11/20/2019 Management of obesity in the first level of care with an intensive lifestyle change program https://translate.googleusercontent.com/translate_f 1/9 Page 1 1526 Nutr Hosp. 2015; 32 (4): 1526-1534 ISSN 0212-1611 • NUHOEQ CODEN SVR 318 Original / Obesity Obesity management in the first level of care with a program intensive lifestyle change Brianda Ioanna Armenta Guirado, Rolando Giovanni Díaz Zavala, Mauro Eduardo Fernando Valencia Juillerat and Trinidad Maybe Silver University of Sonora. Hermosillo (Sonora), Mexico. Summary Objective: compare an Intensive Change Program Lifestyle with Traditional Treatment for Obesity management in the first level of care. Subjects and methods: randomized intervention study zado controlled, in which 42 adults participated with obesity. Subjects assigned to the Intensive Program Lifestyle Change received a protocol of validated behavior change “Balancing Style Life ”in 12 sessions, weekly consultations with a nutritionist logo and meal replacements. The Traditional Treatment It consisted of monthly consultations with a nutritionist who provided nutritional and physical activity guidance. Results: after three months 97% was measured of the participants who started the study. The subjects Intensive Lifestyle Change Program and the Traditional Treatment showed the following changes in body weight: (median [25-75 percentile]) (-4.7 kg [-6.5, -3.1]) vs. (+0.4 kg [-0.3, 1.3]) 62% of Intensive Change Program participants Lifestyle lost more than 5% of body weight, against 0% in the Traditional Treatment group (p <0.001). Conclusions: this study is preliminary evidence that an Intensive Style Change Program of Life can be an effective alternative for treatment Obesity in the first level of attention. ( Nutr Hosp. 2015; 32: 1526-1534) DOI: 10.3305 / nh. 2015.32.4.9366 Keywords: Obesity. First level. Treatment. Lifestyle Change Program. OBESITY MANAGEMENT IN THE PRIMARY CARE SETTING BY AN INTENSIVE LIFESTYLE INTERVENTION Abstract Objective: the aim of this study was to compare an In- tensive Lifestyle Intervention against Traditional Treat- ment for obesity management in the primary care setting. Subjects and methods: interventional randomized controlled study with participation of 42 obese adults. Subjects assigned to the Intensive Lifestyle Intervention received a validated behavior change protocol “Group Lifestyle Balance ”in 12 sessions, weekly consultations by a nutritionist and meal replacements. Traditional Treat- ment consisted of monthly consultations with a nutritio- nist that provided nutritional assessment and physical activity. Results: almost all study participants (97%) were me- asured after 3 months of intervention. Intensive Lifestyle Intervention and Traditional Treatment subjects showed the following changes in body weight: (Median [25-75th percentile]) (-4.7 kg [-6.5, -3.1]) vs. (+0.4 kg [-0.3, 1.3]) Sixty two percent of Intensive Lifestyle Intervention group participants lost more than 5% body weight vs. 0 % in the traditional treatment group (p <0.001). Conclusions: this preliminary evidence showed that an Intensive Lifestyle Intervention can be an effective stra- tegy for obesity management in the primary care setting. ( Nutr Hosp. 2015; 32: 1526-1534) DOI: 10.3305 / nh. 2015.32.4.9366 Key words: Obesity. Primary care Treatment Lifestyle intervention Correspondence: Rolando Giovanni Díaz Zavala. Department of Chemical-Biological Sciences. University of Sonora. Blvd. Luis Donaldo Colosio and CP 83000 Reform. Hermosillo (Sonora), Mexico. E-mail: rolando.diaz@guayacan.uson.mx Received: VI-18-2015. Accepted: 27-VII-2015. 11/20/2019 Management of obesity in the first level of care with an intensive lifestyle change program https://translate.googleusercontent.com/translate_f 2/9 Page 2 1527 Nutr Hosp. 2015; 32 (4): 1526-1534 Management of obesity in the first level of attention with an intensive program lifestyle change of nursing every one to three months, where give recommendations about diet, physical activity and lifestyle 16 . The evaluation of this type of inter- non-intensive venues without change protocols of behavior in randomized clinical trials shows that, under these traditional schemes the results in weight range from an average reduction of 1.5 kg at an increase of 1 kg per year of follow-up 17-19 The present study aimed to evaluate short term a PICEV - a change protocol for behavior validated in 12 sessions, weekly consultations with an intern nutritionist in social service and utilization Meal replacement meal - compared to the traditional treatment in obesity management in The first level of attention. Materials and methods Study design Randomized clinical trial. It was implemented in the Urban Health Center "Dr. Domingo Olivares ”of the Hermosillo city, which is a premier clinic level of care belonging to the Secretariat of Sa- lud of State of Sonora. The recruitment of par- Participants covered a period of one and a half months, beginning in March and ending in the month of April of 2013. Subsequently, the subjects who met with the inclusion / exclusion criteria were assigned randomized to the PICEV group or the treatment group Traditional in May. The intervention lasted 3 months, from May 6 to August 6, 2013. The three provide carers who implemented the intervention they were internship nutritionists in social service who at At the time of the study they provided social service in the health center, one for the PICEV and two for the treatment traditional lying The principal interest variable of the study was to evaluate the change in body weight at 3 months of intervention As secondary variables, it evaluated the change at 3 months in related parameters swim to obesity as: waist circumference, hip circumference and body fat percentage ral, in addition to systolic and diastolic blood pressure. The study protocol was approved by the Committee of Bioethics of the Department of Medicine and Sciences of the Health of the University of Sonora. All participants Cipants signed an informed consent before of starting the study. Participants Participants were recruited through flyers, posters, direct invitation and references by part of the doctor and / or nursing staff. The crite- Inclusion rivers were the following: age> 18 years and <60, Body Mass Index (BMI)> 30 kg / m 2 and <40 Introduction Obesity in Spanish-speaking countries has increased tado at an unprecedented speed. According to the last National Health and Nutrition Survey “ENSANUT 2012 ”obesity affects 32.4% of Mexicans 1 Likewise, the prevalence of obesity in Spain affects 17% of the adult population 2 and countries like Brazil, Argentina and Chile also have high prevalence lessons in the order of 19.5% to 29.4% 3. Obesity It is one of the main risk factors for diabetes type 2 and cardiovascular diseases 4 , which in turn They are among the leading causes of death in Mexico and other Spanish-speaking countries 5 . A loss of weight moderate 5% to 10% in individuals with obesity dad, is associated with significant improvements in the levels of glucose, plasma lipids, reduction in tension arterial, among other benefits 4 Recently, The Panel of Obesity Experts of the United States “Obesity 2013”, has proposed to Intensive Lifestyle Change Programs (PI- CEV) as the gold standard for handling sity 4 . These programs consist of group visits or weekly individuals (≥ 14 sessions in 6 months), in the initial phase of treatment with a health provider trained lud, where the goal is to make changes in diet, physical activity and body weight, using a validated behavior change protocol 4.6 The Diabetes Prevention Program study and the study Actions for Health in Diabetes showed in 2 multicenter randomized clinical trials cos, that it is possible to achieve adequate weight control body, through a PICEV 7.8 . In the study of Diabetes Prevention Program, participants they managed to lose an average of 7 kg per year of treatment and kept 80% of it at 2.8 years 7 . This it resulted in a reduction in the incidence of diabetes 58% among other benefits, compared to a control group 7 . In the study Actions for Health In Diabetes, patients who received PICEV lo- they recorded a 8.7% reduction per year of follow-up and maintained a loss of 4.4% at 4 years and 4.7% at 8 years old 8 . Concomitant to weight reduction, the patients showed improvements in risk factors diovascular 9 , remission of diabetes 10 , depression and apnea of sleep and urinary incontinence 11 in comparison With a control group. Despite the previous evidence, in Mexico and many chos other Spanish-speaking countries, health centers and hospitals do not apply such programs. Have been made efforts to improve obesity management through standards, consensus and clinical practice guidelines 12-15 . Without However, they still lack essential components. ciales to achieve greater weight loss, such as use of a validated protocol 7 and frequent queries (weekly or biweekly) 4 . The programs that are apply in the first level clinics that provide care tion to patients with obesity, usually consist in consultations by the doctor and / or nutritionist and staff 11/20/2019 Management of obesity in the first level of care with an intensive lifestyle change program https://translate.googleusercontent.com/translate_f 3/9 Page 3 1528 Nutr Hosp. 2015; 32 (4): 1526-1534 Brianda Ioanna Armenta Guirado et al. kg / m 2 , availability of time to attend the program ma intervention, accept and sign the consent informed. While the exclusion criteria was- rum: medical conditions that interfere with weight, in which weight loss is contraindicated or that by themselves they cause loss or increase to the same; previous bariatric surgery, participate in other treatment for weight control, use of medication Mentos or substances with effects on body weight, unintentional or intentional weight loss> 5% of Total body weight in the last 6 months, pregnancy, breastfeeding within the last 6 months, another member family bro who has agreed to participate in the study, consumption greater than 14 alcoholic beverages a the week, use of addictive substances such as drugs, psychiatric condition that prevented adherence to treatment, such as severe depression, bipolarity and schizophrenia; diabetes, uncontrolled dyslipidemia, blood pressure ≥160 / 100 mm Hg and illiteracy. The participants who signed the consent informed and that they met the inclusion criteria sion / exclusion, were randomized to one of the two treatment groups The randomization was stratified each by sex, using a computer program. The person who performed the randomization was not in- turned into recruitment, or some other activity Direct contact with study participants. The couple Participants, internship nutritionists in social service and the personnel who made the measurements in the study did not They were blinded to the treatment group. Interventions Traditional treatment A loss target was set Gives weight of 5 to 10% of body weight. To the participants cipantes of this group were invited to attend consultations monthly during the 3 months of the study. It was awarded an advice, provided by the intern nutritionist in social service, which consisted of nutritional guidance tional, where feeding guides were explained as The Dish of Good Eating 20 , recommendation of physical activity, water and fiber consumption. He calculated the total energy expenditure, a restriction of 500 was made at 1000 calories and a meal plan was granted based on the Mexican Equivalent Food System tes 21 . The consultation time was 40 minutes for the first time and 15-20 minutes for consultations subsequent. Intensive Lifestyle Change Program (PICEV). The participants of this group are planned he had the same weight loss goal as when treating to traditional. It worked on 3 main areas to achieve that goal: 1) Behavior change protocol. It was provided to each participant a color manual of the “Equi- librio de Lifestyle ® ”(protocol implemented in the Diabetes Prevention Program) 7 . Said manual It can be obtained free of charge at: http: //www.diabetes- prevention.pitt.edu/index.php/for-the-public/group-lifes- tyle-balance-materials /. The program manual was revised in group sessions of 1.5 hours weekly, during 3 months of intervention (12 sessions in total). They are set a goal for physical activity of 150 minutes per week (2.5 hours), which should be achieved in a free way dual, as well as a goal of reducing consumption of fat, which ranged from 33 to 55 grams. The participants tes made a record of food consumed and a history of physical activity minutes as well as homework contained in each session, which were reviewed so much in the group session, as in the consultation. 2) Individualized nutritional consultation. The participants cipantes attended weekly consultation with the nu- internship triologist in social service, with a duration of one hour the first time, and 20-30 minutes I consulted them later tas. The intern nutritionist in social service granted a hypocaloric diet of 1200-1800 kcal / day (depending on the participant's energy expenditure) with macronutrient distribution of approximately 55% of carbohydrates, 20% protein and 25% gram s 22 . Within the meal plan, a meal replacement in the morning and one at night during the first month of intervention. The second month, full menus were given, five-stroke measure and last month we worked on teaching Mexican System of Equivalent Foods. In the Subsequent consultations checked the weight, progress of goals, adherence to the meal plan, between others. In case the participant is missing some se- sion or consultation, phone calls were made to schedule an appointment and monitor progress in case The patients did not attend the consultation. 3) Meal replacement. To each participant of the PICEV group, a food supplement was provided mentice (commercial smoothie) of 1 kg, similar to the one used in previous studies 8.23 and it was recommended that They will go for 2 meals a day (breakfast and dinner) during the first month. Subsequently, it was recommended to prepare milkshakes with homemade foods, based on milk Skim, seasonal fruits, oilseeds (such as almond, walnut or peanut) and fiber (5 grams of fi- bra psyllium ). The participants had the option of choose a meal plan developed by the nutritionist logo, from the beginning, if it were not your preference the use of food replacement. Training of internship nutritionists in service Social It was provided to the intern nutritionist in social service of the PICEV group a training in the management of obesity that contemplated readings and seminars (approxi- 25 hours) addressing the following topics on obesity: Epidemiology, causes, consequences cias, benefits of losing weight, review of the litter- The effectiveness of interventions for management jo of obesity in the first level and of the programs Page 4 11/20/2019 Management of obesity in the first level of care with an intensive lifestyle change program https://translate.googleusercontent.com/translate_f 4/9 1529 Nutr Hosp. 2015; 32 (4): 1526-1534 Management of obesity in the first level of attention with an intensive program lifestyle change Intensive lifestyle change, review of the efficacy in the management of obesity with different types of diets and meal replacements, clinical evaluation of the patient with obesity, behavioral strategies. The “Lifestyle Balance ® ” program was reviewed and the manual for the lifestyle counselor ® . The training and feedback was provided by a Bachelor of Nutrition, with Master's and Doctorate Level Degree in science in the area of nutrition with experience CIA in the implementation of PICEV for management of obesity The two intern nutritionists on duty Social treatment group group did not receive rum no additional training by the group of research to give advice on change in the Lifestyle. Measurement of interest variables For weight taking a digital scale was used (Model 872, Seca Gmbh & Co., Hamburg, Germany- girl; capacity 200 ± 0.05 kg), the size was used a portable stadiometer (model 213, Seca Gmbh & Co., Hamburg, Germany; capacity 20-205 ± 0.1 cm) following the techniques recommended by Suaver- za and Haua 24 . The BMI was calculated by dividing the weight of the person (kilograms) between the square of his size in meters (kg / m 2 ). The criteria of the Organization were used World Health Standardization (WHO) for classification tion of their nutritional status (overweight, obesity I and Obesity II) 25 . The waist was measured at the level of the scar umbilical and hip at maximum extension level of the buttocks 24 , using an anthropometric tape fiberglass (GÜLICK brand with scale from 0 to 150 cm) For the measurement of bicipital folds and tricipital 24 a harpenden brand plyometer was used, Model CE 0120 (Co. DJM Tanner, England; opening 80 mm and accuracy 0.2 mm.). Density was estimated body with the Durning prediction equation and Womersley 26 , the percentage was subsequently estimated of fat with the Siri equation. Once the body fat percentage, the participants were classified Pantes such as: 1) Healthy, 2) High in fat and 3) Obe- sity, as indicated by the guidelines of the Or- World Health award 27 . Pressure taking arterial was carried out with the use of a hand Omron brand meter, model HEM-7200 INT (Omron Healthcare Co., Ltd, USA), under the guidelines of the Official Mexican Standard-030 28 Statistic analysis Differences in baseline characteristics and changes in the variables of interest at 3 months are carried out by the t-test for samples Dependents for variables with normal distribution and Mann-Whitney U test in case of variables with non-normal distribution. Normality was verified of distributions through the Shapi test- ro-Wilk W., D'Agostino Skewness, Kurtosis and the cur- It is normal. In the comparison of proportions Chi square test was used. The analyzes of comparison of the changes between both groups is performed only with conservative analyzes by intention to treat. A value of p ≤ 0.05 was considered, using two-tailed test as a criterion for in- Dicar statistical significance. In the intentional analysis To discuss, all participants included were randomized at the beginning, regardless of the level of adherence to treatments. In the 3 cases that was- ron exclusion criteria (the 2 violations of the protocol him and the pregnant woman) the final value in weight was replaced by baseline (no change in respect to the beginning) corresponding to the extrapolation of the Basal observation carried towards the end. Every year Statistical lysis was performed with the NCSS program 2009 (Number Cruncher Statistical System, Kaysville, UT, USA). Results Participants A total of 51 individuals were evaluated, of which only 42 participants met the criteria of inclusion. In the PICEV group, 21 individuals received the assigned intervention was rung and there were three interruptions premature (Fig. 1). In Traditional Treatment, of the 21 participants, only one did not receive the intervention In addition, 2 violations were filed. mentions to the protocol In the PICEV group they participate Theses attended 8.2 (66%) of the 12 group sessions Already planned 8.8 (75%) of the 12 individual consultations I planned them. In contrast, in the Treatment group Traditional participants attended 2.1 (70%) of 3 of the agreed consultations. Final measurements were obtained from all participants of both groups (97.6% retention), including the 3 participants with early interruption TICE of the PICEV group and the 2 cases of violation of Traditional Treatment protocol. The only case that was not measured was a woman who became pregnant gives during the study (Fig. 1). The group of Traditional Treatment and the PICEV group were similar in all baseline characteristics (p> 0.05) (Table I). Changes in weight. After three months of inter- The PICEV group lost [median (per- centile 25-75)] -4.70 kg (-6.50, -3.10) against a win- cia of 0.40 kg (-0.35, 1.30) of the Treatment group Traditional (Fig. 2). 62% of the participants of the Intensive Style Change Program group Life lost more than 5% of body weight against 0% of the Traditional Treatment group (p <0.001) (Fig. 3). Page 5 11/20/2019 Management of obesity in the first level of care with an intensive lifestyle change program https://translate.googleusercontent.com/translate_f 5/9 1530 Nutr Hosp. 2015; 32 (4): 1526-1534 Brianda Ioanna Armenta Guirado et al. Change in parameters related to the Sity Regarding the BMI variables, waist circumference, hip circumference and body fat percentage, a reduction was found significant relationship in favor of the PICEV group pos- after the treatment period (p <0.0001) (Table II). On the other hand, in the PICEV group a total of 38% of the participants managed to change the degree of obesity against 0% in the treatment group Traditional treatment (p ≤ 0.01). 14% of the group of PICEV went from having grade II obesity to obesity Grade I. Additionally, 24% of the participants tes diagnosed with grade I obesity, reduced your BMI up to the overweight category. Results similar were observed in the percentage of fat with 43% of PICEV individuals who changed from the category of "Obesity" to "High fat", in contrast with no significant change in the Tra- Traditional treatment (p ≤ 0.001). In the variables of systolic and diastolic blood pressure was not observed any significant difference ( p = 0.38 and p = 0.054, respectively). Fig. 1. — Flowchart of study participants over three months. Page 6 Table I Baseline characteristics of the participants treated in the Intensive Lifestyle Change Program (PICEV) and the Traditional Treatment Group PICEV (n = 21) Control Group (n = 21) ‡ 11/20/2019 Management of obesity in the first level of care with an intensive lifestyle change program https://translate.googleusercontent.com/translate_f 6/9 1531 Nutr Hosp. 2015; 32 (4): 1526-1534 Management of obesity in the first level of attention with an intensive program lifestyle change Side Effects No effect was reported. adverse during the intervention, except for 6 cases You are constipated in the PICEV group and 4 reports of constipation in the Traditional Treatment group nal ( P = 0.46). These participants received indica- nutritional actions that solved the problem in all cases. Discussion The present study suggests that a PICEV – a pro- Tocole of behavior change validated in 12 sessions group, weekly consultations with a nutritionist pa- sante in social service and the use of replacements of meals - can be a potential model for the treatment Obesity treatment at the first level of care. The PICEV induced a loss of 4.7 kg, (5.3%) of body weight after three months of treatment, in addition to improvements in waist, hip and percentage of body fat. Sixty-two percent of the participants cipantes achieved a loss> 5% of body weight, 24% stopped being obese and 14% changed obesity grade II to obesity grade I. On the contrary In the Traditional Treatment, no bene- ficios in any of the parameters of obesity. The previous results are slightly higher res to those found in the studies of the Program of Diabetes Prevention and the Study of Actions in Health in Diabetes that are considered as a reference Characteristic mean ± SD mean ± SD P value * Sex, M / F 4/17 4/17 - Age, years 39.0 ± 9.22 35.8 ± 8.44 0.24 Weight, kg § 87.7 ± (79.4, 98.6) 88.0 ± (82.5, 96.1) 0.89 Size M 1.62 ± 0.09 1.63 ± 0.09 0.70 IMC | , kg / m 2 34.2 ± 2.94 33.8 ± 2.77 0.63 Waist circumference, cm 106 ± 9.52 105 ± 8.40 0.84 Hip circumference, cm 115 ± 7.65 114 ± 9.00 0.67 Systolic Blood Pressure, mmHg § 118 ± (114, 122) 118 ± (112, 128) 0.84 Diastolic Blood Pressure, mmHg § 78.0 ± (71.5, 82.0) 77.5 ± (71.0, 81.0) 0.66 Body fat,% § 41.3 ± (39.2, 43.2) 40.5 ± (38.8, 43.4) 0.80 * T test for independent samples. § They are shown as medium (25th, 75th percentile). Analysis with Mann-Withney test. ‡ N = 20 for all variables, except weight (n = 21). ¦ BMI: body mass index. Fig. 2. — Individual changes dual in body weight with an Intensive Program of Change in Style Life or Traditional Treatment after 3 months of intervention. Page 7 11/20/2019 Management of obesity in the first level of care with an intensive lifestyle change program https://translate.googleusercontent.com/translate_f 7/9 1532 Nutr Hosp. 2015; 32 (4): 1526-1534 Brianda Ioanna Armenta Guirado et al. recencies of what a PICEV represents, in the same 3 month period (5.3% in our study against approximately 4.2 and 2.5%, respectively) 7.8 already the results obtained in the studies by Wadden and Tsai (4% and 5.1%, respectively) to be implemented they took the first level of attention 29,30 , considering the same period of 3 months. A study implements In primary care in Spain, it showed that during a program based on diet, physical activity, psychological support and frequent group sessions in the initial phase, patients reduced 6.8 kg to 6 months, however the final retention of participants was 45% 31 On the other hand, the results observed in the group Po traditional are similar to those found in treatment- 18-20 low frequency . The panel of experts in United States obesity consistently found Tent that this type of treatment has no effect to in body weight 4 , so they should give up- swim completely. Also the panel of experts, based on the review of the evidence, he established that PICEV, like the one implemented in the present study, they are the gold standard in obesity management 4 Several reasons could explain the contrast of Results found. The PICEV includes a protocol the validated behavior change, which contemplates various aspects associated in a better result in body weight (nutritional education, therapy with ductual 32 : emotion management, social support, desa- development and acquisition of skills, establishment of goals, self-monitoring, stimulus control, use ment of meal replacements 8.24 and greater intent sity of treatment 4.33 ), which contrasts in a way Important with traditional consultations. Table II Analysis pot intention to deal with changes in obesity parameters and blood pressure after 3 months of intervention, through an Intensive Lifestyle Change Program (PICEV) and a Traditional Treatment (TT) Variable PICEV Mean ± SD or Medium (P 25.75) (n = 21) TT Mean ± SD or Medium (P 25.75) (n = 21) P value Weight, kg § -4.70 (-6.50, -3.10) 0.40 (-0.35, 1.30) <0.0001 IMC | , kg / m 2 § -1.70 (-2.40, -1.20) 0.10 (-0.15, 0.55) <0.0001 Waist circumference, cm a -5.07 ± 3.20 -0.03 ± 2.46 <0.0001 Hip circumference, cm § -3.00 (-5.50, -2.00) 0.25 (-0.75, 1.75) <0.0001 Systolic Blood Pressure, mmHg § -1.00 (-4.00, 1.50) -0.50 (-2.00, 2.50) 0.38 Diastolic Blood Pressure, mmHg a -1.52 ± 2.66 0.30 ± 3.16 0.054 Body fat,% a -2.56 ± 1.46 0.02 ± 0.79 <0.0001 a T-Student test for independent samples. § They are shown as medium (25th, 75th percentile). Analysis with Mann-Withney test. ¦ BMI: body mass index. Fig. 3. — Percentage of individuals with a loss of weight greater than 5% in the Intensive Program of Cam- Bio of Lifestyle and Traditional Treatment after 3 months of intervention. Page 8 First level health providers frequently they do not diagnose or treat patients with Obesity 34 , so having an effective program it represents an opportunity to refer their patients tes, without being affected by a greater workload. Internship nutritionists in social service or others health providers such as doctors, nurses or psychologists could be trained to implement the program in the first level of care clinics without generating excessive expenses. However, the imple- Mention of a PICEV implies a greater amount of time and space, which limits its application; no However, some researchers who have implemented All these programs in the community have 2. Ministry of Health, Social Services and Equality. Poll National Health Spain 2011/12. Main results. Technical note. 2013 3. Food and Agriculture Organization of The United Nations. The State of Food and Agriculture. FAO 2013. E-ISBN 978-92-5- 107672-9. 4. Jensen MD, Ryan DH, Donato KA, Apovian CM, Ard JD, Co- muzzie AG, et al. Guidelines (2013) for managing overweight and obesity in adults. Obesity 2014; 22: S1-S410. 5. World Health Organization (WHO). Report on the world situation of noncommunicable diseases 2010 Orientation Summary 2010 6. Wadden TA, Webb VL, Moran CH, Bailer BA. Lifestyle Mo- dification for Obesity: New Developments in Diet, Physical Activity, and Behavior Therapy. Circulation 2012; 125: 1157- 1170 7. Diabetes Prevention Program Research Group. Reduction in 11/20/2019 Management of obesity in the first level of care with an intensive lifestyle change program https://translate.googleusercontent.com/translate_f 8/9 1533 Nutr Hosp. 2015; 32 (4): 1526-1534 Management of obesity in the first level of attention with an intensive program lifestyle change counteracted with group sessions 35 The main strengths of this work were- rum the high retention of participants, the random design torizado of the study and that health providers participants had similar experience in handling of obesity at the beginning. On the other hand, among the limitations nes of the study, it should be noted that the study was limited to a health center so it is not representative of the first level of attention. Also, the period intervention is only in the short term, so require studies with long-term follow-up. Conclusions The present study shows preliminary evidence that a PICEV can be an effective alternative to Obesity treatment at the first level of care tion. Similar interventions are required to this work but of greater duration and representativeness of first level of attention, which allow to generalize the findings found. Interest conflict None. Thanks To the University of Sonora for providing the resources and facilities needed to implement the study. To Dr. Eva Moncada García, director of the Centro de Sa- lud Urbano Dr. Domingo Olivares and all the staff that works there, for the facilities granted. To NHL. Aída Duarte Franco and Janeth Suarez Oromuni for their collaboration in the implementation of the intervention. References 1. Gutiérrez JP, Rivera-Dommarco J, Shamah-Levy T, Villalpan- do-Hernández S, Franco A, Cuevas-Nasu L, et al. Poll National Health and Nutrition 2012. National Results. 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