Lineamiento Técnico Atención en Salud a Personas con Obesidad en el I Nivel de Atención de la Caja Costarricense de Seguro Social

Objectives

The 2019 Caja Costarricense de Seguro Social (CCSS) technical guideline standardises comprehensive obesity care at the first level of care, using a life-course approach that integrates health promotion, prevention, assessment and management of obesity-related comorbidities through the institutional health-service network.[1][2][3]It aims to involve individuals, families and communities in reducing chronic-disease risk, while supporting implementation of obesity-care guidance in all health-service establishments by 2021.[2]

• Identify obesity and related risks through age-appropriate anthropometric measures, clinical history, physical examination and relevant laboratory investigations.[3][4][5]
• Prevent and manage associated conditions, including cardiovascular risk, prediabetes, diabetes mellitus, dyslipidaemia, hypertension and metabolic syndrome.[3][6][7]
• Promote sustainable improvements in diet, physical activity, sleep, growth, mental health and family relationships rather than rapid weight loss or pursuit of an ideal-weight target.[8][6][9]
• Address obesity as a multifactorial condition shaped by genetic, environmental, social, psychological, behavioural and medication-related factors, including unhealthy food environments, sedentary behaviour and weight-promoting medicines.[3][10][11]
• Reduce psychological and social consequences associated with obesity, including low self-esteem, anxiety, depression, social exclusion, reduced functional capacity and poorer quality of life.[11][12]
• Tailor care to life stage, with specific assessment and management provisions for children, adolescents, adults and older people.[3][4][5][13]

Implementation

Care is delivered principally through CCSS first-level services, linked to the institutional service network and multidisciplinary teams.[14][15][3]The guideline directs personnel to combine clinical detection and risk assessment with individual and family-based lifestyle support, comorbidity management, referral and counter-referral, clinical recording, and medically determined follow-up.[4][13][16][17]Implementation responsibilities rest with health-area directors and coordinators, Basic Comprehensive Health Care Teams (EBAIS), multidisciplinary support teams, the Health Services Network Directorate and the Area for Comprehensive Care of People.[7][18]

• Refer people with suspected obesity from relevant care settings to EBAIS for assessment, then complete clinical history, examination and laboratory testing in accordance with institutional requirements.[4]
• Assess children aged 2 to under 13 years using accurate weight and height measurements, age- and sex-specific growth-chart trends, personal and family history, perinatal factors, dietary and activity habits, and examination for comorbidities or endogenous obesity.[4]
• Screen children aged 2 to under 6 years for development using the Pretest Denver II and, where required, the full Denver II assessment under applicable regulations.[19]
• Assess people aged 13 years and over for nutritional status, medical, psychological, behavioural and social contributors to weight gain, comorbidities, functional limitations and cardiovascular risk.[5][6]
• Undertake cardiovascular-risk estimation for people with risk factors, men over 40 years, and women over 50 years or who are post-menopausal; use fasting blood glucose, lipid testing and thyroid-stimulating hormone testing where hypothyroidism is suspected.[5][6]
• Promote family-wide changes that reduce sugary drinks and foods high in fat, sugar and salt, limit processed and ultra-processed foods, increase seasonal fruit and vegetables, establish regular meals and breakfast, discourage eating while watching television, and encourage family meals.[19][6][9]
• Encourage regular activity adapted to age, mobility and health status, including at least 60 minutes of moderate or vigorous activity on five days weekly for children, 60 minutes daily for people aged 13 to 18 years, and 30 minutes for adults; limit children’s screen and videogame use to two hours per day.[19][16]
• Maintain healthy growth and avoid rapid weight loss in children, while avoiding hypocaloric or restrictive diets for older adults because of sarcopenia-related frailty risk.[8][9][13]
• Differentiate care according to comorbidity: provide general lifestyle support and family engagement where no comorbidity is identified; reinforce advice, treat the associated condition under applicable guidance, and refer to paediatrics or specialist network services according to need and capacity where comorbidity is present.[16][17]
• Prioritise management of decompensated comorbidities and apply current condition-specific guidance for diabetes, lipid abnormalities, hypertension and metabolic syndrome, subject to network resources.[17][7]
• Record obesity diagnoses in the Unified Digital Health Record using International Classification of Diseases, 10th Revision codes E660, E668 or E669, as applicable; use relevant nosological codes for non-medical professionals.[13]
• Arrange follow-up according to medical judgement, including a four-month review mentioned in the guideline, and interpret requested tests while reinforcing dietary, physical-activity and mental-health advice.[8][13]
• Use referral and counter-referral mechanisms for children without comorbidity, including communication with the relevant teacher and, where present, the Local Coordinating Team of the Integrated Health Services Network.[16]
• Verify compliance through health-area leadership, the Health Services Network Directorate and the Area for Comprehensive Care of People, which also hold monitoring and evaluation responsibilities.[7][18]

The guideline provides clinical assessment and follow-up mechanisms but does not specify a detailed implementation timetable, training plan, budget, financing arrangements, formal performance indicators, reporting schedule, surveillance outputs or sanctions for non-compliance.[14][2][7][18]

Monitoring & Evaluation

Monitoring is primarily embedded in clinical assessment, follow-up, diagnostic recording and managerial compliance arrangements. The guideline includes a national implementation ambition to apply obesity-care guidance in all health-service establishments by 2021, but it does not provide a comprehensive indicator set, reporting schedule, surveillance framework or formal evaluation methodology.[2][7][18]

• Assess and monitor nutritional status through accurate weight and height measurement, age- and sex-appropriate growth-chart interpretation for children and adolescents, and officially adopted body mass index ranges for adults.[4][5]
• Evaluate obesity-related risk and complications through clinical history, physical examination, blood-pressure measurement, cardiovascular-risk estimation where indicated, and laboratory investigations for conditions including prediabetes, diabetes, dyslipidaemia and metabolic syndrome.[4][5][6]
• Undertake specified paediatric testing, including lipid profiles for children with obesity aged over two years regardless of other risk factors, and fasting blood-glucose testing from age 10 years or puberty when at least two type 2 diabetes risk factors are present.[19]
• Use laboratory results obtained within the previous three months where appropriate, and repeat investigations according to the periodicity established in current regulations.[6]
• Arrange clinical follow-up according to medical judgement, with a four-month review identified in the guidance for reinforcing dietary, physical-activity and mental-health advice and reviewing requested diagnostic tests.[8][13]
• Record obesity diagnoses in the Unified Digital Health Record using International Classification of Diseases, 10th Revision codes E660, E668 or E669, according to the applicable diagnosis; non-medical professionals are to use relevant nosological codes consistent with their service offer and care level.[13]
• Use referral and counter-referral processes as part of continuity of care, including nutritional-status and primary-care follow-up forms for children without comorbidity sent to the relevant teacher and, where applicable, the Local Coordinating Team of the Integrated Health Services Network.[16]
• Assign compliance verification to health-area directors and coordinators, the Health Services Network Directorate, and the Area for Comprehensive Care of People.[7][18]
• Assign monitoring and evaluation responsibilities to health-area directors and coordinators and the Health Services Network Directorate.[7][18]

Beyond clinical monitoring and these named responsibilities, the material does not specify performance indicators, routine aggregate reporting, surveillance outputs, evaluation design, public accountability arrangements or sanctions for non-compliance.[15][13][7][18]

Costing & Financing

No implementation costing, budget, funding source, financing plan, resource-mobilisation mechanism, funding-gap estimate or economic assumption is specified. This absence applies to the guideline’s obesity assessment, counselling, laboratory testing, follow-up, referral and multidisciplinary-care components.[2][3][4][5][6]

• Provide multidisciplinary management of metabolic syndrome subject to resources available across the health-service network.[17][7]
• Deliver multidisciplinary group activities for people aged 13 years and over without comorbidity only where these activities are available.[16]
• Refer children with comorbidity to paediatrics according to clinical need and service-network capacity.[17]
• Apply care for decompensated comorbidities and metabolic syndrome in line with relevant technical guidance, subject to available network resources.[17][7]

The references and cited national strategies do not add financial figures, allocations, unit costs, workforce-cost assumptions, procurement requirements or identified financing gaps for this guideline.[20][21][22]