PWM: Pediatric Overweight and Obesity: Methods for Overview of Systematic Reviews (2021)
Methods for Overview of Systematic Reviews to Support Academy Pediatric Overweight and Obesity Prevention and Treatment Position Papers
Current Academy Position Papers are based on systematic reviews.1 A recent scoping review of systematic reviews identified an abundance of current, relevant systematic reviews addressing a wide range of interventions to prevent pediatric overweight and obesity.2 Therefore, an overview of systematic reviews was conducted to address important questions about nutrition practice for RDNs working with the pediatric population. This overview of reviews aligns with the methods outlined by the Cochrane Collaboration.3 Research questions were created by expert panel members to address important topics in the field of pediatric overweight and obesity prevention.
Included systematic reviews were required to address all aspects of the Population-Intervention-Comparison-Outcome (PICO) question: In pediatric individuals (2-5 years, 6-12 years and 13-17 years) in the general population, what is the effect of nutrition interventions on weight-related outcomes?
Systematic reviews were not included if they targeted pediatric individuals with a diagnosed disease, though participants were required to have overweight or obesity to be included in the overview of reviews about obesity treatment. Systematic reviews examining nutrition interventions, alone or as part of multi-disciplinary interventions were included. The outcomes of interest were weight-related measures including BMI measures (z-score, percentile, etc) and prevalence or incidence of overweight or obesity for the overview of reviews on pediatric obesity prevention. The systematic review on pediatric obesity treatment included psychosocial outcomes. Systematic reviews were eligible if they searched at least two databases, assessed the risk of bias in their included primary studies, and were published from January 2017 to January 2021.
Because of the high availability of current and relevant systematic reviews identified, a two-tiered system was employed for the inclusion of systematic reviews in this overview. Systematic reviews are categorized as “Tier 1” if they include a grade for certainty of evidence, as is done in systematic reviews by the Cochrane Collaboration and the Academy.4,5 Systematic reviews that have not graded certainty of evidence were categorized as “Tier 2”. When available, Tier 1 systematic reviews were analyzed to answer research questions. If Tier 1 evidence was not available, Tier 2 evidence was analyzed. A full description of eligibility criteria can be found in the Eligibility Criteria tables for each overview of reviews.
The overview of systematic reviews utilized the search from the related scoping review, which was conducted by an information specialist using Medline (Ebsco), CINAHL (Ebsco), Cochrane Database of Systematic Reviews (Ebsco) and Food Science Source (Ebsco). Research questions developed by the expert panel were then used to select studies from the included pool. This search was updated by EAC staff (See Full Search Strategy).
Title/abstracts were independently screened by two staff members from the Academy using Rayyan screening software.6 Any discrepancies were resolved by consensus. Systematic reviews potentially answering the research question moved onto the full-text review phase of screening. Each study was reviewed for inclusion by at least two Academy staff members and/or expert panel members. Inclusion of systematic reviews for each research question was confirmed by expert panel members.
Data was extracted from the systematic reviews by Academy staff (M.R.) and cross-checked by expert panel members. Data was extracted onto a standardized study characteristics table and included: bibliographic information; age group of included participants; specific sub-population information (ex: individuals with low socioeconomic status or determinants of health); the number and types of articles included in the systematic review, a brief description of the intervention of interest and comparison groups, setting (ex: school, healthcare, home); reported outcomes of interest; if the systematic review included meta-analysis or graded certainty of evidence, and the tool used to assess risk of bias of primary studies.
Risk of Bias Assessment for Included Systematic Reviews
Each included systematic review was assessed for risk of bias using the AMSTAR2 tool. Domains assessed in this tool include protocol registration, adequacy of literature search, justification for excluding individual studies, appropriateness of meta-analysis methods, considerations of risk of bias when interpreting results, and assessment of presence and likely impact of publication bias.7 Risk of bias was determined independently by two reviewers and discrepancies were resolved through consensus.
Synthesis of Results
The study inclusion process was documented in a PRISMA flowchart.8 Evidence for each research question was described narratively in an evidence summary. A conclusion statement was created to directly answer each research question of interest. Meta-analysis of complementary systematic reviews was considered if appropriate.
Certainty of evidence for the research question and outcomes of interest were determined using the GRADE method4 and the process was documented in a summary of findings table. This certainty of evidence included both the items considered in a traditional systematic review (number and types of studies included, consistency between studies, precision, etc.) as well as the risk of bias assessment of the systematic review itself as determined using the AMSTAR2 tool. The evidence was graded as “HIGH”, “MODERATE”, “LOW”, or “VERY LOW”.4
See a visual summary of the review.
- Handu D, Moloney L, Rozga MR, Cheng F, Wickstrom D, Acosta A. Evolving the Academy Position Paper Process: Commitment to Evidence-Based Practice. J Acad Nutr Diet. 2018;118(9):1743-1746.
- Rozga M, Handu D. Current Systems-Level Evidence on Nutrition Interventions to Prevent and Treat Cardiometabolic Risk in the Pediatric Population: An Evidence Analysis Center Scoping Review. J Acad Nutr Diet. 2021.
- Pollock M FR, Becker LA, Pieper D, Hartling L, . Chapter V: Overviews of Reviews. In: Higgins JPT TJ, Chandler J, Cumpston M, Li T, Page MJ, Welch VA (editors), ed. Cochrane Handbook for Systematic Reviews of Interventions version 6.2. Cochrane; 2021.
- Guyatt GH, Oxman AD, Vist GE, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. Bmj. 2008;336(7650):924-926.
- Handu D, Moloney L, Wolfram T, Ziegler P, Acosta A, Steiber A. Academy of Nutrition and Dietetics Methodology for Conducting Systematic Reviews for the Evidence Analysis Library. J Acad Nutr Diet. 2016;116(2):311-318.
- Ouzzani M, Hammady H, Fedorowicz Z, Elmagarmid A. Rayyan-a web and mobile app for systematic reviews. Syst Rev. 2016;5(1):210.
- Shea BJ, Reeves BC, Wells G, et al. AMSTAR 2: a critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both. Bmj. 2017;358:j4008.
- Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. Bmj. 2021;372:n71.
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