In the first round, 97.62% of the experts contacted participated, and in the second round, 73.81% participated. The questions and answers are shown in Tables 1–3.
BLOCK I. Evaluation of the degree of incidence of obesity and associated cardiovascular risk factors
The experts concluded that for an obese patient, regardless of age, it is necessary to assess metabolic and hemodynamic parameters in an opportunistic visit. It was recommended to establish an approach strategy in PC through a checklist. The experts indicated that BMI and WC are underreported and that it would be desirable to include them in cardiovascular risk tables to better calculate the probability of risk.
On the other hand, the patient must be asked and reinforced at each visit regarding their lifestyle and changes in their weight, and adequate compliance with the treatment must be confirmed, with telematic consultation being a good option for follow-up. Additionally, it is necessary to ensure that the patient understands the information provided by the doctor to carry out the treatment correctly and agrees on the periodicity of the review visits.
Experts consider that the incidence of one or more comorbidities is much higher among obese patients than among patients of normal weight and significantly reduces life expectancy. On the other hand, for obese patients receiving antihypertensive and/or dyslipidemia treatment, it is recommended to evaluate the complete lipid profile, basal glycemia, liver enzymes, renal function, and HbA1c (if they have diabetes), in addition to measuring blood pressure, weight and WC.
Finally, there was consensus in the second round that patients with obesity and associated risk factors should be asked whether they have visited a nutrition specialist (public or private) since the last contact with their PC doctor.
On the other hand, no consensus was reached on using the cardiovascular risk calculation tool (SCORE). In addition, screening is carried out only for patients with high/very high cardiovascular risk, and blood pressure measurement is carried out only for a small percentage of patients, since an arm cuff for patients with obesity is not available in most outpatient PC clinics.
In the first round, the degree of agreement was 71.43%, and in the second round, there was no final consensus for 21.43% of the total questions in the block.
BLOCK II. Evaluation of barriers in diagnosis, prescription, and follow-up by the primary care physician or specialist
The experts did not reach a consensus on the possible barriers to using liraglutide 3.0 mg in the PC field. In the second round, only on the part of the doctors did the experts reach a consensus of agreement where they identified the frequency of daily administration of the drug as a barrier.
On the patient's side, in the first round, the experts reached a consensus on the patient's fear of regaining weight after stopping treatment as a possible barrier to using liraglutide. However, in the second round, the experts did not agree on this item.
In the first round, the degree of agreement was 10.00%, and in the second round, there was no final consensus for 90.00% of the total questions in the block.
BLOCK III. Improvement of obesity-related parameters in a patient being treated with lipid-lowering and antihypertensive drugs
The experts agreed that for an obese patient who is taking lipid-lowering and hypotensive drugs, there are improvements in BMI, WC, and C-reactive protein; if lifestyle changes occur, pharmacotherapy should be administered even if it has a high economic cost, and bariatric surgery should be performed on patients with a BMI > 40 kg/m2 and who have failed to lose weight with other measures.
According to the experience of the experts, pharmacotherapy should be started for patients with a BMI ≥ 30 kg/m2, with the best starting guideline being the administration of liraglutide accompanied by changes in lifestyle. Additional laboratory parameters that should be measured are C-reactive protein and ferritin levels.
There was no consensus on administering pharmacotherapy to patients with grade 2 overweight (BMI ≥ 27-29.9 kg/m2) or on performing bariatric surgery on patients with a BMI between 35 and 40 kg/m2. In addition, there was no consensus among the experts as to the best order of prescription of metformin, orlistat, or liraglutide for improving weight, WC, and C-reactive protein levels. In contrast, there was consensus that it was not necessary for the patient to reach a normal weight to obtain beneficial results. In addition, they assumed that pharmacotherapy could lead to adverse effects.
In the first round, the degree of agreement was 52.38%, and in the second round, there was no final consensus for 38.10% of the total questions in the block.
BLOCK IV. Analysis of improvements in cardiovascular parameters in responding patients under pharmacological treatment
The experts agreed that BMI and WC should be included in hospital discharge reports and/or medical records of patients admitted for an acute coronary event and/or coronary revascularization procedure. Likewise, they considered it necessary to start treatment with a glucagon-like peptide-1 (GLP-1) receptor agonist to improve these parameters in nondiabetic patients with chronic coronary disease and a BMI > 30 kg/m2 for whom the therapeutic goals of blood pressure and/or plasma cholesterol levels are not recommended despite standard treatment.
Experts consider that the goal of weight loss in patients with overweight or obesity grade 1 should be approximately 5–10%. On the other hand, for a patient with a BMI > 30 kg/m2 who has suffered a coronary event, it is better to initially combine pharmacological treatment with lifestyle changes.
In the second round, the experts agreed that for some selected patients, when proposing a more intensive treatment, it could be helpful to use an imaging technique that provides information on the distribution and characteristics of visceral fat in ischemic patients with obesity (e.g., liver and pericardial ultrasound, axial computed tomography and magnetic resonance imaging). In addition, they recommended a Mediterranean style diet (enriched with olive oil and nuts) for patients with obesity and coronary heart disease.
There was no consensus that the treatment of choice for coronary patients with a BMI > 35 kg/m2 despite lifestyle changes should be bariatric surgery (in the absence of contraindications).
In the first round, the degree of agreement was 57.14%, and in the second round, there was no final consensus for 14.29% of the total questions in the block.