On March 11th, 2020, the World Health Organization declared COVID-19 a pandemic. The health measures implemented by the governments of all countries were strict, to prevent the virus from spreading out of control. The results of these measures and the situation resulting from the health crisis had an impact not only on the physical health of individuals, but also on their habits, mental health (Constanza et al., 2020; Baenas et al., 2020) and cognitive impairment (Montejo et al., 2021) Moreover, the impact of stress, isolation, boredom and lack of activity and stimuli on substance use, as well as on other addictive behaviors, such as gambling, video games or pornography viewing is widely known (Király et al., 2020). In addition, for many people, these restrictions meant a reduction in their economic income, loss of employment, and significant concern as well as uncertainties for their families' jobs and financial future. This situation raised alarms from governments, especially in relation to gambling activity (Gainsbury et al., 2021).
Background and aims: Since the acceptance of Internet gaming disorder (IGD) as a "disorder due to addictive behaviors", research has proliferated exponentially. The present review focuses on the conceptualization of IGD, its diagnosis and assessment, associated factors and existing prevention and treatment plans to address it. Results and conclusions: The discrepancies between the diagnostic criteria for IGD proposed by the two central diagnostic entities, as well as the questioning of their clinical validity, have generated multiple proposals for the diagnosis and psychometric evaluation of IGD. Likewise, there have been numerous suggestions to prevent this pathology, with the involvement of governments, the gaming industry and health institutions. Finally, multiple treatment plans have been proposed, both pharmacological and psychological, although only the efficacy of cognitive behavioral therapy has been tested. It is essential, therefore, to delve deeper into this disorder by addressing the central limitations of the current literature.
Orexins/hypocretins are neuropeptides implicated in numerous processes, including food intake and cognition. The role of these peptides in the psychopathology of anorexia nervosa (AN) remains poorly understood. The aim of the current study was to evaluate the associations between plasma orexin-A (OXA) concentrations and neuropsychological functioning in adult women with AN, and a matched control group. Fasting plasma OXA concentrations were taken in 51 females with AN and in 51 matched healthy controls. Set-shifting was assessed using the Wisconsin Card Sorting Test (WCST), whereas decision making was measured using the Iowa Gambling Task (IGT). The AN group exhibited lower plasma OXA levels than the HC group. Lower mean scores were obtained on the IGT in AN patients. WCST perseverative errors were significantly higher in the AN group compared to HC. In both the AN and HC group, OXA levels were negatively correlated with WCST non-perseverative errors. Reduced plasma OXA concentrations were found to be associated with set-shifting impairments in AN. Taking into consideration the function of orexins in promoting arousal and cognitive flexibility, future studies should explore whether orexin partly underpins the cognitive impairments found in AN. ; We thank CERCA Programme/Generalitat de Catalunya for institutional support. This manuscript and research was supported by grants from the Ministerio de Economía y Competitividad (PSI2015-68701-R), Ministerio de Sanidad, Servicios Sociales e Igualdad (PR338/17), Instituto de Salud Carlos III (ISCIII) (FIS PI14/00290 and PI17/01167) and co-funded by FEDER funds/European Regional Development Fund (ERDF), a way to build Europe. CIBERObn and CIBERSAM are both initiatives of ISCIII. The funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. This research was supported by a PNSD (PR338/17-MSSSI) grant. GMB is supported by a predoctoral AGAUR grant (2018 FI_B2 00174), grant co-funded by the European Social Fund (ESF) "ESF", investing in your future. With the support of the Secretariat for Universities and Research of the Ministry of Business and Knowledge of the Government of Catalonia. CVA is supported by a predoctoral Grant of the Ministerio de Educación, Cultura y Deporte (FPU16/01453). ABC is funded by a research contract "Miguel Servet" (CP17/00088) from the ISCIII.
AIMS: To describe the current situation of gambling in Spain, sketching its history and discussing the regulations and legislation currently in force within the framework of the European Union (EU), and to review the epidemiology of gambling in Spain, the self-help groups and professional treatments available, and their potential effectiveness. METHODS: A systematic computerized search was performed in three databases (EMBASE, PubMed and PsychINFO, including articles and chapters) and the reference lists from previous reviews to obtain some of the most relevant studies published up to now on the topic of pathologic gambling in Spain. RESULTS: Similar to other EU countries, Spain has a high prevalence of pathologic gambling, focused on specific culturally bounded types of gambling. Expenditure in online gaming has risen significantly in the last few years, prompting the Spanish government to draft new legislation to regulate gaming. CONCLUSIONS: The gaming industry is expected to be one of the fastest growing sectors in Spain in the coming years owing to the rise of new technologies and the development of online gaming
This study cross-sectionally examines in the elderly population: (a) the association of type 2 diabetes with executive function (EF); (b) the effect of BMI on both type 2 diabetes and EF; (c) the association between glycaemia control and EF in type 2 diabetes. 6823 older individuals with overweight/obesity and metabolic syndrome participating in the PREDIMED-PLUS study, were assessed with a battery of cognitive tests and a medical interview. ANOVA showed a significantly worse performance on EF in type 2 diabetes vs. non-diabetic individuals. Two complementary models were displayed: (1) in the whole sample, the presence of type 2 diabetes, depressive symptoms and BMI had a direct negative effect on EF, while apnoea had an indirect negative effect; (2) in the diabetes subsample, higher illness duration was associated with worse performance in EF. Participants with type 2 diabetes and HbA1c<53 mmol/mol displayed better cognitive performance when compared to those with HbA1c≥53 mmol/mol. Our results provide a controlled comprehensive model that integrates relevant neuropsychological and physical variables in type 2 diabetes. The model suggests that, to improve treatment adherence and quality of life once diabetes has been diagnosed, cognitive decline prevention strategies need to be implemented while monitoring depressive symptoms, BMI and glycaemia control. ; This project is funded by Instituto de Salud Carlos III (ISCIII), the Spanish Government Official Agency for funding biomedical research - with competitive grants for the periods 2014–2016, 2015–2017, 2017–2019 and 2018–2020, through the Fondo de Investigación para la Salud (FIS), which is co-funded by the European Regional Development Fund [grants: PI13/00673, PI13/00492, PI13/00272, PI13/01123, PI13/00462, PI13/00233, PI13/02184, PI13/00728 PI13/01090 PI13/01056, PI14/01722, PI14/00636, PI14/00618, PI14/00696, PI14/01206, PI14/01919, PI14/00853, PI14/01374, PI16/00473, PI16/00662, PI16/01873, PI16/01094, PI16/00501, PI16/00533, PI16/00381, PI16/00366, PI16/01522, PI16/01120, PI17/00764, PI17/01183, PI17/00855, PI17/01347, PI17/00525, PI17/01827, PI17/00532, PI17/00215, PI17/01441, PI17/00508, PI17/01732, PI17/00926] and the European Research Council [Advanced Research Grant 2014–2019; agreement #340918]. Additional grants: Acciones Especiales from ISCIIII, Consejería-Salud, Junta -Andalucía [PI0458/2013, PS0358/2016], Recercaixa-grant 2013 [2013ACUP00194], a SEMERGEN grant, International Nut & Dried Fruit Council – FESNAD No. 201302. Fundación Patrimonio Comunal Olivarero is providing the necessary amounts of olive oil. Nuts were initially and only partially provided by Pistachios Growers and Almond Board of California, for the pilot study. This research was also partially funded by EU-H2020 Grant (Eat2beNICE/H2020-SFS-2016–2; Ref 728018), PI14/00290 y PI17/1167(Co-funded by European Regional Development Fund, ERDF, a way to build Europe), PERIS (Generalitat de Catalunya, SLT006/17/00077), Grant PROMETEO/2017/017 (Generalitat Valenciana) and Grant FEA/SEA 2017 for Primary Care Research. We thank CERCA Programme/Generalitat de Catalunya for institutional support. ML-M is supported by a predoctoral Grant of the Ministerio de Educación, Cultura y Deporte (FPU15/02911). None of these funding sources plays any role in the design, collection, analysis, or interpretation of the data or in the decision to submit manuscripts for publication.
<b><i>Aims:</i></b> The aim of this study was to evaluate posttreatment changes of individuals with a diagnosis of gambling disorder (GD) treated with group cognitive behavioral therapy (CBT), to assess the potential moderator effect of sex on CBT outcome, and to explore the best predictors of posttreatment changes, relapse, and dropout rates. <b><i>Methods:</i></b> A cohort design was applied with a prospective follow-up. The sample comprised 440 patients and the CBT intervention consisted of 16 weekly outpatient group sessions and a 3-month follow-up period. <b><i>Results:</i></b> Patients showed significant improvements in both the level of psychopathology and the severity of the gambling behavior. High self-transcendence and the involvement of the spouse or partner in the therapy predicted a higher risk of relapse. Younger age and low education predicted a higher risk of dropout. <b><i>Conclusion:</i></b> Many patients with GD can be treated with strategies to improve self-control and emotional regulation, but other techniques should be incorporated to address the individual characteristics of each patient. This is particularly important in group therapy, in which the same treatment is applied to several patients simultaneously. The involvement of a family member needs to be carefully considered since it may have a negative effect on the response to treatment if not adequately managed.
<b><i>Objectives:</i></b> The main objective of this study was to compare the clinical characteristics and differences in response to treatment of two groups of pathological gamblers: with comorbid Parkinson's disease (PG + PD) and without (PG – PD). <b><i>Methods:</i></b> Clinical and psychopathological profiles and response to cognitive-behavioral treatment were assessed in 15 PG + PD and 45 PG – PD individuals consulting a specialized hospital Unit. <b><i>Results:</i></b> Statistically significant differences were observed between the two groups on a series of clinical variables. PG + PD patients were older and presented later onset of problematic gambling behaviors, lower alcohol consumption and higher bingo playing than PG – PD patients. No significant differences were noted in psychopathology except for lower measures of hostility in the PG + PD group. No statistical differences were detected between groups in terms of response to treatment. <b><i>Conclusion:</i></b> These results may provide guidance for obtaining accurate diagnostic information in pathological gamblers by properly identifying patients with specific needs that may be targeted with treatment.
Altres ajuts: This project was funded by Instituto de Salud Carlos III (ISCIII), the Spanish Government Official Agency for funding biomedical research-with competitive grants leaded by Jordi Salas-Salvadó and Josep Vidal for the periods 2014-2016, 2015-2017, 2017-2019 and 2018-2020, through the Fondo de Investigación para la Salud (FIS), which is co-funded by the European Regional Development Fund [grants: PI13/00233, PI13/00728, PI13/01123, PI13/00462, PI16/00533, PI16/00366, PI16/01094, PI16/00501, PI19/00017, PI19/00781, PI19/01032, PI19/00576]; the Especial Action Project entitled: Implementación y evaluación de una intervención intensiva sobre la actividad física Cohorte PREDIMED-Plus grant to Jordi Salas-Salvadó; the European Research Council [Advanced Research Grant 2014-2019; agreement #340918] granted to Miguel Ángel Martínez-González; the Recercaixa (number 2013ACUP00194) grant to Jordi Salas-Salvadó. ; This study examines if overweight/obesity are related to higher impulsivity, food addiction and depressive symptoms, and if these variables could be modified after 1 year of a multimodal intervention (diet, physical activity, psychosocial support). 342 adults (55-75 years) with overweight/obesity and metabolic syndrome (MetS) from the PREDIMED-Plus Cognition study were randomized to the intervention or to the control group (lifestyle recommendations). Cognitive and psychopathological assessments were performed at baseline and after 1-year follow-up. At baseline, higher impulsivity was linked to higher food addiction and depressive symptoms, but not to body mass index (BMI). Food addiction not only predicted higher BMI and depressive symptoms, but also achieved a mediational role between impulsivity and BMI/depressive symptoms. After 1 year, patients in both groups reported significant decreases in BMI, food addiction and impulsivity. BMI reduction and impulsivity improvements were higher in the intervention group. Higher BMI decrease was achieved in individuals with lower impulsivity. Higher scores in ...
This study examines if overweight/obesity are related to higher impulsivity, food addiction and depressive symptoms, and if these variables could be modified after 1 year of a multimodal intervention (diet, physical activity, psychosocial support). 342 adults (55-75 years) with overweight/obesity and metabolic syndrome (MetS) from the PREDIMED-Plus Cognition study were randomized to the intervention or to the control group (lifestyle recommendations). Cognitive and psychopathological assessments were performed at baseline and after 1-year follow-up. At baseline, higher impulsivity was linked to higher food addiction and depressive symptoms, but not to body mass index (BMI). Food addiction not only predicted higher BMI and depressive symptoms, but also achieved a mediational role between impulsivity and BMI/depressive symptoms. After 1 year, patients in both groups reported significant decreases in BMI, food addiction and impulsivity. BMI reduction and impulsivity improvements were higher in the intervention group. Higher BMI decrease was achieved in individuals with lower impulsivity. Higher scores in food addiction were also related to greater post-treatment impulsivity. To conclude, overweight/obesity are related to higher impulsivity, food addiction and depressive symptoms in mid/old age individuals with MetS. Our results also highlight the modifiable nature of the studied variables and the interest of promoting multimodal interventions within this population. ; This project was funded by Instituto de Salud Carlos III (ISCIII), the Spanish Government Official Agency for funding biomedical research—with competitive grants leaded by Jordi Salas-Salvadó and Josep Vidal for the periods 2014–2016, 2015–2017, 2017–2019 and 2018–2020, through the Fondo de Investigación para la Salud (FIS), which is co-funded by the European Regional Development Fund [grants: PI13/00233, PI13/00728, PI13/01123, PI13/00462, PI16/00533, PI16/00366, PI16/01094, PI16/00501, PI19/00017, PI19/00781, PI19/01032, PI19/00576]; the Especial Action Project entitled: Implementación y evaluación de una intervención intensiva sobre la actividad física Cohorte PREDIMED-Plus grant to Jordi Salas-Salvadó; the European Research Council [Advanced Research Grant 2014–2019; agreement #340918] granted to Miguel Ángel Martínez-González; the Recercaixa (number 2013ACUP00194) grant to Jordi Salas-Salvadó. This research was also partially funded by EU-H2020 Grants (Eat2beNICE/H2020-SFS-2016-2; Ref 728018; and PRIME/H2020-SC1-BHC-2018-2020; Ref: 847879) and Instituto Salud Carlos III (Fondo Investigación Sanitario, FIS: PI17/01167), Grant PROMETEO/2017/017 (Generalitat Valenciana) and Grant FEA/SEA 2017 for Primary Care Research. This work is also partially supported by ICREA under the ICREA Academia programme.
Objectifs :Comparer la consommation de substances, les comportements de jeu et les traits de personnalité de deux groupes d'individus ayant un trouble de jeu pathologique (patients jeunes et adultes) ; explorer l'apport du sexe, de l'âge et des traits de personnalités sur la consommation de substances et évaluer la capacité de prédire la consommation de substances à partir de l'âge et des traits de personnalité.Méthodes :L'échantillon était formé de 428 patients ayant un trouble de jeu pathologique (TJP), divisés en deux groupes selon l'âge (55 jeunes patients [âge ≤ 25 ans] et 373 patients d'âge moyen à avancé [âge > 25 ans]). Tous les patients ont été admis dans un département de psychiatrie et diagnostiqués selon les critères du DSM-IV. En outre, d'autres évaluations cliniques, dont leDiagnostic Questionnaire for Pathological Gamblingen vertu des critères du DSM-IV, leSouth Oaks Gambling Screen(SOGS) et leTemperament and Character Inventory-Revised(TCI-R), ont été utilisées pour examiner les comportements de jeu, la consommation de substances et la personnalité.Résultats :À la comparaison des deux groupes d'âge, nous avons observé des différences statistiquement significatives pour plusieurs variables sociodémographiques. En outre, les plus jeunes patients ayant un TJP présentaient un taux plus élevé de consommation de substances (p = 0,010). Pour ce qui est des traits de personnalité, des différences ont été remarquées seulement à l'échelle de recherche de nouveautés (RN) où les patients plus jeunes obtenaient des cotes élevées (p= 0,006). Des cotes plus élevées (p=0,022) à l'échelle de recherche de nouveautés (RN) et plus basses (p= 0,028) à l'échelle d'auto-transcendance représentaient des traits de personnalité ayant une interrelation significative avec la consommation de tabac (p= 0,003). Toutefois, seul l'âge était associé à la consommation d'autres substances (p=0,003).Conclusions :Les résultats confirment que le trouble de jeu pathologique (TJP) est souvent concomitant avec la consommation de substances. L'interrelation du TJP et de la consommation de tabac, d'alcool et d'autres substances entraîne une gamme d'implications cliniques et liées à la personnalité, particulièrement chez les populations jeunes. Puisque plusieurs études ont démontré que le taux de TJP est plus élevé chez les jeunes, le début précoce du trouble est souvent lié à une gravité accrue et à une persistance des problèmes de jeu. En outre, la présence d'un double diagnostic (consommation de substances) pourrait compliquer la réponse aux traitements. Pour cette raison, l'étude des populations jeunes est d'un intérêt particulier afin de concevoir et de mettre en oeuvre des programmes de traitement qui abordent tous les problèmes liés aux profils cliniques de ce groupe d'âge.
Background and Purpose: Both adherence to the Mediterranean diet (MedDiet) and the use of metformin could benefit the cognitive performance of individuals with type 2 diabetes, but evidence is still controversial. We examined the association between metformin use and cognition in older adults with type 2 diabetes following a MedDiet intervention. Methods: Prospective cohort study framed in the PREDIMED-Plus-Cognition sub-study. The PREDIMED-Plus clinical trial aims to compare the cardiovascular effect of two MedDiet interventions, with and without energy restriction, in individuals with overweight/obesity and metabolic syndrome. The present sub-study included 487 cognitively normal subjects (50.5% women, mean ± SD age of 65.2 ± 4.7 years), 30.4% of them (N = 148) with type 2 diabetes. A comprehensive battery of neurocognitive tests was administered at baseline and after 1 and 3 years. Individuals with type 2 diabetes that exhibited a good glycemic control trajectory, either using or not using metformin, were compared to one another and to individuals without diabetes using mixed-effects models with inverse probability of treatment weights. Results: Most subjects with type 2 diabetes (83.1%) presented a good and stable glycemic control trajectory. Before engaging in the MedDiet intervention, subjects using metformin scored higher in executive functions (Cohen's d = 0.51), memory (Cohen's d = 0.38) and global cognition (Cohen's d = 0.48) than those not using metformin. However, these differences were not sustained during the 3 years of follow-up, as individuals not using metformin experienced greater improvements in memory (β = 0.38 vs. β = 0.10, P = 0.036), executive functions (β = 0.36 vs. β = 0.02, P = 0.005) and global cognition (β = 0.29 vs. β = -0.02, P = 0.001) that combined with a higher MedDiet adherence (12.6 vs. 11.5 points, P = 0.031). Finally, subjects without diabetes presented greater improvements in memory than subjects with diabetes irrespective of their exposure to metformin (β = 0.55 vs. β = 0.10, P < 0.001). However, subjects with diabetes not using metformin, compared to subjects without diabetes, presented greater improvements in executive functions (β = 0.33 vs. β = 0.08, P = 0.032) and displayed a higher MedDiet adherence (12.6 points vs. 11.6 points, P = 0.046). Conclusions: Although both metformin and MedDiet interventions are good candidates for future cognitive decline preventive studies, a higher adherence to the MedDiet could even outweigh the potential neuroprotective effects of metformin in subjects with diabetes. ; Study resulting from the following grants: SLT006/17/00246, SLT002/16/00045 and SLT006/17/00077 funded by the Department of Health of the Generalitat de Catalunya by the calls Acció instrumental de programes de recerca orientats en l'àmbit de la recerca i la innovació en salut and Pla estratègic de recerca i innovació en salut (PERIS). We thank CERCA Programme/Generalitat de Catalunya for institutional support. This project was funded by Instituto de Salud Carlos III (ISCIII), the Spanish Government Official Agency for funding biomedical research-with competitive grants leaded by JS-S and Josep Vidal for the periods 2014–2016, 2015–2017, 2017–2019, and 2018–2020, through the Fondo de Investigación para la Salud (FIS), which is co-funded by the European Regional Development Fund, ERDF, a way to build Europe) [grants: PI13/00233, PI13/00728, PI13/01123, PI13/00462, PI16/00533, PI16/00366, PI16/01094, PI16/00501, PI17/01167, PI19/00017, PI19/00781, PI19/01032, PI19/00576]; the Especial Action Project entitled: Implementación y evaluación de una intervención intensiva sobre la actividad física Cohorte PREDIMED-Plus grant to JS-S; the European Research Council [Advanced Research Grant 2014–2019; agreement #340918] granted to Miguel Ángel Martínez-González; the Recercaixa (number 2013ACUP00194) grant to JS-S. This research was also partially funded by EU-H2020 Grants (Eat2beNICE/H2020-SFS-2016-2; Ref 728018; and PRIME/H2020-SC1-BHC-2018-2020; Ref: 847879), Grant PROMETEO/2017/017 (Generalitat Valenciana) and Grant FEA/SEA 2017 for Primary Care Research. This work is also partially supported by ICREA under the ICREA Academia programme. This work was supported by grants from DIUE de la Generalitat de Catalunya 2017 SGR 138 from the Departament d'Economia i Coneixement de la Generalitat de Catalunya (Spain). NS-D has received the FI 2021 predoctoral grant (FI_B2021/00104) from the Agency for Management of University and Research Grants (AGAUR) of the Generalitat de Catalunya. CV-A was supported by a predoctoral Grant of the Ministerio de Educación, Cultura y Deporte (FPU16/01453). AA-S has received a post-doctoral grant from the Consellería de Innovación, Ciencia y Sociedad Digital, Generalitat Valenciana, Valencia (APOSTD/2020/003). The Physiopathology of Obesity and Nutrition Networking Biomedical Research Center (CIBEROBN) is an initiative of ISCIII.
This study cross-sectionally examines in the elderly population: (a) the association of type 2 diabetes with executive function (EF); (b) the effect of BMI on both type 2 diabetes and EF; (c) the association between glycaemia control and EF in type 2 diabetes. 6823 older individuals with overweight/obesity and metabolic syndrome participating in the PREDIMED-PLUS study, were assessed with a battery of cognitive tests and a medical interview. ANOVA showed a significantly worse performance on EF in type 2 diabetes vs. non-diabetic individuals. Two complementary models were displayed: (1) in the whole sample, the presence of type 2 diabetes, depressive symptoms and BMI had a direct negative effect on EF, while apnoea had an indirect negative effect; (2) in the diabetes subsample, higher illness duration was associated with worse performance in EF. Participants with type 2 diabetes and HbA1c<53 mmol/mol displayed better cognitive performance when compared to those with HbA1c≥53 mmol/mol. Our results provide a controlled comprehensive model that integrates relevant neuropsychological and physical variables in type 2 diabetes. The model suggests that, to improve treatment adherence and quality of life once diabetes has been diagnosed, cognitive decline prevention strategies need to be implemented while monitoring depressive symptoms, BMI and glycaemia control. ; This project is funded by Instituto de Salud Carlos III (ISCIII), the Spanish Government Official Agency for funding biomedical research - with competitive grants for the periods 2014–2016, 2015–2017, 2017–2019 and 2018–2020, through the Fondo de Investigación para la Salud (FIS), which is co-funded by the European Regional Development Fund [grants: PI13/00673, PI13/00492, PI13/00272, PI13/01123, PI13/00462, PI13/00233, PI13/02184, PI13/00728 PI13/01090 PI13/01056, PI14/01722, PI14/00636, PI14/00618, PI14/00696, PI14/01206, PI14/01919, PI14/00853, PI14/01374, PI16/00473, PI16/00662, PI16/01873, PI16/01094, PI16/00501, PI16/00533, PI16/00381, PI16/00366, PI16/01522, PI16/01120, PI17/00764, PI17/01183, PI17/00855, PI17/01347, PI17/00525, PI17/01827, PI17/00532, PI17/00215, PI17/01441, PI17/00508, PI17/01732, PI17/00926] and the European Research Council [Advanced Research Grant 2014–2019; agreement #340918]. Additional grants: Acciones Especiales from ISCIIII, Consejería-Salud, Junta -Andalucía [PI0458/2013, PS0358/2016], Recercaixa-grant 2013 [2013ACUP00194], a SEMERGEN grant, International Nut & Dried Fruit Council – FESNAD No. 201302. Fundación Patrimonio Comunal Olivarero is providing the necessary amounts of olive oil. Nuts were initially and only partially provided by Pistachios Growers and Almond Board of California, for the pilot study. This research was also partially funded by EU-H2020 Grant (Eat2beNICE/H2020-SFS-2016–2; Ref 728018), PI14/00290 y PI17/1167(Co-funded by European Regional Development Fund, ERDF, a way to build Europe), PERIS (Generalitat de Catalunya, SLT006/17/00077), Grant PROMETEO/2017/017 (Generalitat Valenciana) and Grant FEA/SEA 2017 for Primary Care Research. We thank CERCA Programme/Generalitat de Catalunya for institutional support. ML-M is supported by a predoctoral Grant of the Ministerio de Educación, Cultura y Deporte (FPU15/02911). None of these funding sources plays any role in the design, collection, analysis, or interpretation of the data or in the decision to submit manuscripts for publication
