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BMC Med Res Methodol. 2019 Aug 20;19(1):178. doi: 10.1186/s12874-019-0811-z.

Hierarchies of evidence applied to lifestyle Medicine (HEALM): introduction of a strength-of-evidence approach based on a methodological systematic review.

Author information

American College of Lifestyle Medicine, PO Box 6432, Chesterfield, MO, 63006, USA.
The True Health Initiative, Derby, CT, USA.
Yale Griffith Prevention Research Center, 130 Division St, Derby, CT, 06418, USA.
American College of Lifestyle Medicine, PO Box 6432, Chesterfield, MO, 63006, USA.
Applied Clinical Nutrition and Global Public Health Programs, University of New England, 11 Hills Beach Rd, Biddeford, ME, 04005, USA.
Department of Public Health and Community Medicine, Tufts University School of Medicine, 136 Harrison Avenue, Boston, MA, 02111, USA.
Risk Factor Assessment Branch, Division of Cancer Control and Population Sciences, National Cancer Institute, 9609 Medical Center Drive, 4E204, Bethesda, MD, 20850, USA.
Department of Epidemiology and Biostatistics, University of California at San Francisco School of Medicine, 550 16th Street, Second Floor, San Francisco, CA, 94158, USA.
University of California Fielding School of Public Health, 650 Charles E Young Dr S, Los Angeles, CA, 90095, USA.
Brown University School of Public Health, 121 S Main St, Providence, RI, 02903, USA.
Harvard University T.H. Chan School of Public Health, 655 Huntington Avenue, Boston, MA, 02115, USA.
Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA.



Current methods for assessing strength of evidence prioritize the contributions of randomized controlled trials (RCTs). The objective of this study was to characterize strength of evidence (SOE) tools in recent use, identify their application to lifestyle interventions for improved longevity, vitality, or successful aging, and to assess implications of the findings.


The search strategy was created in PubMed and modified as needed for four additional databases: Embase, AnthropologyPlus, PsycINFO, and Ageline, supplemented by manual searching. Systematic reviews and meta-analyses of intervention trials or observational studies relevant to lifestyle intervention were included if they used a specified SOE tool. Data was collected for each SOE tool. Conditions necessary for assigning the highest SOE grading and treatment of prospective cohort studies within each SOE rating framework were summarized. The expert panel convened to discuss the implications of findings for assessing evidence in the domain of lifestyle medicine.


A total of 15 unique tools were identified. Ten were tools developed and used by governmental agencies or other equivalent professional bodies and were applicable in a variety of settings. Of these 10, four require consistent results from RCTs of high quality to award the highest rating of evidence. Most SOE tools include prospective cohort studies only to note their secondary contribution to overall SOE as compared to RCTs. We developed a new construct, Hierarchies of Evidence Applied to Lifestyle Medicine (HEALM), to illustrate the feasibility of a tool based on the specific contributions of diverse research methods to understanding lifetime effects of health behaviors. Assessment of evidence relevant to lifestyle medicine requires a potential adaptation of SOE approaches when outcomes and/or exposures obviate exclusive or preferential reliance on RCTs. This systematic review was registered with the International Prospective Register of Systematic Reviews, PROSPERO [CRD42018082148].


HEALM; Lifestyle medicine; Lifetime effects; SOE; Strength of evidence; Systematic review

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