan="7" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Before the intervention</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8804;7&#37;&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">144&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">20&#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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">24&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">168&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">24&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#62;7&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">146&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">20&#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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">308&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">55&#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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">534&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">75&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab2302085.png"
              ]
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          "en" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Results referring to metabolic control at the end of the PINEC educational intervention&#46;</p>"
        ]
      ]
      6 => array:8 [
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        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
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          "leyenda" => "<p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">McNemar test&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;000&#46;</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=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Consumption pattern&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  " colspan="6" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">After the intervention</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Total</th></tr><tr title="table-row"><th class="td-with-role" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Before the intervention&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  " colspan="2" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Good compliance</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="2" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Regular compliance</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="2" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Poor compliance</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" scope="col"><span class="elsevierStyleItalic">n</span>&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t\t\t</th><th class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">Good compliance&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">198&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">28&#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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">37&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8211;&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">235&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">33&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Regular compliance&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">264&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">37&#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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">79&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&#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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">355&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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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