SEEDO-SEMERGEN consensus document on continuous care of obesity between primary care and specialist Hospital units 2019

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"identificador" => "aff0035" ] 1 => array:2 [ "etiqueta" => "h" "identificador" => "aff0040" ] ] ] 6 => array:3 [ "nombre" => "Rosario" "apellidos" => "Corio" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "g" "identificador" => "aff0035" ] 1 => array:2 [ "etiqueta" => "i" "identificador" => "aff0045" ] ] ] 7 => array:3 [ "nombre" => "Diego" "apellidos" => "Bellido" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "j" "identificador" => "aff0050" ] ] ] 8 => array:3 [ "nombre" => "José-Luís" "apellidos" => "Llisterri" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "k" "identificador" => "aff0055" ] ] ] 9 => array:3 [ "nombre" => "Francisco-José" "apellidos" => "Tinahones" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "l" "identificador" => "aff0060" ] ] ] ] "afiliaciones" => array:12 [ 0 => array:3 [ "entidad" => "Servicio de Endocrinología y Nutrición, Hospital Universitari Parc Taulí, Universitat Autònoma de Barcelona (UAB), Institut d’Investigació i Innovació Parc Taulí (I3PT), Sabadell, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Sociedad Española para el Estudio de la Obesidad (SEEDO), Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Centro de Atención Primaria CAP Terrassa Sud, Mutua de Terrassa, Terrassa, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Servicio de Endocrinología y Nutrición, Complejo Hospitalario de Jaén, Jaén, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "SEMERGEN. MUH H Lluis Alcanyís, Xativa y MUH Casa de la Salud, Universidad de Valencia, Valencia, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Servicio de Endocrinología y Nutrición, Hospital Universitari Arnau de Vilanova. Obesity, Diabetes and Metabolism Research Group (ODIM), Institut de Recerca Biomèdica de Lleida (IRBLleida), Universitat de Lleida, Lleida, Spain" "etiqueta" => "f" "identificador" => "aff0030" ] 6 => array:3 [ "entidad" => "Grupo de Trabajo de Nutrición (SEMERGEN), Spain" "etiqueta" => "g" "identificador" => "aff0035" ] 7 => array:3 [ "entidad" => "Centro de Salud de Valga, Valga, Pontevedra, Spain" "etiqueta" => "h" "identificador" => "aff0040" ] 8 => array:3 [ "entidad" => "Centro de Salud Martí Julià, Cornellà de Llobregat, Spain" "etiqueta" => "i" "identificador" => "aff0045" ] 9 => array:3 [ "entidad" => "Servicio de Endocrinología y Nutrición, Complejo Hospitalario Universitario de Ferrol (CHF), UDC, Ferrol, Spain" "etiqueta" => "j" "identificador" => "aff0050" ] 10 => array:3 [ "entidad" => "Fundación de Investigación SEMERGEN, Madrid, Spain" "etiqueta" => "k" "identificador" => "aff0055" ] 11 => array:3 [ "entidad" => "Servicio de Endocrinología y Nutrición, Hospital Universitario Virgen de la Victoria, Málaga, Spain" "etiqueta" => "l" "identificador" => "aff0060" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Documento de consenso SEEDO-SEMERGEN sobre la continuidad asistencial en obesidad entre Atención Primaria y Unidades Especializadas Hospitalarias 2019" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1738 "Ancho" => 2167 "Tamanyo" => 218422 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Algorithm of pharmacological treatment in obesity proposed by the Spanish and Portuguese Societies for the Study of Obesity<a class="elsevierStyleCrossRef" href="#bib0170">34</a>. B: bupropion; PR: prolonged release; N: naltrexone." ] ] ] "textoCompleto" => "IntroductionThe Spanish Society for the Study of Obesity (SEEDO) made the first estimate of the prevalence of obesity in Spain in 2000, with a progressive increase being witnessed since then.<a class="elsevierStyleCrossRefs" href="#bib0005">1–3</a> In the most recent study, published in 2016, the estimated prevalence of obesity among those over 18 years of age was 21.6%. Obesity is more prevalent in males and increases with age.<a class="elsevierStyleCrossRef" href="#bib0020">4</a> When considering abdominal obesity, defined by waist circumference, the prevalence increases to 33.4% of the population, with this being more frequent in women and progressively increasing with age.When other factors are added to this high prevalence of obesity in our environment, such as it being a chronic disease with a complex approach, and that it associates numerous comorbidities (including type 2 diabetes mellitus [T2DM], high blood pressure, dyslipidaemia, cardiovascular disease, sleep apnoea and hypoapnoea syndrome and cancer), the need to implement and update coordination strategies in clinical care between Primary Care and Specialised Obesity Units becomes apparent.<a class="elsevierStyleCrossRef" href="#bib0025">5</a> In a cross-sectional healthcare model, the Primary Care physicians constitute the driving force behind the whole therapeutic approach related to obesity.<a class="elsevierStyleCrossRef" href="#bib0030">6</a> Cooperatively, the specialists in Endocrinology and Nutrition, who have more specific training to deal with the most complex cases of obesity, and other health professionals such as nurses, nutritionists, psychologists and surgeons, help define a functional unit focused on obesity. Only by improving the coordination between all levels of care, together with a sensible use of available resources, will comprehensive care for this disease be improved. Along with these key-players, employment-based health care plays a relevant although often poorly recognised role in the clinical evaluation of an important segment of the population with obesity. Therefore, coordination between the employment-based doctors and those of Primary Care is necessary to prevent any delay in the intervention of the subjects at risk who are identified in the annual check-ups. The participation of local administrations, educational centres, the food industry, and scientific societies is also mandatory in this fight against obesity.<a class="elsevierStyleCrossRef" href="#bib0035">7</a> To ensure the best coordination between levels, various objectives must be discussed, especially how to:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">a)Develop coordinated protocols for the assessment and treatment of obesity at different levels of clinical care.</li><li class="elsevierStyleListItem" id="lsti0010">b)Agree on the referral criteria between Primary Care and Specialised Obesity Units.</li><li class="elsevierStyleListItem" id="lsti0015">c)Establish contact channels that expedite communication among professionals as well as between professionals and patients. For this, advocating the unified electronic medical record and telemedicine strategies is crucial.</li><li class="elsevierStyleListItem" id="lsti0020">d)Carry out joint continuous training activities; and</li><li class="elsevierStyleListItem" id="lsti0025">e)Develop coordinated lines of research.</li></ul>What should be included in managing excess weight in primary care?Given the complexity of obesity, these indications lay out a comprehensive approach that can be carried out during several visits, adapting to the characteristics of each Primary Care centre. One of the limitations of this guide is that it is based on consensus recommendations among experts and that no tool has been used to assess methodological rigour and transparency, such as AGREE II.<a class="elsevierStyleCrossRef" href="#bib0040">8</a>First of all, the basicsScreening of obesity should be carried out in all the patients who are seen in Primary Care, by means of the periodic measurement of weight and height, and the calculation of the body mass index (BMI): body weight (kg)/height (metres)<a class="elsevierStyleCrossRef" href="#bib0010">2</a> (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). The BMI is correlated with the percentage of body fat, although it may be overestimated in individuals with significant muscle mass (e. g. in body-builders) and underestimated in those with loss of muscle mass (e. g. in elderly ones).<a class="elsevierStyleCrossRef" href="#bib0045">9</a><elsevierMultimedia ident="tbl0005"></elsevierMultimedia>In individuals with a BMI between 25 and 35 kg/m<a class="elsevierStyleCrossRef" href="#bib0010">2</a> the abdominal circumference should also be measured to distinguish between central and peripheral obesity, as this provides additional data for estimating cardiovascular risk.<a class="elsevierStyleCrossRefs" href="#bib0050">10–12</a> However, the requirement of this measurement is debatable in a patient with a BMI ≥ 35 kg/m<a class="elsevierStyleCrossRef" href="#bib0010">2</a>, as they already have a high-risk secondary to their adiposity. The abdominal circumference should be measured with a flexible tape measure placed horizontally, and at the end of a forced expiration, at the level of the upper edge of the iliac crest. A high waist circumference is determined if ≥ 88 cm in women and ≥ 102 cm in men, although in the Asian population the cut-off points decrease to ≥ 80 cm and ≥ 90 cm, respectively.The anamnesisThe clinical history should be aimed at detecting possible causes of secondary obesity, as well as the use of any pharmacological treatments that may promote the condition (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>It is important to ask about the presence of a psychopathological history, anxiety, depression, or eating disorders. Inquire about the family history of obesity, the age of onset and its development. Today we know that low birth weight and rapid weight gain in the first 10 years of life increases the risk of T2DM in adulthood, that the risk of comorbidities associated with obesity increases when it starts before the age of 40, and that the increase of 5 kg after 18 years of age in women and 20 years of age in men increases the risk of T2DM.<a class="elsevierStyleCrossRef" href="#bib0065">13</a>It is convenient to ask about weight fluctuations: maximum and minimum weight, and its development over the last 5 years; question women about post-pregnancy weight increases; inquire about alcohol consumption, due to its high caloric value; and smoking, since its cessation is related to weight gain. Record any possible professional, family or interpersonal limitations that may contribute to obesity or hinder its dietary approach.Ask about the presence of comorbidities associated with obesity: hypertension, dyslipidaemia, alterations in glucose metabolism and T2DM, sleep apnoea-hypoapnoea syndrome, osteoarticular pathology, fatty liver and urinary incontinence. An easy way to assess the impact of obesity on quality of life is for the patient to respond to the 31 questions in the questionnaire Impact of Weight on Quality of Life-Lite (IWQOL-Lite).<a class="elsevierStyleCrossRef" href="#bib0070">14</a>It is important to scrutinize the patient's food habits: ask about the time distribution and frequency of meals, the variety and quantity of food (dietary records), the preferences and frequency of consumption by groups (fruits, vegetables, meats and fats, especially animals); as well as the habit of swallowing fast, the size of the bites, snacks between meals, the place where food is eaten and the distractions when eating (e. g., eating while watching television).Finally, a record should be made of physical activity, of the type and quantity, including daily tasks (domestic, type of work, commuting, leisure, etc.) along with scheduled exercise. Quantify weekly hours and intensity of the exercise.Physical examinationIn addition to recording the basic anthropometric data already mentioned, the search for traits of secondary obesity cannot be ignored, such as the presence of red/purple stretch marks or striae (hypercortisolism), acanthosis nigricans (insulin resistance), papillomatosis (acromegaly), proximal muscle weakness (hypercortisolism, hypothyroidism), acne, and hirsutism (polycystic ovary syndrome). The association with hidradenitis, intertrigo, signs of heart failure, varicose veins with trophic disorders or ulcers in the lower extremities should be explored.And so as not to overestimate the blood pressure, cuffs with an adequate width should be used: from 14 to 15 cm in moderate obesity and from 16 to 18 cm in very obese individuals.When to include complementary tests?The lab test should consider the determination of fasting plasma glucose, glycated haemoglobin, lipid profile (total cholesterol, HDL, LDL and triglycerides), uric acid, thyroid function (TSH, free T4), kidney function (creatinine, glomerular filtration rate and microalbuminuria estimation), proteins (total and albumin), liver enzymes (GOT, GPT, GGT), phosphocalcic metabolism if disorder is suspected (calcium, phosphate, 25-OH vitamin D, PTH), and blood count with anaemia study if necessary. If possible, insulin will also be added to calculate insulin resistance using the homeostatic model assessment (HOMA = glucose (mmol/l) × insulin (µU/mL) / 22.5]. When the suspicion is high and if the means are available, screening should be started for secondary causes of obesity such as endogenous hypercortisolism (cortisol rhythm and/or 24 h urine free cortisol, suppression with 1 mg of dexamethasone), acromegaly (IGF1, hGH) or polycystic ovary syndrome (testosterone, androstenedione, DHEAs), otherwise the patient should be referred to the Specialised Obesity Unit.An electrocardiogram should be recorded every 6 months, although this frequency can be adapted to age and comorbidities.90% of patients with severe obesity present a sleep apnoea-hypoapnoea syndrome, so flags are raised with patients who snore, those who show daytime hypersomnia, and those with an increased neck circumference or with difficult-to control arterial hypertension. The performance of a forced spirometry test may be considered in patients with signs of hypoventilation or respiratory failure.The rest of the complementary tests will depend on the clinical suspicion, and their availability. For example, an echocardiogram in those patients with suspected heart failure or valve disease, long-standing hypertension, and sleep apnoea-hypoapnoea syndrome. A liver ultrasound if there is suspicion of non-alcoholic steatohepatitis or gallstones. A gynaecological ultrasound if polycystic ovary syndrome is suspected. An osteoarticular evaluation with a radiological and functional study. A digestive endoscopy or gastrointestinal motility studies when gastroesophageal reflux disease is suspected. A urodynamic study if there is urinary incontinence.How should the management of excess weight be addressed in primary care? Proposing a diet planThe dietary approach with a diet plan and personalised physical exercise should be the first step in the treatment of obesity (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>).<a class="elsevierStyleCrossRefs" href="#bib0075">15,16</a> A loss of 5−10% of the weight in 6 months can be considered realistic and this alone provides clear health benefits. In patients with BMI ≥ 35 kg/m<a class="elsevierStyleCrossRef" href="#bib0010">2</a> it is possible to aspire higher, with objectives close to 20% or more. The main objective should be to lose weight and not regain it, as well as the treatment of comorbidities.<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>Dietary assessmentBefore starting a change in dietary habits, knowledge about the patient's diet should be obtained, by means of dietary questionnaires or self-consumption records that include home measurements, visual portion atlases or food models. This methodology can underestimate the amounts consumed, but it allows to identify the frequency of food group intake and poor eating habits.Which eating plan should be recommended?The Mediterranean diet is the preferred model supported by SEEDO and SEMERGEN as it best represents in clinical practice a balanced approach within a structure of healthy habits.<a class="elsevierStyleCrossRefs" href="#bib0085">17,18</a> The Mediterranean "low calorie" diet is based on a low intake of saturated fatty acids, trans fats, and added sugars, and a high consumption of fibre and mono-unsaturated fatty acids. It is important to highlight that the restriction of carbohydrates together with the decrease in simple sugars, must be reinforced with a limitation to high glycemic load energy foods, such as bread, potatoes, rice, pasta and refined cereals. These foods can be replaced by a higher consumption of fruits, vegetables, whole grains and nuts.<a class="elsevierStyleCrossRefs" href="#bib0050">10,19,20</a>The energy restriction should not result in a caloric intake below 1,000–1,200 kcal/day in women and 1,200−1,600 kcal/day in men. The calculation of energy expenditure will depend on the sex of the individual, age, BMI and physical activity performed. In clinical practice the following formula can be used: 20−25 kcal × kg × day, to which we subtract 500 kcal of total expenditure.<a class="elsevierStyleCrossRef" href="#bib0105">21</a>It is important for food intake to be orderly, to avoid eating during the night, to avoid foods with added sugars, to moderate alcoholic and non-alcoholic drinks, and to avoid fast food meals.There are a multitude of "popular" diets, with solid or not-so-solid foundations, that offer multiple nutritional proposals which differ to the dietary schemes recommended in the clinical guidelines. Both SEEDO and SEMERGEN speak out against diet models without scientific endorsement. Weight loss should be achieved by means of a balanced low-calorie diet combined with physical exercise and lifestyle changes thereby ensuring long-term success, and always under medical supervision.<a class="elsevierStyleCrossRef" href="#bib0085">17</a> It is essential to insist on the necessity of a varied, healthy and balanced diet in the context of the Mediterranean diet and the practice of regular physical exercise. The marketing of new foods and food supplements must be based on the scientific demonstration of their effectiveness and undesirable effects, with sufficient scientific studies. Furthermore, the eating plan originally aimed at achieving weight loss should be adapted as far as possible to the underlying pathology of the obese patient. An example of this double utility is found in the recommendations published by SEMERGEN and the Spanish Society of Atherosclerosis, in which the interaction of the various nutrients included in the food matrix is evaluated, and it provides useful advice for clinical practice.<a class="elsevierStyleCrossRef" href="#bib0110">22</a>How to achieve patient adherence?It should not be forgotten that eating is a form of pleasure for most human beings, so a totally restrictive or punitive eating plan will never work. Therefore, the worst strategy for an obese patient is the absolute ban on "everything that makes you fat." Endeavours must be made to help the obese patient understand that although they can continue enjoying food intake on certain occasions, this behaviour cannot be followed on the vast majority of days.The most determining factor in the success of a diet is adherence to it, rather than the composition or distribution of nutrients.<a class="elsevierStyleCrossRefs" href="#bib0115">23,24</a> For this reason, an explanation should be given to each patient individually regarding their eating plan, as well as widening their nutritional education as far as possible, until they can organise their daily intake themselves. The greatest achievement is to convince the obese patient that their disease is a chronic process and that the only way to deal with it is to change their diet for the rest of their lives, attaining a healthy and balanced diet. SEEDO advocates establishing specific nutritional education consultancies in each Health Area with expert personnel that include university graduates in Nursing and graduates in Human Nutrition and Dietetics. SEMERGEN deems that Primary Care should have an expert referee in Nutrition to provide advice when needed.What is the proposal for medium- and long-term medical follow-up?After maintaining a change in habits for a period of 3–6 months, the loss of lean mass (unwanted) slows down weight loss, so to maintain or increase weight loss, at the expense of fat mass, a greater caloric restriction or an increase in energy expenditure (e. g., increasing levels of physical activity) will be needed. As previously mentioned, obesity is a chronic disease, so follow-up must be maintained for life, as often as permitted by each health environment.Physical exercise planExercise is a fundamental element in the treatment of obesity, since it improves weight loss, increases the loss of abdominal fat, contributes to the maintenance of lost weight, increases fat-free mass, induces a feeling of well-being and positively affects cardiovascular risk factors. In general, the role of physical exercise in weight control is more important in maintaining lost weight than in the active loss phase, where eating patterns are a priority.The reduction of a sedentary lifestyle must be promoted, and in this sense, any increase in physical activity will be advantageous. In any case, the goal is to be active at least 150 min per week, distributed in 30 min per day, 5 days a week, with no more than 48 h without physical activity.<a class="elsevierStyleCrossRef" href="#bib0085">17</a> As mentioned above, establishing specific nutritional education consultancies in each Health Area with expert personnel is advocated, which means that the figure of the physical educator is essential.Physical exercise for the obese person should always be programmed individually, taking into consideration the conditions of each patient. This will start progressively, with daily activities, or through a training phase, so as to reach the daily goals in stages.<a class="elsevierStyleCrossRef" href="#bib0125">25</a> Given the limitations that the obese patient presents regarding physical effort, motivation is essential and so a stimulating and attractive programme needs to be developed, with an initial phase and an implementation phase.<a class="elsevierStyleCrossRefs" href="#bib0130">26,27</a>In the initial phase, during the first four weeks gentle exercise will be prescribed, such as walking fast for 30 min, at least 3 days a week and increasing slightly in intensity throughout each week. It is useful to have a pedometer as a reference and control element for the patient (<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>).<elsevierMultimedia ident="tbl0020"></elsevierMultimedia>In the implementation phase, the intensity and duration of the exercises will increase, until one hour per session is reached. Exercises of moderate or intense activity such as brisk walking, swimming, cycling, aerobics, or sports should be performed.Better results are achieved with the combination of aerobic exercises (walking, running, swimming, dancing, cycling, etc.) and strength exercises of the major muscle groups.How do pharmacological treatments help?In obesity, when lifestyle modification is not enough, help can be provided by pharmacological treatment.<a class="elsevierStyleCrossRefs" href="#bib0140">28–40</a>When should pharmacological treatment be used?Drugs to treat obesity are indicated in those patients with a BMI ≥ 30 kg/m<a class="elsevierStyleCrossRef" href="#bib0010">2</a> when weight loss > 5% has not been achieved after 6 months of a structured programme of lifestyle changes. Their use is also extended to patients with a BMI ≥ 27 kg/m<a class="elsevierStyleCrossRef" href="#bib0010">2</a> who already have major comorbidities associated with obesity (<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>). Pharmacological treatment should be indicated in subjects "motivated to lose weight", with active participation of the patient in the control of their disease.<a class="elsevierStyleCrossRef" href="#bib0135">27</a> Likewise, the recommendation is to stop the medication if weight loss > 5% is not achieved after 3 months.<elsevierMultimedia ident="tbl0025"></elsevierMultimedia>What options are available?Along with orlistat, available since 1998 in Spain, there is also liraglutide 3.0 and a combination of extended-release bupropion (90 mg) with naltrexone (8 mg). There is no reason why any of these options cannot be prescribed at the Primary Care level. The use of the three options is not recommended in pregnant women and those under 18 years of age. Recently, the Spanish and Portuguese Societies for the Study of Obesity have published a consensus on pharmacological treatment in which they propose an algorithm for action (see <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).<a class="elsevierStyleCrossRef" href="#bib0170">34</a><elsevierMultimedia ident="fig0005"></elsevierMultimedia>OrlistatOrlistat is an inhibitor of gastric and pancreatic lipase, which by inhibiting the hydrolysis of triglycerides received from the diet, reduces the absorption of 30% of the ingested fat. Taking a 120 mg capsule before, during or up to 1 h after breakfast, lunch and dinner. A dose can be skipped if the intake is low in fat (fruit, skimmed milk, etc.).The main side effects are related to the faecal elimination of fat. Up to 50% of patients experience an increase in the number of stools, with steatorrhea, meteorism, faecal urgency and abdominal pain. Therefore, it is contraindicated in patients with malabsorptive intestinal diseases such as ulcerative colitis or Crohn's disease. The most severe complications are related to oxalate nephropathy and liver failure. Its prolonged use can be associated with the malabsorption of fat-soluble vitamins (A, D, E, K), so supplementation would only be necessary if the drug use is chronic. The pharmacological interaction with cyclosporine, levothyroxine sodium or antiepileptic drugs (reducing their action), and the potentiation of the effects of warfarin have been described. Compared with placebo, orlistat achieves a weight loss between 2.5 kg (at a dose of 60 mg every 8 h) and 3.4 kg (at a dose of 120 mg every 8 h).<a class="elsevierStyleCrossRef" href="#bib0165">33</a>Extended-release naltrexone and bupropion combinationNaltrexone is an opioid antagonist used in acute opioid poisoning, while bupropion is a dopamine and norepinephrine reuptake inhibitor antidepressant used in tobacco cessation. Together they act on the hypothalamic melanocortin and reward system areas of the brain, favouring satiety and reducing the sensation of pleasure associated with eating.<a class="elsevierStyleCrossRefs" href="#bib0170">34–36</a>The maximum recommended daily dose is 2 tablets twice a day, for a total dose of 32 mg of naltrexone and 360  mg of bupropion. At the start of treatment, the dose is progressively increased over a period of 4 weeks as follows: one tablet in the morning for the first week; one tablet in the morning and one in the evening during the second week; 2 tablets in the morning and one at night during the third week; and 2 tablets in the morning and 2 at night from the fourth week onwards. It is advisable to bring forward the time of the evening meal, so as to reduce one of the adverse effects, namely insomnia.The most frequent adverse effects described are gastrointestinal (nausea, constipation and vomiting) and neurological (headache, dizziness and dry mouth), together with the elevation of the heart rate and blood pressure. The severe adverse effects are related to depression and the development of manic episodes.Its use is not recommended in patients with uncontrolled hypertension, who are receiving treatment with benzodiazepines, morphine derivatives or monoamine oxidase inhibitors, with liver or kidney failure, with bipolar disorder or a history of an eating disorder (bulimia or anorexia nervosa), with a history of seizures or a known neoplasm of the central nervous system. It is to be used with caution in people over 65 years of age and it is not recommended in people over 75 years of age. Compared to placebo, the daily combination of 32 mg of naltrexone and 360 mg of prolonged-release bupropion achieves a weight loss of 5.4-8.1% (between 33-46% of patients lose > 5% of the initial weight).<a class="elsevierStyleCrossRef" href="#bib0185">37</a>Liraglutide 3.0 mgLiraglutide is a GLP-1 receptor agonist that requires daily subcutaneous administration. There exists extensive experience in its use for the treatment of T2DM, although at lower doses (up to 1.8 mg/day). The mechanisms involved in weight reduction are probably related to a combination of effects on the gastrointestinal tract and via central mechanisms. Active GLP-1 decreases appetite, reduces energy intake, and delays gastric emptying.The starting dose is 0.6 mg daily for the first week, with subsequent increases of 0.6 mg every week up to the maximum maintenance dose of 3.0 mg. In this way, a better gastrointestinal tolerance is achieved. In case of intolerance to the highest doses (2.4 or 3.0 mg) the patient will be directed to the highest tolerated dose. This can be administered at any time of the day without regard to mealtimes, in the abdomen, the thigh or the upper arm.The main side effects are nausea and vomiting, which are mild-moderate in most cases. They occur transiently in the first weeks and rarely lead to drug discontinuation. It can also cause diarrhoea, constipation, and headaches. In cases of repeated vomiting wherein the administration is not suspended, or fluid replacement is not assured, episodes of acute kidney failure have been described. There are currently insufficient data to confirm the association of the use of liraglutide with pancreatitis and pancreatic cancer, although its use is not recommended in patients with this history, nor in those with a personal or family history of medullary thyroid carcinoma or multiple endocrine neoplasm type 2 (MEN-2), women who are pregnant, and those under 18 years of age and over 75 years of age. It can be used in patients with estimated glomerular filtration rate ≥ 30 mL/min. Special caution should be taken in patients with a history of cholelithiasis, gastroparesis, or inflammatory bowel disease.Compared with placebo, liraglutide at a dose of 3.0 mg per day achieves, after 56 weeks, a weight loss that reaches 8.0 ± 6.7% (8.4 ± 7.3 kg) of the initial weight (63% of patients lose > 5% of the initial weight) to which the cardiometabolic benefits already demonstrated must be added.<a class="elsevierStyleCrossRef" href="#bib0195">39</a>Limitations of pharmacological treatmentThe main limitation for the use of any of the 3 available treatment options is that they are not eligible for financing by the public health system. This reduces their accessibility to the most disadvantaged socio-economic strata, where the prevalence of obesity is higher. The side effects of the 3 drugs are frequently transient and do not represent a main cause of discontinuation of the treatment. Other aspects that limit adherence to long-term treatment are the need to take 4 tablets/day of naltrexone/bupropion, the steatorrhea of orlistat, or the daily subcutaneous administration of liraglutide.For how long can pharmacological treatment be used in obesity?This question can be answered by conducting the exercise of replacing "obesity" with any other cardiometabolic pathology, for example "hypertension", "diabetes" or "dyslipidemia". If the treatment is well tolerated and the weight loss exceeds 5% of the initial weight after the first 3 months of treatment, it is understood that the treatment should be continued. And as a chronic disease, its treatment must also be considered chronic, or at least continue until the patient no longer meets the criteria for its indication.How should obesity be monitored in primary care?The frequency of the visits will depend on the associated comorbidity. During the first-year physician consultations would be advisable every 2–3 months at least, and nursing consultations every month - which can be carried out individually or in groups. The frequency of consultations should be adjusted according to the progress of the patient and his/her comorbidities. After the second year, the follow-up interval can be reduced (e. g. every 6 months for the physician consultation and every 3 months for the nursing consultation), with the possibility of individualising according to the progress of each patient.In these consultations, the change in weight and BMI, waist circumference and blood pressure should be evaluated. The prescribed treatment should also be monitored, whether it is dietary or pharmacological behaviour, as well as the main laboratory parameters (glucose, HbA1c, total cholesterol, HDL, LDL, triglycerides, liver enzymes, creatinine, and uric acid).How should treatment of the comorbidities be started?The approach to certain comorbidities in the patient with obesity requires an approach that is somewhat different to that used when the same comorbidity arises in a patient with normal weight. The attitude to be followed in the face of T2DM, dyslipidemia, arterial hypertension and sleep apnoea-hypoapnoea syndrome, due to its close relationship with weight increase is discussed below. In all cases when faced with a BMI ≥ 35 kg/m<a class="elsevierStyleCrossRef" href="#bib0010">2</a>, discuss with the patient the possibility of opting for bariatric surgery, and refer to the Specialised Unit if the patient wishes.Diabetes mellitus type 2The close relationship between excess weight and hydrocarbonated metabolism disorders makes T2DM screening essential in all patients with obesity. The recommendation is to carry out an annual lab test that includes glucose and HbA1c, and the option of practising an oral glucose tolerance test with 75 g in cases of prediabetes (abnormal fasting blood glucose between 100 and 125 mg/dl or HbA1c between 5.7 and 6.5%).<a class="elsevierStyleCrossRef" href="#bib0205">41</a>The initial treatment of any hydrocarbonated disorder in the obese patient consists of a balanced diet and physical exercise aimed at losing weight,<a class="elsevierStyleCrossRef" href="#bib0205">41</a> with the addition of drugs in the presence of diabetes. The first option will be metformin up to the maximum tolerated dose, and if after 3−6 months an acceptable glycemic control is not achieved (HbA1c < 7.0%), a second drug with positive effects on body weight will be added: a sodium-glucose co-transporter-2 inhibitor (SGLT2) or a GLP-1 receptor analogue. Drugs whose use is associated with weight gain, such as sulfonylureas, glitazones and insulin, should be avoided as far as possible. The use of dipeptidyl peptidase 4 (DPP4) inhibitors can be considered in the obese patient due to its neutral effect on weight.<a class="elsevierStyleCrossRef" href="#bib0210">42</a> If the diabetes cannot be controlled with two drugs, a third drug will be added according to that previously stated. Diabetes drugs can be combined with anti-obesity drugs as long as they are not incompatible due to having the same or similar mechanism of action or are from the same family.<a class="elsevierStyleCrossRef" href="#bib0215">43</a>DyslipidemiaFor its screening, the lab test (after 12 h fast) should include the determination of total cholesterol, non-HDL cholesterol, HDL cholesterol, triglycerides and LDL cholesterol (calculated using the Friedewald formula). The dyslipidemia of obesity consists of high triglycerides and low HDL cholesterol. Similar to the rest of the metabolic comorbidities associated with obesity, lifestyle intervention is recommended for its treatment, combining physical exercise and a low-calorie diet that includes a minimum contribution of refined sugars and carbohydrates, avoids trans fatty acids, limits alcohol use and increases fibre intake. In patients with high cardiovascular risk, with metabolic syndrome, prediabetes, hypertension and/or dyslipidemia, the use of statins should be considered, especially when LDL cholesterol levels exceed 100 mg/dl (130 mg/dl if the risk is low). If a high potency statin is not enough, ezetimibe can be added. If elevated triglycerides persist despite the aforementioned measures, combined therapy with fenofibrate should be started (the use of gemfibrozil should be avoided due to the increased risk of myopathy, as should the statin and fenofibrate combination for the same reason). It should not be forgotten that weight reduction is crucial for improving the lipid profile, so any available anti-obesity medication can be added, since all of them have been shown to improve the lipid profile.<a class="elsevierStyleCrossRef" href="#bib0060">12</a>Arterial hypertensionControlling blood pressure in obese patients is more difficult and requires more intensive treatment. Emphasis should again be placed on weight reduction through lifestyle intervention, which will greatly help towards the achievement of blood pressure objectives. When selecting the pharmacological treatment of the obese hypertensive patient, the risk of developing diabetes in the future must be taken into account, so the use of drugs or drug-combinations that reduce the risk of developing the disease are recommended. The use of an angiotensin converting enzyme (ACE) inhibitor or an angiotensin receptor blocker (ARB) is a good option to start treatment, especially if the patient presents metabolic syndrome. If a drug-combination is required, a calcium antagonist should be added rather than a diuretic or a beta-blocker, mainly because the use of the latter two has been associated with weight gain, alterations in insulin sensitivity and in the metabolism of glucose and lipids.In the hypertensive patient who does not achieve good control, and as previously discussed, the combination of prolonged-release bupropion/naltrexone would be contraindicated.<a class="elsevierStyleCrossRef" href="#bib0060">12</a>Sleep apnoea-hypoapnoea syndromeThe anamnesis should be the screening for this syndrome, asking about the frequency of snoring, night-time respiratory stops and hypersomnia during the day. Two short questionnaires are useful, such as the Epworth questionnaire (8 questions on the ease of falling asleep in everyday situations) and the Berlin questionnaire (10 questions on whether the subject snores, wakes up tired after sleeping, and has been diagnosed with arterial hypertension). If the suspicion is high, or the questionnaires indicate a higher risk of suffering from it, the patient should be sent to the corresponding Sleep Unit to arrange for home cardiorespiratory polygraphy or polysomnography.<a class="elsevierStyleCrossRef" href="#bib0060">12</a>When to think about bariatric surgery?It is totally impossible to solve the problem of obesity through bariatric surgery. However, any patient with obesity who meets surgical criteria should be fully informed of this option, regardless of whether they want to opt for this route or whether the healthcare professional is in favour of it or not.What criteria must be met?In 1991 the NIH Consensus Development Conference Panel established the general criteria for choosing candidates for bariatric surgery: patients with a BMI over 40 kg/m<a class="elsevierStyleCrossRef" href="#bib0010">2</a>, and patients with less severe forms of obesity (BMI between 35 and 40 kg/m<a class="elsevierStyleCrossRef" href="#bib0010">2</a>) but with associated severe comorbidities, such as T2DM or sleep apnoea-hypoapnoea syndrome.<a class="elsevierStyleCrossRef" href="#bib0220">44</a> These criteria have been maintained in subsequent consensuses and guidelines.<a class="elsevierStyleCrossRefs" href="#bib0225">45–48</a>In addition, the age of the patient should be considered, with no doubts existing for those between 18 and 60 years of age but ensuring that patients are individualised outside that age range. The progression time of obesity should be longer than 5 years, and duly supervised conservative treatments should have been attempted and failed.The patient must understand that the goal of the surgery is not to reach the ideal weight, and he/she must commit to adhering to the follow-up guidelines after the surgery. In many centres the patient has to sign a commitment form confirming his/her understanding and willingness to adhere.The cognitive capacity of the patient must be sufficient to understand the mechanisms by which weight is lost with surgery, to understand that good results are not always achieved, and the need for long-term follow-up.What are the exclusion criteria?The presence of untreated endocrine disorders that facilitate obesity (such as primary hypothyroidism, Cushing's syndrome, or the existence of an insulinoma), non-stabilised major psychiatric disorders, intellectual disability, eating disorders, and addiction to drugs or alcohol abuse should be considered exclusion criteria.<a class="elsevierStyleCrossRefs" href="#bib0085">17,45,46</a> Restrictions will also be considered: for patients who cannot care for themselves and do not have long-term family or social support that can provide such care; in the face of a severe illness that limits the life expectancy of the patient and will not improve with the weight loss; when the surgical or anaesthetic risk is unacceptable; or when there is a pathology of the digestive system that may be aggravated by surgical changes.Women of childbearing age should avoid pregnancy for at least the first postoperative year.When and how to refer a patient to the specialised obesity unit?Establishing shared referral criteria and fluid communication between both levels of care is essential to consolidate cross-sectional treatment of this disease (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).<elsevierMultimedia ident="fig0010"></elsevierMultimedia>What referral criteria should be used?The criteria for referral to the Specialised Obesity Unit, presented as the doctor specialising in Endocrinology and Nutrition, may depend on the resources, organisation and degree of coordination of the different levels of care in each health area.<a class="elsevierStyleCrossRefs" href="#bib0245">49–51</a> This possibility should be considered in patients who are motivated to lose weight, with a BMI ≥ 35 kg/m<a class="elsevierStyleCrossRef" href="#bib0010">2</a>, at least, in which the approach previously described at the Primary Care level fails to reverse the situation (<a class="elsevierStyleCrossRef" href="#tbl0030">Table 6</a>).<elsevierMultimedia ident="tbl0030"></elsevierMultimedia>Obese women of reproductive age should be informed of the risk that excess weight implies for their future pregnancy, while being attended to in the Primary Care units unless they meet any of the referral criteria.If there is a suspicion that the patient suffers an eating disorder, he/she should be referred to the Psychiatry department or to the corresponding Eating Disorders Unit.Patients with a BMI between 30 and 35 kg/m<a class="elsevierStyleCrossRef" href="#bib0010">2</a> in which their obesity is considered to further poor control of any comorbidity, should be referred to the corresponding specialist (e. g. to the Endocrinology and Nutrition department if it is a T2DM, to the Pulmonology department for sleep apnoea-hypoapnoea syndrome, to the Gynaecology department in case of infertility, etc.), but referral should not be made to the Obesity Units unless the contrary has been previously established.Finally, it is worth remembering how important patient motivation is and their involvement in all processes related to the therapeutic approach to obesity. That is why patients lacking motivation, or who have not attempted to modify their lifestyle habits during the follow-up in Primary Care, will be excluded from referral to the Specialised Units.How is a patient referred to the specialised unit?Ideally, the referral of a patient from Primary Care to the Specialised Unit should be accompanied by a brief and concise report (<a class="elsevierStyleCrossRef" href="#tbl0035">Table 7</a>).<elsevierMultimedia ident="tbl0035"></elsevierMultimedia>What are the specialised obesity units?The Specialised Obesity Units must be able to provide obesity assessment and treatment strategies that are not available in Primary Care, with a relative ability to adapt to the clinical and personal situation of each patient. Formed by a multidisciplinary team, they should develop not only a clinical function but also a teaching and research function. Different scientific societies, such as the European Association for the Study of Obesity (EASO), establish quality and accreditation criteria for these units (Center of Excellence - European Association for the Study of Obesity).<a class="elsevierStyleCrossRef" href="#bib0260">52</a> Similarly, SEEDO supports the development of these specialised and multidisciplinary units in every hospital site.Which professionals participate?Although with a varying degrees of involvement, a Specialised Obesity Unit should have the clinical activity led by endocrinologists, nutritionists, nurses, clinical psychologists, psychiatrists, endoscopists, surgeons, pulmonologists, physiotherapists, physical educators and anaesthesiologists. Additionally, there should also be referee specialists in the cardiology, hepatology, nephrology and neurology areas. Finally, the family doctor should be in communication with the Specialised Obesity Unit, with the aim of facilitating the exchange of information between professionals, optimising the prescribed treatments, and reinforcing the transversal management of this disease.What is the proposal for patient follow-up?Sending an obese patient to a Specialised Unit is not equivalent to achieving a normal weight. The limitations of behavioural treatment as well as current pharmacological options are well known. However, these should not be an impediment to setting individualised weight loss goals and providing the patient with the necessary tools to achieve them, always in a realistic manner. The concept of "ideal weight" does not always help in this regard, since the patient must understand his/her disease and know that any weight loss will be beneficial for his/her quality of life and health.Although the follow-up has to adapt to the possibilities of each Unit, monitoring by the specialist in Endocrinology and Nutrition is advocated after the first visit at 3, 6, 9 and 12 months. These visits will alternate with check-ups by the nursing team and nutritionists responsible for the health education programme, with a similar frequency. Once this 12-month period has ended, the patient can be monitored in Primary Care. It should be noted that this period is indicative and may be prolonged depending on the weight loss or the lack of improvement in comorbidities.What follow-up should be carried out when a patient is discharged from the specialised obesity unit?With few exceptions, the objective of the Specialised Obesity Unit is to be able to return the obese patient to the support of Primary Care.When should a patient be handed back to primary care?In the case of non-operated patients - after 12 months of follow-up. This time is considered sufficient to achieve a weight loss of 5−10% of the initial weight, to stabilise the comorbidities associated with obesity and to have exhausted the therapeutic possibilities with or without success. In the latter case or in the case of non-stabilised comorbidities, the possibility of prolonging follow-up in the Specialised Obesity Unit remains open.In the case of patients who underwent bariatric surgery - after 5 years of follow-up. After this time, the majority of patients who underwent vertical gastrectomy or Roux-en-Y gastric bypass achieve weight and replacement treatment stability, without complications.<a class="elsevierStyleCrossRefs" href="#bib0235">47,53</a> However, patients who undergo purely malabsorptive techniques will remain monitored in the Specialised Obesity Units.How should a patient be handed back to primary care?After the evaluation, therapeutic proposal and treatment in a Specialised Obesity Unit, a report should be issued to Primary Care in order to facilitate continuity of care. In general, the following information should be recorded: reason for which the patient was referred, summary of the medical history and the results of the main tests carried out, the clinical diagnosis (including degree of initial obesity, cardiovascular risk and the obesity-related pathology), applied treatments and therapeutic response, detailing the progress of weight and related pathologies.Finally, it is recommended to attach a follow-up plan that includes the therapeutic objectives, the Primary Care standards, and therapeutic and follow-up recommendations, and the indications, if applicable, about future consultations in the Specialised Unit.How to tackle the challenge of maintaining weight loss in primary care?Weight loss was traditionally considered as the end of the specific treatment. Today it is known that successful weight reduction depends on continuing a long-term maintenance programme33. Observing, monitoring, and motivating patients who have successfully lost weight should be continued for a prolonged, and in some cases, indefinite period. This maintenance programme will include dietary therapy, physical activity and behavioural therapy, and it requires frequent contact between the patient and the different professionals who care for his/her health.Conflict of interestsNone." "textoCompletoSecciones" => array:1 [ "secciones" => array:17 [ 0 => array:3 [ "identificador" => "xres1471568" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1340197" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1471567" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1340198" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "What should be included in managing excess weight in primary care?" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "First of all, the basics" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "The anamnesis" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Physical examination" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "When to include complementary tests?" ] ] ] 6 => array:3 [ "identificador" => "sec0035" "titulo" => "How should the management of excess weight be addressed in primary care? Proposing a diet plan" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0040" "titulo" => "Dietary assessment" ] 1 => array:2 [ "identificador" => "sec0045" "titulo" => "Which eating plan should be recommended?" ] 2 => array:2 [ "identificador" => "sec0050" "titulo" => "How to achieve patient adherence?" ] 3 => array:2 [ "identificador" => "sec0055" "titulo" => "What is the proposal for medium- and long-term medical follow-up?" ] ] ] 7 => array:2 [ "identificador" => "sec0060" "titulo" => "Physical exercise plan" ] 8 => array:3 [ "identificador" => "sec0065" "titulo" => "How do pharmacological treatments help?" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0070" "titulo" => "When should pharmacological treatment be used?" ] 1 => array:3 [ "identificador" => "sec0075" "titulo" => "What options are available?" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0080" "titulo" => "Orlistat" ] 1 => array:2 [ "identificador" => "sec0085" "titulo" => "Extended-release naltrexone and bupropion combination" ] 2 => array:2 [ "identificador" => "sec0090" "titulo" => "Liraglutide 3.0 mg" ] ] ] 2 => array:2 [ "identificador" => "sec0095" "titulo" => "Limitations of pharmacological treatment" ] 3 => array:2 [ "identificador" => "sec0100" "titulo" => "For how long can pharmacological treatment be used in obesity?" ] ] ] 9 => array:2 [ "identificador" => "sec0105" "titulo" => "How should obesity be monitored in primary care?" ] 10 => array:3 [ "identificador" => "sec0110" "titulo" => "How should treatment of the comorbidities be started?" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0115" "titulo" => "Diabetes mellitus type 2" ] 1 => array:2 [ "identificador" => "sec0120" "titulo" => "Dyslipidemia" ] 2 => array:2 [ "identificador" => "sec0125" "titulo" => "Arterial hypertension" ] 3 => array:2 [ "identificador" => "sec0130" "titulo" => "Sleep apnoea-hypoapnoea syndrome" ] ] ] 11 => array:3 [ "identificador" => "sec0135" "titulo" => "When to think about bariatric surgery?" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0140" "titulo" => "What criteria must be met?" ] 1 => array:2 [ "identificador" => "sec0145" "titulo" => "What are the exclusion criteria?" ] ] ] 12 => array:3 [ "identificador" => "sec0150" "titulo" => "When and how to refer a patient to the specialised obesity unit?" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0155" "titulo" => "What referral criteria should be used?" ] 1 => array:2 [ "identificador" => "sec0160" "titulo" => "How is a patient referred to the specialised unit?" ] ] ] 13 => array:3 [ "identificador" => "sec0165" "titulo" => "What are the specialised obesity units?" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0170" "titulo" => "Which professionals participate?" ] 1 => array:2 [ "identificador" => "sec0175" "titulo" => "What is the proposal for patient follow-up?" ] ] ] 14 => array:3 [ "identificador" => "sec0180" "titulo" => "What follow-up should be carried out when a patient is discharged from the specialised obesity unit?" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0185" "titulo" => "When should a patient be handed back to primary care?" ] 1 => array:2 [ "identificador" => "sec0190" "titulo" => "How should a patient be handed back to primary care?" ] 2 => array:2 [ "identificador" => "sec0195" "titulo" => "How to tackle the challenge of maintaining weight loss in primary care?" ] ] ] 15 => array:2 [ "identificador" => "sec0200" "titulo" => "Conflict of interests" ] 16 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-05-22" "fechaAceptado" => "2019-10-24" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1340197" "palabras" => array:4 [ 0 => "Obesity" 1 => "Primary care" 2 => "Continouous healthcare" 3 => "Consensus" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1340198" "palabras" => array:4 [ 0 => "Obesidad" 1 => "Atención primaria" 2 => "Continuidad asistencial" 3 => "Consenso" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "The high prevalence of obesity in our environment, a chronic disease of complex management and responsible for multiple comorbidities, requires the implementation of coordination strategies in clinical care between primary care and specialist hospital units. In a cross-sectional care model, primary care physicians guide all therapeutic management related to obesity. Together with them, specialists in endocrinology and nutrition and other health staff help to form a functional unit that focuses on obesity. The main goal of this document is to improve the coordination between care levels, to optimize resources, avoid patients’ unrealistic expectations and improve patient follow-up after discharge from hospital." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "La elevada prevalencia de Obesidad en nuestro medio, una enfermedad crónica con un abordaje complejo y responsable de múltiples comorbilidades, nos lleva a la necesidad de implementar estrategias de coordinación en la asistencia clínica entre Atención Primaria y las Unidades Especializadas Hospitalarias. En un modelo asistencial transversal, el médico de Atención Primaria constituye el eje conductor de todo el abordaje terapéutico relacionado con la Obesidad. Junto a él, el especialista en Endocrinología y Nutrición y otros profesionales sanitarios ayudan a definir una Unidad funcional centrada en la Obesidad. El objetivo principal de este documento es mejorar la coordinación entre niveles asistenciales en el tratamiento de la obesidad, para optimizar recursos, evitar la creación de falsas expectativas en los pacientes y mejorar su seguimiento al alta hospitalaria." ] ] "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Caixàs A, Villaró M, Arraiza C, Montalvá J-C, Lecube A, Fernández-García J-M, et al. Documento de consenso SEEDO-SEMERGEN sobre la continuidad asistencial en obesidad entre Atención Primaria y Unidades Especializadas Hospitalarias 2019. Med Clin (Barc). 2020. https://doi.org/10.1016/j.medcli.2019.10.014" ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "Endorsed jointly by the scientific societies (SEEDO [Spanish Society for the Study of Obesity] and SEMERGEN [Spanish Society of Primary Care Physicians]). This consensus will not be published in other magazines." ] ] "multimedia" => array:9 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1738 "Ancho" => 2167 "Tamanyo" => 218422 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Algorithm of pharmacological treatment in obesity proposed by the Spanish and Portuguese Societies for the Study of Obesity<a class="elsevierStyleCrossRef" href="#bib0170">34</a>. B: bupropion; PR: prolonged release; N: naltrexone." ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2104 "Ancho" => 3032 "Tamanyo" => 471211 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Algorithm of the therapeutic decision in obesity between healthcare levels." ] ] 2 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Category \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">BMI limit values (kg/m<a class="elsevierStyleCrossRef" href="#bib0010">2</a>) \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">Insufficient weight \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">< 18.5 \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">Normal weight \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">18.5−24.9 \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">Overweight grade I \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">25.0−26.9 \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">Overweight grade II (obesity) \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">27.0−29.9 \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">Type I obesity (mild) \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">30.0−34.9 \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">Type II obesity (moderate) \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">35.0−39.9 \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">Type III obesity (morbid) \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">40.0−49.9 \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">Type IV obesity (extreme) \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">≥ 50.0 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2532279.png" ] ] ] ] "descripcion" => array:1 [ "en" => "SEEDO criteria to define obesity in grades according to BMI in adults." ] ] 3 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "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" 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">Groups \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">Drugs \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 " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">[0.1-2]Psychotropic drugs</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">Antipsychotics \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">Chlorpromazine, clozapine, olanzapine, perphenazine, thioridazine, trifluoperazine, aripiprazole, risperidone, fluphenazine, haloperidol, pimozide \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">Tricyclic antidepressants \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">Amitriptyline, imipramine, nortriptyline, clomipramine, doxepin, trimipramine, desipramine, maprotiline<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \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">Selective serotonin reuptake inhibitors (SSRIs) \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">Paroxetine, mirtazapine, citalopram \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">Monoamine oxidase inhibitors (MAOIs) \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">Selegiline, isocarboxazid, phenelzine \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">Mood stabilizers / antiepileptics \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">Lithium, valproate, carbamazepine, gabapentin \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">Antihistamines \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">Cyproheptadine and others \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 " rowspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">[2.0]Antihypertensive drugs</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">Alpha 1 adrenergic: prazosin, terazosin \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Beta-adrenergics: propranolol, metoprolol \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Others: alpha-methyldopa, clonidine \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 " rowspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">[2.0]Antidiabetics</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">Insulin \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sulfonylureas: glibenclamide, glipizide, gliclazide \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Thiazolidinediones: pioglitazone \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">Contraceptives \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">Especially depot injectables \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">Corticosteroids \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">All \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2532278.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "Heterocyclic." ] ] ] "descripcion" => array:1 [ "en" => "Drugs associated with obesity." ] ] 4 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0025" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Modified from the SEEDO 2007 Consensus<a class="elsevierStyleCrossRef" href="#bib0080">16</a> and SEEDO 2016<a class="elsevierStyleCrossRef" href="#bib0085">17</a>." "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" 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">BMI (kg/m<a class="elsevierStyleCrossRef" href="#bib0010">2</a>) \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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">[0.2-3]Intervention</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">25-26,9 \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">Not justified if the weight is stable, the fat distribution is peripheral and there are no associated diseases. Justified if there is CVRF and/or central fat distribution \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">Dietary adviceEncourage physical activityPeriodic check-ups \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">27-29,9 \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">Objective:Loss of 5-10% body weight \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">Low-calorie dietEncourage physical activityLifestyle changesPeriodic check-upsAssess drug association if there are comorbidities \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">30-34,9 \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">Objective:Loss of 10% body weight \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">Low-calorie dietEncourage physical activityLifestyle changesPeriodic check-upsAssess drug association \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">35-39,9 \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">Objective:Loss > 10% of body weight \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">Initial therapeutic action similar to the previous groupConsider the possibility of bariatric surgery if there are comorbidities \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">> 40 \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">Objective:Loss > 20% of body weight \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">Initial therapeutic action similar to the previous group. Consider bariatric surgery also in the absence of complications \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2532277.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Establishment of an action plan with definition of therapeutic intervention criteria." ] ] 5 => array:8 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0030" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Week \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">Warm up:Walk slowly (min) \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">Exercise:Walk fast (min) \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">Relaxation:Walk slowly (min) \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">Total time (min) \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">1 \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">5 \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">5 \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">5 \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">15 \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">2 \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">5 \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 \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">5 \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">17 \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">3 \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">5 \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 \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">5 \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">19 \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">4 \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">5 \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">11 \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">5 \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">21 \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">5 \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">5 \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">13 \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">5 \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">23 \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">6 \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">5 \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">15 \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">5 \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">25 \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">7 \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">5 \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">18 \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">5 \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">28 \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">8 \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">5 \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">20 \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">5 \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">30 \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">9 \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">5 \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">23 \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">5 \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">33 \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">10 \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">5 \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">26 \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">5 \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">36 \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">11 \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">5 \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">28 \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">5 \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">38 \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">12 \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">5 \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">30 \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">5 \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">40 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2532275.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Progressive physical exercise in the initial phase." ] ] 6 => array:8 [ "identificador" => "tbl0025" "etiqueta" => "Table 5" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0035" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col">Treatment options \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="5" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">[0.2-6]BMI (kg/m<a class="elsevierStyleCrossRef" href="#bib0010">2</a>)</th></tr><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \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">25-26.9 \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">27-29.9 \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">30-34.9 \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">35-39.9 \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">> 40 \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">Diet, exercise and lifestyle changes \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">+ \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">+ \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">+ \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">+ \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">+ \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">Pharmacotherapy \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"> \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">With comorbidity \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">+ \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">+ \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">+ \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">Surgery \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"> \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"> \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"> \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">With comorbidity \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">+ \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2532276.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Indications of the different treatments in obesity based on BMI." ] ] 7 => array:8 [ "identificador" => "tbl0030" "etiqueta" => "Table 6" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0040" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">1 \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">BMI ≥ 40 kg/m<a class="elsevierStyleCrossRef" href="#bib0010">2</a> \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">Due to it being an extreme case of the disease and regardless of the presence of comorbidities \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">2 \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">BMI ≥ 35 kg/m<a class="elsevierStyleCrossRef" href="#bib0010">2</a> + ≥ 2 poorly controlled obesity-related pathologies \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">T2DM (HbA1c ≥ 7.0% despite treatment with SGLT2-i or GLP-1 RA)Sleep apnoea/hypoapnoea syndrome who do not tolerate CPAPHypertension (BP ≥ 140/90 mmHg) despite the combination of 3 or more drugsPolycystic ovary syndrome that prevents gestationSevere osteoarthritis in load joints in < 60 years \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">3 \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">BMI ≥ 35 kg/m<a class="elsevierStyleCrossRef" href="#bib0010">2</a> in which weight loss is a priority \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">On the list for a transplant, knee prosthesis, infertility treatment, etc. \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">4 \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">If the patient wants and meets criteria for bariatric surgery \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">The criteria would be those of section 1 or 2 and no contraindication \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">5 \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">Suspected secondary obesity \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">Cushing's disease, acromegaly \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">6 \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">Suspected syndromic obesity \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">Obesity since childhood, association with hypogonadism, exaggerated hyperphagia, characteristic facies \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2532281.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Criteria for referral of Primary Care to the Specialised Unit." ] ] 8 => array:8 [ "identificador" => "tbl0035" "etiqueta" => "Table 7" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0045" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">1 \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">Reason for referral \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"> \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">2 \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">Main clinical data \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">Age, BMI and waist circumference, comorbidities and degree of their control, and family history if exists \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">3 \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">Obesity history \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">Starting age, precipitating causes, maximum weight, previous attempts, and results \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">4 \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">Actions taken in Primary Care \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">Diets performed, level of physical exercise, follow-up time, prescribed treatments, patient commitment, progress of anthropometric variables \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">5 \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">Analytical data \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">Values of interest that have not been previously commented \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">6 \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">Pharmacotherapy \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"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2532280.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Information to be included in the referral to the Specialised Unit." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:53 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prevalencia de la Obesidad en España: resultados del estudio SEEDO 2000" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J. Aranceta" 1 => "C. Pérez" 2 => "L. Serra" 3 => "L. Ribas" 4 => "J. Quiles" 5 => "J. Vioque" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Med Clin (Barc)" "fecha" => "2003" "volumen" => "120" "paginaInicial" => "608" "paginaFinal" => "612" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prevalencia de Obesidad en España" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "J. Aranceta-Bartrina" 1 => "L. Serra-Majem" 2 => "M. Foz-Sala" 3 => "B. Moreno-Esteban" 4 => "Grupo Colaborativo SEEDO" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Med Clin (Barc)" "fecha" => "2005" "volumen" => "125" "paginaInicial" => "460" "paginaFinal" => "466" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prevalence of general and abdominal obesity in the adult population of Spain, 2008-2010: the ENRICA study" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "J.L. Gutiérrez-Fisac" 1 => "P. Guallar-Castillón" 2 => "L.M. León-Muñoz" 3 => "A. Graciani" 4 => "J.R. Banegas" 5 => "F. Rodríguez-Artalejo" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1467-789X.2011.00964.x" "Revista" => array:6 [ "tituloSerie" => "Obes Rev" "fecha" => "2012" "volumen" => "13" "paginaInicial" => "388" "paginaFinal" => "392" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22151906" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prevalence of general obesity and abdominal obesity in the Spanish adult population (aged 25-64 years) 2014-2015: The ENPE study" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "J. Aranceta-Bartrina" 1 => "C. Pérez-Rodrigo" 2 => "G. Alberdi-Aresti" 3 => "N. Ramos-Carrera" 4 => "S. Lázaro-Masedo" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.rec.2016.02.009" "Revista" => array:6 [ "tituloSerie" => "Rev Esp Cardiol" "fecha" => "2016" "volumen" => "69" "paginaInicial" => "579" "paginaFinal" => "587" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27133458" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Estrategia SEMERGEN, SEEDO y SEEN para la prevención y el tratamiento del sobrepeso y la obesidad en Atención Primaria" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "R. Corio" 1 => "P. Cortés" 2 => "P. Gadea" 3 => "R. Gutiérrez" 4 => "M.L. Díaz" 5 => "C. Matilla" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "SEMERGEN." 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Consensus statement

SEEDO-SEMERGEN consensus document on continuous care of obesity between primary care and specialist Hospital units 2019

Documento de consenso SEEDO-SEMERGEN sobre la continuidad asistencial en obesidad entre Atención Primaria y Unidades Especializadas Hospitalarias 2019

Assumpta Caixàsa,b,

Corresponding author

acaixas@tauli.cat

Corresponding author.

, Mercè Villarób,c, Carmen Arraizab,d, Juan-Carlos Montalváb,e, Albert Lecubeb,f,*, José-Manuel Fernández-Garcíag,h, Rosario Coriog,i, Diego Bellidob,j, José-Luís Llisterrik, Francisco-José Tinahonesb,l

a Servicio de Endocrinología y Nutrición, Hospital Universitari Parc Taulí, Universitat Autònoma de Barcelona (UAB), Institut d’Investigació i Innovació Parc Taulí (I3PT), Sabadell, Spain

b Sociedad Española para el Estudio de la Obesidad (SEEDO), Spain

c Centro de Atención Primaria CAP Terrassa Sud, Mutua de Terrassa, Terrassa, Spain

d Servicio de Endocrinología y Nutrición, Complejo Hospitalario de Jaén, Jaén, Spain

e SEMERGEN. MUH H Lluis Alcanyís, Xativa y MUH Casa de la Salud, Universidad de Valencia, Valencia, Spain

f Servicio de Endocrinología y Nutrición, Hospital Universitari Arnau de Vilanova. Obesity, Diabetes and Metabolism Research Group (ODIM), Institut de Recerca Biomèdica de Lleida (IRBLleida), Universitat de Lleida, Lleida, Spain

g Grupo de Trabajo de Nutrición (SEMERGEN), Spain

h Centro de Salud de Valga, Valga, Pontevedra, Spain

i Centro de Salud Martí Julià, Cornellà de Llobregat, Spain

j Servicio de Endocrinología y Nutrición, Complejo Hospitalario Universitario de Ferrol (CHF), UDC, Ferrol, Spain

k Fundación de Investigación SEMERGEN, Madrid, Spain

l Servicio de Endocrinología y Nutrición, Hospital Universitario Virgen de la Victoria, Málaga, Spain

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The Spanish Society for the Study of Obesity &#40;SEEDO&#41; made the first estimate of the prevalence of obesity in Spain in 2000&#44; with a progressive increase being witnessed since then&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;3</span></a> In the most recent study&#44; published in 2016&#44; the estimated prevalence of obesity among those over 18 years of age was 21&#46;6&#37;&#46; Obesity is more prevalent in males and increases with age&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> When considering abdominal obesity&#44; defined by waist circumference&#44; the prevalence increases to 33&#46;4&#37; of the population&#44; with this being more frequent in women and progressively increasing with age&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">When other factors are added to this high prevalence of obesity in our environment&#44; such as it being a chronic disease with a complex approach&#44; and that it associates numerous comorbidities &#40;including type 2 diabetes mellitus &#91;T2DM&#93;&#44; high blood pressure&#44; dyslipidaemia&#44; cardiovascular disease&#44; sleep apnoea and hypoapnoea syndrome and cancer&#41;&#44; the need to implement and update coordination strategies in clinical care between Primary Care and Specialised Obesity Units becomes apparent&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> In a cross-sectional healthcare model&#44; the Primary Care physicians constitute the driving force behind the whole therapeutic approach related to obesity&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Cooperatively&#44; the specialists in Endocrinology and Nutrition&#44; who have more specific training to deal with the most complex cases of obesity&#44; and other health professionals such as nurses&#44; nutritionists&#44; psychologists and surgeons&#44; help define a functional unit focused on obesity&#46; Only by improving the coordination between all levels of care&#44; together with a sensible use of available resources&#44; will comprehensive care for this disease be improved&#46; Along with these key-players&#44; employment-based health care plays a relevant although often poorly recognised role in the clinical evaluation of an important segment of the population with obesity&#46; Therefore&#44; coordination between the employment-based doctors and those of Primary Care is necessary to prevent any delay in the intervention of the subjects at risk who are identified in the annual check-ups&#46; The participation of local administrations&#44; educational centres&#44; the food industry&#44; and scientific societies is also mandatory in this fight against obesity&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> To ensure the best coordination between levels&#44; various objectives must be discussed&#44; especially how to&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">a&#41;</span><p id="par0015" class="elsevierStylePara elsevierViewall">Develop coordinated protocols for the assessment and treatment of obesity at different levels of clinical care&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">b&#41;</span><p id="par0020" class="elsevierStylePara elsevierViewall">Agree on the referral criteria between Primary Care and Specialised Obesity Units&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">c&#41;</span><p id="par0025" class="elsevierStylePara elsevierViewall">Establish contact channels that expedite communication among professionals as well as between professionals and patients&#46; For this&#44; advocating the unified electronic medical record and telemedicine strategies is crucial&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">d&#41;</span><p id="par0030" class="elsevierStylePara elsevierViewall">Carry out joint continuous training activities&#59; and</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">e&#41;</span><p id="par0035" class="elsevierStylePara elsevierViewall">Develop coordinated lines of research&#46;</p></li></ul></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">What should be included in managing excess weight in primary care&#63;</span><p id="par0040" class="elsevierStylePara elsevierViewall">Given the complexity of obesity&#44; these indications lay out a comprehensive approach that can be carried out during several visits&#44; adapting to the characteristics of each Primary Care centre&#46; One of the limitations of this guide is that it is based on consensus recommendations among experts and that no tool has been used to assess methodological rigour and transparency&#44; such as AGREE II&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">First of all&#44; the basics</span><p id="par0045" class="elsevierStylePara elsevierViewall">Screening of obesity should be carried out in all the patients who are seen in Primary Care&#44; by means of the periodic measurement of weight and height&#44; and the calculation of the body mass index &#40;BMI&#41;&#58; body weight &#40;kg&#41;&#47;height &#40;metres&#41;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; The BMI is correlated with the percentage of body fat&#44; although it may be overestimated in individuals with significant muscle mass &#40;e&#46;&#8239;g&#46; in body-builders&#41; and underestimated in those with loss of muscle mass &#40;e&#46;&#8239;g&#46; in elderly ones&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">In individuals with a BMI between 25 and 35&#8239;kg&#47;m<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> the abdominal circumference should also be measured to distinguish between central and peripheral obesity&#44; as this provides additional data for estimating cardiovascular risk&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#8211;12</span></a> However&#44; the requirement of this measurement is debatable in a patient with a BMI &#8805;&#8239;35&#8239;kg&#47;m<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#44; as they already have a high-risk secondary to their adiposity&#46; The abdominal circumference should be measured with a flexible tape measure placed horizontally&#44; and at the end of a forced expiration&#44; at the level of the upper edge of the iliac crest&#46; A high waist circumference is determined if &#8805;&#8239;88&#8239;cm in women and &#8805;&#8239;102&#8239;cm in men&#44; although in the Asian population the cut-off points decrease to &#8805;&#8239;80&#8239;cm and &#8805;&#8239;90&#8239;cm&#44; respectively&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">The anamnesis</span><p id="par0055" class="elsevierStylePara elsevierViewall">The clinical history should be aimed at detecting possible causes of secondary obesity&#44; as well as the use of any pharmacological treatments that may promote the condition &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">It is important to ask about the presence of a psychopathological history&#44; anxiety&#44; depression&#44; or eating disorders&#46; Inquire about the family history of obesity&#44; the age of onset and its development&#46; Today we know that low birth weight and rapid weight gain in the first 10 years of life increases the risk of T2DM in adulthood&#44; that the risk of comorbidities associated with obesity increases when it starts before the age of 40&#44; and that the increase of 5&#8239;kg after 18 years of age in women and 20 years of age in men increases the risk of T2DM&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">It is convenient to ask about weight fluctuations&#58; maximum and minimum weight&#44; and its development over the last 5 years&#59; question women about post-pregnancy weight increases&#59; inquire about alcohol consumption&#44; due to its high caloric value&#59; and smoking&#44; since its cessation is related to weight gain&#46; Record any possible professional&#44; family or interpersonal limitations that may contribute to obesity or hinder its dietary approach&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Ask about the presence of comorbidities associated with obesity&#58; hypertension&#44; dyslipidaemia&#44; alterations in glucose metabolism and T2DM&#44; sleep apnoea-hypoapnoea syndrome&#44; osteoarticular pathology&#44; fatty liver and urinary incontinence&#46; An easy way to assess the impact of obesity on quality of life is for the patient to respond to the 31 questions in the questionnaire <span class="elsevierStyleItalic">Impact of Weight on Quality of Life-Lite</span> &#40;IWQOL-Lite&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">It is important to scrutinize the patient&#39;s food habits&#58; ask about the time distribution and frequency of meals&#44; the variety and quantity of food &#40;dietary records&#41;&#44; the preferences and frequency of consumption by groups &#40;fruits&#44; vegetables&#44; meats and fats&#44; especially animals&#41;&#59; as well as the habit of swallowing fast&#44; the size of the bites&#44; snacks between meals&#44; the place where food is eaten and the distractions when eating &#40;e&#46;&#8239;g&#46;&#44; eating while watching television&#41;&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Finally&#44; a record should be made of physical activity&#44; of the type and quantity&#44; including daily tasks &#40;domestic&#44; type of work&#44; commuting&#44; leisure&#44; etc&#46;&#41; along with scheduled exercise&#46; Quantify weekly hours and intensity of the exercise&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Physical examination</span><p id="par0085" class="elsevierStylePara elsevierViewall">In addition to recording the basic anthropometric data already mentioned&#44; the search for traits of secondary obesity cannot be ignored&#44; such as the presence of red&#47;purple stretch marks or striae &#40;hypercortisolism&#41;&#44; acanthosis nigricans &#40;insulin resistance&#41;&#44; papillomatosis &#40;acromegaly&#41;&#44; proximal muscle weakness &#40;hypercortisolism&#44; hypothyroidism&#41;&#44; acne&#44; and hirsutism &#40;polycystic ovary syndrome&#41;&#46; The association with hidradenitis&#44; intertrigo&#44; signs of heart failure&#44; varicose veins with trophic disorders or ulcers in the lower extremities should be explored&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">And so as not to overestimate the blood pressure&#44; cuffs with an adequate width should be used&#58; from 14 to 15&#8239;cm in moderate obesity and from 16 to 18&#8239;cm in very obese individuals&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">When to include complementary tests&#63;</span><p id="par0095" class="elsevierStylePara elsevierViewall">The lab test should consider the determination of fasting plasma glucose&#44; glycated haemoglobin&#44; lipid profile &#40;total cholesterol&#44; HDL&#44; LDL and triglycerides&#41;&#44; uric acid&#44; thyroid function &#40;TSH&#44; free T4&#41;&#44; kidney function &#40;creatinine&#44; glomerular filtration rate and microalbuminuria estimation&#41;&#44; proteins &#40;total and albumin&#41;&#44; liver enzymes &#40;GOT&#44; GPT&#44; GGT&#41;&#44; phosphocalcic metabolism if disorder is suspected &#40;calcium&#44; phosphate&#44; 25-OH vitamin D&#44; PTH&#41;&#44; and blood count with anaemia study if necessary&#46; If possible&#44; insulin will also be added to calculate insulin resistance using the <span class="elsevierStyleItalic">homeostatic model assessment</span> &#40;HOMA&#8239;&#61;&#8239;glucose &#40;mmol&#47;l&#41;&#8239;&#215;&#8239;insulin &#40;&#181;U&#47;mL&#41;&#8239;&#47;&#8239;22&#46;5&#93;&#46; When the suspicion is high and if the means are available&#44; screening should be started for secondary causes of obesity such as endogenous hypercortisolism &#40;cortisol rhythm and&#47;or 24&#8239;h urine free cortisol&#44; suppression with 1&#8239;mg of dexamethasone&#41;&#44; acromegaly &#40;IGF1&#44; hGH&#41; or polycystic ovary syndrome &#40;testosterone&#44; androstenedione&#44; DHEAs&#41;&#44; otherwise the patient should be referred to the Specialised Obesity Unit&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">An electrocardiogram should be recorded every 6&#8239;months&#44; although this frequency can be adapted to age and comorbidities&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">90&#37; of patients with severe obesity present a sleep apnoea-hypoapnoea syndrome&#44; so flags are raised with patients who snore&#44; those who show daytime hypersomnia&#44; and those with an increased neck circumference or with difficult-to control arterial hypertension&#46; The performance of a forced spirometry test may be considered in patients with signs of hypoventilation or respiratory failure&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">The rest of the complementary tests will depend on the clinical suspicion&#44; and their availability&#46; For example&#44; an echocardiogram in those patients with suspected heart failure or valve disease&#44; long-standing hypertension&#44; and sleep apnoea-hypoapnoea syndrome&#46; A liver ultrasound if there is suspicion of non-alcoholic steatohepatitis or gallstones&#46; A gynaecological ultrasound if polycystic ovary syndrome is suspected&#46; An osteoarticular evaluation with a radiological and functional study&#46; A digestive endoscopy or gastrointestinal motility studies when gastroesophageal reflux disease is suspected&#46; A urodynamic study if there is urinary incontinence&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">How should the management of excess weight be addressed in primary care&#63; Proposing a diet plan</span><p id="par0115" class="elsevierStylePara elsevierViewall">The dietary approach with a diet plan and personalised physical exercise should be the first step in the treatment of obesity &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#44;16</span></a> A loss of 5&#8722;10&#37; of the weight in 6&#8239;months can be considered realistic and this alone provides clear health benefits&#46; In patients with BMI&#8239;&#8805;&#8239;35&#8239;kg&#47;m<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> it is possible to aspire higher&#44; with objectives close to 20&#37; or more&#46; The main objective should be to lose weight and not regain it&#44; as well as the treatment of comorbidities&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Dietary assessment</span><p id="par0120" class="elsevierStylePara elsevierViewall">Before starting a change in dietary habits&#44; knowledge about the patient&#39;s diet should be obtained&#44; by means of dietary questionnaires or self-consumption records that include home measurements&#44; visual portion atlases or food models&#46; This methodology can underestimate the amounts consumed&#44; but it allows to identify the frequency of food group intake and poor eating habits&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Which eating plan should be recommended&#63;</span><p id="par0125" class="elsevierStylePara elsevierViewall">The Mediterranean diet is the preferred model supported by SEEDO and SEMERGEN as it best represents in clinical practice a balanced approach within a structure of healthy habits&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;18</span></a> The Mediterranean &#34;low calorie&#34; diet is based on a low intake of saturated fatty acids&#44; <span class="elsevierStyleItalic">trans</span> fats&#44; and added sugars&#44; and a high consumption of fibre and mono-unsaturated fatty acids&#46; It is important to highlight that the restriction of carbohydrates together with the decrease in simple sugars&#44; must be reinforced with a limitation to high glycemic load energy foods&#44; such as bread&#44; potatoes&#44; rice&#44; pasta and refined cereals&#46; These foods can be replaced by a higher consumption of fruits&#44; vegetables&#44; whole grains and nuts&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;19&#44;20</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">The energy restriction should not result in a caloric intake below 1&#44;000&#8211;1&#44;200&#8239;kcal&#47;day in women and 1&#44;200&#8722;1&#44;600&#8239;kcal&#47;day in men&#46; The calculation of energy expenditure will depend on the sex of the individual&#44; age&#44; BMI and physical activity performed&#46; In clinical practice the following formula can be used&#58; 20&#8722;25&#8239;kcal&#8239;&#215;&#8239;kg&#8239;&#215;&#8239;day&#44; to which we subtract 500&#8239;kcal of total expenditure&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">It is important for food intake to be orderly&#44; to avoid eating during the night&#44; to avoid foods with added sugars&#44; to moderate alcoholic and non-alcoholic drinks&#44; and to avoid <span class="elsevierStyleItalic">fast food</span> meals&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">There are a multitude of &#34;popular&#34; diets&#44; with solid or not-so-solid foundations&#44; that offer multiple nutritional proposals which differ to the dietary schemes recommended in the clinical guidelines&#46; Both SEEDO and SEMERGEN speak out against diet models without scientific endorsement&#46; Weight loss should be achieved by means of a balanced low-calorie diet combined with physical exercise and lifestyle changes thereby ensuring long-term success&#44; and always under medical supervision&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> It is essential to insist on the necessity of a varied&#44; healthy and balanced diet in the context of the Mediterranean diet and the practice of regular physical exercise&#46; The marketing of new foods and food supplements must be based on the scientific demonstration of their effectiveness and undesirable effects&#44; with sufficient scientific studies&#46; Furthermore&#44; the eating plan originally aimed at achieving weight loss should be adapted as far as possible to the underlying pathology of the obese patient&#46; An example of this double utility is found in the recommendations published by SEMERGEN and the Spanish Society of Atherosclerosis&#44; in which the interaction of the various nutrients included in the food matrix is evaluated&#44; and it provides useful advice for clinical practice&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">How to achieve patient adherence&#63;</span><p id="par0145" class="elsevierStylePara elsevierViewall">It should not be forgotten that eating is a form of pleasure for most human beings&#44; so a totally restrictive or punitive eating plan will never work&#46; Therefore&#44; the worst strategy for an obese patient is the absolute ban on &#34;everything that makes you fat&#46;&#34; Endeavours must be made to help the obese patient understand that although they can continue enjoying food intake on certain occasions&#44; this behaviour cannot be followed on the vast majority of days&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">The most determining factor in the success of a diet is adherence to it&#44; rather than the composition or distribution of nutrients&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">23&#44;24</span></a> For this reason&#44; an explanation should be given to each patient individually regarding their eating plan&#44; as well as widening their nutritional education as far as possible&#44; until they can organise their daily intake themselves&#46; The greatest achievement is to convince the obese patient that their disease is a chronic process and that the only way to deal with it is to change their diet for the rest of their lives&#44; attaining a healthy and balanced diet&#46; SEEDO advocates establishing specific nutritional education consultancies in each Health Area with expert personnel that include university graduates in Nursing and graduates in Human Nutrition and Dietetics&#46; SEMERGEN deems that Primary Care should have an expert referee in Nutrition to provide advice when needed&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">What is the proposal for medium- and long-term medical follow-up&#63;</span><p id="par0155" class="elsevierStylePara elsevierViewall">After maintaining a change in habits for a period of 3&#8211;6&#8239;months&#44; the loss of lean mass &#40;unwanted&#41; slows down weight loss&#44; so to maintain or increase weight loss&#44; at the expense of fat mass&#44; a greater caloric restriction or an increase in energy expenditure &#40;e&#46;&#8239;g&#46;&#44; increasing levels of physical activity&#41; will be needed&#46; As previously mentioned&#44; obesity is a chronic disease&#44; so follow-up must be maintained for life&#44; as often as permitted by each health environment&#46;</p></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Physical exercise plan</span><p id="par0160" class="elsevierStylePara elsevierViewall">Exercise is a fundamental element in the treatment of obesity&#44; since it improves weight loss&#44; increases the loss of abdominal fat&#44; contributes to the maintenance of lost weight&#44; increases fat-free mass&#44; induces a feeling of well-being and positively affects cardiovascular risk factors&#46; In general&#44; the role of physical exercise in weight control is more important in maintaining lost weight than in the active loss phase&#44; where eating patterns are a priority&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">The reduction of a sedentary lifestyle must be promoted&#44; and in this sense&#44; any increase in physical activity will be advantageous&#46; In any case&#44; the goal is to be active at least 150&#8239;min per week&#44; distributed in 30&#8239;min per day&#44; 5 days a week&#44; with no more than 48&#8239;h without physical activity&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> As mentioned above&#44; establishing specific nutritional education consultancies in each Health Area with expert personnel is advocated&#44; which means that the figure of the physical educator is essential&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Physical exercise for the obese person should always be programmed individually&#44; taking into consideration the conditions of each patient&#46; This will start progressively&#44; with daily activities&#44; or through a training phase&#44; so as to reach the daily goals in stages&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> Given the limitations that the obese patient presents regarding physical effort&#44; motivation is essential and so a stimulating and attractive programme needs to be developed&#44; with an initial phase and an implementation phase&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">26&#44;27</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">In the initial phase&#44; during the first four weeks gentle exercise will be prescribed&#44; such as walking fast for 30&#8239;min&#44; at least 3 days a week and increasing slightly in intensity throughout each week&#46; It is useful to have a pedometer as a reference and control element for the patient &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0180" class="elsevierStylePara elsevierViewall">In the implementation phase&#44; the intensity and duration of the exercises will increase&#44; until one hour per session is reached&#46; Exercises of moderate or intense activity such as brisk walking&#44; swimming&#44; cycling&#44; aerobics&#44; or sports should be performed&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">Better results are achieved with the combination of aerobic exercises &#40;walking&#44; running&#44; swimming&#44; dancing&#44; cycling&#44; etc&#46;&#41; and strength exercises of the major muscle groups&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">How do pharmacological treatments help&#63;</span><p id="par0190" class="elsevierStylePara elsevierViewall">In obesity&#44; when lifestyle modification is not enough&#44; help can be provided by pharmacological treatment&#46;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">28&#8211;40</span></a></p><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">When should pharmacological treatment be used&#63;</span><p id="par0195" class="elsevierStylePara elsevierViewall">Drugs to treat obesity are indicated in those patients with a BMI&#8239;&#8805;&#8239;30&#8239;kg&#47;m<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> when weight loss &#62;&#8239;5&#37; has not been achieved after 6&#8239;months of a structured programme of lifestyle changes&#46; Their use is also extended to patients with a BMI&#8239;&#8805;&#8239;27&#8239;kg&#47;m<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> who already have major comorbidities associated with obesity &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>&#41;&#46; Pharmacological treatment should be indicated in subjects &#34;motivated to lose weight&#34;&#44; with active participation of the patient in the control of their disease&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> Likewise&#44; the recommendation is to stop the medication if weight loss &#62;&#8239;5&#37; is not achieved after 3 months&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">What options are available&#63;</span><p id="par0200" class="elsevierStylePara elsevierViewall">Along with orlistat&#44; available since 1998 in Spain&#44; there is also liraglutide&#8239;3&#46;0 and a combination of extended-release bupropion &#40;90&#8239;mg&#41; with naltrexone &#40;8&#8239;mg&#41;&#46; There is no reason why any of these options cannot be prescribed at the Primary Care level&#46; The use of the three options is not recommended in pregnant women and those under 18 years of age&#46; Recently&#44; the Spanish and Portuguese Societies for the Study of Obesity have published a consensus on pharmacological treatment in which they propose an algorithm for action &#40;see <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Orlistat</span><p id="par0205" class="elsevierStylePara elsevierViewall">Orlistat is an inhibitor of gastric and pancreatic lipase&#44; which by inhibiting the hydrolysis of triglycerides received from the diet&#44; reduces the absorption of 30&#37; of the ingested fat&#46; Taking a 120&#8239;mg capsule before&#44; during or up to 1&#8239;h after breakfast&#44; lunch and dinner&#46; A dose can be skipped if the intake is low in fat &#40;fruit&#44; skimmed milk&#44; etc&#46;&#41;&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">The main side effects are related to the faecal elimination of fat&#46; Up to 50&#37; of patients experience an increase in the number of stools&#44; with steatorrhea&#44; meteorism&#44; faecal urgency and abdominal pain&#46; Therefore&#44; it is contraindicated in patients with malabsorptive intestinal diseases such as ulcerative colitis or Crohn&#39;s disease&#46; The most severe complications are related to oxalate nephropathy and liver failure&#46; Its prolonged use can be associated with the malabsorption of fat-soluble vitamins &#40;A&#44; D&#44; E&#44; K&#41;&#44; so supplementation would only be necessary if the drug use is chronic&#46; The pharmacological interaction with cyclosporine&#44; levothyroxine sodium or antiepileptic drugs &#40;reducing their action&#41;&#44; and the potentiation of the effects of warfarin have been described&#46; Compared with placebo&#44; orlistat achieves a weight loss between 2&#46;5&#8239;kg &#40;at a dose of 60&#8239;mg every 8&#8239;h&#41; and 3&#46;4&#8239;kg &#40;at a dose of 120&#8239;mg every 8&#8239;h&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a></p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Extended-release naltrexone and bupropion combination</span><p id="par0215" class="elsevierStylePara elsevierViewall">Naltrexone is an opioid antagonist used in acute opioid poisoning&#44; while bupropion is a dopamine and norepinephrine reuptake inhibitor antidepressant used in tobacco cessation&#46; Together they act on the hypothalamic melanocortin and reward system areas of the brain&#44; favouring satiety and reducing the sensation of pleasure associated with eating&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">34&#8211;36</span></a></p><p id="par0220" class="elsevierStylePara elsevierViewall">The maximum recommended daily dose is 2 tablets twice a day&#44; for a total dose of 32&#8239;mg of naltrexone and 360 &#8239;mg of bupropion&#46; At the start of treatment&#44; the dose is progressively increased over a period of 4 weeks as follows&#58; one tablet in the morning for the first week&#59; one tablet in the morning and one in the evening during the second week&#59; 2 tablets in the morning and one at night during the third week&#59; and 2 tablets in the morning and 2 at night from the fourth week onwards&#46; It is advisable to bring forward the time of the evening meal&#44; so as to reduce one of the adverse effects&#44; namely insomnia&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">The most frequent adverse effects described are gastrointestinal &#40;nausea&#44; constipation and vomiting&#41; and neurological &#40;headache&#44; dizziness and dry mouth&#41;&#44; together with the elevation of the heart rate and blood pressure&#46; The severe adverse effects are related to depression and the development of manic episodes&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">Its use is not recommended in patients with uncontrolled hypertension&#44; who are receiving treatment with benzodiazepines&#44; morphine derivatives or monoamine oxidase inhibitors&#44; with liver or kidney failure&#44; with bipolar disorder or a history of an eating disorder &#40;bulimia or anorexia nervosa&#41;&#44; with a history of seizures or a known neoplasm of the central nervous system&#46; It is to be used with caution in people over 65 years of age and it is not recommended in people over 75 years of age&#46; Compared to placebo&#44; the daily combination of 32&#8239;mg of naltrexone and 360&#8239;mg of prolonged-release bupropion achieves a weight loss of 5&#46;4-8&#46;1&#37; &#40;between 33-46&#37; of patients lose &#62;&#8239;5&#37; of the initial weight&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a></p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Liraglutide 3&#46;0&#8239;mg</span><p id="par0235" class="elsevierStylePara elsevierViewall">Liraglutide is a GLP-1 receptor agonist that requires daily subcutaneous administration&#46; There exists extensive experience in its use for the treatment of T2DM&#44; although at lower doses &#40;up to 1&#46;8&#8239;mg&#47;day&#41;&#46; The mechanisms involved in weight reduction are probably related to a combination of effects on the gastrointestinal tract and via central mechanisms&#46; Active GLP-1 decreases appetite&#44; reduces energy intake&#44; and delays gastric emptying&#46;</p><p id="par0240" class="elsevierStylePara elsevierViewall">The starting dose is 0&#46;6&#8239;mg daily for the first week&#44; with subsequent increases of 0&#46;6&#8239;mg every week up to the maximum maintenance dose of 3&#46;0&#8239;mg&#46; In this way&#44; a better gastrointestinal tolerance is achieved&#46; In case of intolerance to the highest doses &#40;2&#46;4 or 3&#46;0&#8239;mg&#41; the patient will be directed to the highest tolerated dose&#46; This can be administered at any time of the day without regard to mealtimes&#44; in the abdomen&#44; the thigh or the upper arm&#46;</p><p id="par0245" class="elsevierStylePara elsevierViewall">The main side effects are nausea and vomiting&#44; which are mild-moderate in most cases&#46; They occur transiently in the first weeks and rarely lead to drug discontinuation&#46; It can also cause diarrhoea&#44; constipation&#44; and headaches&#46; In cases of repeated vomiting wherein the administration is not suspended&#44; or fluid replacement is not assured&#44; episodes of acute kidney failure have been described&#46; There are currently insufficient data to confirm the association of the use of liraglutide with pancreatitis and pancreatic cancer&#44; although its use is not recommended in patients with this history&#44; nor in those with a personal or family history of medullary thyroid carcinoma or multiple endocrine neoplasm type 2 &#40;MEN-2&#41;&#44; women who are pregnant&#44; and those under 18 years of age and over 75 years of age&#46; It can be used in patients with estimated glomerular filtration rate &#8805;&#8239;30&#8239;mL&#47;min&#46; Special caution should be taken in patients with a history of cholelithiasis&#44; gastroparesis&#44; or inflammatory bowel disease&#46;</p><p id="par0250" class="elsevierStylePara elsevierViewall">Compared with placebo&#44; liraglutide at a dose of 3&#46;0&#8239;mg per day achieves&#44; after 56 weeks&#44; a weight loss that reaches 8&#46;0&#8239;&#177;&#8239;6&#46;7&#37; &#40;8&#46;4&#8239;&#177;&#8239;7&#46;3&#8239;kg&#41; of the initial weight &#40;63&#37; of patients lose &#62;&#8239;5&#37; of the initial weight&#41; to which the cardiometabolic benefits already demonstrated must be added&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a></p></span></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Limitations of pharmacological treatment</span><p id="par0255" class="elsevierStylePara elsevierViewall">The main limitation for the use of any of the 3 available treatment options is that they are not eligible for financing by the public health system&#46; This reduces their accessibility to the most disadvantaged socio-economic strata&#44; where the prevalence of obesity is higher&#46; The side effects of the 3 drugs are frequently transient and do not represent a main cause of discontinuation of the treatment&#46; Other aspects that limit adherence to long-term treatment are the need to take 4 tablets&#47;day of naltrexone&#47;bupropion&#44; the steatorrhea of orlistat&#44; or the daily subcutaneous administration of liraglutide&#46;</p></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">For how long can pharmacological treatment be used in obesity&#63;</span><p id="par0260" class="elsevierStylePara elsevierViewall">This question can be answered by conducting the exercise of replacing &#34;obesity&#34; with any other cardiometabolic pathology&#44; for example &#34;hypertension&#34;&#44; &#34;diabetes&#34; or &#34;dyslipidemia&#34;&#46; If the treatment is well tolerated and the weight loss exceeds 5&#37; of the initial weight after the first 3 months of treatment&#44; it is understood that the treatment should be continued&#46; And as a chronic disease&#44; its treatment must also be considered chronic&#44; or at least continue until the patient no longer meets the criteria for its indication&#46;</p></span></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">How should obesity be monitored in primary care&#63;</span><p id="par0265" class="elsevierStylePara elsevierViewall">The frequency of the visits will depend on the associated comorbidity&#46; During the first-year physician consultations would be advisable every 2&#8211;3 months at least&#44; and nursing consultations every month - which can be carried out individually or in groups&#46; The frequency of consultations should be adjusted according to the progress of the patient and his&#47;her comorbidities&#46; After the second year&#44; the follow-up interval can be reduced &#40;e&#46;&#8239;g&#46; every 6&#8239;months for the physician consultation and every 3 months for the nursing consultation&#41;&#44; with the possibility of individualising according to the progress of each patient&#46;</p><p id="par0270" class="elsevierStylePara elsevierViewall">In these consultations&#44; the change in weight and BMI&#44; waist circumference and blood pressure should be evaluated&#46; The prescribed treatment should also be monitored&#44; whether it is dietary or pharmacological behaviour&#44; as well as the main laboratory parameters &#40;glucose&#44; HbA1c&#44; total cholesterol&#44; HDL&#44; LDL&#44; triglycerides&#44; liver enzymes&#44; creatinine&#44; and uric acid&#41;&#46;</p></span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">How should treatment of the comorbidities be started&#63;</span><p id="par0275" class="elsevierStylePara elsevierViewall">The approach to certain comorbidities in the patient with obesity requires an approach that is somewhat different to that used when the same comorbidity arises in a patient with normal weight&#46; The attitude to be followed in the face of T2DM&#44; dyslipidemia&#44; arterial hypertension and sleep apnoea-hypoapnoea syndrome&#44; due to its close relationship with weight increase is discussed below&#46; In all cases when faced with a BMI&#8239;&#8805;&#8239;35&#8239;kg&#47;m<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#44; discuss with the patient the possibility of opting for bariatric surgery&#44; and refer to the Specialised Unit if the patient wishes&#46;</p><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Diabetes mellitus type 2</span><p id="par0280" class="elsevierStylePara elsevierViewall">The close relationship between excess weight and hydrocarbonated metabolism disorders makes T2DM screening essential in all patients with obesity&#46; The recommendation is to carry out an annual lab test that includes glucose and HbA1c&#44; and the option of practising an oral glucose tolerance test with 75&#8239;g in cases of prediabetes &#40;abnormal fasting blood glucose between 100 and 125&#8239;mg&#47;dl or HbA1c between 5&#46;7 and 6&#46;5&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a></p><p id="par0285" class="elsevierStylePara elsevierViewall">The initial treatment of any hydrocarbonated disorder in the obese patient consists of a balanced diet and physical exercise aimed at losing weight&#44;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a> with the addition of drugs in the presence of diabetes&#46; The first option will be metformin up to the maximum tolerated dose&#44; and if after 3&#8722;6&#8239;months an acceptable glycemic control is not achieved &#40;HbA1c&#8239;&#60;&#8239;7&#46;0&#37;&#41;&#44; a second drug with positive effects on body weight will be added&#58; a sodium-glucose co-transporter-2 inhibitor &#40;SGLT2&#41; or a GLP-1 receptor analogue&#46; Drugs whose use is associated with weight gain&#44; such as sulfonylureas&#44; glitazones and insulin&#44; should be avoided as far as possible&#46; The use of dipeptidyl peptidase 4 &#40;DPP4&#41; inhibitors can be considered in the obese patient due to its neutral effect on weight&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a> If the diabetes cannot be controlled with two drugs&#44; a third drug will be added according to that previously stated&#46; Diabetes drugs can be combined with anti-obesity drugs as long as they are not incompatible due to having the same or similar mechanism of action or are from the same family&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a></p></span><span id="sec0120" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Dyslipidemia</span><p id="par0290" class="elsevierStylePara elsevierViewall">For its screening&#44; the lab test &#40;after 12&#8239;h fast&#41; should include the determination of total cholesterol&#44; non-HDL cholesterol&#44; HDL cholesterol&#44; triglycerides and LDL cholesterol &#40;calculated using the Friedewald formula&#41;&#46; The dyslipidemia of obesity consists of high triglycerides and low HDL cholesterol&#46; Similar to the rest of the metabolic comorbidities associated with obesity&#44; lifestyle intervention is recommended for its treatment&#44; combining physical exercise and a low-calorie diet that includes a minimum contribution of refined sugars and carbohydrates&#44; avoids <span class="elsevierStyleItalic">trans</span> fatty acids&#44; limits alcohol use and increases fibre intake&#46; In patients with high cardiovascular risk&#44; with metabolic syndrome&#44; prediabetes&#44; hypertension and&#47;or dyslipidemia&#44; the use of statins should be considered&#44; especially when LDL cholesterol levels exceed 100&#8239;mg&#47;dl &#40;130&#8239;mg&#47;dl if the risk is low&#41;&#46; If a high potency statin is not enough&#44; ezetimibe can be added&#46; If elevated triglycerides persist despite the aforementioned measures&#44; combined therapy with fenofibrate should be started &#40;the use of gemfibrozil should be avoided due to the increased risk of myopathy&#44; as should the statin and fenofibrate combination for the same reason&#41;&#46; It should not be forgotten that weight reduction is crucial for improving the lipid profile&#44; so any available anti-obesity medication can be added&#44; since all of them have been shown to improve the lipid profile&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p></span><span id="sec0125" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Arterial hypertension</span><p id="par0295" class="elsevierStylePara elsevierViewall">Controlling blood pressure in obese patients is more difficult and requires more intensive treatment&#46; Emphasis should again be placed on weight reduction through lifestyle intervention&#44; which will greatly help towards the achievement of blood pressure objectives&#46; When selecting the pharmacological treatment of the obese hypertensive patient&#44; the risk of developing diabetes in the future must be taken into account&#44; so the use of drugs or drug-combinations that reduce the risk of developing the disease are recommended&#46; The use of an angiotensin converting enzyme &#40;ACE&#41; inhibitor or an angiotensin receptor blocker &#40;ARB&#41; is a good option to start treatment&#44; especially if the patient presents metabolic syndrome&#46; If a drug-combination is required&#44; a calcium antagonist should be added rather than a diuretic or a beta-blocker&#44; mainly because the use of the latter two has been associated with weight gain&#44; alterations in insulin sensitivity and in the metabolism of glucose and lipids&#46;</p><p id="par0300" class="elsevierStylePara elsevierViewall">In the hypertensive patient who does not achieve good control&#44; and as previously discussed&#44; the combination of prolonged-release bupropion&#47;naltrexone would be contraindicated&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p></span><span id="sec0130" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Sleep apnoea-hypoapnoea syndrome</span><p id="par0305" class="elsevierStylePara elsevierViewall">The anamnesis should be the screening for this syndrome&#44; asking about the frequency of snoring&#44; night-time respiratory stops and hypersomnia during the day&#46; Two short questionnaires are useful&#44; such as the Epworth questionnaire &#40;8 questions on the ease of falling asleep in everyday situations&#41; and the Berlin questionnaire &#40;10 questions on whether the subject snores&#44; wakes up tired after sleeping&#44; and has been diagnosed with arterial hypertension&#41;&#46; If the suspicion is high&#44; or the questionnaires indicate a higher risk of suffering from it&#44; the patient should be sent to the corresponding Sleep Unit to arrange for home cardiorespiratory polygraphy or polysomnography&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p></span></span><span id="sec0135" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">When to think about bariatric surgery&#63;</span><p id="par0310" class="elsevierStylePara elsevierViewall">It is totally impossible to solve the problem of obesity through bariatric surgery&#46; However&#44; any patient with obesity who meets surgical criteria should be fully informed of this option&#44; regardless of whether they want to opt for this route or whether the healthcare professional is in favour of it or not&#46;</p><span id="sec0140" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">What criteria must be met&#63;</span><p id="par0315" class="elsevierStylePara elsevierViewall">In 1991 the NIH <span class="elsevierStyleItalic">Consensus Development Conference Panel</span> established the general criteria for choosing candidates for bariatric surgery&#58; patients with a BMI over 40&#8239;kg&#47;m<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#44; and patients with less severe forms of obesity &#40;BMI between 35 and 40&#8239;kg&#47;m<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#41; but with associated severe comorbidities&#44; such as T2DM or sleep apnoea-hypoapnoea syndrome&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a> These criteria have been maintained in subsequent consensuses and guidelines&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">45&#8211;48</span></a></p><p id="par0320" class="elsevierStylePara elsevierViewall">In addition&#44; the age of the patient should be considered&#44; with no doubts existing for those between 18 and 60 years of age but ensuring that patients are individualised outside that age range&#46; The progression time of obesity should be longer than 5 years&#44; and duly supervised conservative treatments should have been attempted and failed&#46;</p><p id="par0325" class="elsevierStylePara elsevierViewall">The patient must understand that the goal of the surgery is not to reach the ideal weight&#44; and he&#47;she must commit to adhering to the follow-up guidelines after the surgery&#46; In many centres the patient has to sign a commitment form confirming his&#47;her understanding and willingness to adhere&#46;</p><p id="par0330" class="elsevierStylePara elsevierViewall">The cognitive capacity of the patient must be sufficient to understand the mechanisms by which weight is lost with surgery&#44; to understand that good results are not always achieved&#44; and the need for long-term follow-up&#46;</p></span><span id="sec0145" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">What are the exclusion criteria&#63;</span><p id="par0335" class="elsevierStylePara elsevierViewall">The presence of untreated endocrine disorders that facilitate obesity &#40;such as primary hypothyroidism&#44; Cushing&#39;s syndrome&#44; or the existence of an insulinoma&#41;&#44; non-stabilised major psychiatric disorders&#44; intellectual disability&#44; eating disorders&#44; and addiction to drugs or alcohol abuse should be considered exclusion criteria&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;45&#44;46</span></a> Restrictions will also be considered&#58; for patients who cannot care for themselves and do not have long-term family or social support that can provide such care&#59; in the face of a severe illness that limits the life expectancy of the patient and will not improve with the weight loss&#59; when the surgical or anaesthetic risk is unacceptable&#59; or when there is a pathology of the digestive system that may be aggravated by surgical changes&#46;</p><p id="par0340" class="elsevierStylePara elsevierViewall">Women of childbearing age should avoid pregnancy for at least the first postoperative year&#46;</p></span></span><span id="sec0150" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0170">When and how to refer a patient to the specialised obesity unit&#63;</span><p id="par0345" class="elsevierStylePara elsevierViewall">Establishing shared referral criteria and fluid communication between both levels of care is essential to consolidate cross-sectional treatment of this disease &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><span id="sec0155" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0175">What referral criteria should be used&#63;</span><p id="par0350" class="elsevierStylePara elsevierViewall">The criteria for referral to the Specialised Obesity Unit&#44; presented as the doctor specialising in Endocrinology and Nutrition&#44; may depend on the resources&#44; organisation and degree of coordination of the different levels of care in each health area&#46;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">49&#8211;51</span></a> This possibility should be considered in patients who are motivated to lose weight&#44; with a BMI&#8239;&#8805;&#8239;35&#8239;kg&#47;m<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#44; at least&#44; in which the approach previously described at the Primary Care level fails to reverse the situation &#40;<a class="elsevierStyleCrossRef" href="#tbl0030">Table 6</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0030"></elsevierMultimedia><p id="par0355" class="elsevierStylePara elsevierViewall">Obese women of reproductive age should be informed of the risk that excess weight implies for their future pregnancy&#44; while being attended to in the Primary Care units unless they meet any of the referral criteria&#46;</p><p id="par0360" class="elsevierStylePara elsevierViewall">If there is a suspicion that the patient suffers an eating disorder&#44; he&#47;she should be referred to the Psychiatry department or to the corresponding Eating Disorders Unit&#46;</p><p id="par0365" class="elsevierStylePara elsevierViewall">Patients with a BMI between 30 and 35&#8239;kg&#47;m<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> in which their obesity is considered to further poor control of any comorbidity&#44; should be referred to the corresponding specialist &#40;e&#46;&#8239;g&#46; to the Endocrinology and Nutrition department if it is a T2DM&#44; to the Pulmonology department for sleep apnoea-hypoapnoea syndrome&#44; to the Gynaecology department in case of infertility&#44; etc&#46;&#41;&#44; but referral should not be made to the Obesity Units unless the contrary has been previously established&#46;</p><p id="par0370" class="elsevierStylePara elsevierViewall">Finally&#44; it is worth remembering how important patient motivation is and their involvement in all processes related to the therapeutic approach to obesity&#46; That is why patients lacking motivation&#44; or who have not attempted to modify their lifestyle habits during the follow-up in Primary Care&#44; will be excluded from referral to the Specialised Units&#46;</p></span><span id="sec0160" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0180">How is a patient referred to the specialised unit&#63;</span><p id="par0375" class="elsevierStylePara elsevierViewall">Ideally&#44; the referral of a patient from Primary Care to the Specialised Unit should be accompanied by a brief and concise report &#40;<a class="elsevierStyleCrossRef" href="#tbl0035">Table 7</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0035"></elsevierMultimedia></span></span><span id="sec0165" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0185">What are the specialised obesity units&#63;</span><p id="par0380" class="elsevierStylePara elsevierViewall">The Specialised Obesity Units must be able to provide obesity assessment and treatment strategies that are not available in Primary Care&#44; with a relative ability to adapt to the clinical and personal situation of each patient&#46; Formed by a multidisciplinary team&#44; they should develop not only a clinical function but also a teaching and research function&#46; Different scientific societies&#44; such as the <span class="elsevierStyleItalic">European Association for the Study of Obesity</span> &#40;EASO&#41;&#44; establish quality and accreditation criteria for these units <span class="elsevierStyleItalic">&#40;Center of Excellence - European Association for the Study of Obesity</span>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">52</span></a> Similarly&#44; SEEDO supports the development of these specialised and multidisciplinary units in every hospital site&#46;</p><span id="sec0170" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0190">Which professionals participate&#63;</span><p id="par0385" class="elsevierStylePara elsevierViewall">Although with a varying degrees of involvement&#44; a Specialised Obesity Unit should have the clinical activity led by endocrinologists&#44; nutritionists&#44; nurses&#44; clinical psychologists&#44; psychiatrists&#44; endoscopists&#44; surgeons&#44; pulmonologists&#44; physiotherapists&#44; physical educators and anaesthesiologists&#46; Additionally&#44; there should also be referee specialists in the cardiology&#44; hepatology&#44; nephrology and neurology areas&#46; Finally&#44; the family doctor should be in communication with the Specialised Obesity Unit&#44; with the aim of facilitating the exchange of information between professionals&#44; optimising the prescribed treatments&#44; and reinforcing the transversal management of this disease&#46;</p></span><span id="sec0175" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0195">What is the proposal for patient follow-up&#63;</span><p id="par0390" class="elsevierStylePara elsevierViewall">Sending an obese patient to a Specialised Unit is not equivalent to achieving a normal weight&#46; The limitations of behavioural treatment as well as current pharmacological options are well known&#46; However&#44; these should not be an impediment to setting individualised weight loss goals and providing the patient with the necessary tools to achieve them&#44; always in a realistic manner&#46; The concept of &#34;ideal weight&#34; does not always help in this regard&#44; since the patient must understand his&#47;her disease and know that any weight loss will be beneficial for his&#47;her quality of life and health&#46;</p><p id="par0395" class="elsevierStylePara elsevierViewall">Although the follow-up has to adapt to the possibilities of each Unit&#44; monitoring by the specialist in Endocrinology and Nutrition is advocated after the first visit at 3&#44; 6&#44; 9 and 12 months&#46; These visits will alternate with check-ups by the nursing team and nutritionists responsible for the health education programme&#44; with a similar frequency&#46; Once this 12-month period has ended&#44; the patient can be monitored in Primary Care&#46; It should be noted that this period is indicative and may be prolonged depending on the weight loss or the lack of improvement in comorbidities&#46;</p></span></span><span id="sec0180" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0200">What follow-up should be carried out when a patient is discharged from the specialised obesity unit&#63;</span><p id="par0400" class="elsevierStylePara elsevierViewall">With few exceptions&#44; the objective of the Specialised Obesity Unit is to be able to return the obese patient to the support of Primary Care&#46;</p><span id="sec0185" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0205">When should a patient be handed back to primary care&#63;</span><p id="par0405" class="elsevierStylePara elsevierViewall">In the case of non-operated patients - after 12 months of follow-up&#46; This time is considered sufficient to achieve a weight loss of 5&#8722;10&#37; of the initial weight&#44; to stabilise the comorbidities associated with obesity and to have exhausted the therapeutic possibilities with or without success&#46; In the latter case or in the case of non-stabilised comorbidities&#44; the possibility of prolonging follow-up in the Specialised Obesity Unit remains open&#46;</p><p id="par0410" class="elsevierStylePara elsevierViewall">In the case of patients who underwent bariatric surgery - after 5 years of follow-up&#46; After this time&#44; the majority of patients who underwent vertical gastrectomy or Roux-en-Y gastric bypass achieve weight and replacement treatment stability&#44; without complications&#46;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">47&#44;53</span></a> However&#44; patients who undergo purely malabsorptive techniques will remain monitored in the Specialised Obesity Units&#46;</p></span><span id="sec0190" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0210">How should a patient be handed back to primary care&#63;</span><p id="par0415" class="elsevierStylePara elsevierViewall">After the evaluation&#44; therapeutic proposal and treatment in a Specialised Obesity Unit&#44; a report should be issued to Primary Care in order to facilitate continuity of care&#46; In general&#44; the following information should be recorded&#58; reason for which the patient was referred&#44; summary of the medical history and the results of the main tests carried out&#44; the clinical diagnosis &#40;including degree of initial obesity&#44; cardiovascular risk and the obesity-related pathology&#41;&#44; applied treatments and therapeutic response&#44; detailing the progress of weight and related pathologies&#46;</p><p id="par0420" class="elsevierStylePara elsevierViewall">Finally&#44; it is recommended to attach a follow-up plan that includes the therapeutic objectives&#44; the Primary Care standards&#44; and therapeutic and follow-up recommendations&#44; and the indications&#44; if applicable&#44; about future consultations in the Specialised Unit&#46;</p></span><span id="sec0195" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0215">How to tackle the challenge of maintaining weight loss in primary care&#63;</span><p id="par0425" class="elsevierStylePara elsevierViewall">Weight loss was traditionally considered as the end of the specific treatment&#46; Today it is known that successful weight reduction depends on continuing a long-term maintenance programme33&#46; Observing&#44; monitoring&#44; and motivating patients who have successfully lost weight should be continued for a prolonged&#44; and in some cases&#44; indefinite period&#46; This maintenance programme will include dietary therapy&#44; physical activity and behavioural therapy&#44; and it requires frequent contact between the patient and the different professionals who care for his&#47;her health&#46;</p></span></span><span id="sec0200" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0220">Conflict of interests</span><p id="par0430" class="elsevierStylePara elsevierViewall">None&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">The high prevalence of obesity in our environment&#44; a chronic disease of complex management and responsible for multiple comorbidities&#44; requires the implementation of coordination strategies in clinical care between primary care and specialist hospital units&#46; In a cross-sectional care model&#44; primary care physicians guide all therapeutic management related to obesity&#46; Together with them&#44; specialists in endocrinology and nutrition and other health staff help to form a functional unit that focuses on obesity&#46; The main goal of this document is to improve the coordination between care levels&#44; to optimize resources&#44; avoid patients&#8217; unrealistic expectations and improve patient follow-up after discharge from hospital&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">La elevada prevalencia de Obesidad en nuestro medio&#44; una enfermedad cr&#243;nica con un abordaje complejo y responsable de m&#250;ltiples comorbilidades&#44; nos lleva a la necesidad de implementar estrategias de coordinaci&#243;n en la asistencia cl&#237;nica entre Atenci&#243;n Primaria y las Unidades Especializadas Hospitalarias&#46; En un modelo asistencial transversal&#44; el m&#233;dico de Atenci&#243;n Primaria constituye el eje conductor de todo el abordaje terap&#233;utico relacionado con la Obesidad&#46; Junto a &#233;l&#44; el especialista en Endocrinolog&#237;a y Nutrici&#243;n y otros profesionales sanitarios ayudan a definir una Unidad funcional centrada en la Obesidad&#46; El objetivo principal de este documento es mejorar la coordinaci&#243;n entre niveles asistenciales en el tratamiento de la obesidad&#44; para optimizar recursos&#44; evitar la creaci&#243;n de falsas expectativas en los pacientes y mejorar su seguimiento al alta hospitalaria&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Please cite this article as&#58; Caix&#224;s A&#44; Villar&#243; M&#44; Arraiza C&#44; Montalv&#225; J-C&#44; Lecube A&#44; Fern&#225;ndez-Garc&#237;a J-M&#44; et al&#46; Documento de consenso SEEDO-SEMERGEN sobre la continuidad asistencial en obesidad entre Atenci&#243;n Primaria y Unidades Especializadas Hospitalarias 2019&#46; Med Clin &#40;Barc&#41;&#46; 2020&#46; <span class="elsevierStyleInterRef" id="intr0005" href="https://doi.org/10.1016/j.medcli.2019.10.014">https&#58;&#47;&#47;doi&#46;org&#47;10&#46;1016&#47;j&#46;medcli&#46;2019&#46;10&#46;014</span></p>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Endorsed jointly by the scientific societies &#40;SEEDO &#91;Spanish Society for the Study of Obesity&#93; and SEMERGEN &#91;Spanish Society of Primary Care Physicians&#93;&#41;&#46; This consensus will not be published in other magazines&#46;</p>"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">SEEDO criteria to define obesity in grades according to BMI in adults&#46;</p>"
        ]
      ]
      3 => array:8 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0020"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "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" 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">Groups&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">Drugs&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 " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#91;0&#46;1-2&#93;<span class="elsevierStyleItalic">Psychotropic drugs</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>Antipsychotics&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">Chlorpromazine&#44; clozapine&#44; olanzapine&#44; perphenazine&#44; thioridazine&#44; trifluoperazine&#44; aripiprazole&#44; risperidone&#44; fluphenazine&#44; haloperidol&#44; pimozide&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"><span class="elsevierStyleHsp" style=""></span>Tricyclic antidepressants&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">Amitriptyline&#44; imipramine&#44; nortriptyline&#44; clomipramine&#44; doxepin&#44; trimipramine&#44; desipramine&#44; maprotiline<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&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"><span class="elsevierStyleHsp" style=""></span>Selective serotonin reuptake inhibitors &#40;SSRIs&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Paroxetine&#44; mirtazapine&#44; citalopram&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"><span class="elsevierStyleHsp" style=""></span>Monoamine oxidase inhibitors &#40;MAOIs&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Selegiline&#44; isocarboxazid&#44; phenelzine&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"><span class="elsevierStyleHsp" style=""></span>Mood stabilizers &#47; antiepileptics&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">Lithium&#44; valproate&#44; carbamazepine&#44; gabapentin&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"><span class="elsevierStyleItalic">Antihistamines</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cyproheptadine and others&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 " rowspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#91;2&#46;0&#93;<span class="elsevierStyleItalic">Antihypertensive drugs</span></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">Alpha 1 adrenergic&#58; prazosin&#44; terazosin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Beta-adrenergics&#58; propranolol&#44; metoprolol&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Others&#58; alpha-methyldopa&#44; clonidine&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 " rowspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#91;2&#46;0&#93;<span class="elsevierStyleItalic">Antidiabetics</span></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">Insulin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sulfonylureas&#58; glibenclamide&#44; glipizide&#44; gliclazide&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Thiazolidinediones&#58; pioglitazone&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"><span class="elsevierStyleItalic">Contraceptives</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Especially depot injectables&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"><span class="elsevierStyleItalic">Corticosteroids</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">All&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                0 => "xTab2532278.png"
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          "notaPie" => array:1 [
            0 => array:3 [
              "identificador" => "tblfn0005"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Heterocyclic&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Drugs associated with obesity&#46;</p>"
        ]
      ]
      4 => array:8 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0025"
            "detalle" => "Table "
            "rol" => "short"
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        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Modified from the SEEDO 2007 Consensus<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> and SEEDO 2016<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a>&#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" 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">BMI &#40;kg&#47;m<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&#91;0&#46;2-3&#93;Intervention</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">25-26&#44;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">Not justified if the weight is stable&#44; the fat distribution is peripheral and there are no associated diseases&#46; Justified if there is CVRF and&#47;or central fat distribution&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">Dietary adviceEncourage physical activityPeriodic check-ups&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">27-29&#44;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"><span class="elsevierStyleItalic">Objective&#58;</span>Loss of 5-10&#37; body weight&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">Low-calorie dietEncourage physical activityLifestyle changesPeriodic check-upsAssess drug association if there are comorbidities&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">30-34&#44;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"><span class="elsevierStyleItalic">Objective&#58;</span>Loss of 10&#37; body weight&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">Low-calorie dietEncourage physical activityLifestyle changesPeriodic check-upsAssess drug association&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">35-39&#44;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"><span class="elsevierStyleItalic">Objective&#58;</span>Loss &#62;&#8239;10&#37; of body weight&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">Initial therapeutic action similar to the previous groupConsider the possibility of bariatric surgery if there are comorbidities&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">&#62;&#8239;40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Objective&#58;</span>Loss &#62;&#8239;20&#37; of body weight&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">Initial therapeutic action similar to the previous group&#46; Consider bariatric surgery also in the absence of complications&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Establishment of an action plan with definition of therapeutic intervention criteria&#46;</p>"
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      5 => array:8 [
        "identificador" => "tbl0020"
        "etiqueta" => "Table 4"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0030"
            "detalle" => "Table "
            "rol" => "short"
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        ]
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Week&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">Warm up&#58;Walk slowly &#40;min&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Exercise&#58;Walk fast &#40;min&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Relaxation&#58;Walk slowly &#40;min&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Total time &#40;min&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-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">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">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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">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="left" valign="\n
                  \t\t\t\t\ttop\n
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                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab2532275.png"
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Progressive physical exercise in the initial phase&#46;</p>"
        ]
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      6 => array:8 [
        "identificador" => "tbl0025"
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        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
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            "identificador" => "at0035"
            "detalle" => "Table "
            "rol" => "short"
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            0 => array:2 [
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                  \t\t\t\t" scope="col">Treatment options&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&#91;0&#46;2-6&#93;BMI &#40;kg&#47;m<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#41;</th></tr><tr title="table-row"><th class="td" title="\n
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                  \t\t\t\t">&#43;&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">&#43;&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">Pharmacotherapy&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">&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">With comorbidity&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">&#43;&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">&#43;&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">&#43;&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">Surgery&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">&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">&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">&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">With comorbidity&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">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab2532276.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Indications of the different treatments in obesity based on BMI&#46;</p>"
        ]
      ]
      7 => array:8 [
        "identificador" => "tbl0030"
        "etiqueta" => "Table 6"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0040"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">1&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">BMI&#8239;&#8805;&#8239;40&#8239;kg&#47;m<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Due to it being an extreme case of the disease and regardless of the presence of comorbidities&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">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">BMI&#8239;&#8805;&#8239;35&#8239;kg&#47;m<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#8239;&#43;&#8239;&#8805;&#8239;2&#8239;poorly controlled obesity-related pathologies&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">T2DM &#40;HbA1c&#8239;&#8805;&#8239;7&#46;0&#37; despite treatment with SGLT2-i or GLP-1 RA&#41;Sleep apnoea&#47;hypoapnoea syndrome who do not tolerate CPAPHypertension &#40;BP&#8239;&#8805;&#8239;140&#47;90&#8239;mmHg&#41; despite the combination of 3 or more drugsPolycystic ovary syndrome that prevents gestationSevere osteoarthritis in load joints in &#60;&#8239;60 years&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">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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">BMI&#8239;&#8805;&#8239;35&#8239;kg&#47;m<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> in which weight loss is a priority&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">On the list for a transplant&#44; knee prosthesis&#44; infertility treatment&#44; etc&#46;&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">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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">If the patient wants and meets criteria for bariatric surgery&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">The criteria would be those of section 1 or 2 and no contraindication&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">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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Suspected secondary obesity&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">Cushing&#39;s disease&#44; acromegaly&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">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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Suspected syndromic obesity&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">Obesity since childhood&#44; association with hypogonadism&#44; exaggerated hyperphagia&#44; characteristic facies&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab2532281.png"
              ]
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Criteria for referral of Primary Care to the Specialised Unit&#46;</p>"
        ]
      ]
      8 => array:8 [
        "identificador" => "tbl0035"
        "etiqueta" => "Table 7"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0045"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">1&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">Reason for referral&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">&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">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">Main clinical data&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">Age&#44; BMI and waist circumference&#44; comorbidities and degree of their control&#44; and family history if exists&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">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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Obesity history&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">Starting age&#44; precipitating causes&#44; maximum weight&#44; previous attempts&#44; and results&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">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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Actions taken in Primary Care&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">Diets performed&#44; level of physical exercise&#44; follow-up time&#44; prescribed treatments&#44; patient commitment&#44; progress of anthropometric variables&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">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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Analytical data&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">Values of interest that have not been previously commented&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">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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Pharmacotherapy&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">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                0 => "xTab2532280.png"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Information to be included in the referral to the Specialised Unit&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:53 [
            0 => array:3 [
              "identificador" => "bib0005"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Prevalencia de la Obesidad en Espa&#241;a&#58; resultados del estudio SEEDO 2000"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "J&#46; Aranceta"
                            1 => "C&#46; P&#233;rez"
                            2 => "L&#46; Serra"
                            3 => "L&#46; Ribas"
                            4 => "J&#46; Quiles"
                            5 => "J&#46; Vioque"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Med Clin &#40;Barc&#41;"
                        "fecha" => "2003"
                        "volumen" => "120"
                        "paginaInicial" => "608"
                        "paginaFinal" => "612"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0010"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Prevalencia de Obesidad en Espa&#241;a"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "J&#46; Aranceta-Bartrina"
                            1 => "L&#46; Serra-Majem"
                            2 => "M&#46; Foz-Sala"
                            3 => "B&#46; Moreno-Esteban"
                            4 => "Grupo Colaborativo SEEDO"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Med Clin &#40;Barc&#41;"
                        "fecha" => "2005"
                        "volumen" => "125"
                        "paginaInicial" => "460"
                        "paginaFinal" => "466"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0015"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Prevalence of general and abdominal obesity in the adult population of Spain&#44; 2008-2010&#58; the ENRICA study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "J&#46;L&#46; Guti&#233;rrez-Fisac"
                            1 => "P&#46; Guallar-Castill&#243;n"
                            2 => "L&#46;M&#46; Le&#243;n-Mu&#241;oz"
                            3 => "A&#46; Graciani"
                            4 => "J&#46;R&#46; Banegas"
                            5 => "F&#46; Rodr&#237;guez-Artalejo"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
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