overweight/obesity prevention, treatment, and maintenance from childhood to adulthood: discussing...

Welcome! Overweight / obesity prevention, treatment, and

maintenance from childhood to adulthood:

Discussing review-level evidence

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Review-level evidence series:1. Peirson, L., Fitzpatrick-Lewis, D., Morrison, K., Ciliska, D., Kenny, M., Ali, M. U., et

al. (2015).Prevention of overweight and obesity in children and youth: A systematic review and meta-analysis. CMAJ Open, 3(1), E23-E33.(2)

2. Peirson L., Fitzpatrick-Lewis D., Morrison K., Warren R., Ali M.U., & Raina P. (2015).Treatment of overweight and obesity in children and youth: a systematic review and meta-analysis. CMAJ Open, 3(1), E35-E46.(2)

3. Peirson, L., Douketis, J., Ciliska, D., Fitzpatrick-Lewis, D., Ali, M. U., & Raina, P. (2014).Prevention of overweight and obesity in adult populations: A systematic review. CMAJ Open, 2(4), E268-E272.(2)

4. Peirson, L., Douketis, J., Ciliska, D., Fitzpatrick-Lewis, D., Ali, M. U., & Raina, P. (2014).Treatment for overweight and obesity in adult populations: a systematic review and meta-analysis. CMAJ Open, 2(4), E306-E317.(2)

5. Peirson, L., Fitzpatrick-Lewis,D., Ciliska, D., Ali, M. U., Raina, P., & Sherifali, D. (2015).Strategies for weight maintenance in adult populations treated for overweight and obesity: a systematic review and meta-analysis. CMAJ Open, 3(1), E47-E54.(2)

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What is www.healthevidence.org?

Evidence

Decision Making

inform

Why use www.healthevidence.org?

1. Saves you time2. Relevant & current evidence 3. Transparent process4. Supports for EIDM available 5. Easy to use

A Model for Evidence-Informed Decision

Making

National Collaborating Centre for Methods and Tools. (revised 2012). A Model for Evidence-Informed Decision-Making in Public Health (Fact Sheet). [http://www.nccmt.ca/pubs/FactSheet_EIDM_EN_WEB.pdf]

Stages in the process of Evidence-Informed Public Health

National Collaborating Centre for Methods and Tools. Evidence-Informed Public Health. [http://www.nccmt.ca/eiph/index-eng.html]

Poll Question #2

Have you heard of PICO(S) before?

1.Yes2.No

Searchable Questions Think “PICOS”

1. Population (situation)

2. Intervention (exposure)

3. Comparison (other group)

4. Outcomes

5. Setting

How often do you use Systematic Reviews to inform a program/services?

A.AlwaysB.OftenC.SometimesD.NeverE.I don’t know what a systematic review is

Poll Question #3

Dr. Leslea Peirson , Ph.D, is a Review Coordinator at McMaster Evidence Review and Synthesis Centre.

Leslea Peirson

Review Series: • Child Prevention

Prevention of overweight and obesity in children and youth: A systematic review and meta-analysis

• Child ManagementTreatment of overweight and obesity in children and youth: A systematic review and meta-analysis

• Adult PreventionPrevention of overweight and obesity in adult populations: A systematic review

• Adult ManagementTreatment for overweight and obesity in adult populations: A systematic review and meta-analysis

• Adult Maintenance Strategies for weight maintenance in adult populations treated for overweight and obesity: A systematic review and meta-analysis

Review Topics and Questions

5 REVIEW TOPICSPrevention of

Overweight/ObesityManagement of

Overweight/ObesityMaintenance of

Weight Loss

Children/Youth Adults

KEY QUESTIONS: What are the benefits and harms of behavioural and/or pharmacological interventions

What Counts as Evidence

P POPULATIONS

I INTERVENTIONS

CDCOMPARATORSDESIGNS

OTOUTCOMESTIMEFRAMES

S SETTINGS

Populations

Review Topics

Child Prevention

Child Management

Adult Prevention

AdultManagement

Adult Maintenance

Populations

0-18 years

normal weightaccepted mixed

weight that included some normal weight

2-18 years

BMI >85th centile

18+ years

BMI ≥18.5 <25accepted mixed

weight that included some normal weight

18+ years

BMI ≥25 <40

18+ years

lost weight in Rx

Interventions

Review Topics

Child Prevention

ChildManagement

Adult Prevention

AdultManagement

Adult Maintenance

Interventions

behavioural diet, exercise, lifestyle


and/or

pharmacologic orlistat


and/or

complementary or alternative


and/or

pharmacologic orlistat, metformin


and/or

pharmacologic orlistat, metformin

ComparatorsDesigns

Review Topics

Child Prevention

ChildManagement

Adult Prevention

AdultManagement

Adult Maintenance

ComparatorsDesigns

Benefits: RCTs with a usual care, no intervention or minimal intervention control group

Harms: any study design with any type of comparator or no control group

OutcomesTimeframe

Review Topics

Child Prevention

ChildManagement

Adult Prevention

AdultManagement

Adult Maintenance

OutcomesTimeframes

change in BMI, BMIz, prevalence

overweight/obesity (≥12w post-baseline)

change in BMI, BMIz, prevalence

overweight/obesity (≥6m post-baseline)

change in kg, BMI, waist

circumference, body fat %

(≥12m post-baseline)

change in kg, BMI, waist

circumference; 5% or 10% loss (≥12m post-baseline)

maintenance of weight loss: kg, BMI, waist circ.,

5%, 10% (longest available)

change in lipids, BP, QOL, fitness(≥12w post-baseline)

change in lipids, BP, glucose, QOL,

fitness (≥6m post-baseline)

change in lipids, BP, glucose;

incidence T2D (≥12m post-baseline)

change in lipids, BP, glucose;

incidence T2D (≥12m post-baseline)

disordered eating, distress, micronutrient

deficits, abnormal growth

(any time)

adverse events (any, serious, GI,

study withdrawal)

(any time)

labelling, disordered

eating, distress, stigma,

nutritional deficits, cost

(any time)

adverse events(any, serious, GI,

study withdrawal)

(any time)

Settings

Review Topics

Child Prevention

ChildManagement

Adult Prevention

AdultManagement

Adult Maintenance

Settingsconducted in, feasible for or referable from primary care

(child prevention included interventions conducted in education settings)

Search and Selection Review Topics

Prevention of Overweight/Obesity

Management of Overweight/Obesity

Maintenance of Weight Loss

Children/Youth

updated Cochrane 2011 search7,318 citations; 468 full-text

updated USPSTF 2010 search2,731 citations; 333 full-text

included 90 studies (123 papers)


no studies targeted only normal weight; all studies

included mixed weight samples

Adults

de novo search (1980→)31,989 citations; 1,191 full-text

updated USPSTF 2011 search3,584 citations; 358 full-text

updated USPSTF 2011 search15,309 citations; 1,549 full-text

included 26 studies (48 papers) included 68 studies (117 papers)


1 study targeted only normal weight; 25 studies included

mixed weight samples

AnalysesRisk of bias assessments for individual studies and across studies (bodies of evidence) available for each outcome

Meta-analyses if possible to pool data (produces forest plots) with sub-group analyses on pre-defined categories (varied by review):

• focus of intervention (behavioural, pharmacological + behavioural)• type of behavioural intervention (diet, exercise, diet + exercise, lifestyle)• intervention setting (non-education, education only, education plus other)• duration of intervention (≤12 months, >12 months)• age group (0-5 years, 6-12 years, 13-18 years)• sex• baseline CVD risk status (high risk, low risk/not specified)• study risk of bias rating (high, unclear, low)

GRADE assessments of the quality of the evidence

Risk of Bias Table Example*

*From Adult Management Review

Meta-analysis Example*


Assessing Quality of the Evidence: GRADEWe assess the body of evidence available for each outcome using the GRADE (Grading of Recommendations, Assessment, Development & Evaluation) system For each body of evidence we make assessments across 5 domains

These evaluations result in one of 4 quality ratings that reflects the degree of confidence that the available evidence correctly reflects the theoretical true effect of the intervention, service or practice

Each body of evidence begins with a high rating which is downgraded one level for every domain judged to have serious concerns (2 levels if concerns are very serious)

Risk of Bias Consistency Directness Precision Reporting BiasAny methodological limitations or flaws?

How much variation between studies

(direction and size of estimates)?

How well does it match the PICO

statement?

Enough participants or events? How wide is

the confidence interval?

Any indications of publication bias?

High Moderate Low Very Lowtrue effect lies close to

estimate; further research unlikely to change this

true effect lies close to estimate but possibility it is

substantially different; further research may change

estimate

true effect may be substantially different from estimate; further

research very likely to have important impact on confidence

and to change estimate

estimate of effect is very uncertain; further research

very likely to have important impact on confidence and to

change estimate

GRADE Table Example*GRADE Evidence Profile Table: Effect of Management Interventions on Loss of ≥5% Baseline Body Weight

Quality Assessment No. of Participants Effect

GRADEQuality

ImportanceNo. of Studies

DesignRisk of

BiasInconsistency Indirectness Imprecision Other Treatment Control

Relative(95% CI)

Absolute per Million (Range)

ARRNNT

(95% CI)

≥5% Weight Loss: Overall

24randomized

trials1

serious risk2

no serious inconsistency3

no serious indirectness4

no serious imprecision5

reporting bias6

2,506/5,498 (45.5802%)

1,149/4,359 (26.3593%)

RR 1.7745 (1.5813 to

1.9915)

204,152 more (from 153,226 to 261,352 more)

20.42%5

(4, 7)LOW CRITICAL

≥5% Weight Loss: by Primary Focus of Intervention – Behavioural

11randomized

trials7

serious risk8




reporting bias12

431/1,615 (26.6873%)

190/1,226 (15.4976%)

RR 1.7532 (1.3520 to

2.2734)

116,728 more (from 54,551 to 197,346 more)

11.67%9

(5, 18)LOW CRITICAL

≥5% Weight Loss: by Primary Focus of Intervention – Pharmacological plus Behavioural

13randomized

trials13

serious risk14




reporting bias18

2,075/3,883 (53.4381%)

959/3,133 (30.6096%)

RR 1.7926 (1.5715 to

2.0447)

242,612 more (from 174,934 to 319,779 more)

24.26%4

(3, 6)LOW CRITICAL

In reviews these tables are followed by detailed footnotes that elaborate on the ratings


Selected Key Findings*: Children

Child Prevention Child Management

Significant benefits for lowered BMI/BMIzSMD -0.07 (-0.10, -0.03) VLSignificant reduction in prevalence ov/obRR 0.94 (0.89, 0.99) VL

Significant benefits for lowered BMI/BMIzSMD -0.53 (-0.69, -0.36) M

Significantly greater benefits forHDL: MD 0.07 (0.04, 0.10) LPF: SMD 0.32 (0.14, 0.50) L

Significantly greater declines/benefits forSBP: MD -3.42 (-6.65, -0.29) MDBP: MD -3.39 (-5.17, -1.60) MQOL:MD 2.10 (0.60, 3.60) M

Few studies reported data for AE; those that did reported no AE or mostly mild/moderate AE

GI difficulties more common in youth taking orlistatRR 3.77 (2.56, 5.55) M

*Results are for intervention group as compared to control group GRADE ratings: moderate=M, low=L, very low=VL; SMD=standardized mean difference, MD=mean difference, RR=risk ratio, BMI=body mass index (kg/m 2), BMIz=BMI z-score, ov/ob=overweight/obesity, WC=waist circumference (cm), 5%=loss of ≥5% initial body weight, 10%=loss of ≥10% initial body weight, BF%=body fat %, TC=total cholesterol (mmol/l), LDL=low-density lipoproteins (mmol/l), HDL=high-density lipoproteins (mmol/l), FG=fasting blood glucose (mmol/l), T2D=type 2 diabetes (incidence), SBP=systolic blood pressure (mmHg), DBP=diastolic blood pressure (mmHg), PF=physical fitness (stages or laps 20m shuttle run), QOL=(overall) quality of life, AE=adverse event GI=gastrointestinal

Selected Key Findings*: Adults

Adult Prevention AdultManagement Adult Maintenance

Significantly greater reductions/benefits forKG: MD -0.73 (-0.93 , -0.54) VLBMI: MD -0.24 (-0.34, -0.15) L WC: MD -0.95 (-1.27, -0.63) VLBF%: MD -1.27 (-1.93, -0.61) L

Significantly greater reductions/benefits forKG: MD -3.02 (-3.52, -2.52) MBMI: MD -1.11 (-1.39, -0.84) MWC: MD -2.78 (-3.34, -2.22) M5%: RR 1.77 (1.58, 1.99) L10%: RR 1.91 (1.69, 2.16) L

Significantly less regain, better maintenanceKG: MD -1.44 (-2.42, -0.47) MBMI: MD -0.95 (-1.67, -0.23) MWC: MD -2.30 (-3.45, -1.15) M5%: RR 1.33 (1.15, 1.54) M

Significantly greater declines inTC: MD -0.06 (-0.11, -0.01) LLDL: MD -0.06 (-0.09, -0.03) LFG: MD -0.04 (-0.08, -0.002) LDBP: MD -0.18 (-0.44, -0.07) VL

Significantly greater declines inTC: MD -0.21 (-0.29, -0.13) MLDL: MD -0.21 (-0.29, -0.12) LFG: MD -0.26 (-0.38, -0.13) MSBP: MD -1.70 (-2.23, -1.17) MDBP: MD -1.42 (-1.88, -0.96) MT2D: RR 0.62 (0.50, 0.77) M

No studies with data on AE of interest

Very few and minor AE for behavioural; GI difficulties more common for drugsRR 1.58 (1.47-1.70) L

*Results are for intervention group as compared to control group GRADE ratings: moderate=M, low=L, very low=VL; SMD=standardized mean difference, MD=mean difference, RR=risk ratio, BMI=body mass index (kg/m 2), BMIz=BMI z-score, ov/ob=overweight/obesity, WC=waist circumference (cm), 5%=loss of ≥5% initial body weight, 10%=loss of ≥10% initial body weight, BF%=body fat %, TC=total cholesterol (mmol/l), LDL=low-density lipoproteins (mmol/l), HDL=high-density lipoproteins (mmol/l), FG=fasting blood glucose (mmol/l), T2D=type 2 diabetes (incidence), SBP=systolic blood pressure (mmHg), DBP=diastolic blood pressure (mmHg), PF=physical fitness (stages or laps 20m shuttle run), QOL=(overall) quality of life, AE=adverse event GI=gastrointestinal

Contextual Questions• Differential findings for sub-groups (e.g.,

ethnicity, age, rural and remote populations, SES)?

• Resource implications and cost-effectiveness• Patients’ and practitioners’ values and

preferences• Risk assessment tools

Poll Question #4Do you agree with the findings of this review series?A.Strongly agreeB.AgreeC.NeutralD.DisagreeE.Strongly disagree

Questions?

A Model for Evidence-Informed Decision

Making

National Collaborating Centre for Methods and Tools. (revised 2012). A Model for Evidence-Informed Decision-Making in Public Health (Fact Sheet). [http://www.nccmt.ca/pubs/FactSheet_EIDM_EN_WEB.pdf]

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overweight/obesity prevention, treatment, and maintenance from childhood to adulthood: discussing...

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