array:24 [
  "pii" => "S1578219011000576"
  "issn" => "15782190"
  "doi" => "10.1016/j.adengl.2011.03.007"
  "estado" => "S300"
  "fechaPublicacion" => "2011-09-01"
  "aid" => "387"
  "copyright" => "Elsevier España, S.L. and AEDV"
  "copyrightAnyo" => "2011"
  "documento" => "article"
  "crossmark" => 0
  "subdocumento" => "fla"
  "cita" => "Actas Dermosifiliogr. 2011;102:505-9"
  "abierto" => array:3 [
    "ES" => true
    "ES2" => true
    "LATM" => true
  ]
  "gratuito" => true
  "lecturas" => array:2 [
    "total" => 3572
    "formatos" => array:3 [
      "EPUB" => 40
      "HTML" => 2399
      "PDF" => 1133
    ]
  ]
  "Traduccion" => array:1 [
    "es" => array:19 [
      "pii" => "S0001731011001712"
      "issn" => "00017310"
      "doi" => "10.1016/j.ad.2011.03.010"
      "estado" => "S300"
      "fechaPublicacion" => "2011-09-01"
      "aid" => "387"
      "copyright" => "Elsevier España, S.L. y AEDV"
      "documento" => "article"
      "crossmark" => 0
      "subdocumento" => "fla"
      "cita" => "Actas Dermosifiliogr. 2011;102:505-9"
      "abierto" => array:3 [
        "ES" => true
        "ES2" => true
        "LATM" => true
      ]
      "gratuito" => true
      "lecturas" => array:2 [
        "total" => 7238
        "formatos" => array:3 [
          "EPUB" => 2
          "HTML" => 4571
          "PDF" => 2665
        ]
      ]
      "es" => array:12 [
        "idiomaDefecto" => true
        "cabecera" => "<span class="elsevierStyleTextfn">Dermatolog&#237;a pr&#225;ctica</span>"
        "titulo" => "Psoriasis y obesidad&#58; revisi&#243;n y recomendaciones pr&#225;cticas"
        "tienePdf" => "es"
        "tieneTextoCompleto" => "es"
        "tieneResumen" => array:2 [
          0 => "es"
          1 => "en"
        ]
        "paginas" => array:1 [
          0 => array:2 [
            "paginaInicial" => "505"
            "paginaFinal" => "509"
          ]
        ]
        "titulosAlternativos" => array:1 [
          "en" => array:1 [
            "titulo" => "Psoriasis and Obesity&#58; A Review and Practical Recommendations"
          ]
        ]
        "contieneResumen" => array:2 [
          "es" => true
          "en" => true
        ]
        "contieneTextoCompleto" => array:1 [
          "es" => true
        ]
        "contienePdf" => array:1 [
          "es" => true
        ]
        "autores" => array:1 [
          0 => array:2 [
            "autoresLista" => "M&#46;M&#46; Far&#237;as, V&#46; Serrano, C&#46; de la Cruz"
            "autores" => array:3 [
              0 => array:2 [
                "nombre" => "M&#46;M&#46;"
                "apellidos" => "Far&#237;as"
              ]
              1 => array:2 [
                "nombre" => "V&#46;"
                "apellidos" => "Serrano"
              ]
              2 => array:2 [
                "nombre" => "C&#46;"
                "apellidos" => "de la Cruz"
              ]
            ]
          ]
        ]
      ]
      "idiomaDefecto" => "es"
      "Traduccion" => array:1 [
        "en" => array:9 [
          "pii" => "S1578219011000576"
          "doi" => "10.1016/j.adengl.2011.03.007"
          "estado" => "S300"
          "subdocumento" => ""
          "abierto" => array:3 [
            "ES" => true
            "ES2" => true
            "LATM" => true
          ]
          "gratuito" => true
          "lecturas" => array:1 [
            "total" => 0
          ]
          "idiomaDefecto" => "en"
          "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219011000576?idApp=UINPBA000044"
        ]
      ]
      "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0001731011001712?idApp=UINPBA000044"
      "url" => "/00017310/0000010200000007/v1_201304241332/S0001731011001712/v1_201304241332/es/main.assets"
    ]
  ]
  "itemSiguiente" => array:19 [
    "pii" => "S1578219011000321"
    "issn" => "15782190"
    "doi" => "10.1016/j.adengl.2011.02.003"
    "estado" => "S300"
    "fechaPublicacion" => "2011-09-01"
    "aid" => "359"
    "copyright" => "Elsevier Espa&#241;a&#44; S&#46;L&#46; and AEDV"
    "documento" => "article"
    "crossmark" => 0
    "subdocumento" => "fla"
    "cita" => "Actas Dermosifiliogr. 2011;102:510-6"
    "abierto" => array:3 [
      "ES" => true
      "ES2" => true
      "LATM" => true
    ]
    "gratuito" => true
    "lecturas" => array:2 [
      "total" => 4019
      "formatos" => array:3 [
        "EPUB" => 43
        "HTML" => 3135
        "PDF" => 841
      ]
    ]
    "en" => array:13 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Original Article</span>"
      "titulo" => "Propranolol for the Treatment of Severe Hemangiomas of Infancy&#58; Results From a Series of 28 Patients"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "tieneResumen" => array:2 [
        0 => "en"
        1 => "es"
      ]
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "510"
          "paginaFinal" => "516"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "es" => array:1 [
          "titulo" => "Tratamiento con propranolol oral para hemangiomas infantiles graves&#58; serie de 28 pacientes"
        ]
      ]
      "contieneResumen" => array:2 [
        "en" => true
        "es" => true
      ]
      "contieneTextoCompleto" => array:1 [
        "en" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "resumenGrafico" => array:2 [
        "original" => 0
        "multimedia" => array:7 [
          "identificador" => "fig0010"
          "etiqueta" => "Figure 2"
          "tipo" => "MULTIMEDIAFIGURA"
          "mostrarFloat" => true
          "mostrarDisplay" => false
          "figura" => array:1 [
            0 => array:4 [
              "imagen" => "gr2.jpeg"
              "Alto" => 598
              "Ancho" => 900
              "Tamanyo" => 46778
            ]
          ]
          "descripcion" => array:1 [
            "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Patient from Figure 1 after 5&#46;5 months of treatment &#40;age 7&#46;5 months&#41;&#46;</p>"
          ]
        ]
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "J&#46; Bernabeu-Wittel, J&#46;J&#46; Pereyra-Rodr&#237;guez, M&#46;E&#46; Mantrana-Bermejo, I&#46; Fern&#225;ndez-Pineda, J&#46;C&#46; de Agust&#237;n, J&#46; Conejo-Mir"
          "autores" => array:6 [
            0 => array:2 [
              "nombre" => "J&#46;"
              "apellidos" => "Bernabeu-Wittel"
            ]
            1 => array:2 [
              "nombre" => "J&#46;J&#46;"
              "apellidos" => "Pereyra-Rodr&#237;guez"
            ]
            2 => array:2 [
              "nombre" => "M&#46;E&#46;"
              "apellidos" => "Mantrana-Bermejo"
            ]
            3 => array:2 [
              "nombre" => "I&#46;"
              "apellidos" => "Fern&#225;ndez-Pineda"
            ]
            4 => array:2 [
              "nombre" => "J&#46;C&#46;"
              "apellidos" => "de Agust&#237;n"
            ]
            5 => array:2 [
              "nombre" => "J&#46;"
              "apellidos" => "Conejo-Mir"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "Traduccion" => array:1 [
      "es" => array:9 [
        "pii" => "S0001731011001128"
        "doi" => "10.1016/j.ad.2011.02.009"
        "estado" => "S300"
        "subdocumento" => ""
        "abierto" => array:3 [
          "ES" => true
          "ES2" => true
          "LATM" => true
        ]
        "gratuito" => true
        "lecturas" => array:1 [
          "total" => 0
        ]
        "idiomaDefecto" => "es"
        "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0001731011001128?idApp=UINPBA000044"
      ]
    ]
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219011000321?idApp=UINPBA000044"
    "url" => "/15782190/0000010200000007/v1_201304241231/S1578219011000321/v1_201304241231/en/main.assets"
  ]
  "itemAnterior" => array:19 [
    "pii" => "S1578219011000424"
    "issn" => "15782190"
    "doi" => "10.1016/j.adengl.2011.03.004"
    "estado" => "S300"
    "fechaPublicacion" => "2011-09-01"
    "aid" => "374"
    "copyright" => "Elsevier Espa&#241;a&#44; S&#46;L&#46; and AEDV"
    "documento" => "article"
    "crossmark" => 0
    "subdocumento" => "ssu"
    "cita" => "Actas Dermosifiliogr. 2011;102:498-504"
    "abierto" => array:3 [
      "ES" => true
      "ES2" => true
      "LATM" => true
    ]
    "gratuito" => true
    "lecturas" => array:2 [
      "total" => 3580
      "formatos" => array:3 [
        "EPUB" => 46
        "HTML" => 2800
        "PDF" => 734
      ]
    ]
    "en" => array:13 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Novelties in Dermatology</span>"
      "titulo" => "Role of Chemokines in Melanoma Progression"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "tieneResumen" => array:2 [
        0 => "en"
        1 => "es"
      ]
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "498"
          "paginaFinal" => "504"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "es" => array:1 [
          "titulo" => "Papel de las quimiocinas en la progresi&#243;n del melanoma"
        ]
      ]
      "contieneResumen" => array:2 [
        "en" => true
        "es" => true
      ]
      "contieneTextoCompleto" => array:1 [
        "en" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "resumenGrafico" => array:2 [
        "original" => 0
        "multimedia" => array:7 [
          "identificador" => "fig0005"
          "etiqueta" => "Figure 1"
          "tipo" => "MULTIMEDIAFIGURA"
          "mostrarFloat" => true
          "mostrarDisplay" => false
          "figura" => array:1 [
            0 => array:4 [
              "imagen" => "gr1.jpeg"
              "Alto" => 2424
              "Ancho" => 2500
              "Tamanyo" => 262194
            ]
          ]
          "descripcion" => array:1 [
            "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Involvement of chemokines and their receptors in selective metastasis in patients with cutaneous melanoma&#46; Black arrows indicate well-characterized interactions between chemokines and their receptors&#59; gray arrows indicate potential associations that remain to be fully characterized&#59; curved arrows indicate the autologous production of chemokines &#40;ligands&#41; by the tumor cells leading to autocrine effects&#46; CNS indicates central nervous system&#46;</p>"
          ]
        ]
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "C&#46; Monteagudo, A&#46; Pell&#237;n-Carcel&#233;n, J&#46;M&#46; Mart&#237;n, D&#46; Ramos"
          "autores" => array:4 [
            0 => array:2 [
              "nombre" => "C&#46;"
              "apellidos" => "Monteagudo"
            ]
            1 => array:2 [
              "nombre" => "A&#46;"
              "apellidos" => "Pell&#237;n-Carcel&#233;n"
            ]
            2 => array:2 [
              "nombre" => "J&#46;M&#46;"
              "apellidos" => "Mart&#237;n"
            ]
            3 => array:2 [
              "nombre" => "D&#46;"
              "apellidos" => "Ramos"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "Traduccion" => array:1 [
      "es" => array:9 [
        "pii" => "S0001731011001402"
        "doi" => "10.1016/j.ad.2011.03.004"
        "estado" => "S300"
        "subdocumento" => ""
        "abierto" => array:3 [
          "ES" => true
          "ES2" => true
          "LATM" => true
        ]
        "gratuito" => true
        "lecturas" => array:1 [
          "total" => 0
        ]
        "idiomaDefecto" => "es"
        "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0001731011001402?idApp=UINPBA000044"
      ]
    ]
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219011000424?idApp=UINPBA000044"
    "url" => "/15782190/0000010200000007/v1_201304241231/S1578219011000424/v1_201304241231/en/main.assets"
  ]
  "en" => array:19 [
    "idiomaDefecto" => true
    "cabecera" => "<span class="elsevierStyleTextfn">Practical Dermatology</span>"
    "titulo" => "Psoriasis and Obesity&#58; A Review and Practical Recommendations"
    "tieneTextoCompleto" => true
    "paginas" => array:1 [
      0 => array:2 [
        "paginaInicial" => "505"
        "paginaFinal" => "509"
      ]
    ]
    "autores" => array:1 [
      0 => array:4 [
        "autoresLista" => "M&#46;M&#46; Far&#237;as, V&#46; Serrano, C&#46; de la Cruz"
        "autores" => array:3 [
          0 => array:4 [
            "nombre" => "M&#46;M&#46;"
            "apellidos" => "Far&#237;as"
            "email" => array:1 [
              0 => "mmfarias&#64;gmail&#46;com"
            ]
            "referencia" => array:2 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "aff0005"
              ]
              1 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">¿</span>"
                "identificador" => "cor0005"
              ]
            ]
          ]
          1 => array:3 [
            "nombre" => "V&#46;"
            "apellidos" => "Serrano"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "aff0005"
              ]
            ]
          ]
          2 => array:3 [
            "nombre" => "C&#46;"
            "apellidos" => "de la Cruz"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">b</span>"
                "identificador" => "aff0010"
              ]
            ]
          ]
        ]
        "afiliaciones" => array:2 [
          0 => array:3 [
            "entidad" => "Departamento de Nutrici&#243;n&#44; Pontificia Universidad Cat&#243;lica de Chile&#44; Santiago&#44; Chile"
            "etiqueta" => "<span class="elsevierStyleSup">a</span>"
            "identificador" => "aff0005"
          ]
          1 => array:3 [
            "entidad" => "Departamento de Dermatolog&#237;a&#44; Pontificia Universidad Cat&#243;lica de Chile&#44; Santiago&#44; Chile"
            "etiqueta" => "<span class="elsevierStyleSup">b</span>"
            "identificador" => "aff0010"
          ]
        ]
        "correspondencia" => array:1 [
          0 => array:3 [
            "identificador" => "cor0005"
            "etiqueta" => "&#8270;"
            "correspondencia" => "Corresponding author&#46;"
          ]
        ]
      ]
    ]
    "titulosAlternativos" => array:1 [
      "es" => array:1 [
        "titulo" => "Psoriasis y obesidad&#58; revisi&#243;n y recomendaciones pr&#225;cticas"
      ]
    ]
    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">It has recently been found that patients with psoriasis have a higher prevalence of certain metabolic disorders considered to be cardiovascular risk factors&#44;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> particularly obesity&#44; diabetes or impaired glucose tolerance&#44; dyslipidemias&#44; and systemic hypertension&#44; which together are known as the metabolic syndrome&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Psoriasis is now also considered to be a marker of increased risk of myocardial infarction in young patients&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Obesity is a chronic disease characterized by excess weight due to increased energy deposits in the form of fat&#46; Specifically&#44; this excess weight due to an increase in body fat mass is described in relation to the height of the patient&#44; and the diagnosis of overweight is established using the body mass index &#40;BMI&#41;&#44; defined as the weight in kilograms divided by the square of the height in meters&#46; The World Health Organization<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> currently recommends classification of the adult population into the following categories according to BMI cutoff points&#58; normal&#44; 18&#46;5 to 24&#46;9&#160;kg&#47;m<span class="elsevierStyleSup">2</span>&#59; overweight&#44; 25 to 29&#46;9<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span>&#59; and obese&#44; greater than 30<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Obesity is a growing epidemic worldwide&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Both overweight and obesity have increased in Spain in recent years&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> The close association between obesity and higher mortality&#44; as well as the increased risk of developing type 2 diabetes&#44; systemic hypertension&#44; dyslipidemia&#44; cardiovascular disease&#44; and cancer&#44; among other diseases&#44; makes obesity a major public health problem&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The association between obesity and certain skin diseases has been extensively studied and demonstrated<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;8</span></a>&#59; in the case of psoriasis&#44; it was first detected in epidemiological studies conducted in Europe&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;10</span></a> In 1986&#44; a Scandinavian study revealed a higher prevalence of obesity in women with psoriasis than in other women&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Later&#44; Herron<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> provided further evidence of this association when he detected a higher probability of developing obesity in his cohort of 500 patients with psoriasis than in the rest of the population of the state of Utah&#44; United States &#40;34&#37; vs 18&#37;&#59; <span class="elsevierStyleItalic">P</span>&#60;&#46;001&#41;&#46; Based on their findings&#44; those authors suggested obesity was a consequence of psoriasis rather than a risk factor for the skin disease&#46; In addition&#44; a study by Neimann<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> demonstrated that the risk of obesity was higher in patients with severe psoriasis &#40;odds ratio &#91;OR&#93;&#44;<span class="elsevierStyleHsp" style=""></span>1&#46;8&#41; than in those with moderate psoriasis &#40;OR&#44;<span class="elsevierStyleHsp" style=""></span>1&#46;3&#41;&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The idea of a connection between nutrition and the clinical course of psoriasis arose when symptomatic improvement was observed during periods of fasting or lower calorie intake&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> The Bardazzi research group&#44;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> with a sample of 33 patients with moderate to severe psoriasis&#44; reported a greater response to biological therapy in those patients who reduced their BMI&#44; even with reductions of as little as 5<span class="elsevierStyleHsp" style=""></span>kg body weight over 8 months of follow-up&#46; In a study performed in Croatia involving 82 patients with a 10-year history of psoriasis vulgaris treated using standard topical treatment&#44; 40 patients received the usual hospital diet and 42 received a low-calorie diet&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> After 4 weeks&#44; the low-calorie-diet group showed a statistically significant improvement in their skin lesions compared to the control group&#46; In another study involving 61 obese patients with moderate or severe psoriasis on treatment with low-dose ciclosporin&#44; the response to the drug was considerably better in the group receiving a low-calorie diet &#40;reduction of 500<span class="elsevierStyleHsp" style=""></span>kcal&#47;day&#41; than in the control group with no change in calorie intake&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Those studies coincide in proposing a low-calorie diet as coadjuvant therapy in the management of psoriasis&#46; It would therefore be interesting to reach a better understanding of this association and to develop useful tools for the nutritional management of these patients in the dermatology clinic&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Obesity and Inflammation</span><p id="par0035" class="elsevierStylePara elsevierViewall">Obesity is currently considered to be a low-grade chronic inflammatory disease characterized by an elevation of the plasma levels of proinflammatory cytokines&#44; such as tumor necrosis factor &#40;TNF&#41; &#945; and interleukin &#40;IL&#41; 6&#44; and of acute-phase proteins such as C-reactive protein &#40;CRP&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> The association of psoriasis with obesity may be explained by the specific inflammatory activity of the adipocytes&#46; Adipose tissue&#44; typically thought of as an energy store&#44; is able to communicate with the rest of the body through the secretion of adipokines&#44; which are molecules with proinflammatory&#44; thrombotic&#44; and vasoactive properties&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Particularly important adipokines are TNF-&#945;&#44; plasminogen activator inhibitor 1&#44; IL-6&#44; and leptin&#46; There is also a fall in the levels of adiponectin&#44; a cytokine with anti-inflammatory activity&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> These signals attract macrophages to the adipose tissue&#46; After entering the adipose tissue&#44; mature macrophages maintain the cytokine secretion&#44; leading to a local primary inflammatory response&#46; The cytokines subsequently trigger the production of inflammatory proteins in the liver&#44; thus causing the low-grade systemic inflammatory state observed in obesity&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> Cytokines also increase lipolysis&#44; leading to a constant release of free fatty acids from the adipose tissue into the peripheral circulation&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> Free fatty acids are considered to be an important link between adipose tissue activity and chronic inflammation as they can increase oxidative stress and thus augment the inflammatory environment and vascular activity&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> It should be noted that predominantly central obesity&#44; compared with a peripheral distribution of fat&#44; is associated with a large amount of visceral fat&#46; Adipocytes in the visceral fat are metabolically more active and they release larger quantities of cytokines and fatty acids&#46; This would lead us to expect an even more active inflammatory environment in patients with abdominal obesity&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Foods have also been implicated in inflammation&#46; Aijada et al<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> showed that eating fast food &#40;900<span class="elsevierStyleHsp" style=""></span>kcal&#44; rich in fats and simple sugars&#41; could lead to an increase in inflammatory factors such as CRP&#46; This effect would be mediated by the activation of the nuclear factor kappa B &#40;NF-&#954;B&#41; present in the white blood cells&#59; the transcriptional activity of NF-&#954;B is related to the release of free oxygen radicals and cytokines with inflammatory activity&#46; This same effect was observed after administering an intravenous infusion of triglycerides to healthy individuals&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">It has been suggested that the inflammatory state associated with obesity is the link between various pathological conditions that make up the metabolic syndrome&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> The effect of the cytokines on insulin sensitivity in the liver<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> and muscle<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> has been studied extensively&#44; whereas the association between psoriasis and obesity has only been demonstrated clinically in recent decades&#44;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">27&#44;28</span></a> and there has been no detailed study of the molecular mechanisms involved&#46; However&#44; psoriasis and obesity are both inflammatory disorders&#44; and the pathophysiological changes&#44; including inflammatory pathways and elevated cytokine levels&#44; are similar in the 2 conditions&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> From this point of view&#44; it would appear reasonable to suggest that a reduction in energy intake&#44; with the consequent weight loss&#44; could contribute positively to reducing the proinflammatory state and improving the clinical course of obese patients with psoriasis&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Recommendations</span><p id="par0055" class="elsevierStylePara elsevierViewall">The high prevalence of comorbid diseases in patients with psoriasis means that they would benefit from a holistic approach with multisystem management&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> It is particularly important to stratify patients according to their cardiovascular risk&#46; For this purpose&#44; the National Psoriasis Foundation<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> recommends adherence to the current guidelines for screening and goals for cardiovascular risk factors established by the American Heart Association &#40;AHA&#41;&#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> Those guidelines have been modified with lower cutoff points for cholesterol levels in patients with high cardiovascular risk&#46; Specialist consultation is recommended in these cases in order to avoid any delay in the initiation of aggressive management of the metabolic parameters&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">All patients&#44; and particularly those with a BMI over 25&#44; should be instructed in nonpharmacological measures aimed at lifestyle changes&#46; The objective is to achieve healthy eating habits that can be maintained over time and that will result in controlled weight loss&#46; A low-calorie diet based on the Step 1 diet &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41; should be recommended&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> This diet involves reducing total calorie intake by 500 to 1000<span class="elsevierStyleHsp" style=""></span>kcal per day&#44; depending on the patient&#39;s energy expenditure&#46; An individual&#39;s energy expenditure at rest can be calculated using measurement techniques&#44; such as indirect calorimetry&#44; or mathematical formulae&#44; the most widely used of which is the Harris-Benedict formula &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#44; which takes into account parameters such as sex&#44; age&#44; and height&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> To achieve good adherence to the dietary therapy&#44; we recommend application of the practical recommendations proposed by the AHA &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> Patients with severe obesity &#40;BMI&#160;&#62;40&#41; should be referred to a specialist to consider surgical treatment&#46; The effectiveness of this type of procedure in the remission of comorbid conditions and in the long-term maintenance of body weight makes it the treatment of choice in patients with severe obesity&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a> There have recently been case reports describing patients with psoriasis whose lesions have shown a marked improvement within months of undergoing gastric bypass surgery&#46;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">37&#44;38</span></a></p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Physical activity should be indicated on an individual basis according to age&#44; tolerance&#44; preference&#44; etc&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> Ideally&#44; patients should start with 30<span class="elsevierStyleHsp" style=""></span>minutes of physical activity 3 times a week&#44;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> but a metabolic effect with major benefit is obtained with at least 150<span class="elsevierStyleHsp" style=""></span>minutes of moderately intense physical activity per week&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a> Furthermore&#44; patients must stop smoking&#44; as this is known to exacerbate psoriasis&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Specialist management is essential when comorbid psychiatric and psychological conditions are detected&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Finally&#44; current evidence indicates that it is essential to take all comorbid metabolic conditions into account before deciding which pharmacological therapy to prescribe for psoriasis&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a> Conditions such as obesity and nonalcoholoic fatty liver or steatohepatitis are relative contraindications for the use of methotrexate&#44; due to the risk of hepatic toxicity&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">42&#44;43</span></a> Some immunomodulating biologic agents&#44; such as alefacept&#44; etanercept&#44; and ustekinumab&#44; are less effective in obese patients&#44; whereas others&#44; such as infliximab&#44; whose dose must be adjusted according to the BMI&#44; maintain their effectiveness&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a> In addition&#44; obesity&#44; hypertension&#44; and dyslipidemia interfere with the use of ciclosporin as they increase the risk of nephrotoxicity&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">41&#44;44</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0080" class="elsevierStylePara elsevierViewall">Conventional psoriasis treatments are based on the severity of the disease&#46; The need for safe and effective treatments has led to a search for modifiable factors that could improve the response to conventional therapy&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">45</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">The pathophysiology of psoriasis and of obesity have common inflammatory pathways and cytokine activation&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">46</span></a> Clinical studies have strengthened the idea that weight loss could have an additional therapeutic effect in the conventional treatment of obese patients with psoriasis&#44; particularly in those with moderate to severe disease&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Furthermore&#44; psoriasis should be considered to be a specific cardiovascular risk factor&#46; A higher incidence of ischemic events has been reported in these patients independently of their other cardiovascular risk factors&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;47</span></a> A possible benefit in the reduction of cardiovascular risk has also been attributed to immunomodulatory treatment with TNF-&#945; inhibitors&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">48</span></a> We hope that the international guidelines for cardiovascular risk prevention will take these findings into consideration in the future&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Education regarding modifiable factors &#40;healthy eating&#44; maintenance of an appropriate weight&#44; physical activity&#44; and quitting smoking&#41; is therefore essential in the treatment of this disease and is one of the primary interventions that can affect the prognosis of patients with psoriasis&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of Interest</span><p id="par0100" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
    "textoCompletoSecciones" => array:1 [
      "secciones" => array:10 [
        0 => array:2 [
          "identificador" => "xres95353"
          "titulo" => "Abstract"
        ]
        1 => array:2 [
          "identificador" => "xpalclavsec82513"
          "titulo" => "Keywords"
        ]
        2 => array:2 [
          "identificador" => "xres95354"
          "titulo" => "Resumen"
        ]
        3 => array:2 [
          "identificador" => "xpalclavsec82514"
          "titulo" => "Palabras clave"
        ]
        4 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Introduction"
        ]
        5 => array:2 [
          "identificador" => "sec0010"
          "titulo" => "Obesity and Inflammation"
        ]
        6 => array:2 [
          "identificador" => "sec0015"
          "titulo" => "Recommendations"
        ]
        7 => array:2 [
          "identificador" => "sec0020"
          "titulo" => "Discussion"
        ]
        8 => array:2 [
          "identificador" => "sec0025"
          "titulo" => "Conflicts of Interest"
        ]
        9 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2011-01-26"
    "fechaAceptado" => "2011-03-26"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec82513"
          "palabras" => array:3 [
            0 => "Psoriasis"
            1 => "Obesity"
            2 => "Inflammation"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec82514"
          "palabras" => array:3 [
            0 => "Psoriasis"
            1 => "Obesidad"
            2 => "Inflamaci&#243;n"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Epidemiological studies have shown that patients with psoriasis have a higher risk of developing certain metabolic disorders&#44; particularly obesity&#46; Psoriasis and obesity are linked through a common pathophysiological mechanism of chronic low-grade inflammation&#46; Not only is obesity associated with a higher incidence of psoriasis and greater severity&#44; but it also affects response to treatment&#46; The dermatologic management of these patients must therefore take their overall metabolic situation into consideration&#46; We present a review of the recent literature on this subject and practical recommendations on the management of this group of patients&#44; including relevant additional tests and advice on diet and a healthy lifestyle&#46;</p>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A trav&#233;s de estudios epidemiol&#243;gicos se ha identificado un mayor riesgo de desarrollar algunas alteraciones metab&#243;licas en los pacientes con psoriasis&#44; dentro de las cuales destaca la obesidad&#46; La obesidad y la psoriasis estar&#237;an vinculadas mediante un mecanismo fisiopatol&#243;gico com&#250;n&#44; que se explica por una inflamaci&#243;n cr&#243;nica de bajo grado&#46; No s&#243;lo la obesidad se asocia con una mayor incidencia y severidad de la psoriasis&#44; sino que tambi&#233;n afecta su respuesta al tratamiento&#46; Como consecuencia&#44; la aproximaci&#243;n dermatol&#243;gica hacia estos pacientes debiera contemplar su condici&#243;n metab&#243;lica global&#46; Se presenta una revisi&#243;n actual de la literatura con respecto a este nuevo tema&#44; as&#237; como recomendaciones pr&#225;cticas para ser consideradas en este grupo de pacientes&#44; tales como ex&#225;menes complementarios&#44; consejo nutricional y de h&#225;bitos de estilo de vida saludables&#46;</p>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara">Please cite this article as&#58; Far&#237;as MM&#44; et al&#46; Psoriasis y obesidad&#58; revisi&#243;n y recomendaciones pr&#225;cticas&#46; Actas Dermosifiliogr&#46; 2011&#59;102&#58;505-9&#46;</p>"
      ]
    ]
    "multimedia" => array:4 [
      0 => array:7 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Abbreviations&#58; HDL-C&#44; high density lipoprotein cholesterol&#59; LDL-C&#44; low density lipoprotein cholesterol&#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"><td 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" style="border-bottom: 2px solid black">Parameter&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">Recommendation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">Objective&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Blood pressure&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">Measure at least every 2 years&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">&#60;120&#47;80<span class="elsevierStyleHsp" style=""></span>mm Hg&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">Body mass index&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">Calculate at least every 2 years&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">&#60; 25 kg&#47;m<span class="elsevierStyleSup">2</span>&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">Abdominal circumference&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">Measure at least every 2 years&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">&#60;88<span class="elsevierStyleHsp" style=""></span>cm in women&#44; &#60;102<span class="elsevierStyleHsp" style=""></span>cm in men&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">Fasting lipid profile&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">Request analyses at least every 5 years&#44; or every 2 years in smokers and in patients with a personal or family history of dyslipidemia&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">Total cholesterol&#44; &#60;200 mg&#47;dL&#59; HDL-C&#44; &#62;50 mg&#47;dL&#59; optimal LDL-C&#44; &#60;100 mg&#47;dL&#59; near optimal&#44; 100-129 mg&#47;dL&#59; borderline high&#44; 130-159 mg&#47;dL&#59; high&#44; 160-189 mg&#47;dL&#59; very high&#44; &#62;190 mg&#47;dL&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">Fasting blood glucose&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">Request analysis at least every 5 years&#44; or every 2 years in patients with risk factors&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">&#60;100 mg&#47;dL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab181801.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">American Heart Association Proposed Recommendations for the Detection of Cardiovascular Risk Factors&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "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"><td 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" style="border-bottom: 2px solid black">Nutrient&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">Recommended Intake&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Calories&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">Reduction of approximately 500 to 1000<span class="elsevierStyleHsp" style=""></span>kcal per day&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">Total fat&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">30&#37; or less of the total calorie intake&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">Saturated fat&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&#37; to 10&#37; of the total calorie intake&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">Monounsaturated fat&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">Up to 15&#37; of the total calorie intake&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">Polyunsaturated fat&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">Up to 10&#37; of the total calorie intake&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">Total cholesterol&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">Less than 300<span class="elsevierStyleHsp" style=""></span>mg per day&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">Protein&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">Approximately 15&#37; of the total calorie intake&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">Carbohydrate&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">At least 55&#37; of the total calorie intake&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">Sodium&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 more than 100 mmoL&#47;day &#40;approximately 2&#46;4<span class="elsevierStyleHsp" style=""></span>g of sodium&#41;&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">Calcium&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">1000 to 1500<span class="elsevierStyleHsp" style=""></span>mg per day&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">Fiber&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">20 to 30<span class="elsevierStyleHsp" style=""></span>g per day&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab181802.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">The Low-Calorie Step I Diet&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" 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">Men&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">Energy expenditure &#40;kcal&#41;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>66<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>&#40;13&#46;7 x weight &#91;kg&#93;&#41;<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>&#40;5 x height &#91;cm&#93;&#41;<span class="elsevierStyleHsp" style=""></span>&#8722;<span class="elsevierStyleHsp" style=""></span>&#40;6&#46;8 x age &#91;y&#93;&#41;&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">Women&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">Energy expenditure &#40;kcal&#41;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>665<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>&#40;9&#46;6 x weight &#91;kg&#93;&#41;<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>&#40;1&#46;8 x height &#91;cm&#93;&#41;<span class="elsevierStyleHsp" style=""></span>&#8722;<span class="elsevierStyleHsp" style=""></span>&#40;4&#46;7 x age &#91;y&#93;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab181804.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Basal Metabolic Rate According to the Harris-Benedict Formula&#46;</p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "tbl0020"
        "etiqueta" => "Table 4"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" 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">Eat a diet rich in fruit and vegetables&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">Choose whole-grain&#44; high-fiber foods&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">Eat fish&#44; particularly oily fish&#44; at least twice a week&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">Choose lean meat and vegetarian alternatives&#44; use fat-free dairy products&#44; and minimize the intake of partially hydrogenated fat&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">Avoid drinks and juices with added sugar&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">Choose and prepare foods with little salt&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">If you consume alcohol&#44; do so in moderation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab181803.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">American Heart Association Nutrition Committee Practical Recommendations to Keep to a Healthy Diet&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:48 [
            0 => array:3 [
              "identificador" => "bib0005"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Psoriasis&#44; a systemic disease&#63;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "L&#46; Puig-Sanz"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Actas Dermosifiliogr"
                        "fecha" => "2007"
                        "volumen" => "98"
                        "paginaInicial" => "396"
                        "paginaFinal" => "402"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17663929"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0010"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Epidemiology of psoriasis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "L&#46; Naldi"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Curr Drug Targets Inflamm Allergy"
                        "fecha" => "2004"
                        "volumen" => "3"
                        "paginaInicial" => "121"
                        "paginaFinal" => "128"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15180464"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0015"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Prevalence and treatment of psoriasis in the United Kingdom&#58; a population-based study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "J&#46; Gelfand"
                            1 => "R&#46; Weinstein"
                            2 => "S&#46; Porter"
                            3 => "A&#46; Neimann"
                            4 => "J&#46; Berlin"
                            5 => "D&#46; Margolis"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1001/archderm.141.12.1537"
                      "Revista" => array:6 [
                        "tituloSerie" => "Arch Dermatol"
                        "fecha" => "2005"
                        "volumen" => "141"
                        "paginaInicial" => "1537"
                        "paginaFinal" => "1541"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16365254"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0020"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "WHO&#46; Physical status&#58; the use and interpretation of anthropometry&#46; Report of a WHO Expert Committee&#46; WHO Technical Report Series 854&#46; Geneva&#58; World Health Organization&#59; 1995&#46; Disponible en&#58; <a class="elsevierStyleInterRef" href="http://whqlibdoc.who.int/trs/WHO_TRS_854.pdf">http&#58;&#47;&#47;whqlibdoc&#46;who&#46;int&#47;trs&#47;WHO&#95;TRS&#95;854&#46;pdf</a> &#40;consultado el 24 de enero de 2011&#41;&#46;"
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0025"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Commentary&#58; understanding the epidemiology of overweight and obesity--a real global public health concern"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "S&#46; Kim"
                            1 => "B&#46; Popkin"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1093/ije/dyi255"
                      "Revista" => array:6 [
                        "tituloSerie" => "Int J Epidemiol"
                        "fecha" => "2006"
                        "volumen" => "35"
                        "paginaInicial" => "60"
                        "paginaFinal" => "67"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16339598"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib0030"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Prevalencia de obesidad en Espa&#241;a tras 14 a&#241;os de seguimiento de la cohorte DRECE"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "M&#46; Rubio"
                            1 => "A&#46; G&#243;mez de la C&#225;mara"
                            2 => "J&#46; del Campo"
                            3 => "C&#46; Jurado"
                            4 => "J&#46; Garc&#237;a"
                            5 => "J&#46; G&#243;mez-Gerique"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Endocr Nutr"
                        "fecha" => "2006"
                        "volumen" => "53"
                        "numero" => "Suppl 1"
                        "paginaInicial" => "83"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            6 => array:3 [
              "identificador" => "bib0035"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Obesity and the skin&#58; Skin physiology and skin manifestations of obesity"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "G&#46; Yosipovitch"
                            1 => "A&#46; DeVore"
                            2 => "A&#46; Dawn"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jaad.2006.12.004"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Am Acad Dermatol"
                        "fecha" => "2007"
                        "volumen" => "56"
                        "paginaInicial" => "901"
                        "paginaFinal" => "916"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17504714"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            7 => array:3 [
              "identificador" => "bib0040"
              "etiqueta" => "8"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Obesity and dermatology"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "N&#46; Scheinfeld"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.clindermatol.2004.01.001"
                      "Revista" => array:6 [
                        "tituloSerie" => "Clin Dermatol"
                        "fecha" => "2004"
                        "volumen" => "22"
                        "paginaInicial" => "303"
                        "paginaFinal" => "309"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15475230"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            8 => array:3 [
              "identificador" => "bib0045"
              "etiqueta" => "9"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Disease concomitance in psoriasis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "T&#46; Henseler"
                            1 => "E&#46; Christophers"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "J Am Acad Dermatol"
                        "fecha" => "1995"
                        "volumen" => "32"
                        "paginaInicial" => "982"
                        "paginaFinal" => "986"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7751469"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            9 => array:3 [
              "identificador" => "bib0050"
              "etiqueta" => "10"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Diseases associated with psoriasis in a general population of 159&#44;200 middle-aged&#44; urban&#44; native Swedes"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "B&#46; Lindegard"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Dermatologica"
                        "fecha" => "1986"
                        "volumen" => "172"
                        "paginaInicial" => "298"
                        "paginaFinal" => "304"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/3089849"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            10 => array:3 [
              "identificador" => "bib0055"
              "etiqueta" => "11"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Impact of obesity and smoking on psoriasis presentation and management"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "M&#46; Heron"
                            1 => "M&#46; Hinckley"
                            2 => "M&#46; Hoffman"
                            3 => "J&#46; Papenfuss"
                            4 => "C&#46; Hansen"
                            5 => "C&#46; Callis"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1001/archderm.141.12.1527"
                      "Revista" => array:6 [
                        "tituloSerie" => "Arch Dermatol"
                        "fecha" => "2005"
                        "volumen" => "141"
                        "paginaInicial" => "1527"
                        "paginaFinal" => "1534"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16365253"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            11 => array:3 [
              "identificador" => "bib0060"
              "etiqueta" => "12"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Prevalence of cardiovascular risk factors in patients with psoriasis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "A&#46; Neimann"
                            1 => "D&#46; Shin"
                            2 => "X&#46; Wang"
                            3 => "D&#46; Margolis"
                            4 => "A&#46; Troxel"
                            5 => "M&#46; Gelfand"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jaad.2006.08.040"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Am Acad Dermatol"
                        "fecha" => "2006"
                        "volumen" => "55"
                        "paginaInicial" => "829"
                        "paginaFinal" => "835"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17052489"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            12 => array:3 [
              "identificador" => "bib0065"
              "etiqueta" => "13"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Additional studies on psoriasis in the tropics and in starvation camps"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "R&#46; Simons"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "J Invest Dermatol"
                        "fecha" => "1949"
                        "volumen" => "12"
                        "paginaInicial" => "285"
                        "paginaFinal" => "294"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18129645"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            13 => array:3 [
              "identificador" => "bib0070"
              "etiqueta" => "14"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Correlation between BMI and PASI in patients affected by moderate to severe psoriasis undergoing biological therapy"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "F&#46; Bardazzi"
                            1 => "R&#46; Balestri"
                            2 => "E&#46; Balde"
                            3 => "A&#46; Antonucci"
                            4 => "S&#46; De Tommaso"
                            5 => "A&#46; Patrizi"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1529-8019.2009.01281.x"
                      "Revista" => array:7 [
                        "tituloSerie" => "Dermatol Ther"
                        "fecha" => "2010"
                        "volumen" => "23"
                        "numero" => "Suppl 1"
                        "paginaInicial" => "S14"
                        "paginaFinal" => "S19"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20136916"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            14 => array:3 [
              "identificador" => "bib0075"
              "etiqueta" => "15"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The role of the low energy diet in psoriasis vulgaris treatment"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "I&#46; Rucevic"
                            1 => "A&#46; Perl"
                            2 => "V&#46; Barisic-Drusko"
                            3 => "M&#46; Adam-Perl"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:7 [
                        "tituloSerie" => "Coll Antropol"
                        "fecha" => "2003"
                        "volumen" => "27"
                        "numero" => "Suppl 1"
                        "paginaInicial" => "41"
                        "paginaFinal" => "48"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12955890"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            15 => array:3 [
              "identificador" => "bib0080"
              "etiqueta" => "16"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Weight loss improves the response of obese patients with moderate-to-severe chronic plaque psoriasis to low-dose cyclosporine therapy&#58; a randomized&#44; controlled&#44; investigator-blinded clinical trial"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "P&#46; Gisondi"
                            1 => "M&#46; Del Giglio"
                            2 => "V&#46; Di Francesco"
                            3 => "M&#46; Zamboni"
                            4 => "G&#46; Girolomoni"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Clin Nutr"
                        "fecha" => "2008"
                        "volumen" => "88"
                        "paginaInicial" => "1242"
                        "paginaFinal" => "1247"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18996858"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            16 => array:3 [
              "identificador" => "bib0085"
              "etiqueta" => "17"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Is obesity an inflammatory condition&#63;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "U&#46; Das"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Nutrition"
                        "fecha" => "2001"
                        "volumen" => "17"
                        "paginaInicial" => "953"
                        "paginaFinal" => "966"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11744348"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            17 => array:3 [
              "identificador" => "bib0090"
              "etiqueta" => "18"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Adipose tissue&#58; from lipid storage compartment to endocrine organ"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "P&#46; Scherer"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.2337/db06-0263"
                      "Revista" => array:6 [
                        "tituloSerie" => "Diabetes"
                        "fecha" => "2006"
                        "volumen" => "55"
                        "paginaInicial" => "1537"
                        "paginaFinal" => "1545"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16731815"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            18 => array:3 [
              "identificador" => "bib0095"
              "etiqueta" => "19"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The metabolic syndrome"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "R&#46; Eckel"
                            1 => "S&#46; Grundy"
                            2 => "P&#46; Zimmet"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/S0140-6736(05)66378-7"
                      "Revista" => array:6 [
                        "tituloSerie" => "Lancet"
                        "fecha" => "2005"
                        "volumen" => "365"
                        "paginaInicial" => "1415"
                        "paginaFinal" => "1428"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15836891"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            19 => array:3 [
              "identificador" => "bib0100"
              "etiqueta" => "20"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Metabolic syndrome&#58; controversial but useful"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "M&#46; Stolar"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Cleve Clin J Med"
                        "fecha" => "2007"
                        "volumen" => "74"
                        "paginaInicial" => "199"
                        "paginaFinal" => "202"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17375800"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            20 => array:3 [
              "identificador" => "bib0105"
              "etiqueta" => "21"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Elevation of free fatty acids induces inflammation and impairs vascular reactivity in healthy subjects"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "D&#46; Tripathy"
                            1 => "P&#46; Mohanty"
                            2 => "S&#46; Dhindsa"
                            3 => "T&#46; Syed"
                            4 => "H&#46; Ghanim"
                            5 => "A&#46; Aljada"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Diabetes"
                        "fecha" => "2003"
                        "volumen" => "52"
                        "paginaInicial" => "2882"
                        "paginaFinal" => "2887"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/14633847"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            21 => array:3 [
              "identificador" => "bib0110"
              "etiqueta" => "22"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Regional postprandial fatty acid metabolism in different obesity phenotypes"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "Z&#46; Guo"
                            1 => "D&#46; Hensrud"
                            2 => "M&#46; Johnson"
                            3 => "M&#46; Jensen"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Diabetes"
                        "fecha" => "1999"
                        "volumen" => "48"
                        "paginaInicial" => "1586"
                        "paginaFinal" => "1592"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10426377"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            22 => array:3 [
              "identificador" => "bib0115"
              "etiqueta" => "23"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Increase in intranuclear nuclear factor kappaB and decrease in inhibitor kappaB in mononuclear cells after a mixed meal&#58; evidence for a proinflammatory effect"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "A&#46; Aljada"
                            1 => "P&#46; Mohanty"
                            2 => "H&#46; Ghanim"
                            3 => "T&#46; Abdo"
                            4 => "D&#46; Tripathy"
                            5 => "A&#46; Chaudhuri"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Clin Nutr"
                        "fecha" => "2004"
                        "volumen" => "79"
                        "paginaInicial" => "682"
                        "paginaFinal" => "690"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15051615"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            23 => array:3 [
              "identificador" => "bib0120"
              "etiqueta" => "24"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Cardiovascular metabolic syndrome - an interplay of&#44; obesity&#44; inflammation&#44; diabetes and coronary heart disease"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "J&#46; Rana"
                            1 => "M&#46; Nieuwdorp"
                            2 => "J&#46; Jukema"
                            3 => "J&#46; Kastelein"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1463-1326.2006.00594.x"
                      "Revista" => array:6 [
                        "tituloSerie" => "Diabetes Obes Metab"
                        "fecha" => "2007"
                        "volumen" => "9"
                        "paginaInicial" => "218"
                        "paginaFinal" => "232"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17391148"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            24 => array:3 [
              "identificador" => "bib0125"
              "etiqueta" => "25"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Mechanism of hepatic insulin resistance in non-alcoholic fatty liver disease"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "V&#46; Samuel"
                            1 => "Z&#46; Liu"
                            2 => "X&#46; Qu"
                            3 => "B&#46; Elder"
                            4 => "S&#46; Bilz"
                            5 => "D&#46; Befroy"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1074/jbc.M313478200"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Biol Chem"
                        "fecha" => "2004"
                        "volumen" => "279"
                        "paginaInicial" => "32345"
                        "paginaFinal" => "32353"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15166226"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            25 => array:3 [
              "identificador" => "bib0130"
              "etiqueta" => "26"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Skeletal muscle insulin resistance&#58; role of inflammatory cytokines and reactive oxygen species"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "Y&#46; Wei"
                            1 => "K&#46; Chen"
                            2 => "A&#46; Whaley-Connell"
                            3 => "C&#46; Stump"
                            4 => "J&#46; Ibdah"
                            5 => "J&#46; Sowers"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1152/ajpregu.00561.2007"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Physiol Regul Integr Comp Physiol"
                        "fecha" => "2008"
                        "volumen" => "294"
                        "paginaInicial" => "R673"
                        "paginaFinal" => "R680"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18094066"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            26 => array:3 [
              "identificador" => "bib0135"
              "etiqueta" => "27"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Chronic inflammation in psoriasis and obesity&#58; Implications for therapy"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "E&#46;A&#46; Hamminga"
                            1 => "A&#46;J&#46; van der Lely"
                            2 => "H&#46;A&#46;M&#46; Newmann"
                            3 => "H&#46;B&#46; Thio"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.mehy.2006.04.028"
                      "Revista" => array:6 [
                        "tituloSerie" => "Med Hypotheses"
                        "fecha" => "2006"
                        "volumen" => "67"
                        "paginaInicial" => "786"
                        "paginaFinal" => "873"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16797862"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            27 => array:3 [
              "identificador" => "bib0140"
              "etiqueta" => "28"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Unfavorable cardiovascular risk profiles in untreated and treated psiriasis patients"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "M&#46; Wakkee"
                            1 => "H&#46; Thio"
                            2 => "E&#46; Prens"
                            3 => "E&#46; Sijbrands"
                            4 => "H&#46; Newmann"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.atherosclerosis.2006.07.011"
                      "Revista" => array:6 [
                        "tituloSerie" => "Atherosclerosis"
                        "fecha" => "2007"
                        "volumen" => "190"
                        "paginaInicial" => "1"
                        "paginaFinal" => "9"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16942772"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            28 => array:3 [
              "identificador" => "bib0145"
              "etiqueta" => "29"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Cardiometabolic comorbidities and the approach to patients with psoriasis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "P&#46; Gisondi"
                            1 => "G&#46; Girolomoni"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:7 [
                        "tituloSerie" => "Actas Dermosifiliogr"
                        "fecha" => "2009"
                        "volumen" => "100"
                        "numero" => "Suppl 2"
                        "paginaInicial" => "14"
                        "paginaFinal" => "21"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20096157"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            29 => array:3 [
              "identificador" => "bib0150"
              "etiqueta" => "30"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "National Psoriasis Foundation clinical consensus on psoriasis comorbidities and recommendations for screening"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "A&#46; Kimball"
                            1 => "D&#46; Gladman"
                            2 => "J&#46; Gelfand"
                            3 => "K&#46; Gordon"
                            4 => "E&#46; Horn"
                            5 => "N&#46; Korman"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jaad.2008.01.006"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Am Acad Dermatol"
                        "fecha" => "2008"
                        "volumen" => "58"
                        "paginaInicial" => "1031"
                        "paginaFinal" => "1042"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18313171"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            30 => array:3 [
              "identificador" => "bib0155"
              "etiqueta" => "31"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "AHA Guidelines for Primary Prevention of Cardiovascular Disease and Stroke&#58; 2002 Update&#58; Consensus Panel Guide to Comprehensive Risk Reduction for Adult Patients Without Coronary or Atherosclerotic Vascular Disease&#46; American Heart Association Science Advisory and Coordinating Committee"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "T&#46; Pearson"
                            1 => "S&#46; Blair"
                            2 => "S&#46; Daniels"
                            3 => "R&#46; Eckel"
                            4 => "J&#46; Fair"
                            5 => "S&#46; Fortmann"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Circulation"
                        "fecha" => "2002"
                        "volumen" => "106"
                        "paginaInicial" => "388"
                        "paginaFinal" => "391"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12119259"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            31 => array:3 [
              "identificador" => "bib0160"
              "etiqueta" => "32"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "S&#46; Grundy"
                            1 => "J&#46; Cleeman"
                            2 => "C&#46; Merz"
                            3 => "H&#46; Brewer"
                            4 => "L&#46;T&#46; Clark"
                            5 => "D&#46; Hunninghake"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1161/01.CIR.0000133317.49796.0E"
                      "Revista" => array:6 [
                        "tituloSerie" => "Circulation"
                        "fecha" => "2004"
                        "volumen" => "110"
                        "paginaInicial" => "227"
                        "paginaFinal" => "239"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15249516"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            32 => array:3 [
              "identificador" => "bib0165"
              "etiqueta" => "33"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "Obesity Society&#46; The Practical Guide&#58; Identification&#44; Evaluation&#44; and Treatment of Overweight and Obesity in Adults&#46; Disponible en&#58; <a class="elsevierStyleInterRef" href="http://www.nhlbi.nih.gov/guidelines/obesity/prctgd_b.pdf">http&#58;&#47;&#47;www&#46;nhlbi&#46;nih&#46;gov&#47;guidelines&#47;obesity&#47;prctgd&#95;b&#46;pdf</a> &#40;consultado el 20 de enero de 2011&#41;&#46;"
                ]
              ]
            ]
            33 => array:3 [
              "identificador" => "bib0170"
              "etiqueta" => "34"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The Harris-Benedict studies of human basal metabolism&#58; history and limitations"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "D&#46; Frankenfield"
                            1 => "E&#46; Muth"
                            2 => "W&#46; Rowe"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/S0002-8223(98)00100-X"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Am Diet Assoc"
                        "fecha" => "1998"
                        "volumen" => "98"
                        "paginaInicial" => "439"
                        "paginaFinal" => "445"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9550168"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            34 => array:3 [
              "identificador" => "bib0175"
              "etiqueta" => "35"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Diet and lifestyle recommendations revision 2006&#58; a scientific statement from the American Heart Association Nutrition Committee"
                      "autores" => array:1 [
                        0 => array:3 [
                          "colaboracion" => "American Heart Association Nutrition Committee"
                          "etal" => true
                          "autores" => array:6 [
                            0 => "A&#46;H&#46; Lichtenstein"
                            1 => "L&#46;J&#46; Appel"
                            2 => "M&#46; Brands"
                            3 => "M&#46; Carnethon"
                            4 => "S&#46; Daniels"
                            5 => "H&#46;A&#46; Franch"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1161/CIRCULATIONAHA.106.176158"
                      "Revista" => array:6 [
                        "tituloSerie" => "Circulation"
                        "fecha" => "2006"
                        "volumen" => "114"
                        "paginaInicial" => "82"
                        "paginaFinal" => "96"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16785338"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            35 => array:3 [
              "identificador" => "bib0180"
              "etiqueta" => "36"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Swedish Obese Subjects Study&#46; Effects of bariatric surgery on mortality in Swedish obese subjects"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "L&#46; Sj&#246;str&#246;m"
                            1 => "K&#46; Narbro"
                            2 => "C&#46; Sj&#246;str&#246;m"
                            3 => "K&#46; Karason"
                            4 => "B&#46; Larsson"
                            5 => "H&#46; Wedel"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1056/NEJMoa066254"
                      "Revista" => array:6 [
                        "tituloSerie" => "N Engl J Med"
                        "fecha" => "2007"
                        "volumen" => "357"
                        "paginaInicial" => "741"
                        "paginaFinal" => "752"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17715408"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            36 => array:3 [
              "identificador" => "bib0185"
              "etiqueta" => "37"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "Hossler E&#44; Maroon M&#44; Moward C&#46; Gastric bypass surgery improves psoriasis&#46; J Am Acad Dermatol&#46; 2010 Jul 21&#46; &#91;Epub ahead of print&#93;&#46; PubMed PMID&#58; 20655127&#46;"
                ]
              ]
            ]
            37 => array:3 [
              "identificador" => "bib0190"
              "etiqueta" => "38"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Remission of psoriasis after open gastric bypass"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "J&#46; De Menezes Ettinger"
                            1 => "E&#46; Azaro"
                            2 => "C&#46; De Souza"
                            3 => "P&#46; Dos Santos Filho"
                            4 => "C&#46; Mello"
                            5 => "M&#46; Neves Jr&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1381/096089206775221998"
                      "Revista" => array:6 [
                        "tituloSerie" => "Obesity Surgery"
                        "fecha" => "2006"
                        "volumen" => "16"
                        "paginaInicial" => "94"
                        "paginaFinal" => "97"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16417765"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            38 => array:3 [
              "identificador" => "bib0195"
              "etiqueta" => "39"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "American College of Sports Medicine Position Stand&#46; Appropriate physical activity intervention strategies for weight loss and prevention of weight regain for adults"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "J&#46; Donnelly"
                            1 => "S&#46; Blair"
                            2 => "J&#46; Jakicic"
                            3 => "M&#46; Manore"
                            4 => "J&#46; Rankin"
                            5 => "B&#46; Smith"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Med Sci Sports Exerc"
                        "fecha" => "2009"
                        "volumen" => "42"
                        "paginaInicial" => "459"
                        "paginaFinal" => "471"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            39 => array:3 [
              "identificador" => "bib0200"
              "etiqueta" => "40"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Psoriasis and obesity&#58; literature review and recommendations for management"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "G&#46; Duarte"
                            1 => "I&#46; Follador"
                            2 => "C&#46; Cavalheiro"
                            3 => "T&#46; Silva"
                            4 => "M&#46; Oliveira"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "An Bras Dermatol"
                        "fecha" => "2010"
                        "volumen" => "85"
                        "paginaInicial" => "355"
                        "paginaFinal" => "360"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20676469"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            40 => array:3 [
              "identificador" => "bib0205"
              "etiqueta" => "41"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "National Psoriasis Foundation&#46; Obesity and psoriasis&#58; from the Medical Board of the National Psoriasis Foundation"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "S&#46; Bremmer"
                            1 => "A&#46; Van Voorhees"
                            2 => "S&#46; Hsu"
                            3 => "N&#46; Korman"
                            4 => "M&#46; Lebwohl"
                            5 => "M&#46; Young"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jaad.2009.09.053"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Am Acad Dermatol"
                        "fecha" => "2010"
                        "volumen" => "63"
                        "paginaInicial" => "1058"
                        "paginaFinal" => "1069"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20692722"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            41 => array:3 [
              "identificador" => "bib0210"
              "etiqueta" => "42"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Role of non-alcoholic steatohepatitis in metrotrexate-induced liver injury"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "G&#46; Langman"
                            1 => "P&#46; Hall"
                            2 => "G&#46; Todd"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "J Gastroenterol Hepatol"
                        "fecha" => "2001"
                        "volumen" => "16"
                        "paginaInicial" => "1395"
                        "paginaFinal" => "1401"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11851839"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            42 => array:3 [
              "identificador" => "bib0215"
              "etiqueta" => "43"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Nonalcoholic fatty liver disease and psoriasis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "R&#46; Rivera"
                            1 => "F&#46; Vanaclocha"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Actas Dermosifiliogr"
                        "fecha" => "2010"
                        "volumen" => "101"
                        "paginaInicial" => "657"
                        "paginaFinal" => "658"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20965008"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            43 => array:3 [
              "identificador" => "bib0220"
              "etiqueta" => "44"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The effect of weight on the efficacy of biological therapy in patients with psoriasis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "L&#46; Clark"
                            1 => "M&#46; Lebwohl"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jaad.2007.11.011"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Am Acad Dermatol"
                        "fecha" => "2008"
                        "volumen" => "58"
                        "paginaInicial" => "443"
                        "paginaFinal" => "446"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18083274"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            44 => array:3 [
              "identificador" => "bib0225"
              "etiqueta" => "45"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Obesity in psoriasis&#58; the metabolic&#44; clinical and therapeutic implications&#46; Report of an interdisciplinary conference and review"
                      "autores" => array:1 [
                        0 => array:3 [
                          "colaboracion" => "International Psoriasis Council"
                          "etal" => false
                          "autores" => array:3 [
                            0 => "W&#46; Sterry"
                            1 => "B&#46;E&#46; Strober"
                            2 => "A&#46; Menter"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1365-2133.2007.08068.x"
                      "Revista" => array:6 [
                        "tituloSerie" => "Br J Dermatol"
                        "fecha" => "2007"
                        "volumen" => "157"
                        "paginaInicial" => "649"
                        "paginaFinal" => "655"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17627791"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            45 => array:3 [
              "identificador" => "bib0230"
              "etiqueta" => "46"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Psoriasis and the metabolic syndrome"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "A&#46; Alsufyani"
                            1 => "A&#46; Golanti"
                            2 => "A&#46;M&#46; Lebwohl"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1529-8019.2010.01307.x"
                      "Revista" => array:6 [
                        "tituloSerie" => "Dermatol Ther"
                        "fecha" => "2010"
                        "volumen" => "23"
                        "paginaInicial" => "137"
                        "paginaFinal" => "143"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20415820"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            46 => array:3 [
              "identificador" => "bib0235"
              "etiqueta" => "47"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Risk of myocardial infarction in patients with psoriasis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "J&#46; Gelfand"
                            1 => "A&#46; Neimann"
                            2 => "D&#46; Shin"
                            3 => "X&#46; Wang"
                            4 => "D&#46; Margolis"
                            5 => "A&#46; Troxel"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1001/jama.296.14.1735"
                      "Revista" => array:6 [
                        "tituloSerie" => "JAMA"
                        "fecha" => "2006"
                        "volumen" => "296"
                        "paginaInicial" => "1735"
                        "paginaFinal" => "1741"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17032986"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            47 => array:3 [
              "identificador" => "bib0240"
              "etiqueta" => "48"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Effects of etanercept on C-reactive protein levels in psoriasis and psoriatic arthritis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "B&#46; Strober"
                            1 => "C&#46; Teller"
                            2 => "P&#46; Yamuchi"
                            3 => "J&#46; Miller"
                            4 => "M&#46; Hooper"
                            5 => "Y&#46; Yang"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1365-2133.2008.08628.x"
                      "Revista" => array:6 [
                        "tituloSerie" => "Br J Dermatol"
                        "fecha" => "2008"
                        "volumen" => "159"
                        "paginaInicial" => "322"
                        "paginaFinal" => "330"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18503600"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
          ]
        ]
      ]
    ]
  ]
  "idiomaDefecto" => "en"
  "url" => "/15782190/0000010200000007/v1_201304241231/S1578219011000576/v1_201304241231/en/main.assets"
  "Apartado" => array:4 [
    "identificador" => "6151"
    "tipo" => "SECCION"
    "en" => array:2 [
      "titulo" => "Practical Dermatology"
      "idiomaDefecto" => true
    ]
    "idiomaDefecto" => "en"
  ]
  "PDF" => "https://static.elsevier.es/multimedia/15782190/0000010200000007/v1_201304241231/S1578219011000576/v1_201304241231/en/main.pdf?idApp=UINPBA000044&text.app=https://actasdermo.org/"
  "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219011000576?idApp=UINPBA000044"
]
Compartir
Información de la revista
Vol. 102. Núm. 7.
Páginas 505-509 (septiembre 2011)
Visitas
8169
Vol. 102. Núm. 7.
Páginas 505-509 (septiembre 2011)
Practical Dermatology
Acceso a texto completo
Psoriasis and Obesity: A Review and Practical Recommendations
Psoriasis y obesidad: revisión y recomendaciones prácticas
Visitas
8169
M.M. Faríasa,
Autor para correspondencia
mmfarias@gmail.com

Corresponding author.
, V. Serranoa, C. de la Cruzb
a Departamento de Nutrición, Pontificia Universidad Católica de Chile, Santiago, Chile
b Departamento de Dermatología, Pontificia Universidad Católica de Chile, Santiago, Chile
Este artículo ha recibido
Información del artículo
Resumen
Texto completo
Bibliografía
Descargar PDF
Estadísticas
Tablas (4)
Table 1. American Heart Association Proposed Recommendations for the Detection of Cardiovascular Risk Factors.
Table 2. The Low-Calorie Step I Diet.
Table 3. Basal Metabolic Rate According to the Harris-Benedict Formula.
Table 4. American Heart Association Nutrition Committee Practical Recommendations to Keep to a Healthy Diet.
Mostrar másMostrar menos
Abstract

Epidemiological studies have shown that patients with psoriasis have a higher risk of developing certain metabolic disorders, particularly obesity. Psoriasis and obesity are linked through a common pathophysiological mechanism of chronic low-grade inflammation. Not only is obesity associated with a higher incidence of psoriasis and greater severity, but it also affects response to treatment. The dermatologic management of these patients must therefore take their overall metabolic situation into consideration. We present a review of the recent literature on this subject and practical recommendations on the management of this group of patients, including relevant additional tests and advice on diet and a healthy lifestyle.

Keywords:
Psoriasis
Obesity
Inflammation
Resumen

A través de estudios epidemiológicos se ha identificado un mayor riesgo de desarrollar algunas alteraciones metabólicas en los pacientes con psoriasis, dentro de las cuales destaca la obesidad. La obesidad y la psoriasis estarían vinculadas mediante un mecanismo fisiopatológico común, que se explica por una inflamación crónica de bajo grado. No sólo la obesidad se asocia con una mayor incidencia y severidad de la psoriasis, sino que también afecta su respuesta al tratamiento. Como consecuencia, la aproximación dermatológica hacia estos pacientes debiera contemplar su condición metabólica global. Se presenta una revisión actual de la literatura con respecto a este nuevo tema, así como recomendaciones prácticas para ser consideradas en este grupo de pacientes, tales como exámenes complementarios, consejo nutricional y de hábitos de estilo de vida saludables.

Palabras clave:
Psoriasis
Obesidad
Inflamación
Texto completo
Introduction

It has recently been found that patients with psoriasis have a higher prevalence of certain metabolic disorders considered to be cardiovascular risk factors,1 particularly obesity, diabetes or impaired glucose tolerance, dyslipidemias, and systemic hypertension, which together are known as the metabolic syndrome.2 Psoriasis is now also considered to be a marker of increased risk of myocardial infarction in young patients.3

Obesity is a chronic disease characterized by excess weight due to increased energy deposits in the form of fat. Specifically, this excess weight due to an increase in body fat mass is described in relation to the height of the patient, and the diagnosis of overweight is established using the body mass index (BMI), defined as the weight in kilograms divided by the square of the height in meters. The World Health Organization4 currently recommends classification of the adult population into the following categories according to BMI cutoff points: normal, 18.5 to 24.9 kg/m2; overweight, 25 to 29.9kg/m2; and obese, greater than 30kg/m2.

Obesity is a growing epidemic worldwide.5 Both overweight and obesity have increased in Spain in recent years.6 The close association between obesity and higher mortality, as well as the increased risk of developing type 2 diabetes, systemic hypertension, dyslipidemia, cardiovascular disease, and cancer, among other diseases, makes obesity a major public health problem.6

The association between obesity and certain skin diseases has been extensively studied and demonstrated7,8; in the case of psoriasis, it was first detected in epidemiological studies conducted in Europe.9,10 In 1986, a Scandinavian study revealed a higher prevalence of obesity in women with psoriasis than in other women.10 Later, Herron11 provided further evidence of this association when he detected a higher probability of developing obesity in his cohort of 500 patients with psoriasis than in the rest of the population of the state of Utah, United States (34% vs 18%; P<.001). Based on their findings, those authors suggested obesity was a consequence of psoriasis rather than a risk factor for the skin disease. In addition, a study by Neimann12 demonstrated that the risk of obesity was higher in patients with severe psoriasis (odds ratio [OR],1.8) than in those with moderate psoriasis (OR,1.3).

The idea of a connection between nutrition and the clinical course of psoriasis arose when symptomatic improvement was observed during periods of fasting or lower calorie intake.13 The Bardazzi research group,14 with a sample of 33 patients with moderate to severe psoriasis, reported a greater response to biological therapy in those patients who reduced their BMI, even with reductions of as little as 5kg body weight over 8 months of follow-up. In a study performed in Croatia involving 82 patients with a 10-year history of psoriasis vulgaris treated using standard topical treatment, 40 patients received the usual hospital diet and 42 received a low-calorie diet.15 After 4 weeks, the low-calorie-diet group showed a statistically significant improvement in their skin lesions compared to the control group. In another study involving 61 obese patients with moderate or severe psoriasis on treatment with low-dose ciclosporin, the response to the drug was considerably better in the group receiving a low-calorie diet (reduction of 500kcal/day) than in the control group with no change in calorie intake.16

Those studies coincide in proposing a low-calorie diet as coadjuvant therapy in the management of psoriasis. It would therefore be interesting to reach a better understanding of this association and to develop useful tools for the nutritional management of these patients in the dermatology clinic.

Obesity and Inflammation

Obesity is currently considered to be a low-grade chronic inflammatory disease characterized by an elevation of the plasma levels of proinflammatory cytokines, such as tumor necrosis factor (TNF) α and interleukin (IL) 6, and of acute-phase proteins such as C-reactive protein (CRP).17 The association of psoriasis with obesity may be explained by the specific inflammatory activity of the adipocytes. Adipose tissue, typically thought of as an energy store, is able to communicate with the rest of the body through the secretion of adipokines, which are molecules with proinflammatory, thrombotic, and vasoactive properties.18

Particularly important adipokines are TNF-α, plasminogen activator inhibitor 1, IL-6, and leptin. There is also a fall in the levels of adiponectin, a cytokine with anti-inflammatory activity.19 These signals attract macrophages to the adipose tissue. After entering the adipose tissue, mature macrophages maintain the cytokine secretion, leading to a local primary inflammatory response. The cytokines subsequently trigger the production of inflammatory proteins in the liver, thus causing the low-grade systemic inflammatory state observed in obesity.20 Cytokines also increase lipolysis, leading to a constant release of free fatty acids from the adipose tissue into the peripheral circulation.19 Free fatty acids are considered to be an important link between adipose tissue activity and chronic inflammation as they can increase oxidative stress and thus augment the inflammatory environment and vascular activity.21 It should be noted that predominantly central obesity, compared with a peripheral distribution of fat, is associated with a large amount of visceral fat. Adipocytes in the visceral fat are metabolically more active and they release larger quantities of cytokines and fatty acids. This would lead us to expect an even more active inflammatory environment in patients with abdominal obesity.22

Foods have also been implicated in inflammation. Aijada et al23 showed that eating fast food (900kcal, rich in fats and simple sugars) could lead to an increase in inflammatory factors such as CRP. This effect would be mediated by the activation of the nuclear factor kappa B (NF-κB) present in the white blood cells; the transcriptional activity of NF-κB is related to the release of free oxygen radicals and cytokines with inflammatory activity. This same effect was observed after administering an intravenous infusion of triglycerides to healthy individuals.21

It has been suggested that the inflammatory state associated with obesity is the link between various pathological conditions that make up the metabolic syndrome.24 The effect of the cytokines on insulin sensitivity in the liver25 and muscle26 has been studied extensively, whereas the association between psoriasis and obesity has only been demonstrated clinically in recent decades,27,28 and there has been no detailed study of the molecular mechanisms involved. However, psoriasis and obesity are both inflammatory disorders, and the pathophysiological changes, including inflammatory pathways and elevated cytokine levels, are similar in the 2 conditions.1 From this point of view, it would appear reasonable to suggest that a reduction in energy intake, with the consequent weight loss, could contribute positively to reducing the proinflammatory state and improving the clinical course of obese patients with psoriasis.

Recommendations

The high prevalence of comorbid diseases in patients with psoriasis means that they would benefit from a holistic approach with multisystem management.29 It is particularly important to stratify patients according to their cardiovascular risk. For this purpose, the National Psoriasis Foundation30 recommends adherence to the current guidelines for screening and goals for cardiovascular risk factors established by the American Heart Association (AHA)(Table 1).31 Those guidelines have been modified with lower cutoff points for cholesterol levels in patients with high cardiovascular risk. Specialist consultation is recommended in these cases in order to avoid any delay in the initiation of aggressive management of the metabolic parameters.32

Table 1.

American Heart Association Proposed Recommendations for the Detection of Cardiovascular Risk Factors.

Parameter  Recommendation  Objective 
Blood pressure  Measure at least every 2 years  <120/80mm Hg 
Body mass index  Calculate at least every 2 years  < 25 kg/m2 
Abdominal circumference  Measure at least every 2 years  <88cm in women, <102cm in men 
Fasting lipid profile  Request analyses at least every 5 years, or every 2 years in smokers and in patients with a personal or family history of dyslipidemia  Total cholesterol, <200 mg/dL; HDL-C, >50 mg/dL; optimal LDL-C, <100 mg/dL; near optimal, 100-129 mg/dL; borderline high, 130-159 mg/dL; high, 160-189 mg/dL; very high, >190 mg/dL 
Fasting blood glucose  Request analysis at least every 5 years, or every 2 years in patients with risk factors  <100 mg/dL 

Abbreviations: HDL-C, high density lipoprotein cholesterol; LDL-C, low density lipoprotein cholesterol.

All patients, and particularly those with a BMI over 25, should be instructed in nonpharmacological measures aimed at lifestyle changes. The objective is to achieve healthy eating habits that can be maintained over time and that will result in controlled weight loss. A low-calorie diet based on the Step 1 diet (Table 2) should be recommended.33 This diet involves reducing total calorie intake by 500 to 1000kcal per day, depending on the patient's energy expenditure. An individual's energy expenditure at rest can be calculated using measurement techniques, such as indirect calorimetry, or mathematical formulae, the most widely used of which is the Harris-Benedict formula (Table 3), which takes into account parameters such as sex, age, and height.34 To achieve good adherence to the dietary therapy, we recommend application of the practical recommendations proposed by the AHA (Table 4).35 Patients with severe obesity (BMI >40) should be referred to a specialist to consider surgical treatment. The effectiveness of this type of procedure in the remission of comorbid conditions and in the long-term maintenance of body weight makes it the treatment of choice in patients with severe obesity.36 There have recently been case reports describing patients with psoriasis whose lesions have shown a marked improvement within months of undergoing gastric bypass surgery.37,38

Table 2.

The Low-Calorie Step I Diet.

Nutrient  Recommended Intake 
Calories  Reduction of approximately 500 to 1000kcal per day 
Total fat  30% or less of the total calorie intake 
Saturated fat  8% to 10% of the total calorie intake 
Monounsaturated fat  Up to 15% of the total calorie intake 
Polyunsaturated fat  Up to 10% of the total calorie intake 
Total cholesterol  Less than 300mg per day 
Protein  Approximately 15% of the total calorie intake 
Carbohydrate  At least 55% of the total calorie intake 
Sodium  Not more than 100 mmoL/day (approximately 2.4g of sodium) 
Calcium  1000 to 1500mg per day 
Fiber  20 to 30g per day 
Table 3.

Basal Metabolic Rate According to the Harris-Benedict Formula.

Men  Energy expenditure (kcal)=66+(13.7 x weight [kg])+(5 x height [cm])(6.8 x age [y]) 
Women  Energy expenditure (kcal)=665+(9.6 x weight [kg])+(1.8 x height [cm])(4.7 x age [y]) 
Table 4.

American Heart Association Nutrition Committee Practical Recommendations to Keep to a Healthy Diet.

Eat a diet rich in fruit and vegetables 
Choose whole-grain, high-fiber foods 
Eat fish, particularly oily fish, at least twice a week 
Choose lean meat and vegetarian alternatives, use fat-free dairy products, and minimize the intake of partially hydrogenated fat 
Avoid drinks and juices with added sugar 
Choose and prepare foods with little salt 
If you consume alcohol, do so in moderation 

Physical activity should be indicated on an individual basis according to age, tolerance, preference, etc.35 Ideally, patients should start with 30minutes of physical activity 3 times a week,30 but a metabolic effect with major benefit is obtained with at least 150minutes of moderately intense physical activity per week.39 Furthermore, patients must stop smoking, as this is known to exacerbate psoriasis.30

Specialist management is essential when comorbid psychiatric and psychological conditions are detected.40

Finally, current evidence indicates that it is essential to take all comorbid metabolic conditions into account before deciding which pharmacological therapy to prescribe for psoriasis.41 Conditions such as obesity and nonalcoholoic fatty liver or steatohepatitis are relative contraindications for the use of methotrexate, due to the risk of hepatic toxicity.42,43 Some immunomodulating biologic agents, such as alefacept, etanercept, and ustekinumab, are less effective in obese patients, whereas others, such as infliximab, whose dose must be adjusted according to the BMI, maintain their effectiveness.41 In addition, obesity, hypertension, and dyslipidemia interfere with the use of ciclosporin as they increase the risk of nephrotoxicity.41,44

Discussion

Conventional psoriasis treatments are based on the severity of the disease. The need for safe and effective treatments has led to a search for modifiable factors that could improve the response to conventional therapy.45

The pathophysiology of psoriasis and of obesity have common inflammatory pathways and cytokine activation.46 Clinical studies have strengthened the idea that weight loss could have an additional therapeutic effect in the conventional treatment of obese patients with psoriasis, particularly in those with moderate to severe disease.14

Furthermore, psoriasis should be considered to be a specific cardiovascular risk factor. A higher incidence of ischemic events has been reported in these patients independently of their other cardiovascular risk factors.3,47 A possible benefit in the reduction of cardiovascular risk has also been attributed to immunomodulatory treatment with TNF-α inhibitors.48 We hope that the international guidelines for cardiovascular risk prevention will take these findings into consideration in the future.

Education regarding modifiable factors (healthy eating, maintenance of an appropriate weight, physical activity, and quitting smoking) is therefore essential in the treatment of this disease and is one of the primary interventions that can affect the prognosis of patients with psoriasis.

Conflicts of Interest

The authors declare that they have no conflicts of interest.

References
[1]
L. Puig-Sanz.
Psoriasis, a systemic disease?.
Actas Dermosifiliogr, 98 (2007), pp. 396-402
[2]
L. Naldi.
Epidemiology of psoriasis.
Curr Drug Targets Inflamm Allergy, 3 (2004), pp. 121-128
[3]
J. Gelfand, R. Weinstein, S. Porter, A. Neimann, J. Berlin, D. Margolis.
Prevalence and treatment of psoriasis in the United Kingdom: a population-based study.
Arch Dermatol, 141 (2005), pp. 1537-1541
[4]
WHO. Physical status: the use and interpretation of anthropometry. Report of a WHO Expert Committee. WHO Technical Report Series 854. Geneva: World Health Organization; 1995. Disponible en: http://whqlibdoc.who.int/trs/WHO_TRS_854.pdf (consultado el 24 de enero de 2011).
[5]
S. Kim, B. Popkin.
Commentary: understanding the epidemiology of overweight and obesity--a real global public health concern.
Int J Epidemiol, 35 (2006), pp. 60-67
[6]
M. Rubio, A. Gómez de la Cámara, J. del Campo, C. Jurado, J. García, J. Gómez-Gerique, et al.
Prevalencia de obesidad en España tras 14 años de seguimiento de la cohorte DRECE.
Endocr Nutr, 53 (2006), pp. 83
[7]
G. Yosipovitch, A. DeVore, A. Dawn.
Obesity and the skin: Skin physiology and skin manifestations of obesity.
J Am Acad Dermatol, 56 (2007), pp. 901-916
[8]
N. Scheinfeld.
Obesity and dermatology.
Clin Dermatol, 22 (2004), pp. 303-309
[9]
T. Henseler, E. Christophers.
Disease concomitance in psoriasis.
J Am Acad Dermatol, 32 (1995), pp. 982-986
[10]
B. Lindegard.
Diseases associated with psoriasis in a general population of 159,200 middle-aged, urban, native Swedes.
Dermatologica, 172 (1986), pp. 298-304
[11]
M. Heron, M. Hinckley, M. Hoffman, J. Papenfuss, C. Hansen, C. Callis, et al.
Impact of obesity and smoking on psoriasis presentation and management.
Arch Dermatol, 141 (2005), pp. 1527-1534
[12]
A. Neimann, D. Shin, X. Wang, D. Margolis, A. Troxel, M. Gelfand.
Prevalence of cardiovascular risk factors in patients with psoriasis.
J Am Acad Dermatol, 55 (2006), pp. 829-835
[13]
R. Simons.
Additional studies on psoriasis in the tropics and in starvation camps.
J Invest Dermatol, 12 (1949), pp. 285-294
[14]
F. Bardazzi, R. Balestri, E. Balde, A. Antonucci, S. De Tommaso, A. Patrizi.
Correlation between BMI and PASI in patients affected by moderate to severe psoriasis undergoing biological therapy.
Dermatol Ther, 23 (2010), pp. S14-S19
[15]
I. Rucevic, A. Perl, V. Barisic-Drusko, M. Adam-Perl.
The role of the low energy diet in psoriasis vulgaris treatment.
Coll Antropol, 27 (2003), pp. 41-48
[16]
P. Gisondi, M. Del Giglio, V. Di Francesco, M. Zamboni, G. Girolomoni.
Weight loss improves the response of obese patients with moderate-to-severe chronic plaque psoriasis to low-dose cyclosporine therapy: a randomized, controlled, investigator-blinded clinical trial.
Am J Clin Nutr, 88 (2008), pp. 1242-1247
[17]
U. Das.
Is obesity an inflammatory condition?.
Nutrition, 17 (2001), pp. 953-966
[18]
P. Scherer.
Adipose tissue: from lipid storage compartment to endocrine organ.
Diabetes, 55 (2006), pp. 1537-1545
[19]
R. Eckel, S. Grundy, P. Zimmet.
The metabolic syndrome.
Lancet, 365 (2005), pp. 1415-1428
[20]
M. Stolar.
Metabolic syndrome: controversial but useful.
Cleve Clin J Med, 74 (2007), pp. 199-202
[21]
D. Tripathy, P. Mohanty, S. Dhindsa, T. Syed, H. Ghanim, A. Aljada, et al.
Elevation of free fatty acids induces inflammation and impairs vascular reactivity in healthy subjects.
Diabetes, 52 (2003), pp. 2882-2887
[22]
Z. Guo, D. Hensrud, M. Johnson, M. Jensen.
Regional postprandial fatty acid metabolism in different obesity phenotypes.
Diabetes, 48 (1999), pp. 1586-1592
[23]
A. Aljada, P. Mohanty, H. Ghanim, T. Abdo, D. Tripathy, A. Chaudhuri, et al.
Increase in intranuclear nuclear factor kappaB and decrease in inhibitor kappaB in mononuclear cells after a mixed meal: evidence for a proinflammatory effect.
Am J Clin Nutr, 79 (2004), pp. 682-690
[24]
J. Rana, M. Nieuwdorp, J. Jukema, J. Kastelein.
Cardiovascular metabolic syndrome - an interplay of, obesity, inflammation, diabetes and coronary heart disease.
Diabetes Obes Metab, 9 (2007), pp. 218-232
[25]
V. Samuel, Z. Liu, X. Qu, B. Elder, S. Bilz, D. Befroy, et al.
Mechanism of hepatic insulin resistance in non-alcoholic fatty liver disease.
J Biol Chem, 279 (2004), pp. 32345-32353
[26]
Y. Wei, K. Chen, A. Whaley-Connell, C. Stump, J. Ibdah, J. Sowers.
Skeletal muscle insulin resistance: role of inflammatory cytokines and reactive oxygen species.
Am J Physiol Regul Integr Comp Physiol, 294 (2008), pp. R673-R680
[27]
E.A. Hamminga, A.J. van der Lely, H.A.M. Newmann, H.B. Thio.
Chronic inflammation in psoriasis and obesity: Implications for therapy.
Med Hypotheses, 67 (2006), pp. 786-873
[28]
M. Wakkee, H. Thio, E. Prens, E. Sijbrands, H. Newmann.
Unfavorable cardiovascular risk profiles in untreated and treated psiriasis patients.
[29]
P. Gisondi, G. Girolomoni.
Cardiometabolic comorbidities and the approach to patients with psoriasis.
Actas Dermosifiliogr, 100 (2009), pp. 14-21
[30]
A. Kimball, D. Gladman, J. Gelfand, K. Gordon, E. Horn, N. Korman, et al.
National Psoriasis Foundation clinical consensus on psoriasis comorbidities and recommendations for screening.
J Am Acad Dermatol, 58 (2008), pp. 1031-1042
[31]
T. Pearson, S. Blair, S. Daniels, R. Eckel, J. Fair, S. Fortmann, et al.
AHA Guidelines for Primary Prevention of Cardiovascular Disease and Stroke: 2002 Update: Consensus Panel Guide to Comprehensive Risk Reduction for Adult Patients Without Coronary or Atherosclerotic Vascular Disease. American Heart Association Science Advisory and Coordinating Committee.
Circulation, 106 (2002), pp. 388-391
[32]
S. Grundy, J. Cleeman, C. Merz, H. Brewer, L.T. Clark, D. Hunninghake, et al.
Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines.
Circulation, 110 (2004), pp. 227-239
[33]
Obesity Society. The Practical Guide: Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. Disponible en: http://www.nhlbi.nih.gov/guidelines/obesity/prctgd_b.pdf (consultado el 20 de enero de 2011).
[34]
D. Frankenfield, E. Muth, W. Rowe.
The Harris-Benedict studies of human basal metabolism: history and limitations.
J Am Diet Assoc, 98 (1998), pp. 439-445
[35]
A.H. Lichtenstein, L.J. Appel, M. Brands, M. Carnethon, S. Daniels, H.A. Franch, American Heart Association Nutrition Committee, et al.
Diet and lifestyle recommendations revision 2006: a scientific statement from the American Heart Association Nutrition Committee.
[36]
L. Sjöström, K. Narbro, C. Sjöström, K. Karason, B. Larsson, H. Wedel, et al.
Swedish Obese Subjects Study. Effects of bariatric surgery on mortality in Swedish obese subjects.
N Engl J Med, 357 (2007), pp. 741-752
[37]
Hossler E, Maroon M, Moward C. Gastric bypass surgery improves psoriasis. J Am Acad Dermatol. 2010 Jul 21. [Epub ahead of print]. PubMed PMID: 20655127.
[38]
J. De Menezes Ettinger, E. Azaro, C. De Souza, P. Dos Santos Filho, C. Mello, M. Neves Jr., et al.
Remission of psoriasis after open gastric bypass.
Obesity Surgery, 16 (2006), pp. 94-97
[39]
J. Donnelly, S. Blair, J. Jakicic, M. Manore, J. Rankin, B. Smith.
American College of Sports Medicine Position Stand. Appropriate physical activity intervention strategies for weight loss and prevention of weight regain for adults.
Med Sci Sports Exerc, 42 (2009), pp. 459-471
[40]
G. Duarte, I. Follador, C. Cavalheiro, T. Silva, M. Oliveira.
Psoriasis and obesity: literature review and recommendations for management.
An Bras Dermatol, 85 (2010), pp. 355-360
[41]
S. Bremmer, A. Van Voorhees, S. Hsu, N. Korman, M. Lebwohl, M. Young, et al.
National Psoriasis Foundation. Obesity and psoriasis: from the Medical Board of the National Psoriasis Foundation.
J Am Acad Dermatol, 63 (2010), pp. 1058-1069
[42]
G. Langman, P. Hall, G. Todd.
Role of non-alcoholic steatohepatitis in metrotrexate-induced liver injury.
J Gastroenterol Hepatol, 16 (2001), pp. 1395-1401
[43]
R. Rivera, F. Vanaclocha.
Nonalcoholic fatty liver disease and psoriasis.
Actas Dermosifiliogr, 101 (2010), pp. 657-658
[44]
L. Clark, M. Lebwohl.
The effect of weight on the efficacy of biological therapy in patients with psoriasis.
J Am Acad Dermatol, 58 (2008), pp. 443-446
[45]
W. Sterry, B.E. Strober, A. Menter, International Psoriasis Council.
Obesity in psoriasis: the metabolic, clinical and therapeutic implications. Report of an interdisciplinary conference and review.
Br J Dermatol, 157 (2007), pp. 649-655
[46]
A. Alsufyani, A. Golanti, A.M. Lebwohl.
Psoriasis and the metabolic syndrome.
Dermatol Ther, 23 (2010), pp. 137-143
[47]
J. Gelfand, A. Neimann, D. Shin, X. Wang, D. Margolis, A. Troxel.
Risk of myocardial infarction in patients with psoriasis.
JAMA, 296 (2006), pp. 1735-1741
[48]
B. Strober, C. Teller, P. Yamuchi, J. Miller, M. Hooper, Y. Yang, et al.
Effects of etanercept on C-reactive protein levels in psoriasis and psoriatic arthritis.
Br J Dermatol, 159 (2008), pp. 322-330

Please cite this article as: Farías MM, et al. Psoriasis y obesidad: revisión y recomendaciones prácticas. Actas Dermosifiliogr. 2011;102:505-9.

Copyright © 2011. Elsevier España, S.L. and AEDV
Descargar PDF
Idiomas
Actas Dermo-Sifiliográficas
Opciones de artículo
Herramientas
es en

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?