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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introducci&#243;n</span><p id="par0005" class="elsevierStylePara elsevierViewall">La fragilidad es un s&#237;ndrome geri&#225;trico caracterizado por un estado de mayor vulnerabilidad a incluso peque&#241;os estresores&#44; resultado de una disminuci&#243;n progresiva de la reserva biol&#243;gica en varios &#243;rganos o sistemas<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">1&#44;2</span></a>&#46; Por ello&#44; ante dichos estresores&#44; las personas fr&#225;giles muestran mayor riesgo de ca&#237;da&#44; hospitalizaci&#243;n&#44; institucionalizaci&#243;n y muerte<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">2</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">En los &#250;ltimos tiempos ha crecido el inter&#233;s sobre los enfoques cognitivo y social de la fragilidad&#44; que se suman a la fragilidad f&#237;sica para formar un nodo de complejas interacciones<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">3&#8211;5</span></a>&#46; La fragilidad social se define como la falta de recursos para satisfacer las necesidades sociales b&#225;sicas de la vida&#44; e incluye en su operacionalizaci&#243;n diversos factores&#44; como redes de apoyo social&#44; situaci&#243;n econ&#243;mica y laboral&#44; empoderamiento y recursos comunitarios<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">5</span></a>&#46; La asociaci&#243;n entre la fragilidad f&#237;sica y la fragilidad social parece ser reversible&#46; Algunos&#47;as autores&#47;as han sugerido que la fragilidad f&#237;sica es un factor de riesgo de la fragilidad social<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">4</span></a>&#44; mientras que otros&#47;as se&#241;alan a la fragilidad social como precursora de la fragilidad f&#237;sica<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">5</span></a>&#46; Ya sea una causa o su consecuencia&#44; identificar los determinantes asociados con la fragilidad social es clave para desarrollar intervenciones efectivas que permitan un envejecimiento saludable&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">La limitaci&#243;n auditiva asociada al envejecimiento es la limitaci&#243;n sensorial m&#225;s frecuente en las personas mayores<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">6</span></a> y se ha asociado prospectivamente con peores indicadores de salud&#44; incluyendo mayor riesgo de fragilidad f&#237;sica<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">7</span></a>&#46; Adem&#225;s&#44; existen evidencias de que la limitaci&#243;n auditiva conduce progresivamente a un peor funcionamiento social<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">8</span></a>&#46; Yoo et al&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">9</span></a> encontraron por primera vez que las personas mayores de 70 a&#241;os del <span class="elsevierStyleItalic">Korean Frailty and Aging Cohort Study</span> con limitaci&#243;n auditiva ten&#237;an el doble de riesgo de fragilidad social&#44; y que la asociaci&#243;n se manten&#237;a aun despu&#233;s de ajustar por la fragilidad f&#237;sica&#46; Dado que los estudios que abordan la fragilidad social pueden ser muy sensibles al contexto cultural&#44; es relevante examinar la asociaci&#243;n entre limitaci&#243;n auditiva y fragilidad social en una muestra de personas mayores de Espa&#241;a&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Adicionalmente&#44; explorar las diferencias seg&#250;n el sexo ayudar&#237;a a dar un paso m&#225;s&#46; Por un lado&#44; la paradoja &#171;hombre-mujer salud-supervivencia&#187;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">10</span></a>&#44; seg&#250;n la cual las mujeres tienen peor salud&#44; pero mayor supervivencia&#44; determina una estructura demogr&#225;fica con predominio de mujeres mayores&#44; que en consecuencia tienen m&#225;s probabilidad de vivir solas y de tener menor calidad de vida&#46; Por otro lado&#44; dado que algunos&#47;as autores&#47;as mantienen que las mujeres tienen redes sociales m&#225;s densas y con mayores niveles de comunicaci&#243;n que los hombres<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">11</span></a>&#44; podr&#237;an ser m&#225;s sensibles a procesos que dificulten su vida social&#44; como una limitaci&#243;n auditiva&#46; De hecho&#44; de acuerdo con Joanovi&#269; et al&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">12</span></a>&#44; cuando se logra corregir la limitaci&#243;n auditiva las mujeres valoran m&#225;s positivamente que los hombres la mejora en la participaci&#243;n social y la intimidad&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">El objetivo de este estudio fue explorar la asociaci&#243;n entre la limitaci&#243;n auditiva y la fragilidad social en una muestra de hombres y mujeres mayores&#44; no institucionalizados&#47;as y usuarios&#47;as de la red de atenci&#243;n primaria de salud de Espa&#241;a&#44; y determinar si existen diferencias seg&#250;n el sexo&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">M&#233;todo</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Dise&#241;o del estudio y participantes</span><p id="par0030" class="elsevierStylePara elsevierViewall">Estudio transversal en una muestra de 445 personas de 65 y m&#225;s a&#241;os de edad no institucionalizadas y usuarias de atenci&#243;n primaria en Asturias &#40;Espa&#241;a&#41;&#46; El reclutamiento se realiz&#243; entre mayo y julio de 2019 mediante muestreo poliet&#225;pico&#44; por conglomerados y estratificado&#46; Los conglomerados fueron centros de atenci&#243;n primaria de zonas urbanas &#40;&#62;50&#46;000 habitantes&#41;&#44; semiurbanas &#40;1&#46;000-50&#46;000&#41; y rurales &#40;&#60;1000&#41;&#44; determinando el n&#250;mero de habitantes los diferentes estratos&#46; As&#237;&#44; se seleccionaron aleatoriamente cuatro centros de salud&#58; uno urbano&#44; dos semiurbanos y uno rural&#46; Posteriormente&#44; un&#47;a profesional de enfermer&#237;a de cada centro invit&#243; a participar de forma consecutiva a los&#47;las pacientes que acud&#237;an al centro de salud para demandar atenci&#243;n sanitaria hasta completar el tama&#241;o muestral&#46; Considerando la frecuencia de fragilidad social hallada por Garre-Olmo et al&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">13</span></a> en la atenci&#243;n primaria de salud de Gerona&#44; se estim&#243; necesario contar con 428 personas para detectar diferencias del 10&#37; entre aquellas con y sin limitaci&#243;n auditiva &#40;potencia estad&#237;stica del 90&#37;&#41;&#46; De las 475 personas interesadas&#44; se excluyeron las que ten&#237;an diagn&#243;stico de demencia &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>18&#41; o presentaban alg&#250;n trastorno musculoesquel&#233;tico agudo &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>12&#41; que limitaba temporalmente su capacidad f&#237;sica &#40;p&#46; ej&#46;&#44; haber tenido en el &#250;ltimo mes un esguince de tobillo&#44; una fractura de cadera&#44; etc&#46;&#41;&#44; porque ello pod&#237;a alterar las determinaciones relacionadas con la fragilidad&#46; Las personas que aceptaron participar y que cumplieron estos criterios fueron citadas para una entrevista cara a cara con el&#47;la mismo&#47;a profesional de enfermer&#237;a en su consulta&#46; Se entren&#243; a los&#47;las cuatro profesionales de enfermer&#237;a para estandarizar el procedimiento y reducir la variabilidad&#46; Los&#47;las participantes otorgaron su consentimiento informado por escrito&#46; El estudio fue aprobado por el Comit&#233; de &#201;tica para la Investigaci&#243;n de Asturias &#40;ref&#46; n&#176; 246&#47;18&#41;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Variables de estudio</span><p id="par0160" class="elsevierStylePara elsevierViewall">1&#46; Limitaci&#243;n auditiva</p><p id="par0035" class="elsevierStylePara elsevierViewall">Para identificar a las personas con limitaci&#243;n auditiva se utilizaron tres preguntas jer&#225;rquicas&#46; Se consider&#243; que un&#47;a participante ten&#237;a limitaci&#243;n auditiva cuando&#44; con independencia del uso de aud&#237;fono&#44; contestaba afirmativamente a la pregunta directa&#58; &#171;&#191;Siente que tiene alg&#250;n problema para o&#237;r&#63;&#187;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">14</span></a>&#46; Cuando la persona respond&#237;a negativamente&#44; para aumentar la capacidad de detecci&#243;n se usaron dos preguntas del <span class="elsevierStyleItalic">Hearing Handicap Inventory for Elderly Screening&#58;</span> &#171;&#191;Tiene dificultad para o&#237;r la televisi&#243;n o la radio porque no oye bien&#63;&#187; y &#171;&#191;Tiene dificultad para o&#237;r cuando alguien le habla en voz baja&#63;&#187;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">15</span></a>&#46; Estas preguntas son suficientes para detectar&#44; con un alto valor predictivo positivo&#44; la limitaci&#243;n auditiva en poblaci&#243;n mayor en atenci&#243;n primaria &#40;v&#46; <a class="elsevierStyleCrossRef" href="#sec0095">tabla I del Ap&#233;ndice <span class="elsevierStyleItalic">online</span></a>&#41;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">16</span></a>&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">2&#46; Fragilidad social</p><p id="par0040" class="elsevierStylePara elsevierViewall">La fragilidad social se identific&#243; seg&#250;n la definici&#243;n operativa de Garre-Olmo et al&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">13</span></a>&#44; que valora seis &#237;tems&#58; vivir solo&#47;a&#44; ausencia de una persona que preste ayuda&#44; contacto infrecuente con familiares&#44; contacto infrecuente con amistades y vecinos&#47;as&#44; falta de confidente y falta de ayuda para las actividades cotidianas en los &#250;ltimos 3 meses &#40;v&#46; <a class="elsevierStyleCrossRef" href="#sec0095">tabla I del Ap&#233;ndice <span class="elsevierStyleItalic">online</span></a>&#41;&#46; Esta conceptualizaci&#243;n est&#225; basada en la teor&#237;a de la acumulaci&#243;n de d&#233;ficits<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">17</span></a> y ha sido utilizada con &#233;xito previamente<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">13</span></a>&#46; Se consider&#243; prefr&#225;gil social a quien presentara una de las seis caracter&#237;sticas&#44; y fr&#225;gil social a quien presentara dos o m&#225;s&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">3&#46; Otras variables</p><p id="par0045" class="elsevierStylePara elsevierViewall">Se recogi&#243; informaci&#243;n sociodemogr&#225;fica &#40;edad&#44; sexo y nivel de estudios&#41;&#44; de actividad f&#237;sica y de estado de salud&#46; La actividad f&#237;sica se valor&#243; con la pregunta&#58; &#171;Durante la &#250;ltima semana&#44; &#191;ha realizado todos los d&#237;as 25-30 minutos de ocio activo&#44; es decir&#44; alguna actividad que le haga sudar o fatigarse&#63;&#187;&#46; Cabrera de Le&#243;n et al&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">18</span></a> recomiendan esta pregunta en la pr&#225;ctica cl&#237;nica por su eficiencia&#44; y consideran f&#237;sicamente activo a quien realiza al menos 25 minutos de ejercicio al d&#237;a&#46; Con respecto al estado de salud&#44; tras medir el peso y la talla de forma estandarizada se calcul&#243; el &#237;ndice de masa corporal &#40;IMC&#41;&#44; se determin&#243; la presencia de deterioro cognitivo&#44; que se estableci&#243; cuando la persona cometi&#243; al menos tres errores en el test de Pfeiffer &#40;&#8805;4 si ten&#237;a estudios elementales y &#8805;2 si ten&#237;a estudios superiores&#41;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">19</span></a>&#44; y se recogi&#243; el estado de salud autoinformado referido a los &#250;ltimos 12 meses&#46; Finalmente&#44; se identific&#243; la fragilidad f&#237;sica utilizando la escala FRAIL<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">20</span></a>&#44; que valora cinco &#237;tems&#58; fatiga&#44; resistencia&#44; deambulaci&#243;n&#44; enfermedades y p&#233;rdida de peso &#40;v&#46; <a class="elsevierStyleCrossRef" href="#sec0095">tabla I del Ap&#233;ndice <span class="elsevierStyleItalic">online</span></a>&#41;&#46; La presencia de cada &#237;tem sum&#243; 1 punto&#46; Se consider&#243; que exist&#237;a prefragilidad cuando la puntuaci&#243;n era de 1 o 2 puntos&#44; y fragilidad f&#237;sica cuando fue &#8805;3 puntos&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">An&#225;lisis de los datos</span><p id="par0050" class="elsevierStylePara elsevierViewall">El an&#225;lisis de los datos se llev&#243; a cabo con el programa STATA v&#46;15&#46; Las variables categ&#243;ricas se describieron con frecuencias &#40;porcentaje&#41; y las continuas con medias &#40;&#177; desviaci&#243;n est&#225;ndar&#41;&#46; Para resumir la asociaci&#243;n entre la limitaci&#243;n auditiva y la fragilidad social se calcularon las <span class="elsevierStyleItalic">odds ratios</span> &#40;OR&#41; y los intervalos de confianza del 95&#37; &#40;IC95&#37;&#41; mediante regresiones log&#237;sticas multinomiales&#46; La variable independiente fue la limitaci&#243;n auditiva y la variable dependiente fue la fragilidad social seg&#250;n tres categor&#237;as&#58; robusto &#40;que se tom&#243; como referencia&#41;&#44; prefr&#225;gil y fr&#225;gil&#46; Se usaron tres modelos de regresi&#243;n&#44; incluyendo ajustes por covariables de forma secuencial&#59; el primero fue crudo&#44; el segundo se ajust&#243; por edad y sexo&#44; y el tercero se ajust&#243; adicionalmente por nivel de estudios&#44; actividad f&#237;sica&#44; IMC&#44; estado cognitivo&#44; estado de salud y fragilidad f&#237;sica&#46; Adem&#225;s&#44; se comprob&#243; si la asociaci&#243;n era dependiente del sexo mediante el uso de t&#233;rminos de interacci&#243;n&#46; Los modelos con y sin t&#233;rminos de interacci&#243;n se compararon con el test de raz&#243;n de verosimilitud&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Dado que realizar las dos preguntas del <span class="elsevierStyleItalic">Hearing Handicap Inventory for Elderly Screening</span> a las personas que respond&#237;an negativamente a la pregunta directa sobre la limitaci&#243;n auditiva podr&#237;a maximizar la sensibilidad y minimizar la especificidad&#44; se realiz&#243; un an&#225;lisis adicional utilizando &#250;nicamente la respuesta a la pregunta directa como criterio de limitaci&#243;n auditiva&#46; Finalmente&#44; para entender la contribuci&#243;n espec&#237;fica de la limitaci&#243;n auditiva a cada uno de los criterios individuales de fragilidad social considerados en este estudio&#44; se realizaron an&#225;lisis adicionales mediante regresi&#243;n log&#237;stica totalmente ajustada&#44; en los que las variables dependientes fueron vivir solo&#47;a&#44; no tener posibilidad de ayuda&#44; no tener contacto regular con familiares&#44; no tener contacto regular con amistades y vecinos&#47;as&#44; ausencia de confidente y falta de ayuda para las actividades cotidianas&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Resultados</span><p id="par0060" class="elsevierStylePara elsevierViewall">La edad media de las personas participantes fue de 76&#44;2 a&#241;os &#40;&#177;7&#44;2&#41;&#46; En la muestra predominaron las mujeres &#40;57&#44;3&#37;&#41;&#44; las personas sin estudios o con estudios elementales&#44; sedentarias y con sobrepeso&#46; Aproximadamente la mitad consideraron que ten&#237;an un estado de salud bueno o mejor&#44; el 7&#44;4&#37; obtuvieron una puntuaci&#243;n en el test de Pfeiffer sugestiva de deterioro cognitivo y el 64&#44;3&#37; eran prefr&#225;giles o fr&#225;giles f&#237;sicos &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;&#46; En cuanto a las variables relacionadas con la audici&#243;n&#44; 36 &#40;8&#44;1&#37;&#41; personas utilizaban aud&#237;fono&#44; aunque solo 10 &#40;27&#44;8&#37;&#41; lograban corregir su limitaci&#243;n auditiva&#46; En general&#44; m&#225;s de la mitad de las personas &#40;54&#44;4&#37;&#41; presentaban alg&#250;n tipo de limitaci&#243;n auditiva &#40;41&#44;4&#37; considerando solo la primera pregunta&#41;&#46; En comparaci&#243;n con quienes no ten&#237;an limitaci&#243;n auditiva&#44; los&#47;las que la presentaban eran de mayor edad&#44; m&#225;s sedentarios y con peor salud autopercibida &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;&#46; Se detectaron 164 personas &#40;36&#44;9&#37;&#41; prefr&#225;giles y 103 &#40;23&#44;1&#37;&#41; fr&#225;giles sociales&#46; La fragilidad social se manifest&#243; con mayor frecuencia en las mujeres y en las personas con peor estado de salud &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;&#46; En general&#44; las mujeres reclutadas fueron significativamente mayores que los hombres&#44; ten&#237;an menor nivel de instrucci&#243;n y presentaron peores indicadores de salud &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">La frecuencia de limitaci&#243;n auditiva fue mayor en las personas prefr&#225;giles y fr&#225;giles sociales &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#46; La limitaci&#243;n auditiva se asoci&#243; con la fragilidad social &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#44;78&#59; IC95&#37;&#58; 1&#44;04-3&#44;06&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a>&#41;&#46; No obstante&#44; se detect&#243; una interacci&#243;n debida al sexo &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;041 en el modelo ajustado&#41;&#44; y en los an&#225;lisis estratificados la asociaci&#243;n solo se hall&#243; en las mujeres &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>3&#44;21&#59; IC95&#37;&#58; 1&#44;44-7&#44;17&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a>&#41;&#46; Los resultados fueron muy similares cuando se utiliz&#243; &#250;nicamente la pregunta directa como forma de medir la limitaci&#243;n auditiva &#40;v&#46; <a class="elsevierStyleCrossRef" href="#sec0095">tabla II del Ap&#233;ndice <span class="elsevierStyleItalic">online</span></a>&#41;&#46; Los resultados fueron en la misma direcci&#243;n y de similar magnitud en los an&#225;lisis basados en la presencia de fragilidad social &#40;no&#47;s&#237;&#41; y no en sus estadios &#40;robusto&#44; prefr&#225;gil o fr&#225;gil&#41;&#46; Adem&#225;s&#44; al excluir a las personas con deterioro cognitivo los resultados fueron pr&#225;cticamente id&#233;nticos &#40;datos no mostrados&#41;&#46; Finalmente&#44; en las mujeres la limitaci&#243;n auditiva se asoci&#243; espec&#237;ficamente con vivir en soledad &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#44;95&#59; IC95&#37;&#58; 1&#44;11-3&#44;41&#41;&#44; no tener posibilidad de ayuda &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>4&#44;22&#59; IC95&#37;&#58; 1&#44;22-14&#44;6&#41; y no disponer de una persona en quien confiar &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#44;35&#59; IC95&#37;&#58; 1&#44;09-5&#44;10&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">tabla 4</a>&#41;&#46; En los hombres no se hall&#243; ninguna asociaci&#243;n entre la limitaci&#243;n auditiva y cada criterio espec&#237;fico de fragilidad social&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Discusi&#243;n</span><p id="par0070" class="elsevierStylePara elsevierViewall">Seg&#250;n los resultados de nuestro estudio&#44; la limitaci&#243;n auditiva se asoci&#243; con la presencia de fragilidad social en las mujeres&#44; pero no en los hombres&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">La limitaci&#243;n auditiva se ha asociado sistem&#225;ticamente con una gran variedad de problemas de salud en las personas mayores&#44; incluyendo ca&#237;das&#44; problemas de movilidad&#44; depresi&#243;n y deterioro cognitivo<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">7&#44;21&#44;22</span></a>&#44; que pueden conducir al aislamiento social &#40;objetivo&#41; y al sentimiento de soledad &#40;subjetivo&#41;&#46; No obstante&#44; nuestros resultados se mantuvieron tras ajustar por algunos de estos indicadores&#44; lo que sugiere que la asociaci&#243;n se produce por una v&#237;a diferente&#46; Quiz&#225;&#44; simplemente&#44; las personas con dificultades para seguir una conversaci&#243;n tiendan a aislarse para evitar ralentizar la comunicaci&#243;n&#44; y porque muchas actividades sociales requieren una audici&#243;n conservada &#40;p&#46; ej&#46;&#44; cine&#44; teatro&#44; cursos&#44; etc&#46;&#41;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">23</span></a>&#46; Adem&#225;s&#44; seg&#250;n un an&#225;lisis realizado sobre la cohorte del UK-Biobank&#44; la soledad puede ser incluso independiente del uso de aud&#237;fono&#44; ya que la verg&#252;enza derivada de este lleva al aislamiento social<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">24</span></a>&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">En la mayor&#237;a de los estudios que abordan asociaciones entre la limitaci&#243;n auditiva y aspectos relacionados con el funcionamiento social&#44; los an&#225;lisis se hacen conjuntamente en hombres y mujeres&#46; No obstante&#44; Shukla et al&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">8</span></a> advirtieron que&#44; en los estudios que exploraron la asociaci&#243;n por separado&#44; la asociaci&#243;n fue m&#225;s fuerte en las mujeres&#44; lo que concuerda con nuestros resultados&#46; Ramage-Morin<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">25</span></a> compar&#243; los sentimientos de aislamiento social de un grupo de personas mayores con limitaci&#243;n auditiva no corregida con los sentimientos de un grupo con limitaci&#243;n auditiva corregida con aud&#237;fono&#46; Sorprendentemente&#44; en los hombres la limitaci&#243;n auditiva corregida se asoci&#243; con mayor soledad&#44; con respecto a los que ten&#237;an una limitaci&#243;n auditiva no corregida&#46; Esto sugiere que los hombres mayores con limitaci&#243;n auditiva reciben m&#225;s soporte social de su entorno que las mujeres en la misma situaci&#243;n&#46; Seg&#250;n Schneider et al&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">26</span></a>&#44; las personas con limitaci&#243;n auditiva tienen mayor necesidad de apoyos formales e informales para mantener su autonom&#237;a&#44; y los hombres pueden ser m&#225;s vulnerables a la dependencia que las mujeres&#46; Tambi&#233;n se podr&#237;a pensar que las mujeres mayores dan m&#225;s importancia que los hombres a la comunicaci&#243;n en las relaciones sociales&#46; No obstante&#44; a pesar de que es una hip&#243;tesis cl&#225;sica&#44; la literatura cient&#237;fica da poco cr&#233;dito a esta idea<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">27</span></a>&#46; En cualquier caso&#44; entender la diferente interpretaci&#243;n que hacen hombres y mujeres de la discapacidad y la soledad durante el envejecimiento&#44; as&#237; como la respuesta de la sociedad&#44; resulta crucial para lograr una atenci&#243;n equitativa<a class="elsevierStyleCrossRefs" href="#bib0315"><span class="elsevierStyleSup">28&#44;29</span></a>&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Otra posible explicaci&#243;n a las diferencias entre sexos puede asentar en la utilizaci&#243;n de medidas autoinformadas&#46; La brecha entre hombres y mujeres en las medidas de salud autoinformadas es concordante en todos los pa&#237;ses del mundo<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">30</span></a>&#46; Aunque parece evidente que los principales factores que sustentan la brecha son de tipo biol&#243;gico y social&#44; tambi&#233;n hay estudios que sugieren que las mujeres perciben en mayor medida limitaciones funcionales que no se corresponden con las determinaciones objetivas<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">31</span></a>&#46; Por lo tanto&#44; no se puede descartar que la desigual interpretaci&#243;n que hacen hombres y mujeres debido a roles socialmente establecidos &#40;diferencias de g&#233;nero&#41; explique este hecho&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Se puede considerar que la fragilidad social integra bajo un mismo constructo los conceptos de aislamiento social y soledad&#44; en la medida en que se construye utilizando una combinaci&#243;n de medidas de funcionamiento social objetivas &#40;p&#46; ej&#46;&#44; convivencia&#41; y subjetivas &#40;p&#46; ej&#46;&#44; presencia de confidente&#41;&#46; Parece razonable&#44; por tanto&#44; que hayamos encontrado resultados congruentes con los estudios que utilizaron los indicadores cl&#225;sicos&#46; Hasta la fecha&#44; el &#250;nico estudio que ha abordado la asociaci&#243;n longitudinal entre la limitaci&#243;n auditiva y la fragilidad social fue el <span class="elsevierStyleItalic">Korean Frailty and Aging Cohort Study</span><a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">9</span></a>&#46; En este estudio&#44; la OR ajustada de fragilidad social asociada a la limitaci&#243;n auditiva fue de 2&#44;17&#44; es decir&#44; solo ligeramente superior a la hallada por nosotros en Espa&#241;a<span class="elsevierStyleBold">&#46;</span> No obstante&#44; sus an&#225;lisis no incorporaron la perspectiva de g&#233;nero&#44; que en nuestro estudio result&#243; central para entender el fen&#243;meno&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Nuestros resultados son relevantes para la pr&#225;ctica cl&#237;nica en atenci&#243;n primaria y en salud comunitaria&#46; En primer lugar&#44; dado que la frecuencia de limitaci&#243;n auditiva en las personas mayores es elevada&#44; y que se asocia con fragilidad social y otros problemas de salud importantes&#44; se deber&#237;a considerar su detecci&#243;n precoz junto con una valoraci&#243;n del mejor m&#233;todo disponible para la rehabilitaci&#243;n&#46; Hasta la fecha&#44; la US-Preventive Services Taskforce manifestaba que no hab&#237;a evidencia a favor ni en contra de la detecci&#243;n precoz de la limitaci&#243;n auditiva en personas mayores&#44; pero en la actualidad su recomendaci&#243;n est&#225; en fase de revisi&#243;n&#44; ya que la evidencia disponible ha aumentado a la par que las herramientas de cribado&#46; Adem&#225;s&#44; en esta revisi&#243;n han incluido el aislamiento social entre los potenciales da&#241;os de la limitaci&#243;n auditiva<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">32</span></a>&#46; En Espa&#241;a&#44; el <span class="elsevierStyleItalic">Programa de Actividades Preventivas y de Promoci&#243;n de la Salud</span> tampoco recomienda el cribado de la limitaci&#243;n auditiva en personas mayores asintom&#225;ticas<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">33</span></a>&#44; aunque tambi&#233;n es esperable una pr&#243;xima actualizaci&#243;n&#46; Desde una perspectiva de salud p&#250;blica&#44; se deber&#237;an estudiar la viabilidad y la eficiencia de la financiaci&#243;n total o parcial de los aud&#237;fonos&#44; y quiz&#225; tambi&#233;n la ampliaci&#243;n de los supuestos que permiten a las personas mayores acceder a los implantes cocleares&#46; Adicionalmente&#44; muchas personas mayores tienen dificultad para reconocer su limitaci&#243;n&#44; lo que conduce a un infradiagn&#243;stico y una menor b&#250;squeda de soluciones<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">9</span></a>&#44; por lo que tambi&#233;n se deber&#237;an considerar intervenciones psicosociales para el afrontamiento de la limitaci&#243;n auditiva&#46; Estas recomendaciones deber&#237;an vigilarse m&#225;s estrechamente en las mujeres&#44; advirtiendo a sus familias del riesgo incrementado de aislamiento social&#46; En segundo lugar&#44; las intervenciones de atenci&#243;n primaria y de salud comunitaria para personas mayores deber&#237;an tener en cuenta de manera sistem&#225;tica la limitaci&#243;n auditiva&#46; Muchas de estas intervenciones requieren unos niveles de funcionamiento f&#237;sico&#44; cognitivo y social elevados<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">34</span></a>&#44; porque es preciso que las personas salgan de sus casas y se comuniquen&#44; y las personas con limitaci&#243;n auditiva pueden quedarse al margen&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Una de las principales fortalezas de este estudio es su realizaci&#243;n en el &#225;mbito de la atenci&#243;n primaria de salud&#46; La mayor parte de los estudios previos se han realizado con cohortes poblacionales&#44; que suelen reclutar participantes con mejor salud y menos problemas sociales que los&#47;las pacientes de atenci&#243;n primaria&#46; De hecho&#44; la frecuencia de fragilidad social hallada por nosotros fue mayor que la observada en otras cohortes<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">4&#44;13&#44;17</span></a>&#46; En consecuencia&#44; es posible que nuestro estudio capture mejor la realidad de la poblaci&#243;n a la que se dirigen las recomendaciones&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Este estudio tambi&#233;n presenta limitaciones&#46; Primero&#44; su naturaleza transversal no permite establecer la direcci&#243;n de las asociaciones&#46; Segundo&#44; no existe una definici&#243;n consensuada de fragilidad social y es posible que este concepto se solape con los de aislamiento social y soledad&#46; En tercer lugar&#44; habr&#237;a sido deseable utilizar mediciones objetivas de audici&#243;n&#46; No obstante&#44; hay una buena correlaci&#243;n entre las medidas objetivas y autoinformadas&#44; siendo este &#250;ltimo el m&#233;todo recomendado para su determinaci&#243;n en el contexto cl&#237;nico<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">16</span></a>&#46; Adem&#225;s&#44; la frecuencia de limitaci&#243;n auditiva hallada por nosotros es similar a la que encuentran otros autores utilizando audiometr&#237;as<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">35</span></a>&#46; Por &#250;ltimo&#44; a pesar de que hemos ajustado por confusores y mediadores importantes en la asociaci&#243;n&#44; carecemos de alguna informaci&#243;n relevante sobre el estilo de vida&#44; en especial el consumo de alcohol y medidas detalladas de actividad f&#237;sica&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">En conclusi&#243;n&#44; la limitaci&#243;n auditiva se asoci&#243; con fragilidad social en las mujeres mayores&#44; pero no en los hombres&#46; Son necesarios estudios longitudinales que confirmen esta asociaci&#243;n y ayuden a entender el efecto diferencial del sexo&#46; Tambi&#233;n se requieren estudios experimentales que investiguen si la rehabilitaci&#243;n de la limitaci&#243;n auditiva puede disminuir la soledad y el aislamiento social en las mujeres mayores&#46;<elsevierMultimedia ident="tb0005"></elsevierMultimedia></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Editora responsable del art&#237;culo</span><p id="par0125" class="elsevierStylePara elsevierViewall">Mar&#237;a del Mar Garc&#237;a-Calvente&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Declaraci&#243;n de transparencia</span><p id="par0130" class="elsevierStylePara elsevierViewall">El autor principal &#40;garante responsable del manuscrito&#41; afirma que este manuscrito es un reporte honesto&#44; preciso y transparente del estudio que se remite a <span class="elsevierStyleSmallCaps">Gaceta Sanitaria&#44;</span> que no se han omitido aspectos importantes del estudio&#44; y que las discrepancias del estudio seg&#250;n lo previsto &#40;y&#44; si son relevantes&#44; registradas&#41; se han explicado&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Contribuciones de autor&#237;a</span><p id="par0135" class="elsevierStylePara elsevierViewall">J&#46; D&#237;az-Alonso y A&#46; Lana dise&#241;aron el estudio&#46; J&#46; D&#237;az-Alonso&#44; A&#46; Bueno-P&#233;rez y L&#46; Tora&#241;o-Ladero realizaron el trabajo de campo&#46; J&#46; D&#237;az-Alonso y A&#46; Lana realizaron los an&#225;lisis estad&#237;sticos&#46; J&#46; D&#237;az-Alonso&#44; A&#46; Bueno-P&#233;rez&#44; L&#46; Tora&#241;o-Ladero y A&#46; Lana redactaron la primera versi&#243;n del manuscrito&#46; F&#46;F&#46; Caballero&#44; E&#46; L&#243;pez-Garc&#237;a y F&#46; Rodr&#237;guez-Artalejo revisaron el borrador del manuscrito y redactaron la versi&#243;n definitiva&#46; Finalmente&#44; todos&#47;as los&#47;las autores&#47;as contribuyeron a la revisi&#243;n cr&#237;tica del documento y aprobaron el texto final para su publicaci&#243;n&#46; Todas las personas firmantes se hacen responsables de todos los aspectos del estudio&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Financiaci&#243;n</span><p id="par0140" class="elsevierStylePara elsevierViewall">Este trabajo fue financiado con una ayuda del Instituto de Investigaci&#243;n Sanitaria de Asturias &#40;Espa&#241;a&#41;&#44; Ref&#46; Formento ProyectosALP&#46; Los financiadores no desempe&#241;aron ning&#250;n papel en el dise&#241;o del estudio ni en la recopilaci&#243;n&#44; el an&#225;lisis y la interpretaci&#243;n de los datos&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Conflictos de intereses</span><p id="par0145" class="elsevierStylePara elsevierViewall">Ninguno&#46;</p></span></span>"
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    "fechaRecibido" => "2020-05-25"
    "fechaAceptado" => "2020-08-31"
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            1 => "Adultos mayores"
            2 => "Presbiacusia"
            3 => "P&#233;rdida auditiva"
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            1 => "Older adults"
            2 => "Presbycusis"
            3 => "Hearing loss"
            4 => "Hearing impairment"
            5 => "Sex"
            6 => "Social isolation"
            7 => "Social support"
            8 => "Social frailty"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objetivo</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Explorar la asociaci&#243;n entre la limitaci&#243;n auditiva y la fragilidad social en una muestra de personas mayores de Espa&#241;a&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">M&#233;todo</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Estudio transversal con una muestra de 445 personas &#40;190 hombres y 255 mujeres&#41; de 65 y m&#225;s a&#241;os de edad no institucionalizadas&#44; reclutadas de centros de atenci&#243;n primaria en Espa&#241;a&#46; La limitaci&#243;n auditiva se determin&#243; de forma autoinformada utilizando tres preguntas&#46; Se consider&#243; que exist&#237;a fragilidad social cuando la persona present&#243; dos o m&#225;s de las siguientes condiciones&#58; vivir solo&#47;a&#44; ausencia de persona que brinde ayuda&#44; contacto infrecuente con la familia&#44; contacto infrecuente con amistades&#44; falta de confidente y falta de ayuda para las actividades cotidianas en los &#250;ltimos 3 meses&#46; Para estudiar la asociaci&#243;n entre la limitaci&#243;n auditiva y la fragilidad social se realizaron modelos de regresi&#243;n log&#237;stica ajustados por posibles factores de confusi&#243;n&#44; incluyendo la presencia de fragilidad f&#237;sica&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">La edad media de los&#47;las participantes fue de 76&#44;2 a&#241;os &#40;77&#44;5 a&#241;os para las mujeres&#41;&#46; El 54&#44;4&#37; presentaban limitaci&#243;n auditiva y el 23&#44;2&#37; fueron considerados&#47;as fr&#225;giles sociales&#46; La limitaci&#243;n auditiva se asoci&#243; con la fragilidad social &#40;<span class="elsevierStyleItalic">odds ratio</span> ajustada &#91;ORa&#93;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#44;78&#59; intervalo de confianza del 95&#37; &#91;IC95&#37;&#93;&#58; 1&#44;04-3&#44;06&#41;&#46; No obstante&#44; la asociaci&#243;n fue dependiente del sexo &#40;p de interacci&#243;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;041&#41; y en los an&#225;lisis estratificados la asociaci&#243;n solo se hall&#243; en las mujeres &#40;ORa<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>3&#44;21&#59; IC95&#37;&#58; 1&#44;44-7&#44;17&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusiones</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">La limitaci&#243;n auditiva se asoci&#243; con fragilidad social en las mujeres&#44; pero no en los hombres&#46; Se precisan estudios longitudinales que confirmen esta asociaci&#243;n y ayuden a entender el efecto diferencial del sexo&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objective</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">To explore the association between hearing loss and social frailty in a sample of Spanish older adults recruited from primary health care network&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Method</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Cross-sectional study on a sample of 445 non-institutionalized adults aged 65 or more years &#40;190 men and 255 women&#41;&#44; recruited from primary care centers in Spain&#46; Three self-reported hearing impairment questions were used to assess hearing loss&#46; Social frailty was deemed to exist when the person presented two or more of the following conditions&#58; living alone&#44; absence of a person to provide help&#44; infrequent contact with family&#44; infrequent contact with friends&#44; lack of confident and lack of help for daily activities in the last 3 months&#46; To study the association between hearing loss and social frailty we used logistic regression models adjusted for potential confounders&#44; including physical frailty&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">The mean age of participants was 76&#46;2 years &#40;77&#46;5 years for women&#41;&#46; More than half of the participants &#40;54&#46;4&#37;&#41; reported hearing loss and the frequency of social frailty was 23&#46;2&#37;&#46; Hearing loss was associated with social frailty &#40;adjusted odds ratio &#91;aOR&#93;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;78&#59; 95&#37; confidence interval &#91;95&#37;<span class="elsevierStyleSmallCaps">C</span>I&#93;&#58; 1&#46;04-3&#46;06&#41;&#46; However&#44; the association was sex-dependent &#40;p for interaction<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;041&#41;&#46; In stratified analysis&#44; the association was only found in women &#40;aOR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>3&#46;21&#59; 95&#37;CI&#58; 1&#46;44-7&#46;17&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusions</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Hearing loss was associated with social frailty in women&#44; but not in men&#46; Longitudinal studies are needed to confirm this association and to understand the differential effect of gender&#46;</p></span>"
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">S&#237;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Robusto&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Prefr&#225;gil&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Fr&#225;gil&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Edad</span><a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Sexo</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hombre&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Mujer&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Nivel de estudios</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Primarios o menos&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Universitarios&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">8 &#40;4&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " colspan="9" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Ocio activo</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>S&#237;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">146 &#40;32&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">79 &#40;38&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">67 &#40;27&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">175 &#40;72&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">114 &#40;69&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="9" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">&#205;ndice de masa corporal</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Normopeso&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Sobrepeso&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Obesidad&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " colspan="9" align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="9" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Estado de salud</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Muy malo&#47;malo&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">31 &#40;12&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">12 &#40;7&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Regular&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">166 &#40;37&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">103 &#40;42&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">220 &#40;90&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">153 &#40;93&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">97 &#40;94&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Nivel de estudios</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Primarios o menos&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Secundarios&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">36 &#40;14&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Universitarios&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">11 &#40;5&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">6 &#40;2&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Ocio activo</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;001&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>S&#237;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">112 &#40;58&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">187 &#40;73&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">78 &#40;41&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">68 &#40;26&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">&#205;ndice de masa corporal</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;159&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Normopeso&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">37 &#40;19&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">41 &#40;16&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Sobrepeso&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">88 &#40;46&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \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">104 &#40;40&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Obesidad&nbsp;\t\t\t\t\t\t\n
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                  \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">65 &#40;34&#44;2&#41;&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">110 &#40;43&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&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  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Estado de salud</span>&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="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">&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">0&#44;021&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Muy malo&#47;malo&nbsp;\t\t\t\t\t\t\n
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                  \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">15 &#40;7&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \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">34 &#40;13&#44;3&#41;&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
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Regular&nbsp;\t\t\t\t\t\t\n
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                  \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">62 &#40;32&#44;6&#41;&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
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                  \t\t\t\t">104 &#40;40&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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