C
Review of Existing Reviews on Obesity Prevention

The Committee on an Evidence Framework for Obesity Prevention Decision Making was tasked to provide an overview of the current nature of the evidence base, that is, the types of evidence that are available on the results of community, environmental, and policy-based obesity prevention initiatives. The narrative interpretation of the collection of reviews in this appendix (termed “appraisals” in this report) is provided in Chapter 3, and includes a description of current methods used to characterize the evidence base and a discussion of the challenges involved in applying traditional evidence hierarchies to population-based prevention efforts.

This overview was not meant to be carried out by an exhaustive literature review but rather through an examination of case studies and existing reviews. The search strategy involved searching major databases including Scopus, PubMed, and Web of Science, from each database’s inception through November 2009, for relevant and published reviews of obesity prevention interventions. Variations of the terms “overweight,” “obesity,” “prevention,” “physical activity,” “nutrition,” “review,” “meta-analysis,” “synthesis,” “summary,” and “recommendations” were used in the search process. Additional appraisals were identified by review of the reference lists of included appraisals and other relevant literature and by discussion with experts in the field. Appraisals that consider only studies of treatment interventions were excluded; some appraisals consider both treatment and prevention studies and were included in the committee’s analysis. Publication date was not a search criterion, yet all of the appraisals in this appendix were published between 1997 and the present.



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C Review of Existing Reviews on Obesity Prevention T he Committee on an Evidence Framework for Obesity Prevention Decision Making was tasked to provide an overview of the current nature of the evidence base, that is, the types of evidence that are available on the results of community, envi- ronmental, and policy-based obesity prevention initiatives. The narrative interpreta- tion of the collection of reviews in this appendix (termed “appraisals” in this report) is provided in Chapter 3, and includes a description of current methods used to char- acterize the evidence base and a discussion of the challenges involved in applying tra- ditional evidence hierarchies to population-based prevention efforts. This overview was not meant to be carried out by an exhaustive literature review but rather through an examination of case studies and existing reviews. The search strategy involved searching major databases including Scopus, PubMed, and Web of Science, from each database’s inception through November 2009, for relevant and published reviews of obesity prevention interventions. Variations of the terms “overweight,” “obesity,” “prevention,” “physical activity,” “nutrition,” “review,” “meta-analysis,” “synthesis,” “summary,” and “recommendations” were used in the search process. Additional appraisals were identified by review of the reference lists of included appraisals and other relevant literature and by discussion with experts in the field. Appraisals that consider only studies of treatment interventions were excluded; some appraisals consider both treatment and prevention studies and were included in the committee’s analysis. Publication date was not a search criterion, yet all of the appraisals in this appendix were published between 1997 and the present. 

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TABLE C-1 Search Strategy Inclusion/Exclusion Criteria Sources of Years Type of Appraisal and Initial No. Informationa Study Included Purpose Identified Subject Demographics American (28) January Systematic review Not reported Healthy children and Dietetic 1982- adolescents aged 2-18 Manual searching To develop a position Association January of bibliographies statement on Position 2004 from gathered individual-, family-, Statement articles and school-, and community- (2006) reviews based interventions for pediatric overweight Bluford (11), (14), (20), 1966- Systematic review Not reported Preschool-age children et al. (27), (28) March aged 2-6 To identify and summarize (2007) 2005 effective evaluated interventions for preventing or treating obesity among preschool children aged 2-6 Brown and (20), (28) January Systematic review 1,553 School children aged Summerbell 2006- 5-18 To determine the (2009) September effectiveness of school-based Excluded: studies that 2007 interventions focused on recruited children on the changing dietary intake and basis of weight; studies physical activity levels to in children with critical prevent childhood obesity illness or eating disorders Bridging the Evidence Gap in Obesity Prevention 

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Outcome Measures Length of (e.g., BMI, diet, physical Intervention Types of Studies (e.g., RCTs, quasi- activity, other behaviors, and/or No. After experimental, qualitative) environment) Follow-up Other Applying Criteria Included: any study design Measure of adiposity > 8 weeks (for Included: English Not reported (BMI, body weight, secondary language Excluded: meta-analyses and skinfold thickness, prevention reviews (different selection criteria) Excluded: conducted percent body fat) trials) in a developing ≥ 6 months country; not peer- reviewed; n < 30 in (for primary prevention secondary prevention trials, n < 60 in trials) (not including primary prevention duration of trials follow-up) ≥ 3 months Included: domestic and international Measure of weight Studies were not 7 (2 treatment studies that used physical activity status, BMI, or body fat study length excluded because and 5 prevention) and nutritional strategies in of their aim (for interventions to prevent or treat example, did not overweight have to include weight change), Excluded: case reports or series design, or duration of intervention or follow- up if ≥ 3 months ≥ 12 weeks RCTs or controlled clinical trials of Included: same criteria Included: minimum 38 lifestyle interventions used by National study length duration of 12 weeks; Institute for Health done in a school Included: study designs that and Clinical Excellence setting (studies were compared lifestyle interventions (NICE) obesity not included or (defined in article) with usual care guidance with one excluded based on or with other active interventions exception—included their aim) studies had to report a weight outcome, either as absolute or change, and could use BMI, BMI z-score, percentage of body fat, skin-fold thickness, and percentage of overweight continued  Appendix C

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TABLE C-1 Continued Search Strategy Inclusion/Exclusion Criteria Sources of Years Type of Appraisal and Initial No. Informationa Study Included Purpose Identified Subject Demographics Campbell (13), (14), (20), January Systematic review 1,043 Included: subjects under et al. (28), (32), (33), 1985- age 18 when the study To assess the effectiveness (2001) (36) October began of interventions designed to 1999 Expert opinion prevent obesity in childhood Excluded: pregnant women, those with eating disorders, and the critically ill n ≥ 30; nonclinical child Connelly (14), (20), (27), Up to April Systematic review Not reported et al. (28) 30, 2006 populations aged 0-18 To present practice-relevant (2007) Manual searching guidance on interventions of bibliographies aimed at reducing at least from gathered one measure of adiposity in articles and child populations that do or reviews do not contain overweight or obese children Conroy (2), (12), (13), 1980- Integrative review 2,028 Not reported et al. (14), (17), (19), September To examine successful (2007) (20), (23), (27), 2005 Canadian nursing (28), (35), (38), and health promotion (39), (43) intervention programs Grey literature, for childhood obesity excluding prevention during gestation newspaper and infancy articles/editorials; manual searching of bibliographies from gathered articles and reviews; ancestry searches on key papers Bridging the Evidence Gap in Obesity Prevention 0

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Outcome Measures Length of (e.g., BMI, diet, physical Intervention Types of Studies (e.g., RCTs, quasi- activity, other behaviors, and/or No. After experimental, qualitative) environment) Follow-up Other Applying Criteria RCTs, non-RCTs with concurrent Included: had to Follow-up Not reported 7 control groups report one or more 1 year, later outcomes (estimates amended of percent body fat, to include BMI, ponderal index, studies or skin-fold thickness) with an and report outcome observation data at baseline and period of ≥ 3 months at postintervention, or at baseline and change from baseline ≥ 12 weeks Included: RCTs, controlled trials of Included: measure of Not reported 28 interventions to prevent overweight index of adiposity study period or obesity Included: peer-reviewed and/or Diet, BMI (adult), Not reported Canadian only; 6 research-based, published articles, high birth weight English and French > 4000 g, low birth policy reports language weight < 2500 g but Excluded: newspaper articles, > 2000 g editorials, general reports, general women’s health materials continued  Appendix C

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TABLE C-1 Continued Search Strategy Inclusion/Exclusion Criteria Sources of Years Type of Appraisal and Initial No. Informationa Study Included Purpose Identified Subject Demographics DeMattia (27), (28) 1966-June Systematic review 222 Children or adolescents, et al. 2004 including at-risk or Updated search: To examine studies that (2007) obese children/teens at (12), (14), (23), Updated used an intervention to outset of study (27), (28) search, reduce sedentary behavior 1966- (SB; defined in article) to Manual searching February control weight in order of bibliographies 2005 to answer the question: Is from gathered an emphasis on reducing articles and SB (e.g., TV, video games) reviews; expert effective at changing opinion behaviors and controlling weight in children and adolescents? Doak et al. (28) Through Review 102 Children and adolescents (2006) June 2003, aged 6-19; targeting of Personal contacts To identify aspects of with obese children if drawn with researchers; overweight and obesity additional from a broad-based Internet; manual prevention programs that update in school population searching of are most likely to succeed August bibliographies if implemented on a large 2005 from reviews; scale MEDLINE searches of authors with ongoing intervention studies Dobbins (14), (19), (20), 1985- Systematic review 143 Children and adolescents et al. (27), (28), (30), September aged 6-18 To summarize the evidence (2001) (38) 2000 for the effectiveness of Review of school-based interventions reference list of in promoting physical retrieved articles activity and fitness in children and adolescents Bridging the Evidence Gap in Obesity Prevention 

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Outcome Measures Length of (e.g., BMI, diet, physical Intervention Types of Studies (e.g., RCTs, quasi- activity, other behaviors, and/or No. After experimental, qualitative) environment) Follow-up Other Applying Criteria Included: RCTs, controlled Included: Measure of SB Not reported Validity criteria 12 clinical trials, comparative studies, and weight (either BMI applied multicenter studies that aimed to or % overweight) reduce SB in a natural setting Excluded: observational cross- over and cohort studies, studies of behavior in a controlled laboratory setting Included: school-based studies Included: Not reported Not reported 25 seeking to alter diet and/or physical anthropometric activity−related behaviors and measurement of body having a broad public health weight or obesity, at base; studies that monitored and baseline and follow-up evaluated in a manner that has been documented (e.g., published) Excluded: studies with aims so narrow that an impact on obesity is unlikely; clinical settings focused on treatment of obese children; pilot studies RCTs; studies with a control group Outcomes must have Included: intervention 19 and measures taken pre- and been reported for applicable to public postintervention; prospective study children and adolescents health practice; designs intervention could be implemented, facilitated, or promoted by staff in local public health units in Ontario continued  Appendix C

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TABLE C-1 Continued Search Strategy Inclusion/Exclusion Criteria Sources of Years Type of Appraisal and Initial No. Informationa Study Included Purpose Identified Subject Demographics Eden et al. (7), (12), (13), 1994- Systematic review ~1,000 Adults in general (2002) (23), (28) March primary care populations To determine whether 2002 Expert opinion; counseling adults in primary manual searching care settings improves and of bibliographies maintains physical activity from pertinent levels articles Bridging the Evidence Gap in Obesity Prevention 

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Outcome Measures Length of (e.g., BMI, diet, physical Intervention Types of Studies (e.g., RCTs, quasi- activity, other behaviors, and/or No. After experimental, qualitative) environment) Follow-up Other Applying Criteria Included: controlled trials, case- Included: behavioral Not reported The patient’s primary 8 (7 RCTs, control studies, observational outcomes (physical care clinician 1 non-RCT) studies activity); if the study performed some was of “good” or “fair” of the counseling quality, according to intervention criteria developed by the U.S. Preventive Services Task Force (USPSTF) continued  Appendix C

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TABLE C-1 Continued Search Strategy Inclusion/Exclusion Criteria Sources of Years Type of Appraisal and Initial No. Informationa Study Included Purpose Identified Subject Demographics Faith et al. (3), (28), (32), Earliest Narrative review Not reported Not reported (2007) (43), (33), (3) data To review critically the indexed Manual searching evidence addressing three through of bibliographies questions that are pertinent November from pertinent to potential macro-level 2004 articles and environmental influences on chapters; obesity management expert opinion; grey literature (government and private foundation reports, excluded dissertations) Bridging the Evidence Gap in Obesity Prevention 

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Outcome Measures Length of (e.g., BMI, diet, physical Intervention Types of Studies (e.g., RCTs, quasi- activity, other behaviors, and/or No. After experimental, qualitative) environment) Follow-up Other Applying Criteria For substudy 1: Included: had to Not reported Not reported 5 (substudy 1), have at least one 17 (substudy 2), Included: focus group, observational of the following: 1 (substudy 3) study, quasi-experimental and food acquisition or experimental designs, RCTs purchasing behavior, Excluded: position or conceptual reported or weighed articles food intake, or body weight or composition For substudy 2: Included: the macro-environmental factor must be studied in such a way that it was not confounded with education-based manipulations aimed at changing behavior through structured information dissemination Excluded: comprehensive multicomponent interventions targeting multiple behaviors (because the specific effects of manipulating individual components could not be disaggregated) For substudy 3: Excluded: studies testing the effects of restrictive parental feeding practices and strategies on child eating behavior and weight (these studies, being largely confined to the home, are less central to the topic of macro-environmental influences) For all substudies: Excluded: studies aimed primarily (or to a large degree) at achieving behavior change through information dissemination continued  Appendix C

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TABLE C-1 Continued Search Strategy Inclusion/Exclusion Criteria Sources of Years Type of Appraisal and Initial No. Informationa Study Included Purpose Identified Subject Demographics Thomas See above 1985-2003 See above See above Included: studies with (2006) elementary or secondary school-aged children, school component Thomas (10), (12), (13), 1984-2003 Systematic review More than 1,100 Children and adolescents et al. (14), (19), (20), aged 6-18 To examine the effectiveness (2004) (27), (28), (38), of interventions for (39) promoting healthy weight, Manual searching preventing overweight/ of 24 relevant obesity, and increasing peer-reviewed physical activity among journals (June school-aged children and 1998-June 2003) youth Timperio (27), (28), (39) 1999- Review (update) Not reported Included: children, et al. September adolescents, young To study the effectiveness (2004) 2003 adults of intervention strategies to promote physical activity among children, adolescents, and young adults Bridging the Evidence Gap in Obesity Prevention 

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Outcome Measures Length of (e.g., BMI, diet, physical Intervention Types of Studies (e.g., RCTs, quasi- activity, other behaviors, and/or No. After experimental, qualitative) environment) Follow-up Other Applying Criteria Included: studies with a comparison Included: self-reported See above Used a recent review 57 group; RCTs and other study dietary intake, BMI, to critique the designs skinfold thickness, results of primary moderate to vigorous studies related to physical activity the effectiveness of (MVPA) changes physical activity and nutrition programs for obesity prevention in children and youth Included: RCTs, cohort studies Included: changes in Not reported Excluded: studies 425 (prospective, with a control group) total caloric intake related to therapeutic and percent calories nutrition and physical from fat, fruit, and activity programs and vegetable intake; those that included changes in body fat; children with known changes in perception illnesses or obese/ of body image; self- overweight children; reported changes in quality assessed using duration, rate, and Mulrow et al. (1997) frequency of physical and Jadad et al. activity; changes in lung (1996) capacity (VO2 max); self-reported changes in inactivity; BMI Excluded: studies that measured only changes in vitamin or fiber intake, changes in knowledge and attitudes re physical activity and nutrition Included: RCTs Not reported Not reported Review of new 31 evidence (update) continued  Appendix C

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TABLE C-1 Continued Search Strategy Inclusion/Exclusion Criteria Sources of Years Type of Appraisal and Initial No. Informationa Study Included Purpose Identified Subject Demographics Van Sluijs (20), (28), (32), Up to Systematic review 3,045 Included: children and adolescents (< 18 years) et al. (35), (39) December To study the effectiveness (2007) 2006 Manual searching of interventions aimed at Excluded: participants of bibliographies promoting physical activity with a specific disease or from gathered in children and adolescents health problem articles Wareham (28), (32) 2000-2005 Critical review Not reported Included: adults and et al. children To study the effectiveness (2005) of physical activity interventions for obesity prevention > 5,000, then Wofford (15), (28) Not Systematic review Included: Eventually (2008) reported limited by date limited search to Manual searching To review evidence related (2004-2008), but preschoolers (prevention) of bibliographies to obesity prevention in included seminal from gathered young children articles, articles articles; Joanna on preschool- Briggs Institute aged children database and relevance (depending to prevention of on author’s obesity subscription) Bridging the Evidence Gap in Obesity Prevention 0

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Outcome Measures Length of (e.g., BMI, diet, physical Intervention Types of Studies (e.g., RCTs, quasi- activity, other behaviors, and/or No. After experimental, qualitative) environment) Follow-up Other Applying Criteria Included: controlled trials (with or Included: outcomes Not reported Used 10-item quality 57: 33 children, without randomization); control related to physical assessment scale 24 adolescents group (non−physical activity activity (self-reported or for methodological intervention) objectively measured) quality (internal validity) Included: observational studies Included: physical Not reported 30: 14 adults, (longitudinal, prospective cohort) activity or body 16 children composition change Excluded: cross-sectional studies Not reported Not reported Not reported The 41 selected 41 for review were chosen because of their relevance to the prevention of overweight and obesity in the preschool population and the “stronger” quality of evidence they presented English language continued  Appendix C

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TABLE C-1 Continued Search Strategy Inclusion/Exclusion Criteria Sources of Years Type of Appraisal and Initial No. Informationa Study Included Purpose Identified Subject Demographics Zenzen (14), (27), (28) 2000-2007 Integrative review Not reported Included: children aged and Kridli 4-18 (kindergarten Manual searching To study the degree (2009) through high school) of bibliographies of variability in the from gathered methodological approaches articles and theoretical frameworks of school-based obesity prevention programs, focused on the following interventions: dietary, physical activity, and healthy lifestyle education; parental involvement NOTES: BMI = body mass index; CDC = Centers for Disease Control and Prevention; N/A = not available; RCT = randomized controlled trial. aElectronic databases are denoted numerically as outlined below: (1) Academic Search Elite (2) ACP Journal Club (American College of Physicians Evidence Based Medicine) (3) AGRICOLA (4) AMED (Allied and Complementary Medicine Database) (5) ARC Service (Agricultural Research Council) (6) AustHealth (7) Best Evidence Database (8) Biological Abstracts (9) BioMed Central (10) BIOSIS Previews (11) Chronic Disease Prevention File (National Center for Chronic Disease Prevention and Health Promotion) (12) CDSR (Cochrane Database of Systematic Reviews) (13) CENTRAL/CCTR (Cochrane Central Register of Controlled Trials) (14) CINAHL (Cumulative Index of Nursing and Allied Health Literature) (15) Cochrane Library (16) Current Contents—Life Sciences (17) DARE (Database of Abstracts of Reviews of Effects) (18) Education Abstracts (19) ERIC (Education Resources Information Centre) (20) EMBASE (Excerpta Medica Database) (21) Environline Bridging the Evidence Gap in Obesity Prevention 

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Outcome Measures Length of (e.g., BMI, diet, physical Intervention Types of Studies (e.g., RCTs, quasi- activity, other behaviors, and/or No. After experimental, qualitative) environment) Follow-up Other Applying Criteria Included: experimental and Not reported Not reported Used conceptual 16 nonexperimental studies framework of Cooper (1984) to guide the systematic review; used Stetler et al. (1998) for assessing quality Included: school-based curriculum programs for obesity prevention; studies needed to manipulate at least one of the variables of dietary habits, physical activity, healthful lifestyle education, and parental involvement; English language (22) Health Source: Nursing/Academic Edition (23) HealthSTAR (Health Services Technology, Administration, and Research) (24) PAIS (Public Affairs Information Service) International (25) ProceedingsFirst (26) PsycARTICLES (27) PsycINFO (Psychological abstracts) (28) PubMed or MEDLINE (29) Population Index (30) Proquest Digital Dissertation Abstracts International (31) Proquest Digital Dissertations and Theses (32) PsychLit—Silver Platter (33) Science Citation Index (Web of Science) (34) ScienceDirect (35) SCOPUS (36) Social Science Citation Index (Web of Science) (37) Social SciSearch (38) Sociological Abstracts (39) SPORTDiscus (40) TRIS (Transportation Research Information Services) (41) TRIP (Turning Research into Practice) (42) Web of Knowledge (43) Web of Science  Appendix C

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