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LeBlanc E, O'Connor E, Whitlock EP, et al. Screening for and Management of Obesity and Overweight in Adults [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2011 Oct. (Evidence Syntheses, No. 89.)

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Screening for and Management of Obesity and Overweight in Adults [Internet].

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Appendix BSearch Strategies

Systematic Evidence Review Search

Databases: PubMed, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effectiveness, National Institute for Health and Clinical Excellence, Institute of Medicine, National Institutes of Health

Dates: 2001 to January 2009

  1. “Obesity”[Majr:NoExp] OR “Obesity, Morbid”[Majr] OR “Overweight”[Majr:NoExp]
  2. “Anti-Obesity Agents”[Majr:NoExp] OR “Appetite Depressants”[Majr] OR “Anti-Obesity Agents ”[Pharmacological Action] OR “Appetite Depressants ” [Pharmacological Action] OR “sibutramine ”[Substance Name] OR “orlistat ”[Substance Name]
  3. “Bariatric Surgery”[Majr:NoExp] OR “Gastric Bypass”[Majr] OR “Gastroplasty”[Majr]
  4. “Body Mass Index”[Majr] OR “Weight Loss”[Majr:NoExp]
  5. #1 OR #2 OR #3 OR #4
  6. #5 AND systematic[sb]
  7. #5 AND systematic[sb] Limits: All Child: 0-18 years
  8. #5 AND systematic[sb] Limits: All Adult: 19+ years
  9. #7 NOT #8
  10. #6 NOT #9
  11. #6 NOT #9 Limits: Humans
  12. #6 NOT #9 Limits: Animals
  13. #12 NOT #11
  14. #10 NOT #13
  15. obesity[ti] OR obese[ti] OR overweight[ti]
  16. bariatric[ti] OR gastroplasty[ti] OR “gastric bypass”[ti] OR “gastric banding”[ti]
  17. bmi[ti] OR “body mass index”[ti]
  18. #15 OR #16 OR #17
  19. #18 AND systematic[sb]
  20. #19 AND (publisher[sb] OR in process[sb] OR pubmednotmedline[sb])
  21. #14 OR #20
  22. #14 OR #20 Limits: Publication Date from 2001 to 2009, English

Key Question Search

Databases: MEDLINE, Cochrane Central Register of Controlled Trials

Dates: 2005 to March 10, 2010

  1. Obesity
  2. Obesity, Morbid
  3. Overweight
  4. 1 or 2 or 3
  5. Mass Screening
  6. screen$.ti,ab.
  7. 5 or 6
  8. 4 and 7
  9. limit 8 to “all child (0 to 18 years)”
  10. limit 8 to “all adult (19 plus years)”
  11. 9 not 10
  12. 8 not 11
  13. limit 12 to animals
  14. limit 12 to humans
  15. 13 not 14
  16. 12 not 15
  17. limit 16 to english language
  18. limit 17 to yr=“2005 - 2009”
  19. from 18 keep 1-500

Metformin Search

Database: MEDLINE

Dates: 2001–2005

  1. metformin.ti,ab.
  2. glucophage.ti,ab.
  3. 1 or 2 or 3
  4. Obesity
  5. Obesity, Morbid
  6. Overweight
  7. Weight Loss
  8. obes$.ti,ab.
  9. overweight.ti,ab.
  10. weight loss.ti,ab
  11. 5 or 6 or 7 or 8 or 9 or 10 or 11
  12. diabetes.ti,ab,hw
  13. 4 and 12 and 13
  14. limit 14 to (clinical trial or controlled clinical trial or meta analysis or randomized controlled trial) (159)
  15. clinical trials as topic/ or controlled clinical trials as topic/ or randomized controlled trials as topic/
  16. Meta-Analysis as Topic
  17. (control$ adj3 trial$).ti,ab.
  18. random$.ti,ab.
  19. clinical trial$.ti,ab.
  20. 16 or 17 or 18 or 19 or 20
  21. 14 and 21
  22. 15 or 22
  23. limit 23 to “all child (0 to 18 years)”
  24. limit 23 to “all adult (19 plus years)”
  25. 24 not 25
  26. 23 not 26
  27. limit 27 to animals
  28. limit 27 to humans
  29. 28 not 29
  30. 27 not 30
  31. limit 31 to english language
  32. limit 32 to yr=“2001 - 2005”
  33. remove duplicates from 33

Inclusion and Exclusion Criteria and Results

Appendix B Table 1Review Inclusion and Exclusion Criteria

PopulationsInclude
  • Adults ages 18 years and older who are obese or overweight.
  • Study participants are either: 1) unselected or low-risk; 2) selected for increased risk of cardiovascular disease, including hypertension, dyslipidemia, or type 2 diabetes mellitus; or 3) selected populations, restricted to patients who are postpartum or have polycystic ovary syndrome.
Exclude
  • Children and adolescents younger than age 18 years.
  • Adults with secondary causes of obesity, such as steroid use.
  • Restricted patient subgroups (i.e., that are not listed above as included, such as pregnant women or people with arthritis, eating disorders, or cardiovascular disease).
  • Populations that do not demonstrate obesity or overweight using body mass index (BMI) or other weight-related measurements
  • Cancer survivors or people who have arthritis, osteoporosis, or liver disease (because of different motivation).
SettingsInclude
  • Studies conducted in primary care, feasible for conducting in primary care, or feasible for referral from primary care. In order for an intervention to be feasible for primary care referral, it needs to be conducted as part of a health care setting or be widely available in the community at a national level.
  • Studies conducted in commercial settings (e.g., Weight Watchers).
  • Geographic settings generalizable to United States (all countries listed as “high” human development on the Human Development Index [>0.90]: Australia, Austria, Belgium, Canada, Denmark, Finland, France, Germany, Greece, Hong Kong, Iceland, Ireland, Israel, Italy, Japan, Korea, Luxembourg, the Netherlands, New Zealand, Norway, Portugal, Singapore, Slovenia, Spain, Sweden, Switzerland, and United Kingdom).
Exclude
  • Settings not generalizable to primary care (e.g., inpatient hospital units, emergency departments, nursing home and other institutionalized settings, school-based programs, occupational settings, churches and faith-based and other community-based settings), unless intervention is primary care feasible.
  • Studies performed in countries with populations not similar to the United States.
InterventionsInclude
  • Interventions focusing on weight loss, including the following broad types:

    Behavioral-based interventions

    Pharmacological (orlistat, sibutramine, and metformin) interventions

    Combination of behavioral-based and pharmacological treatment

  • Must be conducted in a primary care setting, judged to be feasible in “usual” primary care, or feasible for referral. Criteria for primary care feasible are:

    Could target patients seeking care in primary care settings

    The skills to deliver the intervention are or could be present in clinicians and/or related staff in the primary care setting

    Could generally be ordered/initiated by a primary care clinician

Exclude
  • Nonbehavioral or nonpharmacological interventions.
  • Surgical interventions (addressed as a contextual question).
  • Pharmacological agents that are not FDA approved for long-term weight loss:

    New agents being evaluated for FDA approval (e.g., rimonabant)

    Older amphetamine-like agents that have been taken off the market (e.g., fenfluramine and dexfenfluramine), are listed on the FDA site as discontinued (e.g., phenmetrazine or mazindol), or are only approved for short-term weight loss (e.g., phentermine)

  • Complementary and alternative treatments (e.g., chitosan, acupuncture)
  • Primary prevention programs
  • Community-level, population-based strategies
  • Sibutramine trials
OutcomesInclude
  • Health outcomes (reported at ≥12 months after start of intervention or baseline assessment [if intervention start cannot be determined]):

    Decreased morbidity from diabetes mellitus, cardiovascular disease, cancer, arthritis, asthma, or sleep apnea

    Improved depression

    Improved emotional functioning (scores on emotional subscales of quality of life instruments)

    Physical fitness capacity or performance (not behavioral), physical functioning (scores on physical subscales of quality of life measures), or disability (global measures of disability, such as activities of daily living)

    Mortality

  • Intermediate outcomes (reported at ≥48 weeks after start of intervention or baseline assessment [if intervention start cannot be determined]):

    Reduction of weight or adiposity (required outcome); acceptable measures include weight (e.g., kilograms or pounds), relative weight (e.g., BMI, % overweight), total adiposity measures (e.g., DEXA, underwater weight, or comparable), or change in any of these measures.

    Weight maintenance after intervention has ended

    Metabolic consequences: glucose tolerance, blood pressure, dyslipidemia

  • Adverse outcomes:

    Serious treatment-related harms at any time point after an intervention began (e.g., death, medical issue requiring hospitalization or urgent medical treatment)

    Other treatment-related harms reported in trials meeting inclusion criteria for intermediate or health outcomes (e.g., inducement of eating disorders)

Exclude
  • Improved functioning (except as enumerated under health outcomes).
  • Cost effectiveness
  • Intermediate physiological outcomes other than glucose tolerance, blood pressure, or dyslipidemia
  • Behavioral changes (e.g., physical activity or diet)
  • Outcomes reported <12 months after start of intervention or baseline assessment (if time from intervention start cannot be determined), except for harms resulting in death, hospitalization, or the need for urgent medical treatment.
Study DesignsInclude
  • Randomized, controlled trials (RCTs)
  • Controlled clinical trials (CCTs)
  • Harms only: large cohort studies or case-control studies; must have an appropriate comparison group; large event monitoring, systematic evidence reviews of RCTs or CCTs (if useful information)
Exclude
  • Ecological studies
  • Case reports
  • Case series or other noncomparative designs
  • Nonsystematic reviews
  • Letters to the editor
  • Systematic evidence reviews of RCT or CCTs (look at reference list for references and considering including for harms if serious harms or otherwise adds to information)

Appendix B Table 2Quality Rating Criteria

DesignUSPSTF Quality Rating Criteria293NICE Methodology Checklists294
Systematic reviews and meta-analyses
  • Comprehensiveness of sources considered/ search strategy used
  • Standard appraisal of included studies
  • Validity of conclusions
  • Recency and relevance, especially for systematic reviews
  • Study addresses an appropriate and clearly focused question
  • Description of the methodology used is included
  • Literature search is sufficiently rigorous to identify all relevant studies
  • Study quality is assessed and taken into account
  • Enough similarities between selected studies to make combining them reasonable
Case-control studies
  • Accurate ascertainment of cases
  • Nonbiased selection of cases/controls with exclusion criteria applied equally to both
  • Response rate
  • Diagnostic testing procedures applied equally to each group
  • Measurement of exposure accurate and applied equally to each group
  • Appropriate attention to potential confounding variables
  • Study addresses an appropriate and clearly focused question
  • Cases and controls are taken from comparable populations
  • Same exclusion criteria are used for both cases and controls
  • Percentage of each group (cases and controls) that participated in the study is specified
  • Participants and nonparticipants are compared to establish their similarities or differences
  • Cases are clearly defined and differentiated from controls
  • Controls are clearly established as noncases
  • Measures are taken to prevent knowledge of primary exposure influencing case ascertainment
  • Exposure status is measured in a standard, valid, and reliable way
  • Main potential confounders are identified and taken into account in the design and analysis
  • Confidence intervals are provided
Randomized, controlled trials
  • Initial assembly of comparable groups employs adequate randomization, including first concealment and whether potential confounders were distributed equally among groups
  • Maintenance of comparable groups (includes attrition, crossovers, adherence, contamination)
  • Important differential loss to followup or overall high loss to followup
  • Measurements are equal, reliable, and valid (includes masking of outcome assessment)
  • Clear definition of interventions
  • All important outcomes considered
  • Study addresses an appropriate and clearly focused question
  • Assignment of subjects to treatment groups is randomized
  • Adequate concealment method is used
  • Subjects and investigators are kept blind about treatment allocation
  • Treatment and control groups are similar at the start of the trial
  • Only difference between groups is the treatment under investigation
  • All relevant outcomes are measured in a standard, valid, and reliable way
  • Percentage of individuals or clusters recruited into each treatment arm of the study who dropped out before completion is provided
  • All subjects are analyzed in the groups to which they were randomly allocated (often referred to as intention-to-treat analysis)
  • When the study is carried out at more than one site, results are comparable for all sites
Cohort studies
  • Initial assembly of comparable groups employs consideration of potential confounders with either restriction or measurement for adjustment in the analysis; consideration of inception cohorts
  • Maintenance of comparable groups (includes attrition, crossovers, adherence, contamination)
  • Important differential loss to followup or overall high loss to followup
  • Measurements are equal, reliable, and valid (includes masking of outcome assessment)
  • Clear definition of interventions
  • All important outcomes considered
  • Study addresses an appropriate and clearly focused question
  • Two groups being studied are selected from source populations that are comparable in all respects other than the factor under investigation
  • Study indicates how many of participants asked to take part did so, in each group being studied
  • Likelihood that some eligible subjects might have the outcome at the time of enrollment is assessed and taken into account in the analysis
  • Percentage of individuals or clusters recruited into each arm of the study who dropped out before completion is provided
  • Full participants and those lost to followup are compared, by exposure status
  • Outcomes are clearly defined
  • Assessment of outcome is made blind to exposure status
  • Where blinding is not possible, there is some recognition that knowledge of exposure status could have influenced the assessment of outcome
  • Measure of assessment of exposure is reliable
  • Evidence from other sources is used to demonstrate that the method of outcome assessment is valid and reliable
  • Exposure level or prognostic factor is assessed more than once
  • Main potential confounders are identified and taken into account in the design and analysis
  • Confidence intervals are provided
Diagnostic accuracy studies
  • Screening test is relevant, available for primary care, and adequately described
  • Study uses a credible reference standard, performed regardless of test results
  • Reference standard interpreted independently of screening test
  • Handles indeterminate results in a reasonable manner
  • Spectrum of patients included in study
  • Sample size
  • Administration of reliable screening test
  • Nature of the test being studied is clearly specified
  • Test is compared with an appropriate gold standard
  • Where no gold standard exists, a validated reference standard is used as a comparator
  • Patients for testing are selected either as a consecutive series or randomly, from a clearly defined study population
  • Test and gold standard are measured independently (blind) of each other
  • Test and gold standard are applied as close together in time as possible
  • Results are reported for all patients that are entered into the study
  • Prediagnosis is made and reported

Hierarchy of research design:

I.

Properly conducted randomized, controlled trial

II-1.

Well-designed controlled trial without randomization

II-2.

Well-designed cohort or case-control analytic study

II-3.

Multiple time series with or without the intervention; dramatic results from uncontrolled experiments

III.

Opinions of respected authorities, based on clinical experience; descriptive studies or case reports; reports of expert committee

Appendix B Table 3 Inclusion or Exclusion of Articles From the 2003 U.S. Preventive Services Task Force Review, Behavioral Trials

Author, YearIncluded in ReviewReason for Exclusion
Wadden, 2001Comparative effectiveness
Kuller, 2001XNA*
Tuomilehto, 2001XNA
Rothacker, 2001Comparative effectiveness
Jones, 1999XNA
Stevens, 2001XNA
Swinburn, 1999Worksite related
Jakicic, 1999Comparative effectiveness
Leermakers, 1999Comparative effectiveness
Sbrocco, 1999Comparative effectiveness
Fogelholm, 2000Comparative effectiveness
Jeffery, 1997Weight gain prevention
Wing, 1996Comparative effectiveness
Lindholm, 1995Comparative effectiveness
OXCHECK, 1995Not focused on weight loss
Knowler, 2002XNA
Ashley, 2001Comparative effectiveness

* Secondary article to an included article.

Abbreviation: NA=not applicable.

Appendix B Table 4 Inclusion or Exclusion of Articles From the 2003 U.S. Preventive Services Task Force Review, Medication Trials

Author, YearIncluded for
KQs 1–3
Reason for ExclusionIncluded for
KQ 4
Reason for Exclusion
James, 2000Sibutramine studySibutramine study
Fujioka, 2000Sibutramine studySibutramine study
Gokcel, 2001Sibutramine studySibutramine study
Smith, 2001Sibutramine studySibutramine study
Wirth, 2001Sibutramine studySibutramine study
Dujovne, 2001Sibutramine studySibutramine study
Van Gaal, 1998<12 months of followupXNA
Hill, 1999XNAXNA
Karhunen, 2000XNA*XNA*
Micic, 1999<12 months of followupNo harms outcomes
Muls, 2001<12 months of followupXNA
Giugliano, 1993<12 months of followupNo harms outcomes
Rissanen, 1998XNA*XNA*

* Secondary article to an included article.

Abbreviations: KQ=key question; NA=not applicable.

Appendix B Figure 1 shows the search results and article flow of the review. Initially, 11,875 records were identified through database searching, along with 371 records found using other search methods. After duplicates were removed, 6498 records remained and were screened by the review team. Upon review of each study abstract, 5850 records were excluded and 648 full-text articles were assessed for eligibility (22 for Key Question [KQ] 1, 583 for KQ2, 588 for KQ3, and 629 for KQ4). During full-text review, 22 publications were excluded for KQ1 (4 for Relevance, 1 for setting, 1 for outcomes, 5 for interventions, 10 for design, and 1 for quality), 551 for KQ2 (64 for relevance, 17 for setting, 116 for outcomes, 59 for interventions, 265 for design, 20 for quality, and 2 for study period), 490 for KQ3 (64 for relevance, 17 for setting, 10 for population, 49 for outcomes, 61 for interventions, 266 for design, 20 for quality, and 3 for study period), and 569 for KQ4 (66 for relevance, 17 for setting, 9 for population, 197 for outcomes, 79 for interventions, 193 for design, 6 for quality, and 2 for study period). In the end, no studies were included for KQ1, 32 publications (15 trials) were included for KQ2, 98 publications (58 trials) were included for KQ3, and 60 publications (38 trials) were included for KQ4.

Appendix B Figure 1Search Results and Article Flow

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