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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Algorithm of obesity in individuals older than 65 years old&#46;</p>"
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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 global burden of obesity is rapidly increasing worldwide&#46; According to the World Health Organization &#40;WHO&#41;&#44; more than 650 million people worldwide are living with obesity&#44; which predisposes them to several clinical consequences&#44; including cardiovascular disease&#44; type 2 diabetes&#44; cancer&#44; chronic kidney disease&#44; mental health issues&#44; and musculoskeletal disorders&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Concurrently&#44; the elderly population is growing&#44; and healthcare systems must address the needs of a rising number of individuals over the age of 65 who are affected by obesity and its related complications&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">On the other hand&#44; new and effective tools for treating obesity&#44; such as bariatric surgery and drugs like glucagon-like peptide-1 receptor agonists &#40;GLP-1 RA&#41; and novel GIP&#47;GLP-1 receptor agonists&#44; are available&#46; However&#44; their use in older patients is limited due to the lack of robust evidence in this particular population&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Age should not be the sole criterion&#44; known as &#8220;ageism&#44;&#8221; for deciding the therapeutic approach to older patients with obesity&#46; It is crucial to adopt an individualized&#44; person-centered approach based on comprehensive geriatric assessments to accurately evaluate the risk-benefit balance of obesity therapies in the elderly&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Aging is associated with an increase in abdominal white adipose tissue and fat deposition in skeletal muscle&#44; which significantly affects insulin sensitivity&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Obesity is also strongly linked to a diminished quality of life&#46; In this context&#44; prevention and treatment of obesity become even more relevant in older adults&#46; One major concern in treating obesity in elderly individuals is that many may have sarcopenic obesity&#44; which can worsen with weight loss&#44; inevitably resulting in some degree of lean body mass loss&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a> Therefore&#44; it is clinically important to identify which elderly individuals with obesity have sarcopenia&#44; and this can be achieved inexpensively and easily using the SARC-F questionnaire&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Additionally&#44; for this population&#44; it is important to identify other barriers to treatment initiation&#44; such as life expectancy&#44; and evaluate other associated comorbidities&#44; including the degree of frailty &#40;FRAIL scale&#41;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> and&#47;or cognitive impairment &#40;Pfeiffer test&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Lifestyle interventions that include a reduced but sufficient energy intake&#44; age-appropriate protein and macro&#47;micronutrient intake&#44; combined with a comprehensive resistance exercise program tailored to individual limitations&#44; can induce weight loss while improving frailty indices&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> The use of weight loss medications&#44; particularly GLP-1 RA and tirzepatide&#44; provides an additional stage of treatment&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;12</span></a> Their safety and cardiovascular health benefits have been convincingly demonstrated in older obese patients with type 2 diabetes mellitus&#46; This option should not be denied to obese individuals with other obesity-related comorbidities based solely on age&#46; Moreover&#44; recent evidence suggests that bariatric surgery can be safely performed in selected older individuals as a last treatment option&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> Risk-benefit considerations should be carefully weighed and disclosed to candidates&#44; taking into account their good presurgical functional status&#46; From a clinical perspective&#44; physicians must balance the potential risks of weight loss in older individuals against the complications of obesity in order to determine the most suitable patient-centered approach&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The objective of this document is to propose an algorithm of recommendations for the management of obesity in the elderly &#40;above the age of 65&#41;&#44; based on scientific evidence and the expertise of members from the Diabetes&#44; Obesity&#44; and Nutrition Workgroup of the Spanish Society of Internal Medicine&#46; It is important to note that this document does not serve as a clinical practice guideline or review&#46; For that purpose&#44; you can refer to the guidelines and recommendations provided by different scientific societies&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Methods</span><p id="par0030" class="elsevierStylePara elsevierViewall">The methodological structure of the algorithm comprises two distinct parts&#46; The first part aims to assess certain essential aspects &#40;functional status&#44; sarcopenia&#44; and cognitive status&#41; when considering possible treatment recommendations for elderly patients&#46; This will include the following&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Frailty</span><p id="par0035" class="elsevierStylePara elsevierViewall">Frailty is an emerging global health burden with significant implications for clinical practice and public health&#46; It refers to a state of decreased physiological reserve and increased vulnerability to negative health outcomes&#46; Frail individuals face an increased risk of adverse outcomes such as falls&#44; hospitalization&#44; and mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> The FRAIL scale assesses five components&#58; Fatigue&#44; Resistance &#40;inability to climb stairs&#41;&#44; Ambulation &#40;inability to walk a certain distance&#41;&#44; Illnesses&#44; and Loss of weight&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> This simple questionnaire consists of five self-reported YES&#47;NO items&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> A patient is considered frail when they score equal to or higher than 3 on the FRAIL scale&#46; Frailty is a significant determinant when determining therapeutic strategies for elderly patients due to its prognostic implications&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Sarcopenia</span><p id="par0040" class="elsevierStylePara elsevierViewall">Sarcopenia refers to the loss of muscle mass and strength that occurs with aging&#46; It is a major cause of disability and frailty among the elderly population&#46; Sarcopenia leads to disability&#44; falls&#44; and increased mortality&#46; Growing evidence has shown that sarcopenic obesity is associated with accelerated functional decline&#44; increased risks of cardiometabolic diseases&#44; and mortality&#46; Therefore&#44; identifying sarcopenic obesity is crucial for clinicians working with the elderly&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#44;16</span></a> The SARC-F questionnaire has been developed as a rapid diagnostic test for sarcopenia&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Although the screening sensitivity of SARC-F is poor&#44; recent evidence indicates its high specificity&#44; making it an effective tool for selecting subjects who require further testing to confirm a diagnosis of sarcopenia&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> The SARC-F questionnaire consists of five components&#58; Strength&#44; Assistance with walking&#44; Rise from a chair&#44; Climb stairs&#44; and Falls&#46; Each component is scored from 0 to 2&#44; resulting in a total score ranging from 0 to 10&#46; A score equal to or greater than 4 predicts sarcopenia and poor outcomes&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Cognitive decline</span><p id="par0045" class="elsevierStylePara elsevierViewall">Cognitive decline refers to a range of conditions&#44; from mild cognitive impairment to dementia&#44; which represents a severe decline in abilities that interferes with daily life&#46; Clinicians working with elderly patients require a brief and reliable instrument to detect the presence and determine the degree of cognitive impairment&#46; The Pfeiffer test&#44; a 10-item Short Portable Mental Status Questionnaire &#40;SPMSQ&#41;&#44; has been designed&#44; tested&#44; and validated for this purpose&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> The score ranges are as follows&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8226;</span><p id="par0050" class="elsevierStylePara elsevierViewall">0&#8722;2 errors&#58; Intact intellectual functioning</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8226;</span><p id="par0055" class="elsevierStylePara elsevierViewall">3&#8722;4 errors&#58; Mild intellectual impairment</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8226;</span><p id="par0060" class="elsevierStylePara elsevierViewall">5&#8722;7 errors&#58; Moderate intellectual impairment</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8226;</span><p id="par0065" class="elsevierStylePara elsevierViewall">8&#8722;10 errors&#58; Severe intellectual impairment</p></li></ul></p><p id="par0070" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Note&#58;</span> Assessing body composition is not essential for the routine clinical management of obesity&#46; Often&#44; devices and equipment for accurately measuring body fat are not readily available&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Results</span><p id="par0075" class="elsevierStylePara elsevierViewall">The second part of the algorithm presents different treatment recommendations for obesity based on the initial assessment of the patient&#39;s functional&#44; sarcopenia&#44; and cognitive status&#46; Treatment should be grounded in good clinical care and evidence-based interventions&#44; while also being individualized&#44; multidisciplinary&#44; and focused on realistic goals&#44; weight maintenance&#44; and prevention of weight regain&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Two distinct scenarios are considered&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">1</span><p id="par0085" class="elsevierStylePara elsevierViewall">For patients identified with frailty&#44; sarcopenia&#44; or cognitive impairment during the initial assessment&#44; the aim of the recommendations is to prioritize non-pharmacological interventions and preserve quality of life&#44; avoiding restrictive diets <a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">2</span><p id="par0090" class="elsevierStylePara elsevierViewall">For patients who maintain a preserved overall status after the initial assessment&#44; recommendations will be stratified based on the severity of obesity as determined by body mass index &#40;BMI&#44; kg&#47;m<span class="elsevierStyleSup">2</span>&#41;&#58;</p></li></ul></p><p id="par0095" class="elsevierStylePara elsevierViewall">2&#46;1&#46; Patients with a BMI between 30&#8211;34&#46;9 will be encouraged to adopt a healthy lifestyle&#44; including a balanced eating pattern&#44; appropriate physical exercise&#44; tobacco cessation&#44; and good sleep hygiene&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> These recommendations are applicable to all subjects&#44; regardless of their BMI&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">2&#46;2&#46; For patients with a BMI between 35 and 39&#46;9&#44; accompanied by comorbidity and&#47;or an Edmonton Obesity Staging System &#40;EOSS&#41; score &#62;2 &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#44; pharmacological recommendations will be introduced&#46; Options may include liraglutide 3&#46;0&#8239;mg &#40;subcutaneous injection of 3&#8239;mg&#47;24&#8239;h&#41; &#40;no dose adjustment based on age&#59; limited therapeutic experience in patients &#8805;75 years&#41;&#44; semaglutide 2&#46;4&#8239;mg &#40;subcutaneous injection once weekly&#41; &#40;when available&#59; no dose adjustment based on age&#59; limited therapeutic experience in patients &#8805;75 years&#41;&#44; tirzepatide 5&#47;10&#47;15&#8239;mg &#40;subcutaneous injection once weekly&#41; &#40;when available&#59; weight reduction associated with clinically meaningful improvement in body composition across age groups&#44; including those &#8805;65 years&#41;&#44; or orlistat &#40;oral administration of 60&#8722;120&#8239;mg every 8&#8239;h&#41;&#46; GLP1RA is recommended as the initial option due to its efficacy&#46; Re-evaluation should be conducted after 12 weeks&#44; and if a weight loss of at least 5&#37; is not achieved&#44; discontinuation should be considered&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">2&#46;3&#46; For patients with a BMI over 40&#44; in addition to potential pharmacological treatments&#44; the possibility of bariatric surgery would be evaluated on an individual basis for selected cases&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Discussion</span><p id="par0110" class="elsevierStylePara elsevierViewall">Obesity in the elderly not only has a significant impact on morbidity and mortality but also on quality of life&#46; However&#44; the treatment recommendations for this population remain a subject of research and debate due to the lack of sufficient evidence&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">The objective of this document is to propose a set of recommendations for the management of obesity in individuals above the age of 65&#44; based on scientific evidence and the expertise of the members from the Diabetes&#44; Obesity&#44; and Nutrition Workgroup of the Spanish Society of Internal Medicine&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">When dealing with possible treatment recommendations for older adults with obesity&#44; it is crucial to assess certain essential aspects&#44; including functional status&#44; sarcopenia&#44; and cognitive status&#46; Additionally&#44; it is important to have a comprehensive understanding of the risks associated with weight loss on muscle and bone health&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Lifestyle interventions&#44; such as following a Mediterranean diet pattern and engaging in physical exercise&#44; particularly strength training&#44; are considered the best weight loss plan for the elderly&#46; However&#44; it should be noted that pharmacotherapies that are approved by the FDA and&#47;or EMA for adults have not been extensively studied in the elderly population&#46; Bariatric surgery may be an option for selected candidates&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">It is the responsibility of physicians to recognize obesity as a disease and provide appropriate prevention and treatment measures for obese patients&#46; By addressing obesity&#44; healthcare professionals can contribute to improving the overall health and well-being of their patients&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Funding</span><p id="par0135" class="elsevierStylePara elsevierViewall">Pablo P&#233;rez-Mart&#237;nez has received fees for lectures and educational activities from Ferrer&#44; Novo-Nordisk&#44; Boehringer Ingelheim&#44; Amgen&#44; Esteve&#44; Menarini&#44; Servier&#44; and Viatrix&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Ricardo G&#243;mez-Huelgas has received fees for lectures and educational activities from Novo-Nordisk&#44; Lilly&#44; Boehringer Ingelheim&#44; AstraZeneca&#44; Esteve&#44; and Menarini&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Pedro Pablo Casado-Escribano has received fees for lectures and educational activities from Novo-Nordisk&#44; Boehringer Ingelheim&#44; Menarini&#44; AstraZeneca&#44; Sanofi&#44; and Lilly&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Jos&#233; Carlos Ar&#233;valo-Lorido has received fees for lectures and educational activities from Boehringer Ingelheim and AstraZeneca&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Mar&#237;a Isabel P&#233;rez-Soto6 has received fees for lectures and educational activities from Novo-Nordisk&#44; Boehringer Ingelheim&#44; Nestl&#233;&#44; and Menarini&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Juana Carretero-G&#243;mez5 has received fees for lectures and educational activities from Novo-Nordisk&#44; Boehringer Ingelheim&#44; Menarini&#44; and AstraZeneca&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conflicts of interest</span><p id="par0165" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Obesity in the elderly not only impacts morbidity and mortality but their quality of life&#46; This phenomenon has sparked extensive research and debate regarding treatment recommendations&#44; primarly due to the lack evidence in this specific population&#46; When addressing possible treatment recommendations for older adults with obesity&#44; it is crucial to assess certain essential aspects such as functional status&#44; sarcopenia&#44; cognitive status&#44; and others&#46; Intentional weight loss in this population can be both effective and safe&#46; The best weight loss plan for the elderly revolves around adopting a healthy lifestyle&#44; which includes following a Mediterranean diet pattern and engaging in physical exercise&#44; particularly strength training&#46; Additionally&#44; the use of weight loss medications&#44; particularly glucagon-like peptide-1 receptor agonists &#40;GLP-1 RA&#41; and novel glucose-dependent insulinotropic polypeptide &#40;GIP&#41;&#47;GLP-1 receptor agonists&#44; can provide an additional stage of treatment&#46; In selective candidates&#44; bariatric surgery may also be considered&#46; The objective of this document is to propose a comprehensive algorithm of recommendations for the management of obesity in the elderly &#40;above the age of 65&#41;&#44; based on scientific evidence and the expertise of members from the Diabetes&#44; Obesity&#44; and Nutrition Workgroup of the Spanish Society of Internal Medicine&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">La obesidad en los ancianos no solo influye en la morbimortalidad&#44; sino tambi&#233;n en su calidad de vida&#46; Este fen&#243;meno ha suscitado una amplia investigaci&#243;n y debate sobre las recomendaciones terap&#233;uticas&#44; debido principalmente a la falta de datos en esta poblaci&#243;n espec&#237;fica&#46; Cuando se abordan las posibles recomendaciones terap&#233;uticas para adultos mayores con obesidad&#44; es fundamental evaluar ciertos aspectos esenciales&#44; como el estado funcional&#44; la sarcopenia&#44; el estado cognitivo y otros&#46; La p&#233;rdida de peso en esta poblaci&#243;n puede ser tanto eficaz como segura si es intencionada&#46; El mejor plan de p&#233;rdida de peso para los ancianos gira en torno a la adopci&#243;n de unos h&#225;bitos de vida saludables&#44; que incluyen seguir una dieta mediterr&#225;nea y hacer ejercicio f&#237;sico&#44; especialmente el entrenamiento de fuerza&#46; Adem&#225;s&#44; el uso de medicamentos para adelgazar puede proporcionar una fase de tratamiento adicional&#44; en concreto los agonistas del receptor del p&#233;ptido glucagonoide-1 &#40;AR GLP-1&#41; y nuevos polip&#233;ptidos insulin&#243;tropos dependientes de la glucosa &#40;GIP&#41;&#47;agonistas del receptor del GLP-1&#46; Y en determinados candidatos tambi&#233;n se puede plantear la cirug&#237;a bari&#225;trica&#46; El objetivo de este documento es proponer un completo algoritmo de recomendaciones para el manejo de la obesidad en las personas de edad avanzada &#40;mayores de 65 a&#241;os&#41;&#44; basado en datos cient&#237;ficos y en la experiencia de los miembros del Grupo de Trabajo de Diabetes&#44; Obesidad y Nutrici&#243;n de la Sociedad Espa&#241;ola de Medicina Interna&#46;</p></span>"
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Consensus Document
Approach to obesity in the elderly population: a consensus report from the Diabetes, Obesity and Nutrition Working Group of SEMI (Spanish Society of Internal Medicine)
Propuesta acerca de la obesidad en la población anciana: informe de consenso del Grupo de Trabajo de Diabetes, Obesidad y Nutrición de la SEMI (Sociedad Española de Medicina Interna)
Pablo Pérez Martíneza,b,1, Ricardo Gómez-Huelgasb,c,1, Pedro Pablo Casado Escribanod, José Carlos Arévalo-Loridoe, María Isabel Pérez-Sotof, Juana Carretero Gómeze,
Corresponding author
juanicarretero@gmail.com

Corresponding author.
, En representación del Grupo de Trabajo de Diabetes, Obesidad y Nutrición de la SEMI (Sociedad Española de Medicina Interna)
a Servicio de Medicina Interna, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC)/Hospital Universitario Reina Sofía, Universidad de Córdoba, Córdoba, Spain
b CIBER Fisiopatología Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III, Madrid, Spain
c Servicio de Medicina Interna, Instituto de Investigación Biomédica de Málaga (IBIMA)/Hospital Regional Universitario de Málaga, Universidad de Málaga, Málaga, Spain
d Servicio de Medicina Interna, Hospital Universitario La Princesa, Madrid, Spain
e Servicio de Medicina Interna, Hospital Universitario de Badajoz, Badajoz, Spain
f Servicio de Medicina Interna, Hospital Universitario del Vinalopó, Elche, Spain
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Algorithm of obesity in individuals older than 65 years old&#46;</p>"
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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 global burden of obesity is rapidly increasing worldwide&#46; According to the World Health Organization &#40;WHO&#41;&#44; more than 650 million people worldwide are living with obesity&#44; which predisposes them to several clinical consequences&#44; including cardiovascular disease&#44; type 2 diabetes&#44; cancer&#44; chronic kidney disease&#44; mental health issues&#44; and musculoskeletal disorders&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Concurrently&#44; the elderly population is growing&#44; and healthcare systems must address the needs of a rising number of individuals over the age of 65 who are affected by obesity and its related complications&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">On the other hand&#44; new and effective tools for treating obesity&#44; such as bariatric surgery and drugs like glucagon-like peptide-1 receptor agonists &#40;GLP-1 RA&#41; and novel GIP&#47;GLP-1 receptor agonists&#44; are available&#46; However&#44; their use in older patients is limited due to the lack of robust evidence in this particular population&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Age should not be the sole criterion&#44; known as &#8220;ageism&#44;&#8221; for deciding the therapeutic approach to older patients with obesity&#46; It is crucial to adopt an individualized&#44; person-centered approach based on comprehensive geriatric assessments to accurately evaluate the risk-benefit balance of obesity therapies in the elderly&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Aging is associated with an increase in abdominal white adipose tissue and fat deposition in skeletal muscle&#44; which significantly affects insulin sensitivity&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Obesity is also strongly linked to a diminished quality of life&#46; In this context&#44; prevention and treatment of obesity become even more relevant in older adults&#46; One major concern in treating obesity in elderly individuals is that many may have sarcopenic obesity&#44; which can worsen with weight loss&#44; inevitably resulting in some degree of lean body mass loss&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a> Therefore&#44; it is clinically important to identify which elderly individuals with obesity have sarcopenia&#44; and this can be achieved inexpensively and easily using the SARC-F questionnaire&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Additionally&#44; for this population&#44; it is important to identify other barriers to treatment initiation&#44; such as life expectancy&#44; and evaluate other associated comorbidities&#44; including the degree of frailty &#40;FRAIL scale&#41;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> and&#47;or cognitive impairment &#40;Pfeiffer test&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Lifestyle interventions that include a reduced but sufficient energy intake&#44; age-appropriate protein and macro&#47;micronutrient intake&#44; combined with a comprehensive resistance exercise program tailored to individual limitations&#44; can induce weight loss while improving frailty indices&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> The use of weight loss medications&#44; particularly GLP-1 RA and tirzepatide&#44; provides an additional stage of treatment&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;12</span></a> Their safety and cardiovascular health benefits have been convincingly demonstrated in older obese patients with type 2 diabetes mellitus&#46; This option should not be denied to obese individuals with other obesity-related comorbidities based solely on age&#46; Moreover&#44; recent evidence suggests that bariatric surgery can be safely performed in selected older individuals as a last treatment option&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> Risk-benefit considerations should be carefully weighed and disclosed to candidates&#44; taking into account their good presurgical functional status&#46; From a clinical perspective&#44; physicians must balance the potential risks of weight loss in older individuals against the complications of obesity in order to determine the most suitable patient-centered approach&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The objective of this document is to propose an algorithm of recommendations for the management of obesity in the elderly &#40;above the age of 65&#41;&#44; based on scientific evidence and the expertise of members from the Diabetes&#44; Obesity&#44; and Nutrition Workgroup of the Spanish Society of Internal Medicine&#46; It is important to note that this document does not serve as a clinical practice guideline or review&#46; For that purpose&#44; you can refer to the guidelines and recommendations provided by different scientific societies&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Methods</span><p id="par0030" class="elsevierStylePara elsevierViewall">The methodological structure of the algorithm comprises two distinct parts&#46; The first part aims to assess certain essential aspects &#40;functional status&#44; sarcopenia&#44; and cognitive status&#41; when considering possible treatment recommendations for elderly patients&#46; This will include the following&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Frailty</span><p id="par0035" class="elsevierStylePara elsevierViewall">Frailty is an emerging global health burden with significant implications for clinical practice and public health&#46; It refers to a state of decreased physiological reserve and increased vulnerability to negative health outcomes&#46; Frail individuals face an increased risk of adverse outcomes such as falls&#44; hospitalization&#44; and mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> The FRAIL scale assesses five components&#58; Fatigue&#44; Resistance &#40;inability to climb stairs&#41;&#44; Ambulation &#40;inability to walk a certain distance&#41;&#44; Illnesses&#44; and Loss of weight&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> This simple questionnaire consists of five self-reported YES&#47;NO items&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> A patient is considered frail when they score equal to or higher than 3 on the FRAIL scale&#46; Frailty is a significant determinant when determining therapeutic strategies for elderly patients due to its prognostic implications&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Sarcopenia</span><p id="par0040" class="elsevierStylePara elsevierViewall">Sarcopenia refers to the loss of muscle mass and strength that occurs with aging&#46; It is a major cause of disability and frailty among the elderly population&#46; Sarcopenia leads to disability&#44; falls&#44; and increased mortality&#46; Growing evidence has shown that sarcopenic obesity is associated with accelerated functional decline&#44; increased risks of cardiometabolic diseases&#44; and mortality&#46; Therefore&#44; identifying sarcopenic obesity is crucial for clinicians working with the elderly&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#44;16</span></a> The SARC-F questionnaire has been developed as a rapid diagnostic test for sarcopenia&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Although the screening sensitivity of SARC-F is poor&#44; recent evidence indicates its high specificity&#44; making it an effective tool for selecting subjects who require further testing to confirm a diagnosis of sarcopenia&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> The SARC-F questionnaire consists of five components&#58; Strength&#44; Assistance with walking&#44; Rise from a chair&#44; Climb stairs&#44; and Falls&#46; Each component is scored from 0 to 2&#44; resulting in a total score ranging from 0 to 10&#46; A score equal to or greater than 4 predicts sarcopenia and poor outcomes&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Cognitive decline</span><p id="par0045" class="elsevierStylePara elsevierViewall">Cognitive decline refers to a range of conditions&#44; from mild cognitive impairment to dementia&#44; which represents a severe decline in abilities that interferes with daily life&#46; Clinicians working with elderly patients require a brief and reliable instrument to detect the presence and determine the degree of cognitive impairment&#46; The Pfeiffer test&#44; a 10-item Short Portable Mental Status Questionnaire &#40;SPMSQ&#41;&#44; has been designed&#44; tested&#44; and validated for this purpose&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> The score ranges are as follows&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8226;</span><p id="par0050" class="elsevierStylePara elsevierViewall">0&#8722;2 errors&#58; Intact intellectual functioning</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8226;</span><p id="par0055" class="elsevierStylePara elsevierViewall">3&#8722;4 errors&#58; Mild intellectual impairment</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8226;</span><p id="par0060" class="elsevierStylePara elsevierViewall">5&#8722;7 errors&#58; Moderate intellectual impairment</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8226;</span><p id="par0065" class="elsevierStylePara elsevierViewall">8&#8722;10 errors&#58; Severe intellectual impairment</p></li></ul></p><p id="par0070" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Note&#58;</span> Assessing body composition is not essential for the routine clinical management of obesity&#46; Often&#44; devices and equipment for accurately measuring body fat are not readily available&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Results</span><p id="par0075" class="elsevierStylePara elsevierViewall">The second part of the algorithm presents different treatment recommendations for obesity based on the initial assessment of the patient&#39;s functional&#44; sarcopenia&#44; and cognitive status&#46; Treatment should be grounded in good clinical care and evidence-based interventions&#44; while also being individualized&#44; multidisciplinary&#44; and focused on realistic goals&#44; weight maintenance&#44; and prevention of weight regain&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Two distinct scenarios are considered&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">1</span><p id="par0085" class="elsevierStylePara elsevierViewall">For patients identified with frailty&#44; sarcopenia&#44; or cognitive impairment during the initial assessment&#44; the aim of the recommendations is to prioritize non-pharmacological interventions and preserve quality of life&#44; avoiding restrictive diets <a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">2</span><p id="par0090" class="elsevierStylePara elsevierViewall">For patients who maintain a preserved overall status after the initial assessment&#44; recommendations will be stratified based on the severity of obesity as determined by body mass index &#40;BMI&#44; kg&#47;m<span class="elsevierStyleSup">2</span>&#41;&#58;</p></li></ul></p><p id="par0095" class="elsevierStylePara elsevierViewall">2&#46;1&#46; Patients with a BMI between 30&#8211;34&#46;9 will be encouraged to adopt a healthy lifestyle&#44; including a balanced eating pattern&#44; appropriate physical exercise&#44; tobacco cessation&#44; and good sleep hygiene&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> These recommendations are applicable to all subjects&#44; regardless of their BMI&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">2&#46;2&#46; For patients with a BMI between 35 and 39&#46;9&#44; accompanied by comorbidity and&#47;or an Edmonton Obesity Staging System &#40;EOSS&#41; score &#62;2 &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#44; pharmacological recommendations will be introduced&#46; Options may include liraglutide 3&#46;0&#8239;mg &#40;subcutaneous injection of 3&#8239;mg&#47;24&#8239;h&#41; &#40;no dose adjustment based on age&#59; limited therapeutic experience in patients &#8805;75 years&#41;&#44; semaglutide 2&#46;4&#8239;mg &#40;subcutaneous injection once weekly&#41; &#40;when available&#59; no dose adjustment based on age&#59; limited therapeutic experience in patients &#8805;75 years&#41;&#44; tirzepatide 5&#47;10&#47;15&#8239;mg &#40;subcutaneous injection once weekly&#41; &#40;when available&#59; weight reduction associated with clinically meaningful improvement in body composition across age groups&#44; including those &#8805;65 years&#41;&#44; or orlistat &#40;oral administration of 60&#8722;120&#8239;mg every 8&#8239;h&#41;&#46; GLP1RA is recommended as the initial option due to its efficacy&#46; Re-evaluation should be conducted after 12 weeks&#44; and if a weight loss of at least 5&#37; is not achieved&#44; discontinuation should be considered&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">2&#46;3&#46; For patients with a BMI over 40&#44; in addition to potential pharmacological treatments&#44; the possibility of bariatric surgery would be evaluated on an individual basis for selected cases&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Discussion</span><p id="par0110" class="elsevierStylePara elsevierViewall">Obesity in the elderly not only has a significant impact on morbidity and mortality but also on quality of life&#46; However&#44; the treatment recommendations for this population remain a subject of research and debate due to the lack of sufficient evidence&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">The objective of this document is to propose a set of recommendations for the management of obesity in individuals above the age of 65&#44; based on scientific evidence and the expertise of the members from the Diabetes&#44; Obesity&#44; and Nutrition Workgroup of the Spanish Society of Internal Medicine&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">When dealing with possible treatment recommendations for older adults with obesity&#44; it is crucial to assess certain essential aspects&#44; including functional status&#44; sarcopenia&#44; and cognitive status&#46; Additionally&#44; it is important to have a comprehensive understanding of the risks associated with weight loss on muscle and bone health&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Lifestyle interventions&#44; such as following a Mediterranean diet pattern and engaging in physical exercise&#44; particularly strength training&#44; are considered the best weight loss plan for the elderly&#46; However&#44; it should be noted that pharmacotherapies that are approved by the FDA and&#47;or EMA for adults have not been extensively studied in the elderly population&#46; Bariatric surgery may be an option for selected candidates&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">It is the responsibility of physicians to recognize obesity as a disease and provide appropriate prevention and treatment measures for obese patients&#46; By addressing obesity&#44; healthcare professionals can contribute to improving the overall health and well-being of their patients&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Funding</span><p id="par0135" class="elsevierStylePara elsevierViewall">Pablo P&#233;rez-Mart&#237;nez has received fees for lectures and educational activities from Ferrer&#44; Novo-Nordisk&#44; Boehringer Ingelheim&#44; Amgen&#44; Esteve&#44; Menarini&#44; Servier&#44; and Viatrix&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Ricardo G&#243;mez-Huelgas has received fees for lectures and educational activities from Novo-Nordisk&#44; Lilly&#44; Boehringer Ingelheim&#44; AstraZeneca&#44; Esteve&#44; and Menarini&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Pedro Pablo Casado-Escribano has received fees for lectures and educational activities from Novo-Nordisk&#44; Boehringer Ingelheim&#44; Menarini&#44; AstraZeneca&#44; Sanofi&#44; and Lilly&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Jos&#233; Carlos Ar&#233;valo-Lorido has received fees for lectures and educational activities from Boehringer Ingelheim and AstraZeneca&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Mar&#237;a Isabel P&#233;rez-Soto6 has received fees for lectures and educational activities from Novo-Nordisk&#44; Boehringer Ingelheim&#44; Nestl&#233;&#44; and Menarini&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Juana Carretero-G&#243;mez5 has received fees for lectures and educational activities from Novo-Nordisk&#44; Boehringer Ingelheim&#44; Menarini&#44; and AstraZeneca&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conflicts of interest</span><p id="par0165" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Obesity in the elderly not only impacts morbidity and mortality but their quality of life&#46; This phenomenon has sparked extensive research and debate regarding treatment recommendations&#44; primarly due to the lack evidence in this specific population&#46; When addressing possible treatment recommendations for older adults with obesity&#44; it is crucial to assess certain essential aspects such as functional status&#44; sarcopenia&#44; cognitive status&#44; and others&#46; Intentional weight loss in this population can be both effective and safe&#46; The best weight loss plan for the elderly revolves around adopting a healthy lifestyle&#44; which includes following a Mediterranean diet pattern and engaging in physical exercise&#44; particularly strength training&#46; Additionally&#44; the use of weight loss medications&#44; particularly glucagon-like peptide-1 receptor agonists &#40;GLP-1 RA&#41; and novel glucose-dependent insulinotropic polypeptide &#40;GIP&#41;&#47;GLP-1 receptor agonists&#44; can provide an additional stage of treatment&#46; In selective candidates&#44; bariatric surgery may also be considered&#46; The objective of this document is to propose a comprehensive algorithm of recommendations for the management of obesity in the elderly &#40;above the age of 65&#41;&#44; based on scientific evidence and the expertise of members from the Diabetes&#44; Obesity&#44; and Nutrition Workgroup of the Spanish Society of Internal Medicine&#46;</p></span>"
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ISSN: 22548874
Original language: English
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