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. 2025 Mar 29:1-13.
doi: 10.1159/000544880. Online ahead of print.

The Spanish GIRO Guideline: A Paradigm Shift in the Management of Obesity in Adults

Albert Lecube  1   2   3 , Sharona Azriel  3   4 , Esther Barreiro  5   6   7 , Guadalupe Blay  8   9 , Juana Carretero-Gómez  10   11 , Andreea Ciudin  1   2   3 , José Manuel Fernández  12   13 , Lilliam Flores  2   14 , Ana de Hollanda  14   15   16 , Eva Martínez  17   18 , Inka Miñambres  16   19   20 , Violeta Moizé  21 , Cristóbal Morales  2   22 , Violeta Ramírez  23   24 , Javier Salvador  15   16   25 , María José Soler  26   27 , Marta Supervía  28   29   30 , Víctor Valentí  31   32 , Germán Vicente-Rodríguez  16   33   34 , Nuria Vilarrasa  15   16   35 , María M Malagón  2   16   36
Affiliations

The Spanish GIRO Guideline: A Paradigm Shift in the Management of Obesity in Adults

Albert Lecube et al. Obes Facts. .

Abstract

Introduction: Current obesogenic environments, along with intrinsic factors, contribute to the obesity pandemic, which impacts the quality of life and healthcare for individuals with obesity. In addition, discrimination and stigma related to obesity remain widespread in our society. In this scenario, the Spanish Society for the Study of Obesity (SEEDO), in collaboration with 38 recognized scientific societies and 12 patients' organization, has elaborated the Spanish guideline for obesity management in adults, referred to as the GIRO guideline. GIRO aims to drive a shift in obesity management and serve as a guide for healthcare professionals (HCPs) to address this chronic and multifactorial disease.

Methods: A comprehensive systematic review was conducted and completed with experts' contribution, with a particular focus on Spanish society. The quality of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Experts selected the recommendations and determined their strength through consensus.

Results: A total of 121 recommendations were proposed, including 32 adopted from the Canadian Adult Obesity Clinical Practice Guidelines and 89 specific recommendations created for the Spanish context, and were distributed across five areas of application: (1) recognition of obesity as a chronic disease, (2) obesity assessment, (3) multidisciplinary approach to obesity treatment, (4) recommendations for obesity management in special populations, and (5) implementation of the GIRO guideline and future challenges.

Conclusion: The GIRO recommendations are intended to serve as a useful and interactive tool for HCPs, policymakers, and other stakeholders to ensure access to and quality of healthcare for individuals living with obesity.

Keywords: Adipose tissue; Adults; Guideline; Obesity; Recommendations; Spain.

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Conflict of interest statement

SEEDO has paid honoraria to the expert authors of the GIRO guideline for their collaboration and has facilitated the participation of all of them in the meetings for the preparation and promotion of the guidelines. Some of the experts participating in the GIRO guideline had potential conflicts of interest in the 36 months prior to their participation in this project. These are described below: A.L. declares having received fees for conferences from AstraZeneca, Boehringer Ingelheim, Novo Nordisk, Eli Lilly, and Pronokal; for clinical trials from Amgen, AstraZeneca, Boehringer Ingelheim, Lilly, and Novo Nordisk; grants and scholarships for research from Diputació de Lleida, Instituto de Salud Carlos III, and Pfizer; been a member of the advisory board in Boehringer Ingelheim, Eli Lilly, Novo Nordisk, Pronokal; and being contracted by the Institut Català de la Salut (ICS). S.A. declares having received fees for conferences, collaborations, and scientific advice from Abbott, Amgen, Astrazeneca, Boehringer Ingelheim, Daiichi, Dexcom, Lilly, Medtronic, Menarini, Novartis, Novo Nordisk, Roche, and Sanofi. S.A. also declares to belong to the Endocrinology and Nutrition Service of the Hospital Universitario Infanta Sofía (Madrid); and to be an associate professor at the Universidad Europea de Madrid, outside the work presented. E.B. declares participation in a research project partially funded by Menarini S.A. (Spain); and being director of the Document Management Committee and advisory member of the Quality Committee of the Spanish Society of Pneumology and Thoracic Surgery (SEPAR), and Editor-in-Chief of the European Respiratory Journal Open Research of the European Respiratory Society, outside the submitted work. G.B. declares no conflict of interest outside of the work submitted. J.C.-G. declares having received consulting, speaking or clinical trial fees from Abbot Nutrition, Boehringer Ingelheim, Lilly, and Novo Nordisk. A.C. declares participation in the Data Monitoring Committee of Boehringer Ingelheim SYNCRONIZE clinical trial programme and having received fees for Advisory Board, training activities, symposiums, and congress attendance from AstraZeneca, Boehringer Ingelheim, Eli Lilly and Novo Nordisk. J.M.F. declares having received fees for presentations at congresses from Almirall, Fresenius, Lilly, Novo Nordisk, Organon, Ordesa, and Viatris. L.F. declares having received collaboration for lectures from Lilly and Novo Nordisk. A.H. declares receiving speaking fees from Almirall, Esteve, Lilly, and Novo Nordisk; consultancy fees from Lilly; and clinical trial research contracts from Boehringer, Lilly, and Novo Nordisk. E.M. declares no conflict of interest outside of the work submitted. I.M. declares having received fees for advisory boards, lectures, or funding for courses or conferences from AstraZeneca, Boehringer Ingelheim, Daichii Sankyo, Lilly, Novo Nordisk, and Aventis-Sanofi. V.M. declares having received speaking fees from Novo Nordisk and Adventia Pharma. C.M. reports receiving research and speaking fees from Amgen, AstraZeneca, Boehringer Ingelheim, Lilly, Merck, Novartis, Novo Nordisk, and Sanofi. V.R. declares no conflict of interest outside of the work submitted. J.S. declares having received fees for coordination and moderation of the Annual Obesity Meetings 2020, 2021, 2023, and 2024 from Novo Nordisk; for lectures and teaching activities from Lilly and Novo Nordisk; and having participated in clinical trials and studies sponsored by Novo Nordisk. M.J.S. declares having received fees for contracted consultancy and travel support for contracted activities from AstraZeneca, Bayer, Boehringer Ingelheim, Esteve, Fresenius, GSK, ICU Medical, Jansen, Lilly, Mundipharma, Novo Nordisk, Otsuka, Sanofi, Travere Therapeutics, and Vifor; grants from Boehringer Ingelheim, Instituto de Salud Carlos III, Fundación Senefro and Ministerio de Ciencia e Innovación, Marató TV3, ERA PerMed2022; and consultation fees from AstraZeneca, Bayer, Boehringer Ingelheim, GE Healthcare, ICU Medical, Jansen, Medice, Mundipharma, Novo Nordisk, and Vifor. M.S. declares having received conference grants from Novo Nordisk. V.V. declares no conflict of interest outside of the work submitted. G.V.-R. declares research contracts with the Zaragoza City Council, being an expert of the Advisory Committees of the National Commission for the Evaluation of Research Activity, being president of the Physical Exercise and Health Network (EXERNET) and member of the European College of Sport Science (ECSS), outside of the work presented. N.V. declares having received fees from Adventia Pharma, Boehringer Ingelheim, Lilly, and Novo Nordisk. M.M.M. declares having received fees for presentations at conferences and workshops organized by Lilly España and Novo Nordisk.

Figures

Fig. 1.
Fig. 1.
Algorithm of the GIRO guideline for obesity management. *Drug treatment may also be initiated in patients with a BMI ≥27 kg/m2 and at least one obesity-related comorbidity. The maximum or maintenance dose or the maximum tolerated dose must be reached. At the time of writing the GIRO guideline, the drugs approved by both the EMA and the AEMPS for pharmacological treatment of obesity were as follows: liraglutide 3.0 mg, semaglutide 2.4 mg, tirzepatide 5.0 and 10.0 mg, orlistat 120.0 mg, and the combination of extended-release bupropion/naltrexone. **At present in Spain, it would only be possible to combine incretin-based treatment with orlistat. ***Although the effectiveness and durability of endoscopy’s benefits may be lower, the same quality criteria applied to bariatric surgery should still be required. The evidence in favour of surgical treatment is greater than in favour of endoscopic treatment. AEMPS, Spanish Agency for Medicines and Health Products; BMI, body mass index; EMA, European Medicines Agency; VLCD, very low-calorie diet.
Fig. 2.
Fig. 2.
GIRO guideline algorithm for the pharmacological management of obesity using incretin-based therapies. *According to their data sheet, liraglutide should be increased up to 3.0 mg (maintenance dose) or until the maximum tolerated dose is reached; semaglutide should be increased up to 2.4 mg (maintenance dose) or until the maximum tolerated dose is reached; and the recommended maintenance doses of tirzepatide are 5.0 mg, 10.0 mg, and 15.0 mg (in Spain, the 15 mg dose is not available). arGLP1, glucagon-like peptide 1 receptor agonists; CVD, cardiovascular disease; DIRA, dual-incretin receptor agonists; GBP, gastric bypass; HbA1c, haemoglobin A1C; HFpEF, heart failure with preserved ejection fraction; preT2DM, prediabetes mellitus type 2; SG, sleeve gastrectomy; T2DM, type 2 diabetes; OD, once daily; OSA, obstructive sleep apnoea; OW, once weekly.
Fig. 3.
Fig. 3.
The top 10 “turns” proposed by the GIRO guideline. CVD, cardiovascular disease; HCP, healthcare professional; PC, primary care; PwO, people with obesity; QoL, quality of life.
See this image and copyright information in PMC

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