National Institute for Health and Care

Excellence
Final

Overweight and obesity

management: preventing,
assessing and managing
overweight and obesity
[D] Evidence reviews for identifying overweight
and obesity in children, young people and
adults
NICE guideline NG246
Evidence reviews underpinning recommendations 1.1.1 to
1.1.5, 1.8.1 to 1.8.3, 1.9.1 to 1.9.4, 1.10.1, 1.11.5 to 1.11.11
and research recommendations in the NICE guideline
January 2025
Final

These evidence reviews were developed

by NICE
FINAL
Error! No text of specified style in document.

Disclaimer

The recommendations in this guideline represent the view of NICE, arrived at after careful
consideration of the evidence available. When exercising their judgement, professionals are
expected to take this guideline fully into account, alongside the individual needs, preferences and
values of their patients or service users. The recommendations in this guideline are not mandatory
and the guideline does not override the responsibility of healthcare professionals to make decisions
appropriate to the circumstances of the individual patient, in consultation with the patient and/or
their carer or guardian.

Local commissioners and/or providers have a responsibility to enable the guideline to be applied
when individual health professionals and their patients or service users wish to use it. They should do
so in the context of local and national priorities for funding and developing services, and in light of
their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality
of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a
way that would be inconsistent with compliance with those duties.

NICE guidelines cover health and care in England. Decisions on how they apply in other UK countries
are made by ministers in the Welsh Government, Scottish Government, and Northern Ireland
Executive. All NICE guidance is subject to regular review and may be updated or withdrawn.

Copyright

© NICE 2025 All rights reserved. Subject to Notice of rights.

ISBN: 978-1-4731-6765-0
Contents
1 Identifying overweight and obesity in children, young people .................................................... 8
1.1 Review questions .................................................................................................................. 8
1.1.1 Introduction ................................................................................................................. 8
1.1.2 Summary of the protocol ............................................................................................. 8
1.1.3 Methods and process ................................................................................................. 10
1.1.4 Effectiveness and qualitative evidence ...................................................................... 10
1.1.5 Summary of studies included in the effectiveness and qualitative evidence ............ 12
1.1.6 Summary of the effectiveness and qualitative evidence ........................................... 17
1.1.7 Mixed methods integration ....................................................................................... 33
1.1.8 Economic evidence .................................................................................................... 34
1.1.9 Summary of included economic evidence ................................................................. 34
1.1.10 Economic model ....................................................................................................... 34
1.1.11 Unit costs.................................................................................................................. 34
1.1.12 The committee’s discussion and interpretation of the evidence ............................ 34
1.1.13 Recommendations supported by this evidence review ........................................... 42
1.1.14 References – included studies ................................................................................. 43
2 Identifying overweight and obesity in adults .............................................................................45
2.1 Review questions ................................................................................................................. 45
2.1.1 Introduction .............................................................................................................. 45
2.1.2 Summary of the protocol ....................................................................................... 45
2.1.3 Methods and process............................................................................................. 48
2.1.4 Effectiveness and Qualitative evidence .............................................................. 48
2.1.5 Summary of studies included in the effectiveness and qualitative evidence ............ 49
2.1.6 Summary of the effectiveness and qualitative evidence ........................................... 51
2.1.7 Mixed methods integration ....................................................................................... 63
2.1.8 Economic evidence .................................................................................................... 64
2.1.9 Summary of included economic evidence ................................................................. 64
2.1.10 Economic model ....................................................................................................... 64
2.1.11 Unit costs.................................................................................................................. 64
2.1.12 The committee’s discussion and interpretation of the evidence ............................ 64
2.1.13 Recommendations supported by this evidence review ........................................... 71
2.1.14 References – included studies ................................................................................. 71
Appendices .................................................................................................................................73
Appendix A – Review protocols .........................................................................................73
Appendix B - Literature search strategies ....................................................................88
Appendix C - Quantitative and qualitative evidence study selection...................... 133

4
Appendix D – Evidence tables ..................................................................................... 134
Quantitative evidence ................................................................................................................. 134
Children and young people ............................................................................................... 134
Adults 140
Qualitative evidence.................................................................................................................... 149
Children and young people ............................................................................................... 149
Adults 177
Appendix E – Forest plots ............................................................................................ 198
Children and young people ......................................................................................................... 198
Adults........................................................................................................................................... 205
Appendix F – GRADE and CERQual tables ................................................................ 206
GRADE tables ............................................................................................................................... 206
CERQual tables ............................................................................................................................ 213
Appendix G - Economic evidence study selection .................................................... 220
Appendix H – Economic evidence tables ................................................................... 221
Appendix I – Health economic model ........................................................................ 222
Appendix J – Excluded studies ................................................................................... 223
Appendix K – Research recommendations – full details .......................................... 234
Research recommendation 1 ...................................................................................................... 234
Why this is important ........................................................................................................ 234
Rationale for research recommendation .......................................................................... 234
Modified PICO table .......................................................................................................... 234
Research recommendation 2 ...................................................................................................... 236
Why this is important ........................................................................................................ 236
Rationale for research recommendation .......................................................................... 236
Modified PICO table .......................................................................................................... 236
Research recommendation 3 ...................................................................................................... 238
What is the effectiveness of children and young people using waist-to-height ratio to
measure their own central adiposity and what is the acceptability of this
approach among this population? ....................................................................... 238
Why this is important ........................................................................................................ 238
Rationale for research recommendation .......................................................................... 238
Modified PICO table .......................................................................................................... 238
Research recommendation 4 ...................................................................................................... 239
How do beliefs and attitudes about weight in families and carers affect identification,
uptake and adherence to overweight and obesity management interventions
in adults, children and young people? [2023]...................................................... 239
Why this is important ........................................................................................................ 239
Beliefs and attitudes about weight were highlighted in the qualitative evidence as
important influences on how families and carers felt about their child being

5
 identified as overweight or obese and referred to overweight and obesity
management services. This beliefs and attitudes stem from a range of
cultures and backgrounds, and understanding how they affect identification
and uptake of interventions is crucial to effective interventions for these......... 239
Rationale for research recommendation .......................................................................... 240
Importance to ‘patients’ or the population ...................................................................... 240
Beliefs and attitudes are important to the people who hold them and addressing
them appropriately shapes their experiences of healthcare. .............................. 240
Relevance to NICE guidance .............................................................................................. 240
This guideline aims to improve identification uptake and adherence to interventions,
so understanding the beliefs and attitudes that affect them is crucial to
addressing these potential barriers. .................................................................... 240
Relevance to the NHS........................................................................................................ 240
Increased uptake of overweight and obesity management interventions could
prevent children and young people from being exposed to the health risks of
weight related comorbidities ............................................................................... 240
National priorities ............................................................................................................. 240
High 240
Current evidence base ...................................................................................................... 240
Some qualitative evidence has identified that these beliefs and attitudes exist, but
there is little detail available at present. ............................................................. 240
Equality considerations ..................................................................................................... 240
Some beliefs and attitudes may stem from cultural ideas originating in communities
from minority family backgrounds, therefore it is important that these are
treated sensitively and respectfully. .................................................................... 240
Modified PICO table .......................................................................................................... 240
Population ......................................................................................................................... 240
• Children and young people living with overweight or obesity ............................ 240
Intervention ...................................................................................................................... 240
n/a 240
Comparator ....................................................................................................................... 240
n/a 240
Outcome 240
Beliefs and attitudes about weight in families and carers, including perspectives,
experiences, values, preferences, views and considerations .............................. 240
Study design ...................................................................................................................... 240
Qualitative ......................................................................................................................... 240
Timeframe ......................................................................................................................... 240
Any 240
Additional information ...................................................................................................... 240
None 240

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1 Identifying overweight and obesity in

children, young people
1.1 Review questions
What approaches are effective and cost-effective in identifying overweight and obesity in
children and young people, particularly those in black, Asian and minority ethnic groups?
What are the barriers and facilitators to identifying overweight and obesity in children and
young people, particularly those in black, Asian and minority ethnic groups?

1.1.1 Introduction
Overweight, obesity and central adiposity is a risk factor for development of CVD, type 2
diabetes, hypertension, dyslipidaemia or some type of cancer in children and young people.
Currently, people who are overweight, or living with obesity are identified through the
healthcare system opportunistically. NICE 2014 guidance on obesity identification,
assessment, and management (CG189) recommends using clinical judgement to decide
when to measure a person’s height and weight. Opportunities include registration with a
general practice, consultation for related conditions (such as type 2 diabetes and
cardiovascular disease) and other routine health checks.

During the surveillance process, topic experts highlighted that relying on opportunistic
identification, rather than active case finding, increases the likelihood that conditions such as
type 2 diabetes will be under-diagnosed in black, Asian and other minority groups whose risk
of these conditions is increased at a lower BMI than the general population. Topic expert
feedback also indicated that a proactive approach of informing people of their BMI is needed.
The experts also advised that instructions to clinicians, especially GPs, to measure BMI
should be firmer to further support NICE quality standard QS127.

Based on this, review questions were drafted to explore the effectiveness, barriers, and
facilitators of identification of overweight and obesity in children and young adults.

The review exploring the effectiveness, barriers, and facilitators of identification of overweight
and obesity in adults is in section 2.

1.1.2 Summary of the protocol

Table 1 summarises the protocol for the review of effective and cost-effective interventions.
Table 2 summarises the qualitative evidence synthesis for barriers and facilitators of
identification.

Table 1: PICO table effectiveness of approaches in identifying overweight and obesity

in children and young people
Population
• Children and young people aged under 18 years
Where possible, evidence will be stratified by ethnicity:
o White
o Black African/ Caribbean
o Asian (South Asian, Chinese, any other Asian background)
o Other ethnic groups (Arab, any other ethnic group)

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o Multiple/mixed ethnic group

• Parents and carers
• Staff undertaking identification of children and young people with
overweight or obesity and engaging them in weight management services.
Intervention
• Opportunistic identification, including but not confined to:
o When registering with GP
o When receiving consultation for health conditions (e.g., chronic
health conditions)
o During routine check-up/ annual check-up (delivered by GPs,
nurses or pharmacists, social care staff)
o During medication check (e.g., contraception pill check)
o During vaccination appointments
o Visits to secondary care (e.g., outpatient clinics and emergency
departments or physiotherapist appointments)
• Active case finding (defined as searching systematically for at risk people,
rather than waiting for them to present with symptoms or signs of active
disease). This includes but is not confined to:
o Review of medical records
o Receiving or received interventions for example brief physical
activity advice (delivered by GPs, nurses, pharmacists, activity
providers)
o audits of other services (e.g. disability services or endocrinology
services)
• Self-identification or referral
• Parent/ carer-initiated identification or referral
• School nurse/ teacher / health visitor / social services-initiated identification
or referrals
Comparator • No intervention/usual care
• Comparison of interventions
Outcomes Primary outcomes
• Number of children and young people identified as overweight or
obese
• Referral to weight management service
• Health-related quality of life
Secondary outcomes
• Adverse events:
o Eating disorders or disordered eating
o Stigma (including self-stigma and negative body image as
defined in studies)
Study type Quantitative review
• Systematic reviews of included study designs
• RCTs
• Observational studies (cohort studies)
• Mixed methods studies (quantitative evidence that matches the
above study designs only)

Table 2: SPIDER table for barriers and facilitators for identifying overweight and
obesity in children and young people
Sample • Children and young people aged under 18 years
Where possible, evidence will be stratified by ethnicity:
o White
o Black African/ Caribbean
o Asian (South Asian, Chinese, any other Asian background)
o Other ethnic groups (Arab, any other ethnic group)

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o Multiple/mixed ethnic group

• Parents and carers
• Staff undertaking identification of children and young people with overweight
or obesity and engaging them in weight management services.
Phenomenon of
interest Barriers and facilitators to the identification and engagement of overweight and
obese children and young people. These may include:
• Thoughts, views and perceptions of individuals, parents or carers
• Thoughts, views and perceptions of staff undertaking identification of
children and young people who are living with overweight and
obesity
• Issues relating to education
• Issues relating to stigma
• Issues relating to self-esteem
• Issues relating to cultural sensitivities
Design • Systematic reviews of included study designs
• Qualitative studies that collect data from focus groups and
interviews.
• Qualitative studies that collect data from open-ended questions from
questionnaires
• Mixed method study designs (qualitative evidence that matches the
above study designs only)
Evaluation Thematic synthesis

Research type Qualitative and qualitative elements of mixed methods studies

1.1.3 Methods and process

This evidence review was developed using the methods and process described in
Developing NICE guidelines: the manual. This is described further in the methods chapter.
Methods specific to this review question are described in the review protocol in appendix A.
Declarations of interest were recorded according to NICE’s conflicts of interest policy.

1.1.4 Effectiveness and qualitative evidence

1.1.4.1 Included studies

A combined search was conducted for review questions on identification and uptake in
children, young people and adults. Results were uploaded into EPPI Reviewer version 5 and
deduplicated before title and abstract screening. A total of 19,477 studies were identified in
the search which explored both quantitative and qualitative evidence. The search was re-run
in May 2023 to find newly published references prior to consultation and identified a further
1,630 studies.

Quantitative evidence
Following title and abstract screening 55 studies were identified as being potentially relevant
in children and young people. These studies were reviewed against the inclusion criteria as
described in review protocol (Appendix A). Overall, 3 studies were included; 1 RCT, 1 cluster
RCT, and 1 cluster controlled trial. These studies covered the child measurement programs
in schools as the basis for identification.

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Qualitative evidence
Following title and abstract screening 69 studies were identified as being potentially relevant.
These studies were reviewed against the inclusion criteria as described in review protocol
(Appendix A). Overall, 13 studies were included which used interviews and focus groups.
These studies covered the following groups:

• 5 studies from the UK which focused on the national child measurement programme
• 8 from other countries which covered identification in other settings
Two of these qualitative studies were added following an updated search in May 2023. One
UK study and one non-UK study.
See appendix E for evidence tables and the reference list in section 1.1.14. For information
on included studies in adult population see section 2.1.4.

1.1.4.2 Excluded studies

See appendix K for the list of studies excluded at the full text stage with reasons for their
exclusion.

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1.1.5 Summary of studies included in the effectiveness and qualitative evidence

1.1.5.1 Quantitative Evidence

Table 3: Quantitative evidence included in the review of effectiveness of approaches in identifying overweight and obesity in children
and young people
Study
and Population and number
Country Setting Intervention(s) Comparator Follow-up Outcomes
study of participants
design
Bailey- Pennsylvani Convenience Children 5-10 years old Advanced active case Active case finding Surveys • Referral to weight
Davis a, USA sample of (USA school grades 1, 3, finding: SBMIS+ alone: SBMIS sent 4-6 management service
2017 schools and 5) (n=738) (n=731) weeks after
the parents
Cluster- received the
n= 1,469 SBMIS+ reports SBMIS, for the purpose of
controlle SBMIS or
enhanced with education providing parents with
d trial SBMIS+
that included an online annual assessments of
utilising reports
link for parents to self- their child’s weight status
a assess and learn about with an explanation of the
random strategies to reduce the results, recommended
subsam risk of childhood obesity follow-up actions, and
ple of education on healthy
parents eating and active living.
Chomitz Cambridge, 4 elementary Children 5-14 years old Advanced active case Usual care (n=464) Phone call • Number of children
2003 USA schools finding: PI (n=481) within 6 and young people
n= 1,396 Usual care group did not weeks of identified as
RCT Active case finding receive a report card until receiving overweight
alone: GI (n=451) after outcomes were the report • Referral to weight
assessed card management service
For PI and GI groups:
• Tips for healthy living
via reduced
television/video

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Study
and Population and number
Country Setting Intervention(s) Comparator Follow-up Outcomes
study of participants
design
screen time, 1 hour of
physical activity, and
5 servings of fruits
and vegetables.
• Directory of physical
activity options
available to families
in the locality.

The PI group also

received the personalized
health report card of the
children's height, weight,
and weight status, fitness
test results, and
interpretive information.
The materials referred
parents with children
outside the healthy
weight range to follow up
with their primary health
care
Madsen USA 79 schools in Children 8-13 years old Advanced active case Usual care (n=8159) 2 year • Adverse events:
2021 California, (USA school grades 3, 5, finding: screening and study. o Peer teasing
USA and 7) reporting (n=10,041) No BMI screening follow-up o Peer weight
Cluster surveys talk
randomi N= 28,641 Active case finding– were sent 6
to 9 months o Teacher
sed screening only: weight talk
controlle (n=10,441) after BMI
assessment o Family
d trial weight
s (and 1-2
School staff assessed months teasing
BMI each spring among after BMI
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Study
and Population and number
Country Setting Intervention(s) Comparator Follow-up Outcomes
study of participants
design
students in both reports o Family
intervention groups. were sent) encourages
dieting
Parents of students in the o Family
active case finding + weight talk
group were sent a BMI
report each in Autumn
during the 2 year study
SBMIS – School-based body mass index screenings
PI – Personal information intervention
GI – General information intervention

1.1.5.2 Qualitative Evidence

Table 4: Qualitative evidence included in the review of effectiveness of approaches in identifying overweight and obesity in children and
young people
Population and
Study Design and analysis Country Setting sample size Objective
UK studies

Dam (2019) Focus groups using Ellis and UK Schools 18 To investigate how effectively CHAMP (Children's Health and
Hogard’s three-pronged parents/guardians; Monitoring Programme) engaged parents and supported
“trident” model. 11 healthcare/school reductions in childhood obesity, with a view to building an
staff evidence base for parent-only, online feedback interventions
Gainsbury Focus groups and Semi- UK Schools 18 To develop a descriptive account of parents’ experiences of
(2018) structured interviews using a parents/guardians written feedback from the National Child Measurement
critical realist perspective Programme (NCMP), based on primary data collected from
semi-structured focus groups.

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Population and
Study Design and analysis Country Setting sample size Objective
Syrad (2015) Semi-structured interviews UK Schools 52 To explore parental perceptions of overweight children and
using theory of planned parents/guardians associated health risks after receiving National Child
behaviour Measurement Programme (NCMP) weight feedback
Turner (2016) Focus Groups, UK Schools 26 healthcare/school To explore the practice of school health professionals in
Semi-structured interviews, staff addressing childhood obesity at school entry, with a view to
and open ended explaining potential reasons for low referral rates and
questionnaires with no understanding how the role of school health professionals
specified analysis framework can be optimised to address childhood obesity at an early
age.
Coupe 2022 Semi-structured interviews UK Primary schools 23 primary school To understand the utility of child weight related conversations
with no specified analysis teachers with parents through exploring educators’ experiences and
framework perspectives
International studies

Avis (2016) Semi-structured interviews Canada Primary Care 19 healthcare To pilot-test a mixed methods approach to evaluate tools and
with no specified analysis professionals resources (TRs) that healthcare providers (HCPs) use for
framework preventing childhood obesity in primary care, and report a
preliminary descriptive assessment of commonly-used TRs
Hardy (2019) Interviews with no specified Australia Primary care 10 To explore parents’ experiences when discussing child over
analysis framework parents/guardians weight issues with the Maternal and Child Health nurse
Jachyra Interviews using an Canada Children’s 8 children; 8 to examine the perspectives and experiences of children with
(2018) interpretive phenomenological rehabilitation parents/guardians; 5 ASD, their care givers, and HCPs around discussing weight-
analysis (IPA) approach hospital healthcare related topics in healthcare consultations
professionals
Jones (2014) Semi-structured interviews Australia Primary care 10 GPs; 12 families To explore perceptions and experiences of treating childhood
with no specified analysis (5 with children obesity of (i) GPs, (ii) families involved in a childhood obesity
framework present) study in general practice’ and (iii) families not involved in the
project, but who had concerns about childhood obesity.
McPherson Interviews using a relativist Canada Paediatric 18 children; 21 To present the findings of a recent scoping review to children
(2018) ontologic approach hospitals parents/guardians with and without disabilities and their caregivers for their
reactions; and to explore the experiences and perceptions of
the children and their caregivers regarding weight‐related
communication best practices

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Population and
Study Design and analysis Country Setting sample size Objective
Sjunnestrand Interviews using a realist Sweden Child health care 17 nurses To explore CHC (child health care) nurses’ perceptions of
(2019) approach centres speaking to parents about children’s overweight/obesity and
of their role in referring children to treatment for overweight/
obesity
Toftemo Interviews with no specified Norway Well child clinics 11 To explore parents’ views and experiences when health
(2013) analysis framework parents/guardians professionals identify their preschool child as overweight.
Eli 2022 Semi-structured interviews Sweden Primary care 17 parents To shed light on the experiences of parents of preschoolers
using a realist approach with overweight or obesity, following conversations about
their child’s weight with a CHC (child health care) nurse

See appendix E for full evidence tables.

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1.1.6 Summary of the effectiveness and qualitative evidence

1.1.6.1 Quantitative Evidence

Table 5: Advanced active case finding (report card with personal information intervention) versus active case finding (report card with
general information intervention)

No. of studies Sample size Effect estimate (95% CI) Quality Interpretation of effect
Number of children and young people identified as overweight or obese (follow-up 0-6 weeks; assessed with: Parents correctly identifying
their children's weight status)
1 (Chomitz 2003) 1,396 RR 1.08 (0.72 to 1.62) Very low Evidence could not differentiate
between arms
Referral to weight management service (follow-up 0-6 weeks; assessed with: Parents seek medical service for overweight children)
1 (Chomitz 2003) 1,396 RR 3.64 (1.39 to 9.5) Very low Favours advanced active case
finding

Table 6: Advanced active case finding (report card with personal information intervention) versus usual care (no report card)

No. of studies Sample size Effect estimate (95% CI) Quality Interpretation of effect
Number of children and young people identified as overweight or obese (follow-up 0-6 weeks; assessed with: Parents correctly identifying
their children's weight status)
1 (Chomitz 2003) 1,396 RR 1.95 (1.16 to 3.28) Very low Favours advanced active case
finding
Referral to weight management service (follow-up 0-6 weeks; assessed with: Parents seek medical service for overweight children)
1 (Chomitz 2003) 1,396 RR 2.91 (1.19 to 7.08) Very low Favours advanced active case
finding

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Table 7: Active case finding (report card with general information intervention) versus usual care (no report card)

No. of studies Sample size Effect estimate (95% CI) Quality Interpretation of effect
Number of children and young people identified as overweight or obese (follow-up 0-6 weeks; assessed with: Parents correctly identifying
their children's weight status)
1 (Chomitz 2003) 1,396 RR 1.8 (1.08 to 3) Very low Favours active case finding
Referral to weight management service (follow-up 0-6 weeks; assessed with: Parents seek medical service for overweight children)
1 (Chomitz 2003) 1,396 RR 0.8 (0.26 to 2.5) Very low Evidence could not differentiate
between arms

Table 8: All Active case finding (screening with parent report and no parent report) versus usual care (no screening)

No. of studies Sample size Effect estimate (95% CI) Quality Interpretation of effect
Adverse events: peer teasing (follow-up 1 years; measured with: Peer weight teasing index. 1-5 “never” to “almost every day”; range of
scores: 1-5; Better indicated by lower values)
1 (Madsen 2021) 28,641 (79 MD 0.01 higher (0.02 lower to 0.04 Low Evidence could not differentiate
schools) higher) between arms
Adverse events: peer teasing (follow-up 2 years; measured with: Peer weight teasing index. 1-5 “never” to “almost every day”; range of
scores: 1-5; Better indicated by lower values)
1 (Madsen 2021) 28,641 (79 MD 0.02 lower (0.07 lower to 0.03 Low Evidence could not differentiate
schools) higher) between arms
Adverse events: peer talk (follow-up 1 years; measured with: Peer weight talk index. 1-5 “never” to “almost every day”; range of scores: 1-5;
Better indicated by lower values)
1 (Madsen 2021) 28,641 (79 MD 0.05 higher (0.01 to 0.09 Low Favours no screening
schools) higher)
Adverse events: peer talk (follow-up 2 years; measured with: Peer weight talk index. 1-5 “never” to “almost every day”; range of scores: 1-5;
Better indicated by lower values)
1 (Madsen 2021) 28,641 (79 MD 0.00 (0.07 lower to 0.07 higher) Low Evidence could not differentiate
schools) between arms

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No. of studies Sample size Effect estimate (95% CI) Quality Interpretation of effect
Adverse events: teacher weight talk (follow-up 1 years; measured with: "Teachers talk about my weight or size": 1-5 Never to almost every
day; range of scores: 1-5; Better indicated by lower values)
1 (Madsen 2021) 28,641 (79 MD 0.01 lower (0.03 lower to 0.01 Low Evidence could not differentiate
schools) higher) between arms
Adverse events: teacher weight talk (follow-up 2 years; measured with: "Teachers talk about my weight or size": 1-5 Never to almost every
day; range of scores: 1-5; Better indicated by lower values)
1 (Madsen 2021) 28,641 (79 MD 0.00 lower (0.04 lower to 0.04 Low Evidence could not differentiate
schools) higher) between arms

Table 9: Advanced active case finding (screening with parent report) versus active case finding (screening with no parent report) or
usual care (no screening)

No. of studies Sample size Effect estimate (95% CI) Quality Interpretation of effect
Adverse events: family weight teasing (follow-up 1 years; measured with: My family teases or makes fun of me because of my weight. 1-5
Never to almost every day; range of scores: 1-5; Better indicated by lower values)
1 (Madsen 2021) 28,641 (79 MD 0.01 lower (0.04 lower to 0.02 Low Evidence could not differentiate
schools) higher) between arms
Adverse events: family weight teasing (follow-up 2 years; measured with: My family teases or makes fun of me because of my weight. 1-5
Never to almost every day; range of scores: 1-5; Better indicated by lower values)
1 (Madsen 2021) 28,641 (79 MD 0.01 lower (0.06 lower to 0.04 Low Evidence could not differentiate
schools) higher) between arms
Adverse event: family encourages dieting in children who consider themselves as underweight (follow-up 1 years; measured with: Family
encourages dieting. 1 to 4 Not at all to very much; range of scores: 1-4; Better indicated by lower values)
1 (Madsen 2021) 28,641 (79 MD 0.03 higher (0.07 lower to 0.13 Very low Evidence could not differentiate
schools) higher) between arms
Adverse event: family encourages dieting in children who consider themselves as underweight (follow-up 2 years; measured with: Family
encourages dieting. 1 to 4 Not at all to very much; range of scores: 1-4; Better indicated by lower values)
1 (Madsen 2021) 28,641 (79 MD 0.01 higher (0.15 lower to 0.17 Very low Evidence could not differentiate
schools) higher) between arms

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No. of studies Sample size Effect estimate (95% CI) Quality Interpretation of effect
Adverse event: family encourages dieting in children who consider themselves as about the right weight (follow-up 1 years; measured with:
Family encourages dieting. 1 to 4 Not at all to very much; range of scores: 1-4; Better indicated by lower values)
1 (Madsen 2021) 28,641 (79 MD 0.05 lower (0.12 lower to 0.02 Very low Evidence could not differentiate
schools) higher) between arms
Adverse event: family encourages dieting in children who consider themselves as about the right weight (follow-up 2 years; measured with:
Family encourages dieting. 1 to 4 Not at all to very much; range of scores: 1-4; Better indicated by lower values)
1 (Madsen 2021) 28,641 (79 MD 0.07 higher (0.03 lower to 0.17 Very low Evidence could not differentiate
schools) higher) between arms
Adverse event: family encourages dieting in children who consider themselves as somewhat overweight (follow-up 1 years; measured with:
Family encourages dieting. 1 to 4 Not at all to very much; range of scores: 1-4; Better indicated by lower values)
1 (Madsen 2021) 28,641 (79 MD 0.03 higher (0.08 lower to 0.14 Very low Evidence could not differentiate
schools) higher) between arms
Adverse event: family encourages dieting in children who consider themselves as somewhat overweight (follow-up 2 years; measured with:
Family encourages dieting. 1 to 4 Not at all to very much; range of scores: 1-4; Better indicated by lower values)
1 (Madsen 2021) 28,641 (79 MD 0.11 lower (0.28 lower to 0.06 Very low Evidence could not differentiate
schools) higher) between arms
Adverse event: family encourages dieting in children who consider themselves very overweight (follow-up 1 years; measured with: Family
encourages dieting. 1 to 4 Not at all to very much; range of scores: 1-4; Better indicated by lower values)
1 (Madsen 2021) 28,641 (79 MD 0.14 higher (0.08 lower to 0.36 Very low Evidence could not differentiate
schools) higher) between arms
Adverse event: family encourages dieting in children who consider themselves very overweight (follow-up 2 years; measured with: Family
encourages dieting. 1 to 4 Not at all to very much; range of scores: 1-4; Better indicated by lower values)
1 (Madsen 2021) 28,641 (79 MD 0.44 higher (0.66 to 0.82 Low Favours no reporting
schools) higher)
Adverse event: family weight talk in children who consider themselves as underweight (follow-up 1 years; measured with: Family weight-talk
index. 1 to 5 Not at all to very much; range of scores: 1-4; Better indicated by lower values)
1 (Madsen 2021) 28,641 (79 MD 0.07 higher (0.01 to 0.13 Low Favours no reporting
schools) higher)
Adverse event: family weight talk in children who consider themselves as underweight (follow-up 2 years; measured with: Family weight-talk
index. 1 to 5 Not at all to very much; range of scores: 1-4; Better indicated by lower values)

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No. of studies Sample size Effect estimate (95% CI) Quality Interpretation of effect
1 (Madsen 2021) 28,641 (79 MD 0.05 higher (0.05 lower to 0.15 Very low Evidence could not differentiate
schools) higher) between arms
Adverse event: family weight talk in children who consider themselves as about the right weight (follow-up 1 years; measured with: Family
weight-talk index. 1 to 5 Not at all to very much; range of scores: 1-4; Better indicated by lower values)
1 (Madsen 2021) 28,641 (79 MD 0.01 lower (0.06 lower to 0.04 Very low Evidence could not differentiate
schools) higher) between arms
Adverse event: family weight talk in children who consider themselves as about the right weight (follow-up 2 years; measured with: Family
weight-talk index. 1 to 5 Not at all to very much; range of scores: 1-4; Better indicated by lower values)
1 (Madsen 2021) 28,641 (79 MD 0.02 lower (0.09 lower to 0.05 Very low Evidence could not differentiate
schools) higher) between arms
Adverse event: family weight talk in children who consider themselves as somewhat overweight (follow-up 1 years; measured with: Family
weight-talk index. 1 to 5 Not at all to very much; range of scores: 1-4; Better indicated by lower values)
1 (Madsen 2021) 28,641 (79 MD 0.04 lower (0.11 lower to 0.03 Very low Evidence could not differentiate
schools) higher) between arms
Adverse event: family weight talk in children who consider themselves as somewhat overweight (follow-up 2 years; measured with: Family
weight-talk index. 1 to 5 Not at all to very much; range of scores: 1-4; Better indicated by lower values)
1 (Madsen 2021) 28,641 (79 MD 0.06 higher (0.05 lower to 0.17 Very low Evidence could not differentiate
schools) higher) between arms
Adverse event: family weight talk in children who consider themselves as very overweight (follow-up 1 years; measured with: Family weight-
talk index. 1 to 5 Not at all to very much; range of scores: 1-4; Better indicated by lower values)
1 (Madsen 2021) 28,641 (79 MD 0.13 higher (0.01 to 0.25 Low Favours no reporting
schools) higher)
Adverse event: family weight talk in children who consider themselves as very overweight (follow-up 2 years; measured with: Family weight-
talk index. 1 to 5 Not at all to very much; range of scores: 1-4; Better indicated by lower values)
1 (Madsen 2021) 28,641 (79 MD 0.24 lower (0.47 to 0.01 lower) Low Favours reporting
schools)

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Table 10: Advanced active case finding (report enhanced with education) versus active case finding alone (report alone)

No. of studies Sample size Effect estimate (95% CI) Quality Interpretation of effect
Referral to weight management service (follow-up 0-8 weeks; assessed with: "Report prompted you to visit a healthcare provider or registered
dietitian about your child’s weight status")
1 (Bailey- Davies 2017) 1469 (31 0R: 0.8 (95%CI not reported) Very low Evidence could not differentiate
schools) between arms*
*Based on p-value reported in paper (p value= 0.16)

See appendix G for full GRADE tables.

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1.1.6.2 Qualitative Evidence

Table 11: Summary of the barriers and facilitators to identification in children and young people
International CERQual
Finding UK Studies studies Illustrative quotes explanation Confidence
Barriers in the UK NCMP
Parents were offended by the Dam 2019 Hardy 2019 “As a parent, if there’s something that you feel International UK group:
identification Gainsbury Jachyra 2018 like that you are not doing, if your child is not group was High
In the UK and internationally: 2018 Jones 2014 where they should be, it can give you feelings downgraded
Coupe 202 McPherson that you are failing as a parent” once for minor
• Many were angry or upset to International
2018 UK Parent concerns about
receive feedback group:
Sjunnestrand methodological
• They felt like they were being Moderate
2019 limitations and
judged and assumptions were Toftemo 2013 “How dare somebody tell me that my child is
relevance.
being made about their overweight”
parenting. UK Parent
• They objected to terminology
such as ‘obese’ and ‘overweight’. “I've been to some [HCPs] where they're just,
• There was concern about really almost nasty … very judgmental and …
stigmatising the child by labelling they just make you feel worse than you
them as overweight. already feel … you shouldn't have to be
• They felt their children were treated in that way”
happy as they were and should International parent
not be burdened with this
concern until they’ve grown.

In the UK only:
• They felt that people who did not
know their child had no right to
comment
Parents ignored the identification Gainsbury Hardy 2019 “after talking to other parents whose children International UK group:
In the UK only: 2018 Jones 2014 were also obese or whatever, you sort of group was High
Syrad 2015 realise that it wasn’t something that we could downgraded 3
• They saw it as irrelevant Turner
information times for minor

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International CERQual
Finding UK Studies studies Illustrative quotes explanation Confidence
• They discussed it with other 2016 take seriously … I didn’t follow it up in any concerns about International
parents and the consensus was way I just sort of let it go.’” methodological group: Very
to ignore it UK Parent limitations and low
• Some parents had other priorities relevance, and
so were not interested in their for serious
“It’s being targeted at parents who isn’t giving
child’s weight concerns about
them fruit and veg and just doing the cheap
coherence and
• Many parents felt it was intended rubbishy food… For the ones of us who are
adequacy
for other parents, whom they doing it [right] then you just ignore it and think
judged as having unhealthy whatever, I know I’m doing right.”
lifestyles that required UK Parent
intervention.
Parents disagreed with the Dam 2019 Hardy 2019 “I look at him and I see puppy fat, I don’t see International UK group:
identification Gainsbury Sjunnestrand overweight fat, I think they’re two different group was High
In the UK and internationally: 2018 2019 things” downgraded
Syrad 2015 Toftemo 2013 UK Parent once for minor
• They did not think their child was International
Turner Eli 2022 concerns about
overweight group:
2016 methodological
• They discussed with friends and “I can’t think why they would even say that Moderate
limitations,
family who agreed and reinforced he’s overweight or obese and needs to go on
relevance and
that the child was not overweight. a healthy eating class, that’s disgusting”
adequacy
• They believed their child’s weight UK Mother-in-law of parent
was normal for a growing child
pre-puberty “Her “puppy‐fat” will disappear as she gets
older”
In the UK only: International parent
• They provided alternative
explanations for their size, such
as ‘solid’ or ‘tall’
• Many disagreed with how they
were measured. They felt that
BMI was not appropriate.

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International CERQual
Finding UK Studies studies Illustrative quotes explanation Confidence
Parents agreed with the Dam 2019 Hardy 2019 “‘If she’s not active I would be worried but International UK group:
identification, but felt that Syrad 2015 Jones 2014 she’s active, she runs, she do all of them group was High
overweight is not a problem Coupe Toftemo 2013 things so I’m not worried about her health” downgraded 3
In the UK and internationally: 2022 Eli 2022 UK Parent times for minor International
• They valued ‘health and concerns about group: Very
happiness’ over weight methodological low
“I don't even make spaghetti sauce from
limitations,
• Some children had health scratch anymore due to being time poor”
relevance and
conditions or other International parent coherence, and
circumstances that prevented for moderate
them from losing weight "Some of our cultures of children that we are concerns about
• Some cultures favour a larger working with, it is a sign of wealth if you are adequacy
body type for children overweight …so there’s also that cultural
• Some were more concerned element that we’re pushing against”
about eating disorders and UK teacher
stigma that could result from
addressing weight than about
“You don’t want him to get eating disorders
weight itself
either. How can you help him with this without
it going the other way, so to speak”
In the UK only: International parent
• Their child was happy with their
body and not being bullied, so
there’s no need to do anything
• Their child was fit and physically
active, so weight didn’t impact
their health

Staff describe practical limitations on Dam 2019 Sjunnestrand “there’s no way we can deliver this [weight UK group was UK group:
what they can do Turner 2019 management] at the moment – [we’re busy downgraded Moderate
In the UK and internationally: 2016 Jones 2014 with] immunisations, your safeguarding, your once for minor
Coupe Hardy 2019 general public health” concerns about
• They felt unable to offer much International
2022 UK School nurse adequacy and
support to families who were group: Very
identified. coherence low

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International CERQual
Finding UK Studies studies Illustrative quotes explanation Confidence
• They felt that parents were not “if the child is sitting there and you say to the International
open to engaging with them child…what did you have for your tea last group was
about children’s weight night, and they will confess all sorts” downgraded 3
UK School nurse times for minor
In the UK only: concerns about
methodological
• They often had too many “specialists may feel the matter is too trivial
limitations,
competing priorities. for paediatric review”
relevance, and
• They felt that they lacked the International HCP adequacy, and
skills, knowledge, and training to for moderate
deal with weight. concerns about
• They were concerned that coherence
parents were working against the
school’s health policies by
providing unhealthy packed
lunches or not providing PE kits.

International barriers and facilitators

HCPs provided context for normal Avis 2016 “We reward and praise [the parents] when Downgraded Moderate
weight and growth Hardy 2019 [the children] gain weight and then all of a once for minor
Parents were not sure what a ‘normal’ Jones 2014 sudden we say the child has gained too much concerns about
weight should be for their child’s age and Sjunnestrand weight and it’s difficult for the parents to keep methodological
circumstances. They considered gaining 2019 up.” limitations and
weight to be a natural part of growing, so Toftemo 2013 International nurse relevance
found it difficult to assess if there was a
problem: Parents wanted the GPs expert
judgement on whether to be concerned “‘since my daughter was 18 months old she
and what action to take. has always been around 10 per cent above
the healthy weight limit for her age. When she
was four and a half, the doctor said to
maintain her weight”
International parent

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International CERQual
Finding UK Studies studies Illustrative quotes explanation Confidence

“It’s great to have formal guidelines just to

know that you’re doing what is recommended,
just that reassurance . . . and then also if a
parent decides, you know that doesn’t seem
reasonable at all, then I can pull it up and say
well this is what it is, right?”
International HCP

HCPs were able to discuss and Avis 2016 “there are many situations … that can arise No downgrading High
explain weight issues Hardy 2019 where one needs to be uncomfortable or bring required
Many parents needed information and a Jachyra 2018 up something that perhaps the parents don’t
chance to ask questions about weight. Jones 2014 agree with. My role is to stand up for the child
HCPs provided this and selected the right McPherson if I see a difficulty or so”
resources and referrals. Parents saw 2018 International GP
HCPs as credible and trustworthy Sjunnestrand
sources of information 2019
Toftemo 2013 “in general GPs reinforce the basics, diet
Eli 2022 exercise because GPs are a natural source of
HCPs considered it was their role to information”
identify overweight. They felt they had a International parent
responsibility of discuss weight with
reluctant parents as a way of advocating
for the child.
Collaboration with other professionals Hardy 2019 “I just think that if you hear it more than one Downgraded Moderate
facilitated engagement Jones 2014 time, or like from different doctors, it might once for minor
HCPs felt that their role in identifying McPherson help you … so I think if multiple people are concerns about
overweight was part of a collaboration 2018 telling you that it is a problem … you can fix it, methodological
and was most effective when they had Sjunnestrand then that's better” limitations,
support from specialists and other staff. 2019 International Child relevance and
coherence
Many children received general healthy “‘ancillary staff [in the practice] helping,
lifestyle advice at school, and felt that this perhaps a dietitian could have helped”

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International CERQual
Finding UK Studies studies Illustrative quotes explanation Confidence
was complemented by specific and International parent
personal advice from a HCP.
A trusting relationship between HCP Avis 2016 “There's a stigma that comes with it [obesity] No downgrading High
and families was important Hardy 2019 … but address it as any other condition that required
HCPs described their efforts to build and Jachyra 2018 you have and not
maintain trust which enabled them Jones 2014 treating it, like, “oh you have a weight
present identification of overweight as McPherson problem,” but “you have a weight problem and
genuine concern rather than judgement. 2018 this is what we can do about it.”
Parents were more open to engaging Sjunnestrand
International child
with weight management with a known 2019
and trusted HCP. Toftemo 2013
Eli 2022 “He really cares about our child, so it’s a good
thing”
Parents preferred having their child’s International parent
weight monitored over a period of time by
the same HCP, rather than being
identified as an issue in a single instance.

Both HCPs and families expressed that it

is better to consider weight management
as something to work on as together
rather than a problem presented to the
family.
HCPs tailored conversations to the Avis 2016 “the doctor sits, takes time, sees the real No downgrading High
patients Hardy 2019 problem that maybe it is not food but required
Parents appreciated a holistic Jachyra 2018 something else’”
assessment of their child’s health with Jones 2014 International parent
weight as a component within a context McPherson
of other issues. 2018
Sjunnestrand “We have very different genes for this
2019 [overweight]… I don’t know much about that
HCPs described how they personalised Eli 2022 but it’s obvious… It’s much more difficult for
their consultations by adapting to parents some families than others”
priorities and concerns, even if that International nurse
meant avoid the issue until a better time.

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International CERQual
Finding UK Studies studies Illustrative quotes explanation Confidence

HCPs and parents emphasised the

importance of choice in whether to
discuss weight. Some did not want their
child to be weighed or to be involved in
the conversation.

Barriers and facilitators for specific groups

Younger age groups Jones 2014 “It’s good to have grandparents close by, but Downgraded Low
• Parents preferred earlier McPherson my child knows that if she goes there, she’ll twice for minor
identification to prevent problems 2018 have anything she asks for… because concerns about
as the child grows up Toftemo 2013 grandparents somehow have a right to spoil and relevance
them, especially with sweets. It’s an and coherence,
• Parents did not want their child to
everlasting job when we try to restrict this” and moderate
be involved conversations about
International parent concerns about
weight, so felt this was easier
methodological
when children were younger and
limitations
understood less. “[Best] not to wait until they're 18 because
• Grandparents and other their habits are already established”
caregivers did not take weight International parent
seriously in young children,
which made it harder to control
Disability and complex health issues Jachyra 2018 “People look at [Child] and assume she’s lazy. Downgraded Moderate
• Some HCPs were reluctant to McPherson They look at me and assume I am a bad once for minor
add weight concerns to the 2018 parent… But they don’t see that I am concerns about
medical burden of a child with constantly trying to do everything I can to help methodological
complex health needs her… It’s not like I am ignoring medical advice limitations,
on purpose” relevance and
• Some parents felt that their ability
International parent adequacy
to manage their child’s disability
was being judged in addition to
their parenting skills “The doctor now is much better because they
treat me like a friend and helps me feel good
• There were often many about my weight because he really
caregivers and HCPs involved in understands me, my challenges and my
managing the child’s health, who complicated life”
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International CERQual
Finding UK Studies studies Illustrative quotes explanation Confidence
all needed to be engaged with International young person
weight management via a holistic
‘therapeutic partnership’
• Specialist HCPs in hospitals
were often not equipped to deal
with general health issues such
as weight
Autism Jachyra 2018 “Even though I don’t like talking about my Downgraded Moderate
• HCPs adapted the way they McPherson weight, at least if I know it’s coming, I can once for minor
communicated weight 2018 prepare for it. There is nothing worse than concerns about
identification, using clear learning something new about your body and methodological
concrete terms. not expecting it” limitations,
International young person relevance and
• HCPs often used visual aids
adequacy
which young people found
patronising “I have one family where the child just seems
• Medication caused weight gain to be exquisitely sensitive to the weight
and made it difficult to control effects. We’ve tried taking him off the
weight. This trade off between medication and it doesn’t seem to work. They
harms and benefits posed a can’t access appropriate behavioral resources
difficult dilemma for parents and and so we’re sort of stuck between a rock and
HCPs a hard place on how to manage his behavior
• Many young people were right now. This child has probably gained 50
uncomfortable with having their pounds on this med, and he’s very young. His
weight discussed; it provoked cholesterol is now abnormal. So it’s tough.”
anxiety. Some preferred to International Paediatrician
discuss it gradually to get used to
the idea.
• Parents were concerned that if
weight loss became an autistic
child’s ‘special interest’ they
could be vulnerable to eating
disorders
Race and culture Avis 2016 “being chubby represented good health” Downgraded Low
Jones 2014 twice for minor
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International CERQual
Finding UK Studies studies Illustrative quotes explanation Confidence
• Different cultures have different McPherson International HCP concerns about
size norms and ideals 2018 methodological
• Culture and language barriers limitations and
made it harder for HCPs to relevance and
discuss weight with some moderate
families concerns about
adequacy

See appendix G for full GRADE-CERQual tables.

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Theme map: Summary of the barriers and facilitators to identification of children and young people

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1.1.7 Mixed methods integration

Are the results/findings from individual syntheses supportive or contradictory?

The quantitative evidence focused on active case finding interventions that were based on
the case finding systems similar to the National Child Measurement Program, which is
outside the remit for this guideline. The qualitative evidence covered identification
experiences from the NCMP for the UK which provides a context for the current barriers and
facilitators families experience, and evidence opportunistic identification practices in other
OECD countries which do not use an NCMP equivalent to explore the possible benefits or
recommending other forms of identification.
The UK qualitative evidence indicates a range of barriers that families experience when their
children are identified as overweight or obese through the NCMP, which can be viewed with
the context from the quantitative evidence that active case finding approaches do increase
identification. It appears that while there are negative experiences associated with these
programs in schools, this is not sufficient to prevent it from being effective, however these
barriers may cause problems further along the process towards weight management.

Does the qualitative evidence explain why the intervention is/is not effective?
The UK qualitative evidence indicates that there are many barriers to active case finding
through the NCMP, mostly based around how the parent feels about their child being
identified in this way. This does not explain why active case finding is effective in increasing
identification of overweight and obesity, but does highlight a possibility that active case-
finding could be more effective if the barriers were addressed.

Does the qualitative evidence explain differences in the direction and size of effect
across the included quantitative studies?
The quantitative evidence examined 4 stigma outcomes: ‘family weight teasing’, ‘peer weight
teasing’, ‘teachers commenting on weight’, and ‘family encouraging the child to diet’. Only
‘family encouraging the child to diet’ was significantly increased with active case finding. The
qualitative evidence described concerns about stigma and the child or young person’s self-
esteem, however none of the specific elements investigated in the quantitative evidence
were mentioned. This suggests that the lack of difference found with active case finding in
those areas may have because those specific elements were not the most prevalent
concerns.

Which aspects of the quantitative evidence were/were not explored in the qualitative
studies?
The quantitative evidence compared active case finding and enhanced active case finding.
Active case finding through the NCMP was the focus of the UK qualitative studies, but the
participants in these studies did not experience anything similar to the enhanced active case
finding used in the quantitative evidence so could not provide views or experiences on it.

Which aspects of the qualitative evidence were/were not tested in the quantitative
studies?
The quantitative studies only examined identification through active case finding in the
context of programs similar to the national child measurement program, whereas the

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qualitative evidence looked directly at the NCMP in the UK. The qualitative evidence also
examined opportunistic identification by professionals in schools and healthcare settings.

1.1.8 Economic evidence

1.1.8.1 Included studies

A combined search was conducted for economic evidence on identification and uptake in
children, young people and adults. This search retrieved 444 studies, and all of them were
excluded after the title and abstract screening. Thus, the review for this question does not
include any study from the existing literature.

1.1.8.2 Excluded studies

All studies were excluded at the title and abstract screening stage.

1.1.9 Summary of included economic evidence

No existing economic studies was included for this review question.

1.1.10 Economic model

No economic modelling was conducted for this review question.

1.1.11 Unit costs

Not applicable.

1.1.12 The committee’s discussion and interpretation of the evidence

The committee discussion of the quantitative evidence and qualitative evidence are
presented together.

1.1.12.1. The outcomes that matter most

Quantitative evidence
During the development of the review protocol, the committee identified a number of
important outcomes such as number of children and young people identified as overweight or
obese, referral to weight management services and health related quality of life. Other
important outcomes included adverse events such as stigma, eating disorders and
disordered eating behaviours.
The consensus was that the direct measure of identification – the number of children and
young people identified – was the most important outcome for decision making. The
committee were also interested in stigma as a factor in how often to take measurements and
how to approach talking to people about weight. There was less focus on referral to weight
management services and health related quality of life. The committee also noted that eating
disorders and disordered eating can be prevalent in young people, particularly among people
who identify as women or girls, however no suitable quantitative evidence was found.

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Qualitative evidence
Qualitative outcomes were individual perspectives, experiences, values, beliefs, preferences,
views and considerations that describe the barriers and facilitators to identification of
overweight and obesity. These outcomes were grouped into 3 categories, with 13 themes:
• Barriers in the UK NCMP: offence; ignored; disagreed; not a problem; practical
limitations
• International barriers and facilitators: discussion; context for ‘normal’; collaboration;
tailored conversations
• Barriers and facilitators for specific groups: younger age groups; disability and health;
autism; race and culture
Evidence from the UK was considered more important than evidence from other countries.
The only UK evidence available was on the national child measurement programme, which is
outside of the remit of this guideline. Therefore, these outcomes were used to describe
barriers experienced in this setting and to contrast to settings described in international
studies.
The committee found the evidence on international barriers and facilitators particularly useful
for informing opportunistic identification in primary care settings. They also found the barriers
and facilitators for specific groups useful when considering the equality impact assessment to
ensure the recommendations do not widen health inequalities.

1.1.12.2 The quality of the evidence

Quantitative evidence
The quantitative evidence was rated from very low to low confidence using the GRADE
criteria. All 3 studies were rated as high risk of bias, so all outcomes were downgraded to
very serious concerns in this domain. There were also several outcomes that were
downgraded for imprecision due to confidence intervals crossing the MIDs or confidence
intervals not being reported.
The committee were concerned specifically with the lack of directness and the small number
of studies. All 3 quantitative studies looked at school screening interventions in the USA so,
in the committees view, were not suitable to make recommendations on directly.
Qualitative evidence
The committee were satisfied that the confidence ratings had been given to the qualitative
evidence using the GRADE-CERQUAL criteria. The majority of the themes were rated as
high confidence (7 themes) or moderate confidence (6 themes). There were 2 themes rated
as low confidence reflecting the smaller pool of evidence for specific groups. There were also
3 themes rated as very low confidence reflecting the lack of evidence for the UK barrier
themes being present in the international studies. These themes were downgraded due to
this lack of evidence creating minor concerns across most domains,
These confidence ratings aided the interpretation of the differences between UK school-
based identification and international opportunistic identification. In this analysis, international
studies were not downgraded for relevance because they were not attempting to extrapolate
to the experiences of people in the UK. Instead they were used to contrast other identification
in other similar healthcare systems to the UK, so were relevant to that specific purpose.
Gaps in the evidence

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Although the review questions focused on people from minority ethnic family backgrounds,
there were no quantitative studies that looked at these groups specifically and only a small
amount of qualitative evidence available covering issues relating to ethnicity and culture.
There was also a limited range of ages (5-14 years) represented in the quantitative data due
to the focus within the school setting, whereas the qualitative data also included pre-school
age children (2-5 years) and some older teenagers (14-18 years). Taking these limitations
into account, the committee chose to draft a research recommendation to address this lack
of evidence. Without any additional evidence to base changes on, they chose to retain the
three existing recommendations on specific advice for people from minority ethnic family
backgrounds.
The qualitative evidence highlighted the range of concerns parents and guardians had about
the potential negative impact of their children being identified as having overweight or
obesity, however there was very little quantitative research measuring whether these
adverse effects occurred. The committee felt this was an important gap in the evidence, so
drafted a research recommendation on the adverse effects of identification, with a particular
focus on the risk of developing eating disorders as they felt this was the most serious
concern regarding children and young people.

1.1.12.3 Benefits and harms

Current practice
A briefing for NICE guideline developers and committee members on obesity, weight
management and health inequalities highlighted in England, more than 3 in 10 children aged
10-11 years (36.6%) are overweight or living with obesity.. This briefing also included the
findings from the 2020/21 National Child Measurement Programme which found that children
living in the most deprived areas were more than twice as likely to be obese than those living
in the least deprived areas. For children leaving primary school, the gap in obesity
prevalence between those from the most and least deprived areas has grown between
2006/7 and 2019/20. With childhood obesity being a stronger predictor of adult obesity and
associated morbidities, it is important that children and young people living with overweight,
and obesity are identified early.
Existing NICE guidance states that healthcare professionals should use clinical judgement to
decide when to measure a child or young person’s height and weight. Opportunities include
when registering with a GP, consultations for related conditions (such as type 2 diabetes and
cardiovascular disease) and other routine health checks.
The committee further noted that in practice, there are two main established methods of
identification: ‘National child measurement programme (NCMP)’ and ‘Healthy Child
Programme: Pregnancy and the First 5 Years of Life’. Along with tracking growth and
development, both of these use forms of active case finding to identify overweight, defined as
searching systematically for at risk people, rather than waiting for them to present with
symptoms or signs of active disease.
Evidence was primarily identified for the effectiveness of active case finding, which involved
case finding in school settings with parents receiving feedback. These interventions
mimicked the NCMP and while evidence did show some favourable outcomes (e.g., number
of children and young people identified as overweight or obese), such programmes would be
outside the remit of NICE recommendations.

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Although these programmes are outside of the remit of this guideline the committee felt it
was important to consider other situations where measurements regularly occur, particularly
through opportunistic methods of identification which are actively used in practice. While no
new quantitative evidence on opportunistic identification was found for children and young
people, the committee’s consensus was to adapt the existing recommendations to remain in
line with current practice, in the absence of evidence to suggest a better alternative.
The committee decided to add a recommendation to ensure that there are processes to
identify children and young people with overweight and obesity in addition to the national
child measurement program. They wanted to acknowledge that while these programs
regularly identify children with overweight or obesity, identification should also take place in
other settings. The NCMP measures children at age 4-5 and age 10-11 in primary schools, it
varies by local area whether feedback is provided to families or carers as this is not a
mandated part of the program. The committee felt it was important that children between
these ages and children and young people in secondary schools also had opportunities for
identification.
They also considered this to be a health inequality concern: children and young people who
do not attend mainstream state education do not take part in the NCMP. There are many
reasons why children might not attend mainstream state education, some of which are a
result social or health factors (for example, some looked after children or children with
disabilities). It is important that these children have the opportunity to be identified
opportunistically in other settings to ensure that they are not further disadvantaged as a
knock on effect of the factors that may cause them to miss out on standard education.

Opportunities for measurement

The previous NICE recommendations suggested opportunities for identification, however the
committee noted that these are less relevant for children and young people as they tend to
be measured more routinely than adults. They discussed the most appropriate time to take
measurements and concluded that routine health checks were the best regular opportunity
and made a recommendation to reflect this.
The committee debated how often a child or young person should be measured. They felt
that regular measurement of height and weight was an important part of providing healthcare
to children, as it can indicate a range of potential problems aside from overweight and
obesity (e.g., failure to thrive, eating disorders etc.). Some members believed that children
should be measured at every health encounter because of this reason. Other committee
members commented that measurements should be taken when it is appropriate rather than
at every opportunity regardless of the purpose of the encounter. They decided on committee
consensus that it should be left to professional judgement to decide when it is appropriate to
take measurements and added that routine health checks may be appropriate appointments.
The committee also discussed the phrase ‘use clinical judgement’ and concluded that
professional judgement is more appropriate, as measures of growth are essential for a wide
range of practitioners to use as a marker of general health and development. This judgement
should take into consideration the context of the family’s health, circumstances, openness
toengage and the appropriateness of discussing weight (for example, discussing weight with
children and young people with eating disorders). As older children and young people are not
routinely weighed as often as young children and are not part of the national child
measurement program, professional judgement should take this into account to ensure that
they older children do not miss out of the opportunity for identification of overweight or
obesity. Furthermore, as these measures are vital markers of health and development in

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children and young people, the committee also stressed the importance of maintaining an
up-to-date record of these measurements.
Based on these discussions, committee amended the recommendation to highlight that
professional judgement should be used to decide when to record an up-to-date measure of a
child or young person’s height and weight. They also amended the recommendation to
highlight that appropriate times can include health checks, because measurement is usually
taken at these checks.
Additionally, the committee further considered the existing recommendations on central
adiposity in children and young people. As waist to height ratio can be considered to assess
and predict health risks associated with central adiposity the committee drafted a further
recommendation to highlight that health and care professionals can consider measuring a
child or young person’s waist circumference to allow waist-to-height ratio to be calculated to
predict health risks associated with central adiposity. There was some discussion over
whether children and young people would be able to measure their own waist-to-height ratio,
but there was no evidence on either the effectiveness or the acceptability of encouraging
them to do this. The committee drafted a research recommendation to investigate this.
The committee noted that the updated recommendations should encourage health and care
practitioners to consider keeping an up-to-date record of markers of health and development
in children and young people. These recommendations were designed to be in line with the
advice provided in previous Public Health England (PHE) guidance, which states that the
first step in identifying families at risk of overweight and obesity is to measure the child or
young person’s height and weight and professional judgement should be used to determine
when it is appropriate to initiate a conversation about weight.
It was further noted that some parents may already be concerned about their child’s weight
or may have been informed about their child’s weight through feedback letters through
NCMP. This may encourage them to self-refer for a discussion about their child’s weight. As
there was no evidence on self-referral, based on their understanding of practice, the
committee recommended that health and care professionals should ensure that records are
kept up to date for children and young people who have been self-referred. The committee
also used the advice outlined in the PHE guidance which states that when parents seek
weight management based on the NCMP letter, the measurements should be repeated to
ensure that records are kept up to date. The committee further highlighted that this
recommendation will encourage professionals to maintain an up-to-date record of markers of
health and development in children and young people.

Consent and taking measurements

The committee noted that is important to have the individual in mind when introducing
conversations about weight and recognising when it is not appropriate. While the existing
recommendation did focus on using clinical judgement, it did not mention the importance of
consent. Therefore, the committee agreed that it is very important for healthcare
professionals to ask permission from the child, young people or their parents/carers, before
engaging in discussions on the degree of overweight, obesity and central adiposity.
Healthcare professionals should also consider a child’s (aged under 16 years of age)
capacity to consent by determining the Gillick competency.
Qualitative evidence highlighted the negative emotions felt by parents who were told their
child was overweight when they did not feel that they had been given the opportunity to
consent to them being measured for this purpose. Based on this, the committee agreed that
it was important to explain what the measurement is for and why it is important, and to obtain

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consent before any discussions take place. Based on this understanding, the previous
recommendation was amended to outline that measurements should only be taken once
consent is granted. This statement is in line with NICE guidance on babies, children and
young people’s experiences of healthcare which also highlights children and young people
under 16 years can make decisions about their healthcare and consent to treatment if they
are assessed to be Gillick competent.
Additionally, the committee recommended that before discussing weight, health and care
professionals should talk about the condition first (e.g., patient coming in for hip pain) to
avoid diagnostic overshadowing, and then use professional judgement to identify whether it’s
an appropriate opportunity to have a discussion about weight. The committee considered the
qualitative evidence from adults that in cases of opportunistic identification, people often felt
that the issue they presented with was overshadowed by discussions of weight which could
be stigmatising and unhelpful. They were concerned that this could also be the case for
children and young people, although there was no direct evidence of this in the review. Upon
discussion of committee members’ experiences, they decided that the recommendation
should apply to all age groups, so chose to also include it in the recommendations for
children and young people.

Stigma and principles of care

The committee highlighted that there is stigma associated with being measured and the
subsequent discussions of results. The qualitative evidence addressed both the stigma to the
child of being identified as overweight and the stigma driving parents’ negative reactions to
their child being identified. Many parents were offended and felt judged. Several parents in
the qualitative evidence review expressed that they did not want their child to be involved in,
or aware of, the conversation about weight, to protect them from weight stigma. The
committee pointed out that in practice, as measurements are conducted during routine health
checks, the discussion of weight may have occurred several times. This can further
perpetuate the feeling of being judged and stigmatised.
The qualitative evidence also addressed the views of healthcare professionals. This
evidence showed that while healthcare professionals understood the importance of
developing a trusting relationship with families, some did feel that that they lacked skills,
knowledge, and training to deal with weight. Based on these findings and their understanding
of practice, the committee highlighted the importance of outlining the ethos or key principles
of care for health and care professionals
Based on this evidence, the committee outlined that before discussing degree of overweight
and obesity with children and young people, their parents and carers, health and care
professionals should consider the context and the appropriateness of the discussion as there
may be instances when it is not appropriate or important to discuss weight or take
measurements. They further highlighted that weight may have been raised on numerous
occasions, health and care professionals should respect the decision to not discuss it further
on this occasion and to explore the reason for refusal at an appropriate time. Additionally, as
parents may be worried about the impact of weight stigma, health and care professionals
should also consider the appropriateness of having the child or young person involved in the
discussions and should give the parent or guardian the opportunity to decide this. If the child
or young person is involved in the conversation, the committee felt this could be managed by
tailoring the conversation to their age, maturity and understanding of the subject.
Concerns were raised in the qualitative evidence that young people, particularly teenage
girls, may be vulnerable to eating disorders. The committee decided it was important to

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highlight this as a recommendation, so that practitioners are mindful of the risk when
deciding whether it is appropriate to measure weight. They stated that mental health support
should be available, but it is not within the remit of this guideline.
Furthermore, the committee also mentioned that a potential unintended consequence of
being measured is that it can have a profound effect of how a child or young person feels
about themselves and runs a risk of perpetuating or triggering overemphasis on body image
and size, as well as disordered eating or eating disorders. The qualitative evidence showed
that parents were concerned about identification harming their child’s self-esteem. Evidence
also suggested that they did not like the terms such as obese and overweight and valued
health and happiness of their child rather than weight.
In light of this stigma, the committee agreed that sensitivity should be emphasised in the
recommendation, and that stigmatising language should be avoided and the focus should be
on using person first language for example, child or young person living with obesity. The
committee also highlighted that health and care professionals should engage with children
and young people and their families or carers to identify their preferred terms. The committee
also discussed how sensitivity should also be a core aspect of the principles of care section
that applies across the guideline.
Based on this understanding, the committee recommended that all discussions linked to the
degree of overweight and obesity are conducted in a sensitive manner. The committee also
outlined steps that can help health and care professionals ensure discussions are handled
sensitively. These include, using sensitive, non-stigmatising language and preferred terms,
engaging with children, young people their families or carer to identify preferred terms and
also providing age-appropriate explanations with a focus on improvement in health as
opposed to simply talking about weight. They also highlighted that all forms of
communication should include non-stigmatising language and images.
Qualitative evidence also showed that parents were not sure what a ‘normal’ weight should
be for their child’s age and circumstances and healthcare professionals found that many
parents needed information and a chance to ask questions about weight and healthcare
professionals provided this and selected the right resources and referrals. The committee
noted that use of resources such as growth charts can be useful during discussions about
weight. Based on this understanding, the committee recommended that accurate facts and
figures, for example growth charts should be used to ensure that discussions that place in a
sensitive manner. Other committee members also suggested using waist to height ratio as
an alternative, as it does not need to be adjusted for age and sex and can be communicated
easily.
The committee also stressed the importance of person-centred care. Qualitative evidence
demonstrated that parents appreciated a holistic assessment of their child’s health with
weight as a component within a context of other issues. Healthcare professionals also
described how they personalised their consultations by adapting to parents’ priorities and
concerns. Based on this finding, the committee agreed that in order to ensure discussions
are conducted in a sensitive manner, it was important to use a person-centred and solution-
based approach in which factors such as the families’ thoughts and views, previous weight
management experience, their level of readiness to engage and cultural, religious/faith and
spiritual beliefs were taken into consideration. They also noted that it was important to
remain mindful of the barriers that may prevent or restrict weight loss.
The committee noted that these steps were important for the development of a trusting
relationship between people and health and care professionals. They also noted by taking a
positive and sensitive approach to measurement and subsequent discussion of weight would

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allow conversations to occur in a respectful manner. The committee also highlighted that
these recommendations are in agreement with PHE guidance as well guidance on healthier
weight competency framework produced by Health Education England which states that
health and care staff that are involved with engaging with people (including children and
young people) about a healthier weight should be able to understand the stigma that is
associated with weight, the impact this can have on people, be able to identify implications of
the child or young person’s weight status and be able to discuss empathically and accurately.
While training is outside the remit of this update, the committee also noted that there are
various resources that are available that provide further guidance on the steps healthcare
professionals can take to discuss weight in a sensitive manner. This includes guidance
produced by Obesity UK on language matters. There are also training courses produced by
the Royal College of General Practitioners (RCGP) which explore the effect of weight stigma
in children and by World Obesity Federation which explore how to raise the issue about
obesity with patients. Additionally, there are webinars available such as those produced by
the European Association for the Study of Obesity (EASO) which also focus on how
healthcare professionals should talk about weight. While some of the training courses focus
on adult population, the committee did consider these as useful tools for health and care
professionals working within paediatric weight management. Short of recommending formal
training, the committee opted to recommend that healthcare professionals should be aware
of what weight management services are locally available, as vital knowledge base.

1.1.12.4 Cost effectiveness and resource use

No health economic studies were identified for this question.
The committee made a recommendation to use professional judgement to decide when to
record weight and height of a child or young person. The more inclusive term “professional
judgement” will allow a wider range of practitioners to make their decisions on weight and
height measurement based on a variety of clinical and personal considerations. The
committee also made recommendations to tackle issues related to stigma that repeated
measurement can cause in children and young people, especially among those who are
vulnerable to eating disorder.
Overall, the new recommendations are not expected to increase NHS resources significantly.
It is possible that weight and height will be measured more often following the
recommendation thus possibly increasing the length of appointments. However, the more
flexible approach is expected to lead to more appropriate measurements enhancing NHS
efficiency in the identification of children and young people who are overweight or obese.
Moreover, the additional recommendations on tackling stigma are expected to reduce
children and young people’s distress during visits and routine health checks which will
improve their quality of life and reduce their likelihood of not attending follow-up
appointments.

1.1.12.5 Other factors the committee took into account

Wider determinants and the context of overweight and obesity

Upon discussion of the wider evidence base from reviews 1.3, 1.4 and 2.3, the committee
drafted an overarching recommendation in the principles of care to think about the wider
determinants and the context of overweight and obesity. This recommendation included a
non-exhaustive list of examples to encourage consideration of overweight and obesity as a
complex health issue which requires a holistic approach. The committee chose to use this as

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both a standalone recommendation and a recommendation to cross-refer to throughout the

guideline when these factors are relevant.

People from minority ethnic family backgrounds

Although the review question focused particularly on people from minority ethnic family
backgrounds, there were no quantitative studies that looked at these groups specifically and
only a small amount of qualitative evidence available covering issues relating to ethnicity and
culture. The committee looked at the equality impact assessment and considered how the
recommendations may affect people from different family backgrounds. They highlighted that
the new recommendations were applicable for children from minority ethnic family
backgrounds as the core principles of these recommendations were demonstrating sensitivity
and using a person-centred approach which takes ethnicity into consideration. The
committee also noted that there is a need to spread awareness amongst health and care
professionals as well as the public of the increased risk people from minority ethnic family
backgrounds face at a lower BMI.
Based on this understanding the committee retained existing NICE recommendations which
promote this understanding and as well as recommendations that promote the use of existing
local information networks to share information on the increased risks these group face at a
lower BMI.

Children and young people with disabilities, learning disabilities and

neurodevelopmental disabilities
Although there was some evidence that families of children with disabilities faced some
additional challenges, the committee felt that people with physical disabilities, learning and
neurodevelopmental disabilities were adequately covered by the recommendations they
drafted and would additionally be identified during regular specialist health checks.
Additionally, it was highlighted that there are existing NICE guidelines that can help health
and care professionals plan the care for children and young people with learning disabilities
and neurodevelopmental disabilities. This includes guidance on learning disabilities and
behaviour that challenges: service design and delivery (NG93).

Looked after children

No evidence was identified on the particular needs of looked after children, however social
complexity should be taken into consideration. Additionally, the NICE guideline on looked-
after children and young people (NG205) includes recommendations on building expertise
about trauma and raising awareness.

1.1.13 Recommendations supported by this evidence review

[To be completed once editorially complete version of the guideline is available for
submission to NICE for quality assurance, consultation and publication]
This evidence review supports recommendations [add recommendation numbers] and the
research recommendation on [add topic of research recommendation]. Other evidence
supporting these recommendations can be found in the evidence reviews on [add topic of
evidence review and review letter (A, B, C, etc)]. OR No recommendations were made from
this evidence review. Amend as needed

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1.1.14 References – included studies

1.1.14.1 Effectiveness
Bailey-Davis, Lisa, Peyer, Karissa L, Fang, Yinan et al. (2017) Effects of Enhancing School-Based
Body Mass Index Screening Reports with Parent Education on Report Utility and Parental Intent To
Modify Obesity Risk Factors. Childhood obesity (Print) 13(2): 164-171

Chomitz, Virginia R, Collins, Jessica, Kim, Juhee et al. (2003) Promoting healthy weight among
elementary school children via a health report card approach. Archives of pediatrics & adolescent
medicine 157(8): 765-72

Madsen, Kristine A, Thompson, Hannah R, Linchey, Jennifer et al. (2021) Effect of School-Based
Body Mass Index Reporting in California Public Schools: A Randomized Clinical Trial. JAMA
pediatrics 175(3): 251-259

1.1.14.2 Qualitative evidence

Avis, Jillian L S, Komarnicki, Angela, Farmer, Anna P et al. (2016) Tools and resources for
preventing childhood obesity in primary care: A method of evaluation and preliminary assessment.
Patient education and counseling 99(5): 769-75

Dam, Rinita, Robinson, Heather Anne, Vince-Cain, Sarah et al. (2019) Engaging parents using
web-based feedback on child growth to reduce childhood obesity: a mixed methods study. BMC
public health 19(1): 300

Gainsbury, Alexa and Dowling, Sally (2018) 'A little bit offended and slightly patronised': parents'
experiences of National Child Measurement Programme feedback. Public health nutrition 21(15):
2884-2892

Hardy, Kelly, Hooker, Leesa, Ridgway, Lael et al. (2019) Australian parents' experiences when
discussing their child's overweight and obesity with the Maternal and Child Health nurse: A
qualitative study. Journal of Clinical Nursing 28(1920): 3610-3617

Jachyra, Patrick, Anagnostou, Evdokia, Knibbe, Tara Joy et al. (2018) Weighty Conversations:
Caregivers', Children's, and Clinicians' Perspectives and Experiences of Discussing Weight-
Related Topics in Healthcare Consultations. Autism Research 11(11): 1500-1510

Jones, Kay M; Dixon, Maureen E; Dixon, John B (2014) GPs, families and children's perceptions of
childhood obesity. Obesity research & clinical practice 8(2): e140-8

McPherson, A. C, Knibbe, T. J, Oake, M et al. (2018) "Fat is really a four-letter word": Exploring
weight-related communication best practices in children with and without disabilities and their
caregivers. Child: Care, Health and Development 44(4): 636-643

Sjunnestrand, My, Nordin, Karin, Eli, Karin et al. (2019) Planting a seed - child health care nurses'
perceptions of speaking to parents about overweight and obesity: a qualitative study within the
STOP project. BMC public health 19(1): 1494

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Syrad, H, Falconer, C, Cooke, L et al. (2015) 'Health and happiness is more important than weight':
A qualitative investigation of the views of parents receiving written feedback on their child's weight
as part of the National Child Measurement Programme. Journal of Human Nutrition and Dietetics
28(1): 47-55

Toftemo, Ingun, Glavin, Kari, Lagerlov, Per et al. (2013) Parents' views and experiences when their
preschool child is identified as overweight: A qualitative study in primary care. Family Practice
30(6): 719-723

Turner, Gillian L, Owen, Stephanie, Watson, Paula M et al. (2016) Addressing childhood obesity at
school entry: Qualitative experiences of school health professionals. Journal of Child Health Care
20(3): 304-313

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2 Identifying overweight and obesity in

adults
2.1 Review questions
What approaches are effective and cost-effective in identifying overweight and obesity in
adults, particularly those in black, Asian and minority ethnic groups?
What are the barriers and facilitators to identifying overweight and obesity in adults,
particularly those in black, Asian and minority ethnic groups?

2.1.1 Introduction
Overweight, obesity and central adiposity is a risk factor for development of CVD, type 2
diabetes, hypertension, dyslipidaemia or some type of cancer in adults. Currently, people
who are overweight, or living with obesity are identified through the healthcare system
opportunistically. NICE 2014 guidance on obesity identification, assessment, and
management (CG189) recommends using clinical judgement to decide when to measure a
person’s height and weight. Opportunities include registration with a general practice,
consultation for related conditions (such as type 2 diabetes and cardiovascular disease) and
other routine health checks.
During the surveillance process, topic experts highlighted that relying on opportunistic
identification, rather than active case finding, increases the likelihood that conditions such as
type 2 diabetes will be under-diagnosed in black, Asian and other minority groups whose risk
of these conditions is increased at a lower BMI than the general population. Topic expert
feedback also indicated that a proactive approach of informing people of their BMI is needed.
The experts also advised that instructions to clinicians, especially GPs, to measure BMI
should be firmer to further support NICE quality standard QS127.
Based on this, review questions were drafted to explore the effectiveness, barriers, and
facilitators of identification of overweight and obesity in adults.

2.1.2 Summary of the protocol

Table 12 summarises the protocol for the review of effective and cost-effective interventions.
Table 13 summarises the qualitative evidence synthesis for barriers and facilitators of
identification.

Table 12: PICO table effectiveness of approaches in identifying overweight and

obesity in adults
Population
• Adults 18 years and over.
Where possible, evidence will be stratified by ethnicity:
o White
o Black African/ Caribbean
o Asian (South Asian, Chinese, any other Asian background)
o Other ethnic groups (Arab, any other ethnic group)
o Multiple/mixed ethnic group
• Staff undertaking identification of adults with overweight or obesity and
engaging them in weight management services.

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Intervention • Opportunistic identification, including but not confined to:

o When registering with GP
o When receiving consultation for health conditions (e.g., chronic
health conditions)
o During routine check-up / annual check-ups (delivered by GPs,
nurses, pharmacists and social care staff)
o During medication checks (e.g., contraception pill check)
o During vaccination appointments
o Visits to secondary care (e.g., outpatient clinics and emergency
departments or physiotherapist appointments)

• Active case finding (defined as searching systematically for at risk

people, rather than waiting for them to present with symptoms or signs of
active disease). This includes but is not confined to:
o Review of medical records
o Receiving or received interventions for example brief physical
activity advice (delivered by GPs, nurses, pharmacists, activity
providers)
o audits of other services (e.g., disability services or endocrinology
services)
• Receiving or received interventions for example brief physical activity
advice, diabetes prevention programme, smoking cessation programme,
counselling for low calorie diets (delivered by GPs, nurses, pharmacists,
activity providers)
• Self-identification or referral
• Carer initiated identification or referral
Comparator • No intervention/usual care
• Comparison of interventions

Outcomes Primary outcomes:

• Number of people identified as overweight or obese
• Referral to weight management service
• Health- related quality of life
Secondary outcomes
• Adverse events:
o Eating disorders or disordered eating
o Stigma (including self-stigma and negative body image as defined
in studies)
Study type Quantitative review
• Systematic reviews of included study designs
• RCTs
• Observational studies (cohort studies)
• Mixed methods studies (quantitative evidence that matches the
above study designs only)

Table 13: SPIDER table for barriers and facilitators for identifying overweight and
obesity in adults
Sample • Adults 18 years and over.
Where possible, evidence will be stratified by ethnicity:
o White
o Black African/ Caribbean
o Asian (South Asian, Chinese, any other Asian background)
o Other ethnic groups (Arab, any other ethnic group)

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o Multiple/mixed ethnic group

• Staff undertaking identification of adults with overweight or obesity and
engaging them in weight management services.
Phenomenon of Barriers and facilitators to the identification and engagement of overweight and
interest obese people including, but not limited to:
• Thoughts, views and perceptions of individuals or carers
• Thoughts, views and perceptions of staff undertaking identification of people
who are living with overweight of obesity
• Issues relating to education
• Issues relating to stigma
• Issues relating to self-esteem
• Issues relating to cultural sensitivities

Design • Systematic reviews of included study designs

• Qualitative studies that collect data from focus groups and interviews.
• Qualitative studies that collect data from open-ended questions from
questionnaires
• Mixed method study designs (qualitative evidence that matches the
above study designs only)
Evaluation Thematic synthesis

Research type Qualitative and qualitative elements of mixed methods

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2.1.3 Methods and process

This evidence review was developed using the methods and process described in
Developing NICE guidelines: the manual. This is described further in the methods chapter.
Methods specific to this review question are described in the review protocol in appendix A.
Declarations of interest were recorded according to NICE’s conflicts of interest policy.

2.1.4 Effectiveness and Qualitative evidence

2.1.4.1 Included studies

A combined search was conducted for review questions on identification and uptake in
children, young people and adults. A total of 19,477 studies were identified in the search
which explored both quantitative and qualitative evidence. The search was re-run in May
2023 to find newly published references prior to consultation and identified a further 1,630
studies.

Quantitative evidence
Following title and abstract screening 20 studies were identified as being potentially relevant
in adults. These studies were reviewed against the inclusion criteria as described in review
protocol (Appendix A). Overall, 3 studies were included; 2 RCTs and 1 cluster RCT. These
studies covered opportunistic approaches for identification.

Qualitative evidence
Following title and abstract screening 26 studies were identified as being potentially relevant.
These studies were reviewed against the inclusion criteria as described in review protocol
(Appendix A). Overall, 8 studies were included which used semi-structured interviews/ focus
groups. There were 4 studies from the UK and 4 studies from other countries. All studies
addressed opportunistic identification in primary care.

See appendix E for evidence tables and the reference list in section 1.2.14. For information
on included studies in children and young people, see section 1.1.4.

2.1.4.2 Excluded studies

See appendix K for the list of studies excluded at full text screening with reasons for their
exclusion.

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2.1.5 Summary of studies included in the effectiveness and qualitative evidence

2.1.5.1 Quantitative Evidence

Table 14: Quantitative evidence included in the review of effectiveness of approaches in identifying overweight and obesity in adults
Study and
Population and number of
study Country Setting Intervention Comparator Follow-up Outcomes
participants
design

Lee 2009 USA Medical 29 nurses; 1,804 patients Opportunistic Clinical log without • Diagnosis of
school identification using decision support None overweight
RCT clinical decision support (n=997) • Missed diagnosis
system
(n=1,874)
Tang 2012 USA Primary care 30 doctors; 2,114 patients Opportunistic No change to electronic • Diagnosis of
clinic identification using new health record None overweight
RCT electronic health record (n=1,156) • Weight counselling
tools
(n=958)
Wee 2010 USA primary care 23 clinic clusters; 60,224 Opportunistic No change to electronic • Diagnosis of
clinics patients identification using new health record None overweight
Cluster electronic health record (n=33,763) • Missed diagnosis
RCT tools • Documentation of
(n=26,481) BMI

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2.1.5.2 Qualitative Evidence

Table 15: Qualitative evidence included in the review of effectiveness of approaches in identifying overweight and obesity in adults
Population and
Study Design and analysis Country Setting sample size Objective
Atlantis 2021 Semi-structured interviews Australia General practice 5 GPs; 25 patients To assess the clinical usefulness of a new screening
with no specified analysis tool based on the Edmonton Obesity Staging System
framework (EOSS) for activating weight management discussions
in general practice
Beeken 2021 'Community jury' Focus Australia Commercial 13 members of the To elicit the views of people with overweight and obesity
Groups with no specified research public about the role of GPs in initiating conversations about
analysis framework organisation weight management.
Blackburn 2015 Semi-structured interviews UK General practice 17 GPs; 17 nurses To explore general practitioners’ (GPs) and primary
using Theoretical Domains care nurses’ perceived barriers to raising the topic of
Framework weight in general practice
Doherty 2019 Semi-structured interviews UK General practice 7 GPs; 1 nurse; 6 To explore GPs and other HCPs’ views and
with no specified analysis other HCPs experiences of barriers and facilitators to providing
framework evidence-based weight management interventions for
adults with intellectual disabilities
Glenister 2017 Semi-structured interviews Australia Rural GP 7 GPs; 7 patients To examine how GPs in rural areas talk about
with no specified analysis practices overweight and obesity with their patients, specifically to
framework identify key barriers to effective conversations
Gunther 2012 Semi-structured interviews UK General practice 7 GPs; 7 nurses; 9 To uncover and describe barriers and enablers to
with no specified analysis patients implementing NICE’s recommendations on the
framework management of obesity in adults in general practice,
using practical qualitative methods.
Holmgren 2019 Interviews using grounded Sweden Primary care 10 public health To develop a theory explaining how public health nurses
theory nurses accomplish and adapt counselling in lifestyle habits to
decrease obesity in people with mobility disability
Phillips 2014 Semi-structured interviews UK Primary care 16 nurses To use qualitative semi-structured interviews to explore
with no specified analysis health boards how practice nurses manage obesity within primary care
framework and to identify good practice and explore barriers to
achieving effective management

See appendix E for full evidence tables.

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2.1.6 Summary of the effectiveness and qualitative evidence

2.1.6.1 Quantitative Evidence

Table 16: Opportunistic identification using electronic tools vs usual care with no tool use
No. of studies Sample size Effect estimate (95% CI) Quality Interpretation of effect
Diagnosis of overweight/obesity: assessed by number of patients diagnosed
3 (Lee 2009 64162 RR 6.61 Very low Favours electronic record tools
Wee 2010 (3.56 to 12.28)
Tang 2012)
Weight counselling: assessed by number of patients who received weight counselling
1 (Tang 2012) 400 RR 1.83 Low Favours electronic record tools
(1.22 to 2.75)
Missed diagnoses: assessed number of patients with BMI>=25 who were not diagnosed as overweight/obese
2 (Lee 2009 36535 RR 0.32 Very low Favours electronic record tools
Wee 2010) (0.29 to 0.37)
Documentation of BMI: assessed by number of patients whose BMI was recorded
1 (Wee 2010) 60244 RR 1 Low Evidence could not differentiate
(1 to 1) between arms

See appendix G for full GRADE tables.

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2.1.6.2 Qualitative Evidence

Table 17: Summary of the barriers and facilitators to identification in adults

CERQual
Finding Studies Illustrative quotes explanation Confidence
Barriers and facilitators to identification in general
Healthcare providers felt that tools and guidance on Atlantis 2021 “so we just need to maximise everybody at Downgraded Moderate
identifying overweight were useful, but there was Blackburn every level and you can’t do that unless you once for minor
often a lack of consistency and availability. 2015 have a common consensus about where we concerns about
Doherty 2019 are going. Actually, it is really hard to have a coherence
Glenister common consensus”
Tools that help guide conversations were considered
Gunther GP
particularly valuable. The ‘EOSS-2 risk tool’ was
2012
examined in one paper and generally praised. Some
Holmgren
GPs commented on the lack of tools available to them “In terms of the medical tool box, pneumonia:
2019
though. we have a tool for that, diabetes: we have a
tool for that … for obesity: we’ve got nothing.”
GPs appreciated guidance that enabled them to have GP
information on comorbidities and risk factors readily
available. Some GPs wanted more guidance on how to “All the government guidelines I’ve read,
adapt their approach to people with disabilities. there’s never anything really that’s targeted
towards that group [people with intellectual
GPs also commented that guidelines and policies were disabilities].”
not implemented consistently. Some felt that obesity was HCP
not prioritised by management. They were concerned
that with no standardised approach among HCPs, there
would be unequal provision of treatment.
Atlantis 2021 “You can lead a horse to water but you can’t Downgraded Moderate
There were mixed opinions on whether it is a HCPs Beeken 2021 stop it eating cream cakes.” once for minor
responsibility to identify overweight or obese Blackburn concerns about
people. GP
2015 coherence
Gunther
2012 “if it’s not a doctor, then who? Because,
Holmgren family, they’re just going to irritate people.
Most patients felt that HCPs were in an appropriate role
to identify overweight, as they could approach it 2019

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CERQual
Finding Studies Illustrative quotes explanation Confidence
objectively and clinically. They felt it would be better Phillips 2014 Friends, they’re just going to try to butter it
received than if a friend or relative commented on it. up”
Patient

Some HCPs agreed that it was an important part of their “‘I don’t really see it as my job. I think by the
role in maintaining patients’ health and took an active time they get to me, they come with a specific
interest in weight management. Some of these felt that problem or some complexity associated with
they had a responsibility to help prevent obesity by them”
intervening when patients started to gain weight rather GP
than when they reached a certain BMI.

Others disagreed as they felt it was not their

responsibility and not their place to comment. They
claimed that they were unable to make a difference to
patients’ weight and felt it was up to the individual to
choose to manage it themselves. Furthermore, several
HCPs felt their jobs remit was quite specific and their
daily work did not involve public health promotion.
Barriers and facilitators to identification of an individual
Identifying overweight or obesity was seen as a Blackburn “I think it’s that we don’t get any training on No High
difficult conversation to initiate, so HCPs needed to 2015 how to talk to people about their weight and downgrading
feel confident in their ability to do it well. Doherty 2019 how best to advise people to lose weight” required
Gunther GP
2012
Some HCPs who lacked this confidence avoided
Holmgren
addressing weight for fear that it could do more harm “if some course comes up about obesity,
2019
than good if they were to upset or alienate their patient. that’s the last thing I’m gonna go to. Whereas
Of these HCPs, some felt they didn't have enough if there’s a course on new treatments in
knowledge or training on the subject of weight hypertension or new treatments in epilepsy
management and others felt that they didn't have or… that’s what I’m gonna go to.”
enough skills or experience in communicating sensitive GP
issues.

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CERQual
Finding Studies Illustrative quotes explanation Confidence
HCPs also felt they needed specific training in how to “I’ve got a thirteen percent chance of having a
approach these issues with patients who have learning heart attack, does that mean I am going to
disabilities, as there are additional barriers to have a heart attack?... I think we are not
communication in these interactions. always good at explaining that as GPs – I
think particularly with people who have
For many GPs, however, training on weight learning disabilities.”
management topics was not prioritised when there is GP
limited time to undertake professional development
courses.
Competing priorities in a clinical interaction often Blackburn “We’ve got enough to do, in terms or sorting No High
meant that weight was not addressed. 2015 and presenting the complaint and then sorting downgrading
Doherty 2019 out the ongoing stuff and sorting out the required
Glenister critical health stuff and that’s quite enough for
Time constraints were frequently mentioned as a reason
Gunther 10 minutes, thank you very much.’ (GP 2)”
for not identifying overweight in eligible patients. HCPs
2012
felt that they already had too little time to cover
Holmgren
everything essential to the primary purpose of the “I said ‘I wouldn’t mind having a chat with
2019
appointment, so did not have time for anything else. someone about my weight’, and she [GP]
Phillips 2014
Patients agreed that the primary purpose of the said ‘We’ll talk about it later’, because
appointment should always be prioritised but also found everything’s always rushed.”
it frustrating to run out of time when they did want to Patient
discuss their weight.
“So I feel constrained in what I can do. And
HCPs also described how their practice managers and we have even had the PCT [primacy care
commissioners did not see weight as a priority so trust] in checking on our Orlistat prescribing.”
discouraged staff from dedicating time and resources to GP
it. They felt that the pressure they were under to meet
certain targets made it harder to use their judgement.

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CERQual
Finding Studies Illustrative quotes explanation Confidence
Opinions varied as to which patients should be Beeken 2021 “Don’t a lot of doctors take your blood Downgraded Moderate
identified and whether a conversation about weight Blackburn pressure every time you walk into there once for minor
should occur for an individual. 2015 anyway, so why can’t they use the scales?” concerns about
Glenister Patient coherence
Gunther
Patients tended to prefer the idea of routine weight
2012
assessment for everyone, to normalise the idea of “I do believe that there are some people who
Holmgren
monitoring weight. They felt that it would be less are overweight and still remarkably healthy
2019
stigmatising as it would prevent them from feeling and actually their weight isn’t really an issue
Phillips 2014
singled out and judged. HCPs on the other hand felt that that I need to be too concerned about.”
this approach was less efficient; targeting people at high GP
risk was a better use of limited time and resources.
“But it really comes down to the consent of
Furthermore, some HCPs felt that it is only necessary to the patient. That’s the thing that I feel most
identify overweight if a patient has comorbidities or other strongly about. [pre-appointment
health issues that are affected by it. These HCPs felt questionnaire] is given to the patient so that
firmly that weight is not inherently a health problem, so they feel like they’re more in control of the
an otherwise healthy overweight person does not need discussion that’s going to occur.”
to manage their weight.
Patient

The patients' consent and choice in whether to discuss

weight was often seen as the deciding factor in whether
to initiate a weight conversation. Some HCPs felt that
weight should only be discussed and documented if the
patient brings it up and asks for support. Others felt that
gauging a patient's openness to the idea before making
any formal identification was the best approach. They
felt it could harm the relationship to bring it up with a
patient who was unwilling, so allowing them to control
the conversation was less confrontational.
Barriers and facilitators to raising the topic of weight with a patient
A good relationship between patient and HCP made Atlantis 2021 “‘you don’t have to bring it up just as a No High
it easier to initiate a conversation about weight. Beeken 2021 problem with weight. You can say, ‘How are downgrading
Blackburn you going? How’s everything? What have you required
2015 been doing lately? How do you feel?’”
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CERQual
Finding Studies Illustrative quotes explanation Confidence
An ongoing relationship allowed HCPs to raise the issue Glenister Patient
gradually and to choose the right moment. They stated Gunther
that it was much harder to do this in a single time-limited 2012
“Being a rather larger person myself, I find it
interaction. They also commented that using Holmgren
sometimes a little bit sensitive to say, ‘You
identification tools helped to introduce the subject by 2019
really ought to lose some weight’, when,
making it less personal and distancing themselves from Phillips 2014
actually, the same person could be saying it
the source of the conversation. back to me.”
Nurse
The HCP’s weight could function as either a barrier or a
facilitator. Some HCPs felt that being overweight
themselves undermined the message they were trying to “if I have to not talk about something or talk
convey. In other cases, patients felt more comfortable about something very sort of gently in order to
talking to another overweight person who would preserve my reputation as being non-
understand their experience and not judge them. judgmental then I will do that.”
GP
Some GPs commented that they valued the relationship
they had built with their patients above the need to
identify overweight. They felt the risk of damaging that
relationship and their wider reputation as a trustworthy
GP by offending their patients was not worth the
benefits.

Framing the identification of overweight as a general Atlantis 2021 “…discussion around medical illness rather Downgraded Moderate
status was less productive than framing Beeken 2021 than judgmental values about failure or once for minor
identification as a health concern. Doherty 2019 success as far as their obesity is concerned. concerns about
Holmgren It did help to focus the attention away from relevance
2019 personal failure and towards medical
Health concerns felt more appropriate for a HCP to
Phillips 2014 conditions”
comment on, and particularly if the health issue was
linked to an ongoing comorbidity or the problem the GP
patient was presenting with. Patients felt more
comfortable with this approach as it took the focus away “However high you are, I’m stocky, another
from their appearance and the social stigma of weight. guy is skinny. There’s a difference straight
HCPs agreed with this and commented that it removes away. It doesn’t mean anything, but I’m not
going to go along and have someone write
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CERQual
Finding Studies Illustrative quotes explanation Confidence
the suggestion of blame and made it easier to motive me a letter saying I’m fat. It’s hard to judge
their patients. how fat you might be’”
Patient
Furthermore, patients did not trust BMI measures and
saw a high BMI as insufficient reason to identify
someone as overweight. They needed more direct “We had another guy who had a learning
evidence of how their weight was affecting their health to disability and he was working really, really
see the relevance of it. hard… Now his goal, was to be able to
reduce his size enough so he could buy a
There was one clear exception to this theme: HCPs jacket…a particular brand of jacket he wanted
working with patients who have learning disabilities to be able to buy”
found it more productive to focus on appearance and GP
lifestyle than on health. They found it easier to
communicate tangible benefits of weight management
than more abstract health implications.

Most HCPs considered weight conversations to be Atlantis 2021 “No, if they were coming for something No High
challenging due to the stigma of being overweight. Beeken 2021 completely unrelated because they would downgrading
Blackburn probably have had plenty of people doing it to required
2015 them already, and it will have [annoyed them]
HCPs were concerned that patients may take offense at
Glenister to be quite honest. If I went to the doctors
having their weight commented on. They worried about
Gunther with conjunctivitis and had a weight problem I
the words they use to describe weight being stigmatising
2012 would be pretty [annoyed] to be quite honest
and unintentionally implying their patients’ choices are
Holmgren if you then started telling me about my
shameful or blameworthy. Some HCPs empathised with
2019 weight”
patients who reacted negatively and felt uncomfortable
Phillips 2014 Nurse
with having caused conflict.

Many patients described previous bad experiences “I remember this one explicitly, the
where HCPs had talked about their weight in insulting or anaesthesiologist … she was quite rude
insensitive terms. These experiences made them feel about my weight … she said I was lazy … I
wary and defensive when weight was brought up in didn’t even know this person, I don’t see why
subsequent medical encounters. she had the right to even start commenting.”
Patient

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CERQual
Finding Studies Illustrative quotes explanation Confidence
Some patients and felt that raising the subject of their “So, that’s why we’re changing the question
weight in a clinical encounter, particularly when it was to lifestyle, yes? So, it’s not as focused on
not relevant, was inherently stigmatising. They were weight, but it’s also looking at all of the factors
concerned that HCPs viewed them primarily as an that are contributing to the overweight or
overweight person and the expressed the desire to be obese situation? It’s all- encompassing. It’s
treated the same as anyone else. not selecting certain groups of people, or
pointing the finger, ‘You’ve done this wrong,
and now you’re fat.’”
Patient
Barriers and facilitators to discussing weight management
Discussions of weight were dependent on the Atlantis 2021 “most of that data would be in my database Downgraded Moderate
patient’s motivation to engage with weight Gunther anyway… then it would be very easy for me once for minor
management 2012 to say, look, Mom, dad had diabetes too, concerns about
Holmgren you’re at an extreme high risk.” coherence
2019 GP
With a motivated patient, the conversation is often well
Phillips 2014
received and support or referral to weight loss services
are welcomed. If a patient is not motivated, however, “So I think this is more reinforcement. I’m
these conversations may be less productive unless the more confident that I can lose weight. She’s
HCP is able to actively motivate them through the [GP] there to help and refer me to the people
conversation. Many HCPs described this as the key part that can help me as well.”
of their role in identifying overweight. Some described Patient
how motivational interviewing techniques can be helpful
to achieve this.
“So it’s kind of motivated me take some
action. Yeah, I mean, the results of the blood
Personalised risks and benefits were more effective in tests kind of made me think about it a bit
creating engagement than generic risk factors. Patients more, because I hadn’t really had too many
felt more motivated to manage their weight when issues previously, and knowing that not
thinking about how it might affect their own health and everything’s perfect, definitely give me some
interact with health issues they were experiencing. motivation. I know that if I follow the plan, it
will definitely help me be more active and
healthier and longer for your long term health
issues.”
Patient

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CERQual
Finding Studies Illustrative quotes explanation Confidence
HCPs discussed the importance of tailoring Beeken 2021 “You gauge the patient on that first meeting. No High
conversations to the patient they are talking to. Doherty 2019 So if they, ‘I don’t know what I’m doing’ then downgrading
Gunther you kind of make it to suit – you know, you go required
2012 back to basics…. But if you get patients that
GPs described how they adapted to a range of patients’
Holmgren come in and say ‘Look, I’ve done weight-
knowledge, personal risks factors and previous weight
2019 watchers, I know what I should be doing. I
management experience. For example, some patients
Phillips 2014 know what I shouldn’t be eating and I know I
had unreasonable expectations of a ‘quick fix’ solution
akin to medication, with little knowledge of how to should be exercising, and I know I should be
approach weight management. Other patients were doing this and this’ And they’ve got more of
highly knowledgeable but had experienced cycles of an idea, then you do it a little bit differently.
weight loss and regain over many years. These You say, ‘OK, lets try this’. Your approach
situations required different approaches to take into with them is slightly different because of their
account the patient’s perspective given and to motivate knowledge”
achievable weight management. GP

HCPs also mentioned other factors affecting how weight “I try to personalize, try to scan that person's
management conversations are approached: ability to do and that you give advices based
• Physical disabilities can make weight on that…”
management more challenging and less GP
accessible, so GPs described their attempts to
adapt the conversation to the patients’ needs “A lot of them feel they are quite healthy,
and conditions. especially in our culture [South Asian ethnic
• Learning disabilities can create challenges in groups], they don’t like anyone who is slimly
communicating the risks and benefits of weight, built, especially with kids; so that kind of, that
so extra consideration is needed to how the kind of mentality kind of goes with them into
conversation is handled. to adulthood.”
• HCPs also expressed the challenges of tailoring
to different cultural beliefs about weight.
HCPs who worked with patients with learning Doherty 2019 “You’re trying to motivate a carer to motivate Downgraded Low
disabilities described the additional considerations the patient. So, it’s second hand motivation” twice for
when carers or support workers are involved. GP moderate
concerns about
They had the added challenge of motivating both the adequacy and
patient and the carer, as patients with learning
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CERQual
Finding Studies Illustrative quotes explanation Confidence
disabilities often didn’t have full control over their diet “They [carers] just feed him junk food cos minor concerns
and exercise. that’s what he eats and he won’t eat anything about relevance
else. And they’re not gonna have a conflict
They found that carers were sometimes unsupportive of with him…I can see an attitude of well, this
weight management. This meant that even if a patient person’s not got much in their life and if they
was engaged and motivated during the conversation, like eating burgers well let them eat burgers,
their carer’s attitude prevented any further action. cos what else have they got.”
GP
Barriers and facilitators to referral and management
HCPs advised their patients on diet and exercise, Atlantis 2021 “I can talk ‘til I’m blue in the face about the Downgraded Moderate
and helped them to plan their weight management Glenister health benefits of losing weight, I have no once for minor
individually. Gunther idea how to get people started on that concerns about
2012 journey.” coherence
Holmgren GP
In many cases, GPs felt that patients who were willing to
2019
engage in weight management could do so
Phillips 2014
independently. They offered information on diet and “What they’re doing – they’re not doing any
exercise and often invited them to make a follow up exercise in between those times, because
appointment but did not refer them to a programme. when you ask them they say ‘no, I’m going to
the gym twice a week’, and they think that’s
In other cases HCPs felt that patients were unlikely to be all they have to do.”
able to follow and maintain a weight management plan Nurse
without further support. They felt that they didn’t know
how to give the right advice in a way that would be “I would prefer NHS [support] with small
effective, and that specialist help was needed. groups of 10–15 at a time, perhaps weigh
them ... I just say I think coming regularly and
Some HCPs wanted to provide structured ongoing meet and talk with people is important”
support within their clinic, but this was not often possible. Patient
Patients were keen to utilise these services if and when
they were available.
A referral for weight management was often Blackburn “They have reduced the number of dietary No High
dependent on whether there are appropriate 2015 services in the whole of [area], so it’s very downgrading
services available to refer patients to. Doherty 2019 difficult to actually refer somebody, and they required
Glenister are all now based in [area], so if people don’t

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CERQual
Finding Studies Illustrative quotes explanation Confidence
In many areas there were either very few services or the Gunther drive, they are just not going to go, that is
HCPs did not know what services there were. Many 2012 even if they have an appointment.’”
services were oversubscribed and GPs commented that Holmgren GP
if they were to refer every eligible patient, their local 2019
services would not have the capacity to cope with the Phillips 2014
“The people at the council who’ve had twenty
demand. Some patients were unable to pay for years’ experience working in learning
commercial weight management services outside of the
disability probably have zero experience in
NHS.
health, and it’s probably linking those together
that’s going to be key.”
Often the services that patients were referred to were HCP
not appropriate for their needs. Patients who have a very
high BMI require more specialist support manage their
weight safely. Patients whose needs are complicated by “The doctor did try and put me down for the
physical or learning disabilities also require services that gym, but they said I was too heavy for it. I did
can accommodate them. go to the physiotherapist assistants ... it was
only temporary because that’s the way NHS
works”
HCPs felt that there was little collaboration between
Patient
weight management service providers and professionals
who specialise in disability support, and that this is
essential to making services more accessible. The
consensus among HCPs and patients was that services
need to be expanded and invested in to be fully
inclusive.

See appendix G for full GRADE-CERQual tables.

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Theme map: Summary of the barriers (grey) and facilitators (green) to opportunistic identification of adults in a clinical setting. Each pillar represents a set
of themes describing what influences a healthcare professional’s ability to proceed with identification.

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2.1.7 Mixed methods integration

Are the results/findings from individual syntheses supportive or contradictory?

The qualitative and quantitative findings were not directly comparable as the barriers and
facilitators to identification were not directly targeted by the interventions to increase
identification. Likewise, the success and suitability of the interventions was not explored in
the qualitative evidence as it examined barriers and facilitators in the current system.
Therefore it is difficult to integrate the findings directly.
It is important to note that the quantitative studies were all conducted in the USA, while the
qualitative studies were describing patient and clinician experiences in the UK. This makes it
harder to make a direct comparison as the populations, health care systems and social
context are different. Therefore it is hard to tell whether the intervention in the quantitative
results supports the qualitative account of UK experiences. There were, however, no direct
contradictions between the two evidence bases.

Does the qualitative evidence explain why the intervention is/is not effective?
In the qualitative evidence, some healthcare practitioners described the benefits of having
tools and guidance in place at their clinic to support making identifications, which may
explain why the tools used in the interventions were effective. It can also be inferred from the
qualitative findings that the barriers around raising the topic are eased by having it raised
externally by the computer prompt. It may also have reduced the stigma of singling out a
patient if the prompt is used for everyone and communicated as a calculation, rather than
singling out a patient based on the clinicians perception of them as overweight.

Does the qualitative evidence explain differences in the direction and size of effect
across the included quantitative studies?
Diagnosis of overweight or obesity from the total number of patients seen is the only
outcome with results that vary in magnitude (but all favour the use of tools). The differences
between studies are more likely to be a product of variance from using different intervention
methods than from the qualitative experience of identification.

Which aspects of the quantitative evidence were/were not explored in the qualitative
studies?
The qualitative evidence did not explore how patients felt about being identified using
opportunistic identification prompts. The committee commented that the interventions
described in the quantitative evidence were similar to systems that are commonly used in the
UK, but the qualitative evidence did not directly reference them.

Which aspects of the qualitative evidence were/were not tested in the quantitative
studies?
The qualitative evidence provided a wealth of barriers and facilitators across the span of a
clinical encounter, whereas the quantitative evidence only examined opportunistic
identification using system prompts. There is scope for quantitative investigation on
addressing the barriers in clinicians approaches to identification in general; whether to
identify an individual; how to raise the topic of weight; how to discuss weight; and referral to
services.

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2.1.8 Economic evidence

2.1.8.1 Included studies

A combined search was conducted for economic evidence on identification and uptake in
children, young people and adults. This search retrieved 444 studies, and all of them were
excluded after the title and abstract screening. Thus, the review for this question does not
include any study from the existing literature.

2.1.8.2 Excluded studies

Not applicable.

2.1.9 Summary of included economic evidence

No existing economic studies were included for this review question.

2.1.10 Economic model

No economic modelling was conducted for this review question.

2.1.11 Unit costs

Not applicable.

2.1.12 The committee’s discussion and interpretation of the evidence

The committee discussion of the quantitative evidence and qualitative evidence are
presented together.

2.1.12.1. The outcomes that matter most

Quantitative evidence
During the development of the review protocol, the committee identified a number of
important outcomes such as people identified as overweight or obese, referral to weight
management services and health related quality of life. Other important outcomes included
adverse events such as stigma, eating disorders and disordered eating behaviours.
The committee consensus was that the direct measure of identification – the number of
people identified – was the most important outcome for decision making. The committee
were also interested in stigma as a factor in how often to take measurements and how to
approach talking to people about weight. There was less focus on referral to weight
management services and health related quality of life. The committee also noted that eating
disorders and disordered eating can be prevalent in young people, particularly among
women, however no quantitative evidence was found on this as an adverse event.
Qualitative evidence

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Qualitative outcomes were individual perspectives, experiences, values, beliefs, preferences,

views and considerations that describe the barriers and facilitators to identification of
overweight and obesity. These outcomes covered 5 broad themes with 13 subthemes:
• Identification in general: tools and guidance; responsibility to identify
• Identification of an individual: confidence; competing priorities; which patients should
be identified
• Raising the topic of weight with a patient: relationship between patient and HCP;
framing as a health concern; stigma
• Discussing weight management: motivation; tailoring conversations; carers and
support workers
• Referral and management: advice and planning; referrals
Evidence from the UK was considered more important than evidence from other countries.
As there was a mixture of UK and international evidence for all themes, it was inferred that
the international evidence was applicable to a UK setting. The committee were particularly
interested in themes that described stigma and patient choice in weight management
discussions, which they applied to the recommendations they created.

2.1.12.2 The quality of the evidence

The quantitative evidence was rated from low to moderate confidence using the GRADE
criteria. Two out of the 3 studies were rated as moderate risk of bias, which resulted in the
outcomes being downgraded. There were also issues with consistency as one of the
outcomes had an I²= 36% and another had an I² = 93%, which is likely a result of differences
between the tools and how they were implemented. Despite this, the evidence showed a
clear benefit of using these tools so the committee were satisfied with interpreting the
evidence as favouring these interventions.
The committee were satisfied with the confidence ratings given to the qualitative evidence
using the GRADE-CERQUAL criteria. The majority of the themes were rated as high
confidence (6 themes) or moderate confidence (6 themes). There was 1 theme rated as low
confidence. Themes were mostly downgraded due to minor concerns about coherence
arising from conflicting or inconsistent views within the data. The committee felt this evidence
base was strong enough to support recommendations made from it.
Although there was sufficient quantitative evidence of adequate quality to recommend using
tools to prompt clinicians to address weight opportunistically, the committee felt that it was
not appropriate to make a recommendation on this without specific tools available. They
were also concerned that the quantitative evidence only covered one intervention type, but
decided not to make a research recommendation as they did not have any other specific
interventions to request further research on.
The committee also noted that both the quantitative and qualitative evidence was focused on
healthcare settings. They felt it was important to also consider how social care and health
advocates in the community could contribute to identification of overweight and obesity. The
evidence was also limited in terms of age, as none of the studies looked at older adults.
Although the review questions focused on people from minority ethnic family backgrounds,
there were no quantitative studies that looked specifically at these populations and limited
qualitative evidence addressing issues that affect them. Taking these limitations into account,
the committee chose to draft a research recommendation. They felt that the lack of evidence
on people from minority ethnic family backgrounds was the most important gap, so opted to
focus solely on recommending further research on this population. Without any additional

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evidence to base changes on, they chose to retain the three existing recommendations on
raising awareness among people from minority ethnic family backgrounds.

2.1.12.3 Benefits and harms

Current practice
A briefing for NICE guideline developers and committee members on obesity, weight
management and health inequalities highlighted that the greatest rates of adult obesity are
seen in the most deprived parts of the country. The difference is particularly pronounced for
women, where 39% of women in the most deprived areas are obese, compared with 22% in
the least deprived areas. This disparity highlights the importance of identification and
subsequent uptake of weight management services.
Existing NICE guidance states that healthcare professionals should use clinical judgement to
decide when to measure a person’s height and weight. Opportunities include when
registering with a GP, consultations for related conditions (such as type 2 diabetes and
cardiovascular disease) and other routine health checks.
Unlike for children and young people, the committee noted that there aren’t established
measurement programmes for adults, but the Quality Outcomes Framework (QOF) does
recommend the establishment and maintenance of a register of patients aged 18 years or
over with a BMI ≥30 in the preceding 12 months. Within health and social care practice, there
is also a push towards making every contact count (MECC) which is a behaviour change
approach that enables the opportunistic delivery of consistent and concise healthy lifestyle
information and enables individuals to engage in conversations about their health.
While the quantitative evidence primarily focused on the use of electronic record tools, these
tools do already form part of opportunistic identification. Also, as opportunistic identification is
one of the main methods of identification, the committee wished to retain the existing
recommendation but amend it to match current practice.

Opportunities for measurement

The committee debated how often people should be measured. Some members supported
the idea of measurements be conducted routinely. The committee members also felt that
height and weight are important parameters in a clinical setting, and that there are many
reasons to regularly measure people (e.g., eating disorders and cancer etc.) beyond
identifying overweight and obesity. The committee also hypothesised that if measurements
are conducted more routinely, the stigma associated with being measured may be reduced.
They also discussed what would constitute ‘routine measurement’ and whether this should
be every 6 months, every year, or every appointment. However, there were concerns about
adding further burden to the service by suggesting measurements should be taken at every
appointment. The lived experiences of the committee members also highlighted that being
regularly weighed by their GP was seen as unnecessary and humiliating, and they did not
want to experience that further.

Some committee members also countered that it is inappropriate to measure at every

contact. They were concerned about the stigma of addressing weight in situations where it
wasn’t relevant to the person or their condition. The qualitative evidence also showed that
there are competing priorities in a clinical interaction which often meant that weight was not
addressed. The committee agreed with this finding and highlighted that in practice, routine
consultations do not allow enough time for weight to be discussed. However, they stated that

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the primary purpose of the appointment should always be prioritised. The committee also
noted the evidence of diagnostic overshadowing, defined as the attribution of symptoms to
an existing diagnosis rather than a potential co-morbid condition: in cases of opportunistic
identification, people often felt that the issue they presented with was overshadowed by
discussions of weight which could be stigmatising and unhelpful. Lay members confirmed
that this was a very common experience and so suggested that avoiding diagnostic
overshadowing should be explicitly included in the recommendations in order to reverse the
trend.

Based on this discussion, the committee suggested that weight should be measured when it
is clinically relevant rather than at every opportunity so that it can be addressed appropriately
and respectfully. As previously mentioned, the QOF states that if someone has been
identified as overweight or obese, they should be measured for 12 months. While the
committee chose not to specify this in the recommendations, they wished to emphasise the
importance of maintaining a record.

Existing NICE recommendations also stated that healthcare professionals should use clinical
judgement to decide when to measure a person’s height and weight. The committee
discussed the phrase ‘use clinical judgement’ and concluded that professional judgement is
more appropriate, as it applies to a wider range of roles. This judgement should take into
consideration the context of the person’s health, circumstances, openness to engage and the
appropriateness of discussing weight. The qualitative evidence contained many accounts of
negative experiences where healthcare providers did not take these contextual factors into
account, so the committee felt that it was important to keep these issues at the forefront
when making a professional judgement.

Based on these discussions the committee amended the existing recommendations to state
that professional judgement should be used to decide when to record an up-to-date measure
of a person’s height and weight. As existing guidance also state that waist-to-height ratio can
be used as a practical measure of central adiposity, the committee further amended the
recommendation to state that waist circumference can also be measured in people with BMI
below 35 kg/m2 to enable waist-to-height ratio to be calculated. They also chose to expand
upon what opportunities may be appropriate and to highlight the influence of social context
and ethnicity, as these were common themes in the qualitative evidence.

Additionally, the committee recommended that before discussing weight, health and care
professionals should talk about the condition first (e.g., patient coming in for hip pain) to
avoid diagnostic overshadowing, and then use professional judgement to identify if it’s an
appropriate opportunity to have a discussion about weight.

Lastly, existing guidance encourages people with BMI below 35 kg/m2 to assess their waist-
to-height ratio as a method of assessing central adiposity and seeking advice and further
clinical assessment if the measurements indicate increased risk. This could mean that health
and care professionals may see more people wanting to discuss their results. Based on this
understanding, the committee further recommended that health and care professionals
should ensure that records are kept up to date for people who have self-referred to discuss
their weight or health risks associated with central adiposity.

The committee noted that the updated recommendations should encourage health and care
practitioners to consider maintaining an up-to-date record of a person’s measurements. They
also noted that the new recommendations are in line with advice provided in Public Health

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England’s (PHE) guidance, which also promotes weight being measured and discussed as
part of routine consultation.

Consent and taking measurements

The committee noted that is important to have the individual in mind when introducing
conversations about weight and recognising when it is not appropriate. While the existing
recommendation did focus on using clinical judgement, it did not mention the importance of
consent. Therefore, the committee agreed that it is very important for healthcare
professionals to ask permission before engaging in discussions on the degree of overweight,
obesity and central adiposity.
The qualitative evidence demonstrated that the patients’ consent and choice in whether to
discuss weight was often seen as the deciding factor in whether to initiate a conversation.
The committee agreed with this finding and felt it was important acknowledge that some
people do not want to be weighed on any occasion, and that their wishes should be
respected. Based on this understanding, the existing recommendation was amended to state
that measurements should only be taken once consent is granted and that health and care
professionals should seek permission before conducting any discussions about the degree of
overweight or obesity.

Stigma and principle of care

The committee highlighted that there is stigma associated with being measured and with the
subsequent discussions of results. The qualitative evidence highlighted that many patients
had experiences where healthcare professionals had talked about their weight in an
insensitive manner. These experiences had made them feel wary and defensive when weight
was brought up in subsequent medical encounters. Qualitative evidence indicated that
patients also felt that raising the subject of their weight in a clinical encounter, especially
when it was not relevant was stigmatising.
Additionally, patients felt more comfortable when discussions were linked to health concerns
as it took the focus away from their appearance and the social stigma of weight. However,
patients did not trust BMI measures and saw a high BMI as insufficient reason to identify
someone as overweight. They needed more direct evidence of how their weight was
affecting their health to see the relevance of it.
The qualitative evidence also addressed the views of healthcare professionals. This
evidence showed that healthcare professionals agreed that they had a responsibility to help
prevent obesity, but some did state that they found it difficult to initiate conversations about
weight. Those who lacked the confidence to discuss weight avoided addressing weight as
they felt they could do more harm than good. They also felt that they didn’t have enough
knowledge or training on the subject of weight management and others felt they didn’t have
enough skills or experience in communicating sensitive issues.
The evidence also showed that the conversation, support or referral to weight loss services
was often well received when the patient was motivated. If a patient was not motivated, the
conservations were usually less productive. The evidence also highlighted how general
practitioners adapted their discussions to a range of patients’ knowledge, personal risks
factors and previous weight management experience. Evidence also showed that factors
such as physical disabilities, learning disabilities and cultural beliefs about weight should be
considered during discussions.

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Based on these findings and their understanding of practice, the committee highlighted the
importance of outlining the ethos or key principles of care for health and care professionals.
The committee outlined that before discussions take place about the degree of overweight
and obesity, health and care professionals should take into account the context and
appropriateness of the discussion or appointment and to respect someone’s choice not to
discuss their weight on this occasion as it may have been raised on numerous occasions.
Furthermore, the committee also mentioned that a potential unintended consequence of
being measured is that it can have a profound effect of how the person feels about
themselves and runs a risk of perpetuating or triggering over-emphasis on body image and
size, as well as disordered eating or eating disorders. Based on this understanding the
committee stressed the importance of ensuring that all discussions linked to the degree of
overweight and obesity are conducted in a sensitive manner.
To further support health and care professionals, the committee outlined steps that can
ensure conversations occur in a sensitive manner. This includes using, non-stigmatising
language and preferred terms such as ‘person living with obesity’ and engaging with adults to
identify their preferred terms. All forms of communication should also use non-stigmatising
language and images.
The committee also stressed the importance of using a person-centred, solution-based
approach during discussions which considers factors such as previous weight management
experience, the level of readiness to engage, cultural, religious/faith and spiritual beliefs
about overweight and obesity and being mindful of the barriers that prevent or restrict weight
loss. The committee further stated that it is important for the focus of discussion to be on
improvements in health as opposed to simply taking about weight.

Lastly, evidence demonstrated that in many areas there were either very few overweight or
obesity services or healthcare professionals did not know what services there were. While
the committee agreed the availability of overweight or obesity services is an issue in many
areas across the UK, they also highlighted that it was important for health and care
professionals involved in identification of overweight and obesity to be aware of the range of
services are locally available.
The committee noted that these steps were important for the development of a trusting
relationship between people and health and care professionals. They also noted by taking a
positive and sensitive approach to measurement and subsequent discussion of weight would
allow conversations to occur in a respectful manner. The committee also highlighted that
these recommendations are in agreement with PHE guidance as well as guidance on a/the
healthier weight competency framework produced by Health Education England which states
that health and care staff that are involved with engaging with people about a healthier
weight should be able to understand the stigma that is associated with weight, the impact this
can have on people, be able to identify implications of the person’s weight status and be able
to discuss empathically and accurately.
While training is outside the remit of this update, the committee also noted that there are
various resources that are available that provide further guidance on the steps healthcare
professionals can take to discuss weight in a sensitive manner. This includes guidance
produced by Obesity UK on language matters. There are also training courses produced by
the Royal College of General Practitioners (RCGP) which explore the effect of weight stigma
in children and by World Obesity Federation which explore how to raise the issue about
obesity with patients. Additionally, there are webinars available such as those produced by
the European Association for the Study of Obesity (EASO) which also focus on how
healthcare professionals should talk about weight.

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2.1.12.4 Cost effectiveness and resource use

No health economic studies were identified for this question.
The committee made a recommendation to use professional judgement to decide when to
record weight and height of a person. The more inclusive term “professional judgement” will
allow a wider range of practitioners to make their decisions on weight and height
measurement based on a variety of clinical and personal considerations. The committee
made additional recommendations to tackle issues related with stigma by highlighting the
importance of taking into account the context, socio-economic background and ethnicity.
Overall, the new recommendations are not expected to increase NHS resource significantly.
It is possible that weight and height will be measured more often following the
recommendation, thus possibly increasing the length of appointments. However, the more
flexible approach is expected to lead to more appropriate measurements enhancing NHS
efficiency in the identification of people who are overweight or obese. Moreover, the
additional recommendations tackling stigma are expected to reduce people’s distress during
visits and routine health checks which will improve their quality of life and reduce their
likelihood of not attending follow-up appointments.

2.1.12.5 Other factors the committee took into account

Wider determinants and the context of overweight and obesity

Upon discussion of the wider evidence base from reviews 1.3, 1.4, and in line with the
recommendations made for children and young people, the committee drafted an
overarching recommendation in the principles of care to think about the wider determinants
and the context of overweight and obesity. This recommendation included a non-exhaustive
list of examples to encourage consideration of overweight and obesity as a complex health
issue which requires a holistic approach. The committee chose to use this as both a
standalone recommendation and a recommendation to cross-refer to throughout the
guideline when these factors are relevant.

People from minority ethnic family backgrounds

Although the review question focused particularly on people from minority ethnic family
backgrounds, there were no quantitative studies that looked at these groups specifically and
very little qualitative evidence on their experiences. The committee looked at the equality
impact assessment and considered how the recommendations may affect people from
different minority ethnic family backgrounds.
They highlighted that the new recommendations were applicable for people from minority
ethnic family backgrounds as the core principles of these recommendations were
demonstrating sensitivity and using a person-centred approach which takes ethnicity into
consideration. The committee also noted that there is need to spread awareness amongst
health and care professionals as well as the public of the increased risk people from minority
ethnic family backgrounds face at a lower BMI.
Based on this understanding the committee retained existing NICE recommendations which
promote this understanding and as well as recommendations that promote the use of existing
local information networks to share information on the increased risks these group face at a
lower BMI.

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People with disabilities, learning disabilities and neurodevelopmental disabilities

There was some evidence of additional challenges in identifying overweight in people with
learning disabilities due to communication difficulties or continuity of care with support
workers. The committee felt that people with disabilities, learning disabilities and
neurodevelopmental disabilities were adequately covered by the recommendations they
drafted and would additionally be identified during regular specialist health checks.
Furthermore, it was highlighted that there are existing NICE guidelines that can help health
and care professionals plan the care for people with learning disabilities and
neurodevelopment disabilities. These include guidance on learning disabilities and behaviour
that challenges: service design and delivery (NG93), care and support for people growing
older with learning disabilities (NG96), autism spectrum disorder in adults: diagnosis and
management (CG142) which can help healthcare professionals.

Older adults
No qualitative or quantitative evidence was identified on the identification of people from
older age groups, however their individual needs and circumstances should be considered
using a person centred approach, which is highlighted in the recommendations.

2.1.13 Recommendations supported by this evidence review

This evidence review supports recommendations 1.1.1 to 1.1.5, 1.8.1 to 1.8.3, 1.9.1 to 1.9.4,
1.10.1, 1.11.5 to 1.11.11 and the research recommendations outlined in appendix K.

2.1.14 References – included studies

2.1.14.1 Effectiveness
Lee, Nam-Ju, Chen, Elizabeth S, Currie, Leanne M et al. (2009) The effect of a mobile clinical
decision support system on the diagnosis of obesity and overweight in acute and primary care
encounters. ANS. Advances in nursing science 32(3): 211-21

Tang, Joyce W, Kushner, Robert F, Cameron, Kenzie A et al. (2012) Electronic tools to assist with
identification and counseling for overweight patients: a randomized controlled trial. Journal of
general internal medicine 27(8): 933-9

Wee, Christina C., Baer, Heather J., Orav, Endel J. et al. (2016) Use of electronic health records for
addressing overweight and obesity in rimary care: Results from a cluster-randomized controlled
trial. Journal of General Internal Medicine 31(2suppl1): 452-s453

2.1.14.2 Qualitative evidence

Atlantis, Evan, John, James Rufus, Fahey, Paul Patrick et al. (2021) Clinical usefulness of brief
screening tool for activating weight management discussions in primary cARE (AWARE): A
nationwide mixed methods pilot study. PloS one 16(10): e0259220

Beeken, Rebecca J., Scott, Anna M., Sims, Rebecca et al. (2021) A Community Jury on initiating
weight management conversations in primary care. Health expectations : an international journal of
public participation in health care and health policy 24(4): 1450-1458

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Blackburn M, Stathi A, Keogh E et al. (2015) Raising the topic of weight in general practice:
perspectives of GPs and primary care nurses. BMJ open 5(8): e008546

Doherty, Alison J, Jones, Stephanie P, Chauhan, Umesh et al. (2019) Healthcare practitioners'
views and experiences of barriers and facilitators to weight management interventions for adults
with intellectual disabilities. Journal of applied research in intellectual disabilities : JARID 32(5):
1067-1077

Glenister KM; Malatzky CA; Wright J (2017) Barriers to effective conversations regarding
overweight and obesity in regional Victoria. Australian family physician 46(10): 769-773

Gunther, Stephen, Guo, Fenglin, Sinfield, Paul et al. (2012) Barriers and enablers to managing
obesity in general practice: a practical approach for use in implementation activities. Quality in
primary care 20(2): 93-103

Holmgren, Marianne, Sandberg, Magnus, Ahlstrom, Gerd et al. (2019) To initiate the conversation-
Public health nurses' experiences of working with obesity in persons with mobility disability. Journal
of Advanced Nursing 75(10): 2156-2166

Phillips, Katie; Wood, Fiona; Kinnersley, Paul (2014) Tackling obesity: the challenge of obesity
management for practice nurses in primary care. Family practice 31(1): 51-9

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Appendices
Appendix A – Review protocols
Review protocol for identifying overweight and obesity

1. Review title Identifying effective approaches for identifying overweight and obesity in adults and in children and young people.

Identifying barriers to and facilitators for identifying overweight and obesity in adults and in children and young people.

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2. Review question 1.3 a) What approaches are effective and cost-effective in identifying overweight and obesity in children and young people,
particularly those in black, Asian and minority ethnic groups?

1.3 b) What approaches are effective and cost-effective in identifying overweight and obesity in adults, particularly those in
black, Asian and minority ethnic groups?

1.3 c) What are the barriers and facilitators to identifying overweight and obesity in children and young people, particularly
those in black, Asian and minority ethnic groups?

1.3 d) What are the barriers and facilitators to identifying overweight and obesity in adults, particularly those in black, Asian
and minority ethnic groups?

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3. Objective Identifying the most effective and cost-effective approaches for identifying overweight and obesity in adults and in children
and young people, particularly those in black, Asian and minority ethnic groups.

Identifying barriers and facilitators to identifying overweight and obesity in adults and in children and young people,
particularly those in black, Asian and minority ethnic groups, and increasing their uptake to weight management services.

4. Searches Databases to be searched:

• Medline/MIP/MEP
• Embase
• Cochrane CDSR/CENTRAL
• HMIC
• SPP
• PsycInfo

Searches will be restricted by:

• English language
• Human studies
• Systematic reviews
• UK and OECD countries
• Date: 2000 – current
• Experimental studies (e.g.RCT/Controlled trials)
• UK and OECD countries
• Date: 2000 – current
• Observational studies (as needed)
• UK and OECD countries
• Date: 2000 – current
• Qualitative studies
• Country limit: UK. Expand to Australia, Canada, Ireland, the Netherlands and Scandinavia (Denmark,
Norway, and Sweden) if insufficient UK studies are found.
• Date limit: 2010 - current
• Mixed method studies
• Country limit: UK. Expand to Australia, Canada, Ireland, the Netherlands, and Scandinavia (Denmark,
Norway, and Sweden) if insufficient UK studies are found.

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• Date limit: 2010 - current

The searches will be re-run 6 weeks before final submission of the review and further studies retrieved for inclusion.

The full search strategies for MEDLINE database will be published in the final review.
5. Condition or domain Weight management / obesity management
being studied
6. Population Inclusion for RQ1.3a and 1.3c
• Children and young people aged under 18 years
Where possible, evidence will be stratified by ethnicity:
o White
o Black African/ Caribbean
o Asian (South Asian, Chinese, any other Asian background)
o Other ethnic groups (Arab, any other ethnic group)
o Multiple/mixed ethnic group

Further stratification within this group will be informed by the analysis undertaken in the included studies. Studies that do not
stratify by ethnic group will not be excluded though.

• Parents and carers

• Staff undertaking identification of children and young people with overweight or obesity and engaging them in weight
management services.

Inclusion for RQ1.3b and 1.3d

• Adults 18 years and over.
Where possible, evidence will be stratified by ethnicity:
• White
• Black African/ Caribbean
• Asian (South Asian, Chinese, any other Asian background)
• Other ethnic groups (Arab, any other ethnic group)
• Multiple/mixed ethnic group

Further stratification within this group will be informed by the analysis undertaken in the included studies. Studies that do not
stratify by ethnic group will not be excluded though.

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• Staff undertaking identification of adults with overweight or obesity and engaging them in weight management services.

Exclusion:
• People whose body weight is below the healthy range (underweight)
• Pregnant women
• Children under the age of 2 years
• 1.3a and 1.3c only: People aged 18 years and over
• 1.3b and 1.3d only: Children and young people under 18 years
7. Intervention 1.3a and d) Methods of identification:
• Opportunistic identification, including but not confined to:
o When registering with GP
o When receiving consultation for health conditions (e.g., chronic health conditions)
o During routine check-up/ annual check-up (delivered by GPs, nurses or pharmacists, social care staff)
o During medication check (e.g., contraception pill check)
o During vaccination appointments
o Visits to secondary care (e.g., outpatient clinics and emergency departments or physiotherapist appointments)

• Active case finding (defined as searching systematically for at risk people, rather than waiting for them to present with
symptoms or signs of active disease). This includes but is not confined to:
o Review of medical records
o Receiving or received interventions for example brief physical activity advice (delivered by GPs, nurses,
pharmacists, activity providers)
o audits of other services (e.g. disability services or endocrinology services)
• Self-identification or referral
• Parent/ carer-initiated identification or referral
• School nurse/ teacher / health visitor / social services-initiated identification or referrals

1.3b and 1.3d) Methods of identification

• Opportunistic identification, including but not confined to:
o When registering with GP
o When receiving consultation for health conditions (e.g., chronic health conditions)
o During routine check up/ annual check-ups (delivered by GPs, nurses, pharmacists and social care staff)

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o During medication checks (e.g. contraception pill check)

o During vaccination appointments
o Visits to secondary care (e.g., outpatient clinics and emergency departments or physiotherapist appointments)

• Active case finding (defined as searching systematically for at risk people, rather than waiting for them to present with
symptoms or signs of active disease). This includes but is not confined to:
o Review of medical records
o Receiving or received interventions for example brief physical activity advice (delivered by GPs, nurses,
pharmacists, activity providers)
o audits of other services (e.g. disability services or endocrinology services)
• Receiving or received interventions for example brief physical activity advice, diabetes prevention programme, smoking
cessation programme, counselling for low calorie diets (delivered by GPs, nurses, pharmacists, activity providers)

• Self-identification or referral
• Carer initiated identification or referral

8. Comparator/Reference Quantitative review

standard/Confounding • No intervention/usual care
factors • Comparison of interventions

Qualitative review
Not applicable

9. Types of study to be Quantitative review

included • Systematic reviews of included study designs
• RCTs
• Observational studies (cohort studies)
• Mixed methods studies (quantitative evidence that matches the above study designs only)

A stepped approach will be used to select quantitative studies:

• Systematic reviews and RCTs will be prioritised.
• Then, if there is insufficient evidence, observational studies (cohort studies) will be included as needed.

Qualitative review

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• Systematic reviews of included study designs

• Qualitative studies that collect data from focus groups and interviews.
• Qualitative studies that collect data from open-ended questions from questionnaires
• Mixed method study designs (qualitative evidence that matches the above study designs only)

A stepped approach will be used to select qualitative studies:

• UK studies will be prioritised
• If there is insufficient UK evidence in some areas, studies based in Australia, Canada, Ireland, the Netherlands and
Scandinavia (Denmark, Norway, and Sweden) will be included because they also have universal healthcare and
similar populations to the UK.
• Interview and focus group study designs will be prioritised.
• If there is insufficient evidence from interviews and focus groups, studies using questionnaires with open-ended
questions will be included.

There is no strict definition of insufficient evidence, but in discussion with the guideline committee we will consider whether
we have enough to form the basis for a recommendation.

10. Other exclusion • Non-English language studies

criteria • Quantitative studies published prior to 2000
• Qualitative studies published prior to 2010
• Non-OECD
• Conference abstracts
• Narrative reviews
• Studies with samples who are already engaged in weight-loss interventions
• Studies evaluating weight management programmes
• Studies focusing on training needs.
11. Context This review is part of an update of the NICE guideline for weight management: preventing, assessing and managing
overweight and obesity (update). Specifically, the questions in this protocol seek to update elements from obesity:
identification, assessment and management (2014) NICE guideline CG189, weight management: lifestyle services for
overweight or obese adults (2014) NICE guideline PH53, weight management: lifestyle services for overweight or obese
children and young people (2013) NICE guideline PH47 and obesity prevention (2006) NICE guideline CG43. Central
adiposity is a risk factor for development of CVD, type 2 diabetes, hypertension, dyslipidaemia or some type of cancer in
children and young people. Currently, people who are overweight, or living with obesity are identified through the healthcare

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system opportunistically. There is concern that relying on opportunistic identification, rather than active case finding,
increases the likelihood that conditions such as type 2 diabetes will be under-diagnosed in black, Asian and other minority
groups whose risk of these conditions is increased at a lower BMI and waist circumference than the general population.
The questions this protocol seeks to investigate:
1) What approaches are effective and cost-effective in identifying overweight and obesity in children and young people,
particularly those in black, Asian and minority ethnic groups?
2) What approaches are effective and cost-effective in identifying overweight and obesity in adults, particularly those in
black, Asian and minority ethnic groups?
3) What are the barriers and facilitators to identifying overweight and obesity in children and young people, particularly those
in black, Asian and minority ethnic groups?
4) What are the barriers and facilitators to identifying overweight and obesity in adults, particularly those in black, Asian and
minority ethnic groups?
12. Primary outcomes RQ1.3a and RQ1.3c:
(critical outcomes)
Quantitative review
• Number of children and young people identified as overweight or obese
• Referral to weight management service
• Health-related quality of life

Qualitative review
Barriers and facilitators to the identification and engagement of overweight and obese children and young people. These
may include:
• Thoughts, views and perceptions of individuals, parents or carers
• Thoughts of staff undertaking identification of children and young people who are living with overweight and obesity
o Issues relating to education
o Issues relating to stigma
o Issues relating to self-esteem
o Issues relating to cultural sensitivities

RQ1.3b and RQ1.3d:

• Number of people identified as overweight or obese
• Referral to weight management service

Barriers and facilitators to the identification and engagement of overweight and obese people including, but not limited to:

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• Thoughts, views and perceptions of individuals or carers

• Thoughts of staff undertaking identification of people who are living with overweight of obesity
• Issues relating to education
• Issues relating to stigma
• Issues relating to self-esteem
• Issues relating to cultural sensitivities

13. Secondary outcomes • Adverse events:

(important outcomes) o Eating disorders or disordered eating
o Stigma (including self-stigma and negative body image as defined in studies)
14. Data extraction • All references identified by the searches and from other sources will be uploaded into EPPI reviewer and de-
(selection and coding) duplicated. 10% of the abstracts will be reviewed by two reviewers, with any disagreements resolved by discussion or, if
necessary, a third independent reviewer.

• This review will make use of the priority screening functionality within the EPPI-reviewer software. A stopping
criteria will also be used. We will sift at least 60% of the database. After that we will stop screening if a further 5% (of the
total records) of the records are sifted and not included.

• The full text of potentially eligible studies will be retrieved and will be assessed in line with the criteria outlined
above. A standardised form will be used to extract data from studies (see Developing NICE guidelines: the manual section
6.4). Study investigators may be contacted for missing data where time and resources allow.

15. Risk of bias (quality) Risk of bias will be assessed using an preferred checklist as described in Developing NICE guidelines: the manual.
assessment

16. Strategy for data • A mixed methods approach with be used to address questions 1.3 and 1.4 in conjunction.
synthesis
• The quantitative (RQ1.3) and qualitative (RQ1.4) reviews will be conducted separately (segregated study design)
but at the same time. The evidence from the reviews will then be analysed in relation to each other (convergent synthesis of
results). (See below for more details. The findings will not be integrated by transforming one type of evidence into the other
(e.g. quantitative findings into qualitative findings).

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Quantitative review:

• For the quantitative component, data will be extracted from quantitative and mixed methods (quantitative component
only) studies. Where possible, meta-analyses of outcome data will be conducted for all comparators that are reported by
more than one study, with reference to the Cochrane Handbook for Systematic Reviews of Interventions (Higgins et al.
2011). Data will be separated into the groups identified in section 17.

• Continuous outcomes will be analysed as mean differences, unless multiple scales are used to measure the same
factor. In these cases, standardised mean differences will be used instead. Pooled relative risks will be calculated for
dichotomous outcomes (using the Mantel–Haenszel method) reporting numbers of people having an event. Absolute
risks will be presented where possible.

• Fixed- and random-effects models (der Simonian and Laird) will be fitted for all comparators, with the presented analysis
dependent on the degree of heterogeneity in the assembled evidence. Fixed-effects models will be deemed to be
inappropriate if one or both of the following conditions is met:

o Significant between study heterogeneity in methodology, population, intervention or comparator was identified
by the reviewer in advance of data analysis.
o The presence of significant statistical heterogeneity in the meta-analysis, defined as I2≥50%.

• In any meta-analyses where some (but not all) of the data comes from studies at high risk of bias, a sensitivity analysis
will be conducted, excluding those studies from the analysis. Results from both the full and restricted meta-analyses will
be reported. Similarly, in any meta-analyses where some (but not all) of the data comes from indirect studies, a
sensitivity analysis will be conducted, excluding those studies from the analysis.

• GRADE will be used to assess the quality of the outcomes. Outcomes using evidence from RCTs, non-randomised trials
and cohort studies will be rated as high quality initially and downgraded from this point. Controlled before and after
studies and interrupted time series will be rated as low quality initially. Reasons for upgrading the certainty of the
evidence will also be considered.

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• Where 10 or more studies are included as part of a single meta-analysis, a funnel plot will be produced to graphically
assess the potential for publication bias.

• Meta-analyses will be carried out separately for each study type per outcome, but the similarities and differences
between the results obtained from the different study types will be noted.

• Critical quantitative outcomes will be prioritised for mixed method approach, depending on the evidence identified.

Qualitative review:

• Where multiple qualitative studies are identified for a single question, information from the studies will be combined
using a thematic synthesis. By examining the findings of each included study, themes will be independently identified
and coded in NVivo release 1.5.1.

• Once all of the included studies have been examined and coded, the resulting themes and sub-themes will be evaluated
to examine their relevance to the review question, the importance given to each theme, and the extent to which each
theme recurs across the different studies. The qualitative synthesis will use these themes to develop an analytical
interpretation of the evidence with regard to the overarching review questions.

• CERQual will be used to assess the confidence we have in the summary findings of each of the identified themes.
Evidence from all qualitative study designs (interviews, focus groups etc.) is initially rated as high confidence and the
confidence in the evidence for each theme will be downgraded from this initial point.

• If there are more than 20 studies included in the review, we will use the Ames et al. (2019) approach to prioritise
evidence.

Synthesising the findings of mixed method reviews.

• Where mixed methods studies are identified that present data in a form that cannot be extracted and analysed
separately as quantitative and qualitative data, the results of the studies will be reported separately for each study. Any

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correlations or discrepancies between the findings of the mixed methods studies and the syntheses of the quantitative
and qualitative findings of the above analyses will be noted.

Mixed method synthesis of findings from the quantitative and qualitative reviews

• A convergent segregated approach will be used the synthesise and integrate the qualitative and quantitative aspects of
the reviews, where sufficient data has been identified to enable this. Where appropriate, a synthesis matrix will be
produced to combine results from the two different analytical approaches. Findings from one analytical approach will be
compared to findings from the second approach, and outcomes paired up if they provided relevant information on the
same underlying topic for example, barriers to identification may be paired up with interventions that address these
barriers. The agreement between the findings of the two approaches will be qualitatively assessed, with each paired set
of findings put into categories relating to the strength of the identified correlation. The 5 questions required by JBI for
convergent segregated integration approach will be systematically applied.

• The results may be presented as a concept diagram which will summarise the quantitative findings mapped onto the
qualitative ones, if this is thought to be informative.

17. Analysis of sub-groups Results will be separated into the following for analysis:
System levels:
• service provider level (for example GP practices, practitioners, WM service providers, other professionals)
• individual level (individuals, parents and carers)
• mixed levels

Where possible stratification by the following sub-groups will be undertaken:

• Ethnicity (as detailed in section 6)

• Age:
o Children aged 2 up to 5 years (Early years)
o Children aged 6 up to 11 years (Primary school)

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o Children and young people aged 12 up to 16 years (Secondary school)

o Young people aged 17 up to 18 years (post-16 education)
o Younger adults
o Older adults
• Sex
• People with learning and physical disabilities
• People with chronic disease affecting mobility (e.g., neurological, musculoskeletal, and respiratory conditions)
• People with serious mental illness
• Socioeconomic group
• Index of multiple deprivation
• Intensity and/or duration of intervention
• Setting of delivery (e.g., hospitals, GP practice, residential homes)
• Severity of obesity
• Women with previous gestational diabetes
18. Type and method of ☒ Intervention
review ☐ Diagnostic
☐ Prognostic
☒ Qualitative
☐ Epidemiologic
☐ Service Delivery
☒ Other (mixed methods)

19. Language English

20. Country England

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See methods document

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Appendix B - Literature search strategies

Search design and peer review
A NICE information specialist conducted the literature searches for the evidence review. The
clinical searches were run on 21st January and 24th January. The searches were re-run on 12th
and 13th April 2023. The cost-effective searches were run on 1st and 2nd February. This search
report is compliant with the requirements of PRISMA-S.
The MEDLINE strategy below was quality assured (QA) by a trained NICE information
specialist. All translated search strategies were peer reviewed to ensure their accuracy. Both
procedures were adapted from the 2016 PRESS Checklist.
The principal search strategy was developed in MEDLINE (Ovid interface) and adapted, as
appropriate, for use in the other sources listed in the protocol, taking into account their size,
search functionality and subject coverage.

Review management
The search results were managed in EPPI-Reviewer v5. Duplicates were removed in EPPI-
R5 using a two-step process. First, automated deduplication is performed using a high-value
algorithm. Second, manual deduplication is used to assess ‘low-probability’ matches. All
decisions made for the review can be accessed via the deduplication history.

Prior work
A set of 13 test papers were supplied by the analysts and the committee.

Limits and restrictions

English language limits were applied in adherence to standard NICE practice and the review
protocol.
Limits to exclude letters, editorials, news, conferences were applied in adherence to standard
NICE practice and the review protocol.
The search was limited from 2000 to 2022, for systematic reviews, RCTs and observational
studies. The search was limited from 2010 to 2022 for qualitative studies, as defined in the
review protocol.
The limit to remove animal studies in the searches was the standard NICE practice, which
has been adapted from: Dickersin, K., Scherer, R., & Lefebvre, C. (1994). Systematic
Reviews: Identifying relevant studies for systematic reviews. BMJ, 309(6964), 1286.

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Search filters

Clinical/public health searches

• RCT filters:
o McMaster Therapy – Medline - “best balance of sensitivity and
specificity” version.
Haynes RB et al. (2005) Optimal search strategies for retrieving
scientifically strong studies of treatment from Medline: analytical survey.
BMJ, 330, 1179-1183.

o McMaster Therapy – Embase “best balance of sensitivity and

specificity” version.

Wong SSL et al. (2006) Developing optimal search strategies for

detecting clinically sound treatment studies in EMBASE. Journal of the
Medical Library Association, 94(1), 41-47.

• Systematic reviews filters:

o Lee, E. et al. (2012) An optimal search filter for retrieving systematic
reviews and meta-analyses. BMC Medical Research Methodology,
12(1), 51.

In MEDLINE, the standard NICE modifications were used: pubmed.tw

added; systematic review.pt added from MeSH update 2019.

In Embase, the standard NICE modifications were used: pubmed.tw

added to line medline.tw.

• Observational filter:
o The terms used for observational studies are standard NICE practice
that have been developed in house.
o The observational filter was adapted to remove controlled studies,
cross-sectional studies, case series studies.

• OECD filter:
o The OECD countries filters were used without modification:
o Ayiku, L., Hudson, T., Williams, C., Levay, P., & Jacobs, C. (submitted
for publication) The NICE OECD countries geographic search filters:
Part 2 - Validation of the MEDLINE and Embase (Ovid) filters. Journal
of the Medical Library Association (in peer review)

• Qualitative filter:
o The terms used for qualitative studies are standard NICE practice that
have been developed in house.

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Cost effectiveness searches

The NICE cost utility (specific) filter was applied to the Medline and Embase searches to
identify cost utility studies.

• Cost Utility filter is available via the ISSG search filters resource

Key decisions

For qualitative studies, the date limit was amended to 2010-2022. For systematic reviews,
RCTs and observational studies, the search was limited from 2000-2022. Non-OECD
countries were excluded from both sets of results, for Medline and Embase searches only.

The Medline and Embase searches were split into two files, one for qualitative studies and
one containing SR, RCTs and observational studies – this was to allow the analysts to limit
by study type within EPPI.

The results for RQ1.3 were imported into the same EPPI review as RQ1.4, this was to
reduce the number of duplicates between both sets of results.

The searches were translated from the Medline search strategy. If a MeSH term or
alternative was not available, the term was not included in that translation. For instance,
Obesity Management/ was not used in the Cochrane search.

The HMIC and SPP searches did not include any subject headings, instead heading words
were searched using the method outlined in Finnegan, A and Levay, P (2021) Translated
search strategies may require truncated subject headings for efficient public health retrieval.
Health Information and Libraries Journal

3 additional papers were added after the main search by the analyst. The papers were
identified by citation searching.

DARE (CRD) was not searched as it contains historical information. This review question
was interested in recently published evidence.

The database searches were re-run on 12th and 13th April 2023.

For the cost utility searches, a modified version of the searches was run in INAHTA and NHS
EED. This decision was taken because the search strategy is complex and the search
functionality in both databases would not be compatible.

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Clinical/public health searches

Main search – Databases

• Databas • No. of
• Databas • Dat • Databas
e segment or results
e e searched e platform
version downloaded

Qualitative -2180
1946 to January
Medline 21/01/2022 OVID
20, 2022 SR/RCT/Observationa
l - 3504

Medline in 1946 to January

21/01/2022 OVID 31
process 20, 2022

Medline ePub
21/01/2022 OVID January 20, 2022 29
ahead

Qualitative -3424
1974 to 2022
Embase 21/01/2022 OVID
January 20
SR/RCT/Observationa
l - 5227

Health
Management
1979 to November
Information 24/01/2022 OVID
2021
143
Consortium
(HMIC)

Social Policy and 24/01/2022

OVID 202201 69
Practice (SPP)

24/01/2022 1987 to January

PsycInfo OVID
Week 3 2022
5537

Issue 1 of 12,
Cochrane CDSR 21/01/2022 Wiley
January 2022
17

Cochrane Issue 1 of 12,

21/01/2022 Wiley 2053
CENTRAL January 2022

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Re-run search – Databases

Database
Date Database No. of results
Database segment or
searched platform downloaded
version

Qualitative - 110
1946 to April 12,
Medline 12/04/2023 OVID SR/RCT/Observational -
2023
171

12/04/2023 1946 to April 12,

Medline in process OVID 0
2023

12/04/2023 Qualitative - 14
Medline ePub ahead OVID April 12, 2023 SR/RCT/Observational -
13

12/04/2023 Qualitative - 383

1974 to 2023 April
Embase OVID SR/RCT/Observational -
12
579

Health Management
1979 to January
Information Consortium 12/04/2023 OVID 1
2023
(HMIC)

Social Policy and Practice 12/04/2023

OVID 202301 17
(SPP)

12/04/2023 2002 to April

PsycInfo OVID 406
Week 1 2023

Issue 4 of 12, April

Cochrane CDSR 13/04/2023 Wiley 2
2023

Issue 4 of 12, April

Cochrane CENTRAL 13/04/2023 Wiley 139
2023

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Search strategy history

Database name: Medline

1 Weight Reduction Programs/ (2658)
2 exp *obesity/ or overweight/ or Obesity Management/ (186290)
3 (obes* or preobese* or overweight* or over-weight*).ti,ab. (309636)
4 or/2-3 (336913)
5 (weight* adj1 (loss* or management* or reduc* or lifestyle* or life-style* or control* or
health*) adj2 (servic* or intervent* or program* or plan* or refer* or scheme* or treatment* or
trial* or therap* or clinic* or session*)).ti,ab. (11425)
6 4 and 5 (8939)
7 ((obes* or preobes* or overweight* or over-weight*) adj2 (loss* or management* or
reduc* or lifestyle* or life-style* or control* or health* or prevent*) adj2 (servic* or intervent* or
program* or plan* or refer* or scheme* or treatment* or trial* or therap* or clinic* or
session*)).ti,ab. (3231)
8 1 or 6 or 7 (13083)
9 exp *Obesity/di, pc or *Overweight/di, pc (14964)
10 ((obes* or preobese* or overweight* or over-weight*) adj1 (detect* or identif* or
diagnos*) adj3 (refer* or sign-post* or signpost* or transfer* or recruit* or evaluat* or advic* or
diagnos*)).ti,ab. (435)
11 or/9-10 (15272)
12 8 or 11 (26353)
13 "referral and consultation"/ or remote consultation/ or diagnostic self evaluation/ or exp
"Appointments and Schedules"/ (101388)
14 ((opportun* or holistic* or routine* or consultat* or appointment* or checkup* or check-
up*) adj3 (identif* or refer* or signpost* or sign-post* or transfer* or recruit* or detect* or
advic* or intervent* or diagnos*)).ti,ab. (48179)
15 (case-find* or active-case*).ti,ab. (6233)
16 self care/ or self-management/ (38709)
17 (self-refer* or self-report* or self-diagnos* or self-evaluat* or self-manag*).ti,ab.
(183140)
18 exp Health Personnel/ or "Attitude of Health Personnel"/ or professional-family
relations/ or professional-patient relations/ (665840)
19 ((clinician* or physician* or doctor* or nurse*1 or pharmacy* or pharmacies* or
pharmacist* or consultant* or practition* or primary-care* or dietician* or nutritionist* or GP*1
or HCP*1) adj3 (identif* or refer* or signpost* or sign-post* or transfer* or recruit* or detect*
or advic* or intervent* or diagnos*)).ti,ab. (83864)

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20 ((medical* or health or healthcare or clinical*) adj2 (staff* or team* or provide* or

agenc*) adj3 (identif* or refer* or sign-post* or signpost* or transfer* or recruit* or detect* or
advic* or intervent* or diagnos*)).ti,ab. (6008)
21 Mass Screening/ (111647)
22 (screen* adj3 (identif* or refer* or sign-post* or signpost* or transfer* or recruit* or
detect* or advic* or intervent* or diagnos*)).ti,ab. (76168)
23 school health services/ or school nursing/ (22306)
24 ((school* or highschool* or primaryschool* or preschool* or nurser* or universit* or
educat* or pupil* or teach* or student*) adj3 (identif* or refer* or sign-post* or signpost* or
transfer* or recruit* or detect* or advic* or intervent* or diagnos*)).ti,ab. (64735)
25 ((Setting-based or communit* or clinic-based or work-based or workplace*) adj3
(identif* or refer* or sign-post* or signpost* or transfer* or recruit* or evaluat* or advic* or
diagnos*)).ti,ab. (22301)
26 exp Family/ (346379)
27 ((family* or famili* or parent* or grandparent* or mother* or mum*3 or father* or dad*3
or grandparent* or grandmother* or grandfather* or grandad* or sister* or brother* or sibling*
or twin*1) adj3 (identif* or refer* or sign-post* or signpost* or transfer* or recruit* or evaluat*
or advic* or diagnos*)).ti,ab. (63309)
28 ((barrier* or facilitat* or hinder* or block* or obstacle* or restrict* or restrain* or obstruct*
or impede* or delay* or constrain* or hindrance or enhance* or encourag* or support* or
promot* or optimiz* or optimis* or motivat* or incentiv* or persuad* or persuasion or intend*
or intention or counsel* or hesitan* or attrition) adj1 (identif* or refer* or sign-post* or
signpost* or transfer* or recruit* or detect* or advic* or intervent* or diagnos*)).ti,ab. (64242)
29 ((increas* or improv* or rais* or higher or decreas* or reduc* or poor* or low or lower or
drop* or withdraw* or quit* or likely or unlikely or positiv* or negativ* or influen*) adj1 (identif*
or refer* or sign-post* or signpost* or transfer* or recruit* or detect* or advic* or intervent* or
diagnos*)).ti,ab. (125200)
30 Home Nursing/ or Home Care Services/ (42842)
31 ((home* or resident*) adj3 (identif* or refer* or sign-post* or signpost* or transfer* or
recruit* or detect* or advic* or intervent* or diagnos*)).ti,ab. (17773)
32 ((carer* or social-work* or health-visit*) adj3 (identif* or refer* or sign-post* or signpost*
or transfer* or recruit* or detect* or advic* or intervent* or diagnos*)).ti,ab. (2123)
33 ((survey* or audit* or questionnaire* or framework*) adj3 (identif* or refer* or sign-post*
or signpost* or transfer* or recruit* or detect* or advic* or intervent* or diagnos*)).ti,ab.
(37486)
34 or/13-33 (1814809)
35 12 and 34 (6925)
36 limit 35 to english language (6719)
37 animals/ not humans/ (4912184)

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38 36 not 37 (6703)
39 limit 38 to ed=20000101-20221231 (6460)
40 limit 38 to ed=20100101-20221231 (5218)
41 Qualitative Research/ (71057)
42 Nursing Methodology Research/ (16404)
43 Interview.pt. (29252)
44 exp Interviews as Topic/ (66659)
45 Questionnaires/ (524195)
46 Narration/ (9459)
47 Health Care Surveys/ (33820)
48 (qualitative$ or interview$ or focus group$ or questionnaire$ or narrative$ or narration$
or survey$).tw. (1475112)
49 (ethno$ or emic or etic or phenomenolog$ or grounded theory or constant compar$ or
(thematic$ adj4 analys$) or theoretical sampl$ or purposive sampl$).tw. (96027)
50 (hermeneutic$ or heidegger$ or husser$ or colaizzi$ or van kaam$ or van manen$ or
giorgi$ or glaser$ or strauss$ or ricoeur$ or spiegelberg$ or merleau$).tw. (10630)
51 (metasynthes$ or meta-synthes$ or metasummar$ or meta-summar$ or metastud$ or
meta-stud$ or metathem$ or meta-them$).tw. (1617)
52 "critical interpretive synthes*".tw. (112)
53 (realist adj (review* or synthes*)).tw. (558)
54 (noblit and hare).tw. (74)
55 (meta adj (method or triangulation)).tw. (32)
56 (CERQUAL or CONQUAL).tw. (220)
57 ((thematic or framework) adj synthes*).tw. (1058)
58 or/41-57 (1687537)
59 40 and 58 (2291)
60 Observational Studies as Topic/ (7380)
61 Observational Study/ (119126)
62 Epidemiologic Studies/ (8971)
63 exp Case-Control Studies/ (1274562)
64 exp Cohort Studies/ (2282419)
65 Comparative Study.pt. (1907076)

95
Overweight and obesity management: preventing, assessing and managing overweight and
obesity: identifying overweight and obesity in children, young people and adults FINAL
(January 2025)
FINAL

66 case control$.tw. (126463)

67 (cohort adj (study or studies)).tw. (221163)
68 cohort analy$.tw. (8472)
69 (follow up adj (study or studies)).tw. (48575)
70 (observational adj (study or studies)).tw. (110576)
71 longitudinal.tw. (240704)
72 prospective.tw. (565128)
73 retrospective.tw. (538883)
74 or/60-73 (4458821)
75 randomized controlled trial.pt. (556026)
76 randomi?ed.mp. (891783)
77 placebo.mp. (211820)
78 or/75-77 (946506)
79 (MEDLINE or pubmed).tw. (214279)
80 systematic review.tw. (168603)
81 systematic review.pt. (178926)
82 meta-analysis.pt. (150882)
83 intervention$.ti. (147478)
84 or/79-83 (477420)
85 39 and (74 or 78 or 84) (3632)
86 afghanistan/ or africa/ or africa, northern/ or africa, central/ or africa, eastern/ or "africa
south of the sahara"/ or africa, southern/ or africa, western/ or albania/ or algeria/ or andorra/
or angola/ or "antigua and barbuda"/ or argentina/ or armenia/ or azerbaijan/ or bahamas/ or
bahrain/ or bangladesh/ or barbados/ or belize/ or benin/ or bhutan/ or bolivia/ or borneo/ or
"bosnia and herzegovina"/ or botswana/ or brazil/ or brunei/ or bulgaria/ or burkina faso/ or
burundi/ or cabo verde/ or cambodia/ or cameroon/ or central african republic/ or chad/ or
exp china/ or comoros/ or congo/ or cote d'ivoire/ or croatia/ or cuba/ or "democratic republic
of the congo"/ or cyprus/ or djibouti/ or dominica/ or dominican republic/ or ecuador/ or egypt/
or el salvador/ or equatorial guinea/ or eritrea/ or eswatini/ or ethiopia/ or fiji/ or gabon/ or
gambia/ or "georgia (republic)"/ or ghana/ or grenada/ or guatemala/ or guinea/ or guinea-
bissau/ or guyana/ or haiti/ or honduras/ or independent state of samoa/ or exp india/ or
indian ocean islands/ or indochina/ or indonesia/ or iran/ or iraq/ or jamaica/ or jordan/ or
kazakhstan/ or kenya/ or kosovo/ or kuwait/ or kyrgyzstan/ or laos/ or lebanon/ or
liechtenstein/ or lesotho/ or liberia/ or libya/ or madagascar/ or malaysia/ or malawi/ or mali/
or malta/ or mauritania/ or mauritius/ or mekong valley/ or melanesia/ or micronesia/ or
monaco/ or mongolia/ or montenegro/ or morocco/ or mozambique/ or myanmar/ or namibia/
or nepal/ or nicaragua/ or niger/ or nigeria/ or oman/ or pakistan/ or palau/ or exp panama/ or
papua new guinea/ or paraguay/ or peru/ or philippines/ or qatar/ or "republic of belarus"/ or

96
Overweight and obesity management: preventing, assessing and managing overweight and
obesity: identifying overweight and obesity in children, young people and adults FINAL
(January 2025)
FINAL

"republic of north macedonia"/ or romania/ or exp russia/ or rwanda/ or "saint kitts and nevis"/
or saint lucia/ or "saint vincent and the grenadines"/ or "sao tome and principe"/ or saudi
arabia/ or serbia/ or sierra leone/ or senegal/ or seychelles/ or singapore/ or somalia/ or
south africa/ or south sudan/ or sri lanka/ or sudan/ or suriname/ or syria/ or taiwan/ or
tajikistan/ or tanzania/ or thailand/ or timor-leste/ or togo/ or tonga/ or "trinidad and tobago"/
or tunisia/ or turkmenistan/ or uganda/ or ukraine/ or united arab emirates/ or uruguay/ or
uzbekistan/ or vanuatu/ or venezuela/ or vietnam/ or west indies/ or yemen/ or zambia/ or
zimbabwe/ (1193249)
87 "organisation for economic co-operation and development"/ (411)
88 australasia/ or exp australia/ or austria/ or baltic states/ or belgium/ or exp canada/ or
chile/ or colombia/ or costa rica/ or czech republic/ or exp denmark/ or estonia/ or europe/ or
finland/ or exp france/ or exp germany/ or greece/ or hungary/ or iceland/ or ireland/ or israel/
or exp italy/ or exp japan/ or korea/ or latvia/ or lithuania/ or luxembourg/ or mexico/ or
netherlands/ or new zealand/ or north america/ or exp norway/ or poland/ or portugal/ or exp
"republic of korea"/ or "scandinavian and nordic countries"/ or slovakia/ or slovenia/ or spain/
or sweden/ or switzerland/ or turkey/ or exp united kingdom/ or exp united states/ (3374331)
89 european union/ (17062)
90 developed countries/ (21041)
91 or/87-90 (3389530)
92 86 not 91 (1106684)
93 59 not 92 (2180)
94 85 not 92 (3504)
95 59 and 92 (111)
96 85 and 92 (128)

Database name: Medline in process

1 Weight Reduction Programs/ (0)
2 exp *obesity/ or overweight/ or Obesity Management/ (0)
3 (obes* or preobese* or overweight* or over-weight*).ti,ab. (3980)
4 or/2-3 (3980)
5 (weight* adj1 (loss* or management* or reduc* or lifestyle* or life-style* or control* or
health*) adj2 (servic* or intervent* or program* or plan* or refer* or scheme* or treatment* or
trial* or therap* or clinic* or session*)).ti,ab. (133)
6 4 and 5 (97)
7 ((obes* or preobes* or overweight* or over-weight*) adj2 (loss* or management* or
reduc* or lifestyle* or life-style* or control* or health* or prevent*) adj2 (servic* or intervent* or
program* or plan* or refer* or scheme* or treatment* or trial* or therap* or clinic* or
session*)).ti,ab. (45)

97
Overweight and obesity management: preventing, assessing and managing overweight and
obesity: identifying overweight and obesity in children, young people and adults FINAL
(January 2025)
FINAL

8 1 or 6 or 7 (137)
9 exp *Obesity/di, pc or *Overweight/di, pc (0)
10 ((obes* or preobese* or overweight* or over-weight*) adj1 (detect* or identif* or
diagnos*) adj3 (refer* or sign-post* or signpost* or transfer* or recruit* or evaluat* or advic* or
diagnos*)).ti,ab. (7)
11 or/9-10 (7)
12 8 or 11 (144)
13 "referral and consultation"/ or remote consultation/ or diagnostic self evaluation/ or exp
"Appointments and Schedules"/ (0)
14 ((opportun* or holistic* or routine* or consultat* or appointment* or checkup* or check-
up*) adj3 (identif* or refer* or signpost* or sign-post* or transfer* or recruit* or detect* or
advic* or intervent* or diagnos*)).ti,ab. (578)
15 (case-find* or active-case*).ti,ab. (44)
16 self care/ or self-management/ (0)
17 (self-refer* or self-report* or self-diagnos* or self-evaluat* or self-manag*).ti,ab. (2279)
18 exp Health Personnel/ or "Attitude of Health Personnel"/ or professional-family
relations/ or professional-patient relations/ (0)
19 ((clinician* or physician* or doctor* or nurse*1 or pharmacy* or pharmacies* or
pharmacist* or consultant* or practition* or primary-care* or dietician* or nutritionist* or GP*1
or HCP*1) adj3 (identif* or refer* or signpost* or sign-post* or transfer* or recruit* or detect*
or advic* or intervent* or diagnos*)).ti,ab. (811)
20 ((medical* or health or healthcare or clinical*) adj2 (staff* or team* or provide* or
agenc*) adj3 (identif* or refer* or sign-post* or signpost* or transfer* or recruit* or detect* or
advic* or intervent* or diagnos*)).ti,ab. (68)
21 Mass Screening/ (0)
22 (screen* adj3 (identif* or refer* or sign-post* or signpost* or transfer* or recruit* or
detect* or advic* or intervent* or diagnos*)).ti,ab. (1127)
23 school health services/ or school nursing/ (0)
24 ((school* or highschool* or primaryschool* or preschool* or nurser* or universit* or
educat* or pupil* or teach* or student*) adj3 (identif* or refer* or sign-post* or signpost* or
transfer* or recruit* or detect* or advic* or intervent* or diagnos*)).ti,ab. (671)
25 ((Setting-based or communit* or clinic-based or work-based or workplace*) adj3
(identif* or refer* or sign-post* or signpost* or transfer* or recruit* or evaluat* or advic* or
diagnos*)).ti,ab. (250)
26 exp Family/ (0)
27 ((family* or famili* or parent* or grandparent* or mother* or mum*3 or father* or dad*3
or grandparent* or grandmother* or grandfather* or grandad* or sister* or brother* or sibling*
or twin*1) adj3 (identif* or refer* or sign-post* or signpost* or transfer* or recruit* or evaluat*
or advic* or diagnos*)).ti,ab. (629)

98
Overweight and obesity management: preventing, assessing and managing overweight and
obesity: identifying overweight and obesity in children, young people and adults FINAL
(January 2025)
FINAL

28 ((barrier* or facilitat* or hinder* or block* or obstacle* or restrict* or restrain* or obstruct*

or impede* or delay* or constrain* or hindrance or enhance* or encourag* or support* or
promot* or optimiz* or optimis* or motivat* or incentiv* or persuad* or persuasion or intend*
or intention or counsel* or hesitan* or attrition) adj1 (identif* or refer* or sign-post* or
signpost* or transfer* or recruit* or detect* or advic* or intervent* or diagnos*)).ti,ab. (874)
29 ((increas* or improv* or rais* or higher or decreas* or reduc* or poor* or low or lower or
drop* or withdraw* or quit* or likely or unlikely or positiv* or negativ* or influen*) adj1 (identif*
or refer* or sign-post* or signpost* or transfer* or recruit* or detect* or advic* or intervent* or
diagnos*)).ti,ab. (1588)
30 Home Nursing/ or Home Care Services/ (0)
31 ((home* or resident* or residenc*) adj3 (identif* or refer* or sign-post* or signpost* or
transfer* or recruit* or detect* or advic* or intervent* or diagnos*)).ti,ab. (202)
32 ((carer* or social-work* or health-visit*) adj3 (identif* or refer* or sign-post* or signpost*
or transfer* or recruit* or detect* or advic* or intervent* or diagnos*)).ti,ab. (23)
33 ((survey* or audit* or questionnaire* or framework*) adj3 (identif* or refer* or sign-post*
or signpost* or transfer* or recruit* or detect* or advic* or intervent* or diagnos*)).ti,ab. (411)
34 or/13-33 (8666)
35 12 and 34 (30)
36 limit 35 to english language (30)
37 animals/ not humans/ (0)
38 36 not 37 (30)
39 limit 38 to dt=20000101-20221231 (30)
40 limit 38 to dt=20100101-20221231 (30)
41 Qualitative Research/ (0)
42 Nursing Methodology Research/ (0)
43 Interview.pt. (63)
44 exp Interviews as Topic/ (0)
45 Questionnaires/ (0)
46 Narration/ (0)
47 Health Care Surveys/ (0)
48 (qualitative$ or interview$ or focus group$ or questionnaire$ or narrative$ or narration$
or survey$).tw. (14194)
49 (ethno$ or emic or etic or phenomenolog$ or grounded theory or constant compar$ or
(thematic$ adj4 analys$) or theoretical sampl$ or purposive sampl$).tw. (1810)
50 (hermeneutic$ or heidegger$ or husser$ or colaizzi$ or van kaam$ or van manen$ or
giorgi$ or glaser$ or strauss$ or ricoeur$ or spiegelberg$ or merleau$).tw. (49)

99
Overweight and obesity management: preventing, assessing and managing overweight and
obesity: identifying overweight and obesity in children, young people and adults FINAL
(January 2025)
FINAL

51 (metasynthes$ or meta-synthes$ or metasummar$ or meta-summar$ or metastud$ or

meta-stud$ or metathem$ or meta-them$).tw. (28)
52 "critical interpretive synthes*".tw. (6)
53 (realist adj (review* or synthes*)).tw. (18)
54 (noblit and hare).tw. (3)
55 (meta adj (method or triangulation)).tw. (1)
56 (CERQUAL or CONQUAL).tw. (13)
57 ((thematic or framework) adj synthes*).tw. (32)
58 or/41-57 (15150)
59 40 and 58 (11)
60 Observational Studies as Topic/ (0)
61 Observational Study/ (0)
62 Epidemiologic Studies/ (0)
63 exp Case-Control Studies/ (0)
64 exp Cohort Studies/ (0)
65 Comparative Study.pt. (0)
66 case control$.tw. (1302)
67 (cohort adj (study or studies)).tw. (4937)
68 cohort analy$.tw. (195)
69 (follow up adj (study or studies)).tw. (277)
70 (observational adj (study or studies)).tw. (2023)
71 longitudinal.tw. (3398)
72 prospective.tw. (6245)
73 retrospective.tw. (8329)
74 or/60-73 (20306)
75 randomized controlled trial.pt. (0)
76 randomi?ed.mp. (6953)
77 placebo.mp. (1662)
78 or/75-77 (7442)
79 (MEDLINE or pubmed).tw. (4622)
80 systematic review.tw. (4474)

100
Overweight and obesity management: preventing, assessing and managing overweight and
obesity: identifying overweight and obesity in children, young people and adults FINAL
(January 2025)
FINAL

81 systematic review.pt. (178)

82 meta-analysis.pt. (47)
83 intervention$.ti. (1891)
84 or/79-83 (7972)
85 39 and (74 or 78 or 84) (21)
86 85 or 59 (29)

Database name: Medline ePub ahead

1 Weight Reduction Programs/ (0)
2 exp *obesity/ or overweight/ or Obesity Management/ (0)
3 (obes* or preobese* or overweight* or over-weight*).ti,ab. (5829)
4 or/2-3 (5829)
5 (weight* adj1 (loss* or management* or reduc* or lifestyle* or life-style* or control* or
health*) adj2 (servic* or intervent* or program* or plan* or refer* or scheme* or treatment* or
trial* or therap* or clinic* or session*)).ti,ab. (257)
6 4 and 5 (180)
7 ((obes* or preobes* or overweight* or over-weight*) adj2 (loss* or management* or
reduc* or lifestyle* or life-style* or control* or health* or prevent*) adj2 (servic* or intervent* or
program* or plan* or refer* or scheme* or treatment* or trial* or therap* or clinic* or
session*)).ti,ab. (64)
8 1 or 6 or 7 (236)
9 exp *Obesity/di, pc or *Overweight/di, pc (0)
10 ((obes* or preobese* or overweight* or over-weight*) adj1 (detect* or identif* or
diagnos*) adj3 (refer* or sign-post* or signpost* or transfer* or recruit* or evaluat* or advic* or
diagnos*)).ti,ab. (14)
11 or/9-10 (14)
12 8 or 11 (249)
13 "referral and consultation"/ or remote consultation/ or diagnostic self evaluation/ or exp
"Appointments and Schedules"/ (0)
14 ((opportun* or holistic* or routine* or consultat* or appointment* or checkup* or check-
up*) adj3 (identif* or refer* or signpost* or sign-post* or transfer* or recruit* or detect* or
advic* or intervent* or diagnos*)).ti,ab. (1157)
15 (case-find* or active-case*).ti,ab. (118)
16 self care/ or self-management/ (0)
17 (self-refer* or self-report* or self-diagnos* or self-evaluat* or self-manag*).ti,ab. (5728)

101
Overweight and obesity management: preventing, assessing and managing overweight and
obesity: identifying overweight and obesity in children, young people and adults FINAL
(January 2025)
FINAL

18 exp Health Personnel/ or "Attitude of Health Personnel"/ or professional-family

relations/ or professional-patient relations/ (0)
19 ((clinician* or physician* or doctor* or nurse*1 or pharmacy* or pharmacies* or
pharmacist* or consultant* or practition* or primary-care* or dietician* or nutritionist* or GP*1
or HCP*1) adj3 (identif* or refer* or signpost* or sign-post* or transfer* or recruit* or detect*
or advic* or intervent* or diagnos*)).ti,ab. (2122)
20 ((medical* or health or healthcare or clinical*) adj2 (staff* or team* or provide* or
agenc*) adj3 (identif* or refer* or sign-post* or signpost* or transfer* or recruit* or detect* or
advic* or intervent* or diagnos*)).ti,ab. (208)
21 Mass Screening/ (0)
22 (screen* adj3 (identif* or refer* or sign-post* or signpost* or transfer* or recruit* or
detect* or advic* or intervent* or diagnos*)).ti,ab. (1827)
23 school health services/ or school nursing/ (0)
24 ((school* or highschool* or primaryschool* or preschool* or nurser* or universit* or
educat* or pupil* or teach* or student*) adj3 (identif* or refer* or sign-post* or signpost* or
transfer* or recruit* or detect* or advic* or intervent* or diagnos*)).ti,ab. (2093)
25 ((Setting-based or communit* or clinic-based or work-based or workplace*) adj3
(identif* or refer* or sign-post* or signpost* or transfer* or recruit* or evaluat* or advic* or
diagnos*)).ti,ab. (588)
26 exp Family/ (0)
27 ((family* or famili* or parent* or grandparent* or mother* or mum*3 or father* or dad*3
or grandparent* or grandmother* or grandfather* or grandad* or sister* or brother* or sibling*
or twin*1) adj3 (identif* or refer* or sign-post* or signpost* or transfer* or recruit* or evaluat*
or advic* or diagnos*)).ti,ab. (1425)
28 ((barrier* or facilitat* or hinder* or block* or obstacle* or restrict* or restrain* or obstruct*
or impede* or delay* or constrain* or hindrance or enhance* or encourag* or support* or
promot* or optimiz* or optimis* or motivat* or incentiv* or persuad* or persuasion or intend*
or intention or counsel* or hesitan* or attrition) adj1 (identif* or refer* or sign-post* or
signpost* or transfer* or recruit* or detect* or advic* or intervent* or diagnos*)).ti,ab. (1946)
29 ((increas* or improv* or rais* or higher or decreas* or reduc* or poor* or low or lower or
drop* or withdraw* or quit* or likely or unlikely or positiv* or negativ* or influen*) adj1 (identif*
or refer* or sign-post* or signpost* or transfer* or recruit* or detect* or advic* or intervent* or
diagnos*)).ti,ab. (2852)
30 Home Nursing/ or Home Care Services/ (0)
31 ((home* or resident* or residenc*) adj3 (identif* or refer* or sign-post* or signpost* or
transfer* or recruit* or detect* or advic* or intervent* or diagnos*)).ti,ab. (515)
32 ((carer* or social-work* or health-visit*) adj3 (identif* or refer* or sign-post* or signpost*
or transfer* or recruit* or detect* or advic* or intervent* or diagnos*)).ti,ab. (111)
33 ((survey* or audit* or questionnaire* or framework*) adj3 (identif* or refer* or sign-post*
or signpost* or transfer* or recruit* or detect* or advic* or intervent* or diagnos*)).ti,ab. (1155)
34 or/13-33 (19369)

102
Overweight and obesity management: preventing, assessing and managing overweight and
obesity: identifying overweight and obesity in children, young people and adults FINAL
(January 2025)
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35 12 and 34 (47)
36 limit 35 to english language (47)
37 animals/ not humans/ (0)
38 36 not 37 (47)
39 limit 38 to dt=20000101-20221231 (47)
40 limit 38 to dt=20100101-20221231 (46)
41 Qualitative Research/ (0)
42 Nursing Methodology Research/ (0)
43 Interview.pt. (1)
44 exp Interviews as Topic/ (0)
45 "Questionnaires"/ (0)
46 Narration/ (0)
47 Health Care Surveys/ (0)
48 (qualitative$ or interview$ or focus group$ or questionnaire$ or narrative$ or narration$
or survey$).tw. (40247)
49 (ethno$ or emic or etic or phenomenolog$ or grounded theory or constant compar$ or
(thematic$ adj4 analys$) or theoretical sampl$ or purposive sampl$).tw. (4474)
50 (hermeneutic$ or heidegger$ or husser$ or colaizzi$ or van kaam$ or van manen$ or
giorgi$ or glaser$ or strauss$ or ricoeur$ or spiegelberg$ or merleau$).tw. (267)
51 (metasynthes$ or meta-synthes$ or metasummar$ or meta-summar$ or metastud$ or
meta-stud$ or metathem$ or meta-them$).tw. (118)
52 "critical interpretive synthes*".tw. (13)
53 (realist adj (review* or synthes*)).tw. (48)
54 (noblit and hare).tw. (2)
55 (meta adj (method or triangulation)).tw. (0)
56 (CERQUAL or CONQUAL).tw. (32)
57 ((thematic or framework) adj synthes*).tw. (95)
58 or/41-57 (41291)
59 40 and 58 (28)
60 Observational Studies as Topic/ (0)
61 Observational Study/ (1)
62 Epidemiologic Studies/ (0)

103
Overweight and obesity management: preventing, assessing and managing overweight and
obesity: identifying overweight and obesity in children, young people and adults FINAL
(January 2025)
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63 exp Case-Control Studies/ (0)

64 exp Cohort Studies/ (0)
65 Comparative Study.pt. (0)
66 case control$.tw. (2520)
67 (cohort adj (study or studies)).tw. (9240)
68 cohort analy$.tw. (329)
69 (follow up adj (study or studies)).tw. (642)
70 (observational adj (study or studies)).tw. (4335)
71 longitudinal.tw. (6870)
72 prospective.tw. (12470)
73 retrospective.tw. (18571)
74 or/60-73 (42134)
75 randomized controlled trial.pt. (1)
76 randomi?ed.mp. (13966)
77 placebo.mp. (3004)
78 or/75-77 (14929)
79 (MEDLINE or pubmed).tw. (9391)
80 systematic review.tw. (9514)
81 systematic review.pt. (154)
82 meta-analysis.pt. (80)
83 intervention$.ti. (4088)
84 or/79-83 (16965)
85 39 and (74 or 78 or 84) (31)
86 85 or 59 (38)

Database name: Embase

1 weight loss program/ (2786)
2 exp *obesity/ or obesity management/ (264774)
3 (obes* or preobese* or overweight* or over-weight*).ti,ab. (522231)
4 or/2-3 (572270)

104
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obesity: identifying overweight and obesity in children, young people and adults FINAL
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5 (weight* adj1 (loss* or management* or reduc* or lifestyle* or life-style* or control* or

health*) adj2 (servic* or intervent* or program* or plan* or refer* or scheme* or treatment* or
trial* or therap* or clinic* or session*)).ti,ab. (19696)
6 4 and 5 (14558)
7 ((obes* or preobes* or overweight* or over-weight*) adj2 (loss* or management* or
reduc* or lifestyle* or life-style* or control* or health* or prevent*) adj2 (servic* or intervent* or
program* or plan* or refer* or scheme* or treatment* or trial* or therap* or clinic* or
session*)).ti,ab. (4943)
8 1 or 6 or 7 (20264)
9 exp obesity/di, pc (28933)
10 ((obes* or preobese* or overweight* or over-weight*) adj1 (detect* or identif* or
diagnos*) adj3 (refer* or sign-post* or signpost* or transfer* or recruit* or evaluat* or advic* or
diagnos*)).ti,ab. (855)
11 or/9-10 (29611)
12 8 or 11 (47599)
13 patient referral/ or teleconsultation/ or self evaluation/ or consultation/ or hospital
management/ (342200)
14 ((opportun* or holistic* or routine* or consultat* or appointment* or checkup* or check-
up*) adj3 (identif* or refer* or signpost* or sign-post* or transfer* or recruit* or detect* or
advic* or intervent* or diagnos*)).ti,ab. (81898)
15 (case-find* or active-case*).ti,ab. (8856)
16 self care/ (66632)
17 (self-refer* or self-report* or self-diagnos* or self-evaluat* or self-manag*).ti,ab.
(280867)
18 exp health care personnel/ or exp health personnel attitude/ or human relation/ or
professional-patient relationship/ (1923282)
19 ((clinician* or physician* or doctor* or nurse*1 or pharmacy* or pharmacies* or
pharmacist* or consultant* or practition* or primary-care* or dietician* or nutritionist* or GP*1
or HCP*1) adj3 (identif* or refer* or signpost* or sign-post* or transfer* or recruit* or detect*
or advic* or intervent* or diagnos*)).ti,ab. (146096)
20 ((medical* or health or healthcare or clinical*) adj2 (staff* or team* or provide* or
agenc*) adj3 (identif* or refer* or sign-post* or signpost* or transfer* or recruit* or detect* or
advic* or intervent* or diagnos*)).ti,ab. (10217)
21 mass screening/ (58373)
22 (screen* adj3 (identif* or refer* or sign-post* or signpost* or transfer* or recruit* or
detect* or advic* or intervent* or diagnos*)).ti,ab. (126450)
23 school health services/ or school nursing/ (17755)

105
Overweight and obesity management: preventing, assessing and managing overweight and
obesity: identifying overweight and obesity in children, young people and adults FINAL
(January 2025)
FINAL

24 ((school* or highschool* or primaryschool* or preschool* or nurser* or universit* or

educat* or pupil* or teach* or student*) adj3 (identif* or refer* or sign-post* or signpost* or
transfer* or recruit* or detect* or advic* or intervent* or diagnos*)).ti,ab. (106935)
25 ((Setting-based or communit* or clinic-based or work-based or workplace*) adj3
(identif* or refer* or sign-post* or signpost* or transfer* or recruit* or evaluat* or advic* or
diagnos*)).ti,ab. (34452)
26 exp family/ (546616)
27 ((family* or famili* or parent* or grandparent* or mother* or mum*3 or father* or dad*3
or grandparent* or grandmother* or grandfather* or grandad* or sister* or brother* or sibling*
or twin*1) adj3 (identif* or refer* or sign-post* or signpost* or transfer* or recruit* or evaluat*
or advic* or diagnos*)).ti,ab. (99342)
28 ((barrier* or facilitat* or hinder* or block* or obstacle* or restrict* or restrain* or obstruct*
or impede* or delay* or constrain* or hindrance or enhance* or encourag* or support* or
promot* or optimiz* or optimis* or motivat* or incentiv* or persuad* or persuasion or intend*
or intention or counsel* or hesitan* or attrition) adj1 (identif* or refer* or sign-post* or
signpost* or transfer* or recruit* or detect* or advic* or intervent* or diagnos*)).ti,ab. (105807)
29 ((increas* or improv* or rais* or higher or decreas* or reduc* or poor* or low or lower or
drop* or withdraw* or quit* or likely or unlikely or positiv* or negativ* or influen*) adj1 (identif*
or refer* or sign-post* or signpost* or transfer* or recruit* or detect* or advic* or intervent* or
diagnos*)).ti,ab. (206385)
30 exp home care/ (80580)
31 ((home* or resident* or residenc*) adj3 (identif* or refer* or sign-post* or signpost* or
transfer* or recruit* or detect* or advic* or intervent* or diagnos*)).ti,ab. (30902)
32 ((carer* or social-work* or health-visit*) adj3 (identif* or refer* or sign-post* or signpost*
or transfer* or recruit* or detect* or advic* or intervent* or diagnos*)).ti,ab. (3632)
33 ((survey* or audit* or questionnaire* or framework*) adj3 (identif* or refer* or sign-post*
or signpost* or transfer* or recruit* or detect* or advic* or intervent* or diagnos*)).ti,ab.
(63583)
34 or/13-33 (3592210)
35 12 and 34 (11963)
36 limit 35 to english language (11467)
37 nonhuman/ not human/ (4919293)
38 36 not 37 (11419)
39 limit 38 to dc=20000101-20221231 (11038)
40 limit 38 to dc=20100101-20221231 (8850)
41 Qualitative Research/ (95638)
42 exp Interview/ (321295)
43 exp Questionnaire/ (810654)

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44 exp Observational Method/ (7063)

45 Narrative/ (17336)
46 (qualitative$ or interview$ or focus group$ or questionnaire$ or narrative$ or narration$
or survey$).tw. (2249202)
47 (ethno$ or emic or etic or phenomenolog$ or grounded theory or constant compar$ or
(thematic$ adj4 analys$) or theoretical sampl$ or purposive sampl$).tw. (143170)
48 (hermeneutic$ or heidegger$ or husser$ or colaizzi$ or van kaam$ or van manen$ or
giorgi$ or glaser$ or strauss$ or ricoeur$ or spiegelberg$ or merleau$).tw. (14766)
49 (metasynthes$ or meta-synthes$ or metasummar$ or meta-summar$ or metastud$ or
meta-stud$ or metathem$ or meta-them$).tw. (2195)
50 "critical interpretive synthes*".tw. (145)
51 (realist adj (review* or synthes*)).tw. (705)
52 (noblit and hare).tw. (96)
53 (meta adj (method or triangulation)).tw. (41)
54 (CERQUAL or CONQUAL).tw. (286)
55 ((thematic or framework) adj synthes*).tw. (1493)
56 or/41-55 (2498835)
57 Clinical study/ (157041)
58 Case control study/ (182646)
59 Family study/ (25370)
60 Longitudinal study/ (166184)
61 Retrospective study/ (1187991)
62 comparative study/ (932299)
63 Prospective study/ (739574)
64 Randomized controlled trials/ (218570)
65 63 not 64 (731026)
66 Cohort analysis/ (796848)
67 cohort analy$.tw. (15859)
68 (Cohort adj (study or studies)).tw. (374930)
69 (Case control$ adj (study or studies)).tw. (153929)
70 (follow up adj (study or studies)).tw. (68137)
71 (observational adj (study or studies)).tw. (207615)

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Overweight and obesity management: preventing, assessing and managing overweight and
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72 (epidemiologic$ adj (study or studies)).tw. (114163)

73 (cross sectional adj (study or studies)).tw. (274799)
74 case series.tw. (124894)
75 case series.tw. (124894)
76 prospective.tw. (973105)
77 retrospective.tw. (1056160)
78 or/57-62,65-77 (4679041)
79 random:.tw. (1745052)
80 placebo:.mp. (487682)
81 double-blind:.tw. (226763)
82 or/79-81 (2010365)
83 (MEDLINE or pubmed).tw. (327778)
84 exp systematic review/ or systematic review.tw. (394189)
85 meta-analysis/ (235116)
86 intervention$.ti. (230131)
87 or/83-86 (798763)
88 40 and 56 (3641)
89 39 and (78 or 82 or 87) (5533)
90 afghanistan/ or africa/ or "africa south of the sahara"/ or albania/ or algeria/ or andorra/
or angola/ or argentina/ or "antigua and barbuda"/ or armenia/ or exp azerbaijan/ or
bahamas/ or bahrain/ or bangladesh/ or barbados/ or belarus/ or belize/ or benin/ or bhutan/
or bolivia/ or borneo/ or exp "bosnia and herzegovina"/ or botswana/ or exp brazil/ or brunei
darussalam/ or bulgaria/ or burkina faso/ or burundi/ or cambodia/ or cameroon/ or cape
verde/ or central africa/ or central african republic/ or chad/ or exp china/ or comoros/ or
congo/ or cook islands/ or cote d'ivoire/ or croatia/ or cuba/ or cyprus/ or democratic republic
congo/ or djibouti/ or dominica/ or dominican republic/ or ecuador/ or el salvador/ or egypt/ or
equatorial guinea/ or eritrea/ or eswatini/ or ethiopia/ or exp "federated states of micronesia"/
or fiji/ or gabon/ or gambia/ or exp "georgia (republic)"/ or ghana/ or grenada/ or guatemala/
or guinea/ or guinea-bissau/ or guyana/ or haiti/ or honduras/ or exp india/ or exp indonesia/
or iran/ or exp iraq/ or jamaica/ or jordan/ or kazakhstan/ or kenya/ or kiribati/ or kosovo/ or
kuwait/ or kyrgyzstan/ or laos/ or lebanon/ or liechtenstein/ or lesotho/ or liberia/ or libyan
arab jamahiriya/ or madagascar/ or malawi/ or exp malaysia/ or maldives/ or mali/ or malta/
or mauritania/ or mauritius/ or melanesia/ or moldova/ or monaco/ or mongolia/ or
"montenegro (republic)"/ or morocco/ or mozambique/ or myanmar/ or namibia/ or nauru/ or
nepal/ or nicaragua/ or niger/ or nigeria/ or niue/ or north africa/ or oman/ or exp pakistan/ or
palau/ or palestine/ or panama/ or papua new guinea/ or paraguay/ or peru/ or philippines/ or
polynesia/ or qatar/ or "republic of north macedonia"/ or romania/ or exp russian federation/
or rwanda/ or sahel/ or "saint kitts and nevis"/ or "saint lucia"/ or "saint vincent and the
grenadines"/ or saudi arabia/ or senegal/ or exp serbia/ or seychelles/ or sierra leone/ or

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singapore/ or "sao tome and principe"/ or solomon islands/ or exp somalia/ or south africa/ or
south asia/ or south sudan/ or exp southeast asia/ or sri lanka/ or sudan/ or suriname/ or
syrian arab republic/ or taiwan/ or tajikistan/ or tanzania/ or thailand/ or timor-leste/ or togo/ or
tonga/ or "trinidad and tobago"/ or tunisia/ or turkmenistan/ or tuvalu/ or uganda/ or exp
ukraine/ or exp united arab emirates/ or uruguay/ or exp uzbekistan/ or vanuatu/ or
venezuela/ or viet nam/ or western sahara/ or yemen/ or zambia/ or zimbabwe/ (1498651)
91 exp "organisation for economic co-operation and development"/ (1882)
92 exp australia/ or "australia and new zealand"/ or austria/ or baltic states/ or exp
belgium/ or exp canada/ or chile/ or colombia/ or costa rica/ or czech republic/ or denmark/ or
estonia/ or europe/ or exp finland/ or exp france/ or exp germany/ or greece/ or hungary/ or
iceland/ or ireland/ or israel/ or exp italy/ or japan/ or korea/ or latvia/ or lithuania/ or
luxembourg/ or exp mexico/ or netherlands/ or new zealand/ or north america/ or exp
norway/ or poland/ or exp portugal/ or scandinavia/ or sweden/ or slovakia/ or slovenia/ or
south korea/ or exp spain/ or switzerland/ or "Turkey (republic)"/ or exp united kingdom/ or
exp united states/ or western europe/ (3527520)
93 european union/ (29020)
94 developed country/ (34350)
95 or/91-94 (3558195)
96 90 not 95 (1361029)
97 88 not 96 (3424)
98 89 not 96 (5227)
99 88 and 96 (217)
100 89 and 96 (306)

Database name: PsycInfo

1 Weight Loss/ (3908)
2 exp *obesity/ or overweight/ (21840)
3 (obes* or preobese* or overweight* or over-weight*).ti,ab. (44017)
4 or/2-3 (44815)
5 (weight* adj1 (loss* or management* or reduc* or lifestyle* or life-style* or control* or
health*) adj2 (servic* or intervent* or program* or plan* or refer* or scheme* or treatment* or
trial* or therap* or clinic* or session*)).ti,ab. (3866)
6 4 and 5 (2949)
7 ((obes* or preobes* or overweight* or over-weight*) adj2 (loss* or management* or
reduc* or lifestyle* or life-style* or control* or health* or prevent*) adj2 (servic* or intervent* or
program* or plan* or refer* or scheme* or treatment* or trial* or therap* or clinic* or
session*)).ti,ab. (1263)

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8 1 or 6 or 7 (6811)
9 exp Obesity/ or *Overweight/ (25881)
10 ((obes* or preobese* or overweight* or over-weight*) adj1 (detect* or identif* or
diagnos*) adj3 (refer* or sign-post* or signpost* or transfer* or recruit* or evaluat* or advic* or
diagnos*)).ti,ab. (78)
11 or/9-10 (25898)
12 8 or 11 (28533)
13 Professional Referral/ or Professional Consultation/ or Videoconferencing/ or Self-
Evaluation/ (18251)
14 ((opportun* or holistic* or routine* or consultat* or appointment* or checkup* or check-
up*) adj3 (identif* or refer* or signpost* or sign-post* or transfer* or recruit* or detect* or
advic* or intervent* or diagnos*)).ti,ab. (10035)
15 (case-find* or active-case*).ti,ab. (886)
16 self-care/ or self-management/ (9729)
17 (self-refer* or self-report* or self-diagnos* or self-evaluat* or self-manag*).ti,ab.
(150118)
18 exp Health Personnel/ or exp health personnel attitudes/ or therapeutic processes/
(184656)
19 ((clinician* or physician* or doctor* or nurse*1 or pharmacy* or pharmacies* or
pharmacist* or consultant* or practition* or primary-care* or dietician* or nutritionist* or GP*1
or HCP*1) adj3 (identif* or refer* or signpost* or sign-post* or transfer* or recruit* or detect*
or advic* or intervent* or diagnos*)).ti,ab. (22967)
20 ((medical* or health or healthcare or clinical*) adj2 (staff* or team* or provide* or
agenc*) adj3 (identif* or refer* or sign-post* or signpost* or transfer* or recruit* or detect* or
advic* or intervent* or diagnos*)).ti,ab. (2111)
21 screening/ or health screening/ or screening tests/ (20010)
22 (screen* adj3 (identif* or refer* or sign-post* or signpost* or transfer* or recruit* or
detect* or advic* or intervent* or diagnos*)).ti,ab. (12055)
23 School Nurses/ (898)
24 ((school* or highschool* or primaryschool* or preschool* or nurser* or universit* or
educat* or pupil* or teach* or student*) adj3 (identif* or refer* or sign-post* or signpost* or
transfer* or recruit* or detect* or advic* or intervent* or diagnos*)).ti,ab. (69131)
25 ((Setting-based or communit* or clinic-based or work-based or workplace*) adj3
(identif* or refer* or sign-post* or signpost* or transfer* or recruit* or evaluat* or advic* or
diagnos*)).ti,ab. (11756)
26 exp family/ or exp "family and parenting measures"/ or exp parental attitudes/ (275166)
27 ((family* or famili* or parent* or grandparent* or mother* or mum*3 or father* or dad*3
or grandparent* or grandmother* or grandfather* or grandad* or sister* or brother* or sibling*

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Overweight and obesity management: preventing, assessing and managing overweight and
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or twin*1) adj3 (identif* or refer* or sign-post* or signpost* or transfer* or recruit* or evaluat*

or advic* or diagnos*)).ti,ab. (29512)
28 ((barrier* or facilitat* or hinder* or block* or obstacle* or restrict* or restrain* or obstruct*
or impede* or delay* or constrain* or hindrance or enhance* or encourag* or support* or
promot* or optimiz* or optimis* or motivat* or incentiv* or persuad* or persuasion or intend*
or intention or counsel* or hesitan* or attrition) adj1 (identif* or refer* or sign-post* or
signpost* or transfer* or recruit* or detect* or advic* or intervent* or diagnos*)).ti,ab. (22982)
29 ((increas* or improv* or rais* or higher or decreas* or reduc* or poor* or low or lower or
drop* or withdraw* or quit* or likely or unlikely or positiv* or negativ* or influen*) adj1 (identif*
or refer* or sign-post* or signpost* or transfer* or recruit* or detect* or advic* or intervent* or
diagnos*)).ti,ab. (24488)
30 exp home care/ (6777)
31 ((home* or resident*) adj3 (identif* or refer* or sign-post* or signpost* or transfer* or
recruit* or detect* or advic* or intervent* or diagnos*)).ti,ab. (7304)
32 ((carer* or social-work* or health-visit*) adj3 (identif* or refer* or sign-post* or signpost*
or transfer* or recruit* or detect* or advic* or intervent* or diagnos*)).ti,ab. (2969)
33 ((survey* or audit* or questionnaire* or framework*) adj3 (identif* or refer* or sign-post*
or signpost* or transfer* or recruit* or detect* or advic* or intervent* or diagnos*)).ti,ab.
(19146)
34 or/13-33 (751923)
35 12 and 34 (6834)
36 animals/ not humans/ (4446)
37 35 not 36 (6833)
38 english.lg. or "first posting".ps. (3889938)
39 37 and 38 (6719)
40 limit 39 to up=20000101-20221231 (6431)
41 limit 40 to ("0200 book" or "0240 authored book" or "0280 edited book" or "0300
encyclopedia" or "0400 dissertation abstract") (894)
42 40 not 41 (5537)

Database name: HMIC

1 (obes* or preobese* or overweight* or over-weight*).ti,ab. (4480)
2 (obes* or preobese* or overweight* or over-weight*).hw. (3716)
3 or/1-2 (5151)
4 (weight* adj1 (loss* or management* or reduc* or lifestyle* or life-style* or control* or
health*) adj2 (servic* or intervent* or program* or plan* or refer* or scheme* or treatment* or
trial* or therap* or clinic* or session*)).ti,ab. (265)

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5 ((weight* adj1 (loss* or management* or reduc* or lifestyle* or life-style* or control* or

health*)) and (servic* or intervent* or program* or plan* or refer* or scheme* or treatment* or
trial* or therap* or clinic* or session*)).hw. (63)
6 or/4-5 (298)
7 3 and 6 (250)
8 ((obes* or preobes* or overweight* or over-weight*) adj2 (loss* or management* or
reduc* or lifestyle* or life-style* or control* or health* or prevent*) adj2 (servic* or intervent* or
program* or plan* or refer* or scheme* or treatment* or trial* or therap* or clinic* or
session*)).ti,ab. (115)
9 ((obes* or preobes* or overweight* or over-weight*) and (loss* or management* or
reduc* or lifestyle* or life-style* or control* or health* or prevent*) and (servic* or intervent* or
program* or plan* or refer* or scheme* or treatment* or trial* or therap* or clinic* or
session*)).hw. (463)
10 or/8-9 (550)
11 ((obes* or preobese* or overweight* or over-weight*) adj1 (detect* or identif* or
diagnos*) adj3 (refer* or sign-post* or signpost* or transfer* or recruit* or evaluat* or advic* or
diagnos*)).ti,ab. (12)
12 (((obes* or preobese* or overweight* or over-weight*) and (detect* or identif* or
diagnos*)) adj3 (refer* or sign-post* or signpost* or transfer* or recruit* or evaluat* or advic*
or diagnos*)).hw. (24)
13 or/11-12 (34)
14 7 or 10 or 13 (738)
15 ((opportun* or holistic* or routine* or consultat* or appointment* or checkup* or check-
up*) adj3 (identif* or refer* or signpost* or sign-post* or transfer* or recruit* or detect* or
advic* or intervent* or diagnos*)).ti,ab. (1302)
16 ((opportun* or holistic* or routine* or consultat* or appointment* or checkup* or check-
up*) and (identif* or refer* or signpost* or sign-post* or transfer* or recruit* or detect* or
advic* or intervent* or diagnos*)).hw. (363)
17 (case-find* or active-case*).ti,ab. (232)
18 (case-find* or active-case*).hw. (0)
19 (self-refer* or self-report* or self-diagnos* or self-evaluat* or self-manag*).ti,ab. (4349)
20 (self-refer* or self-report* or self-diagnos* or self-evaluat* or self-manag*).hw. (560)
21 ((clinician* or physician* or doctor* or nurse*1 or pharmacy* or pharmacies* or
pharmacist* or consultant* or practition* or primary-care* or dietician* or nutritionist* or GP*1
or HCP*1) adj3 (identif* or refer* or signpost* or sign-post* or transfer* or recruit* or detect*
or advic* or intervent* or diagnos*)).ti,ab. (6685)
22 ((clinician* or physician* or doctor* or nurse*1 or pharmacy* or pharmacies* or
pharmacist* or consultant* or practition* or primary-care* or dietician* or nutritionist* or GP*1
or HCP*1) and (identif* or refer* or signpost* or sign-post* or transfer* or recruit* or detect* or
advic* or intervent* or diagnos*)).hw. (3172)

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23 ((medical* or health or healthcare or clinical*) adj2 (staff* or team* or provide* or

agenc*) adj3 (identif* or refer* or sign-post* or signpost* or transfer* or recruit* or detect* or
advic* or intervent* or diagnos*)).ti,ab. (464)
24 (((medical* or health or healthcare or clinical*) and (staff* or team* or provide* or
agenc*)) adj3 (identif* or refer* or sign-post* or signpost* or transfer* or recruit* or detect* or
advic* or intervent* or diagnos*)).hw. (357)
25 (screen* adj3 (identif* or refer* or sign-post* or signpost* or transfer* or recruit* or
detect* or advic* or intervent* or diagnos*)).ti,ab. (1313)
26 (screen* and (identif* or refer* or sign-post* or signpost* or transfer* or recruit* or
detect* or advic* or intervent* or diagnos*)).hw. (584)
27 ((school* or highschool* or primaryschool* or preschool* or nurser* or universit* or
educat* or pupil* or teach* or student*) adj3 (identif* or refer* or sign-post* or signpost* or
transfer* or recruit* or detect* or advic* or intervent* or diagnos*)).ti,ab. (2532)
28 ((school* or highschool* or primaryschool* or preschool* or nurser* or universit* or
educat* or pupil* or teach* or student*) and (identif* or refer* or sign-post* or signpost* or
transfer* or recruit* or detect* or advic* or intervent* or diagnos*)).hw. (735)
29 ((Setting-based or communit* or clinic-based or work-based or workplace*) adj3
(identif* or refer* or sign-post* or signpost* or transfer* or recruit* or evaluat* or advic* or
diagnos*)).ti,ab. (1668)
30 ((Setting-based or communit* or clinic-based or work-based or workplace*) and (identif*
or refer* or sign-post* or signpost* or transfer* or recruit* or evaluat* or advic* or
diagnos*)).hw. (1362)
31 ((family* or famili* or parent* or grandparent* or mother* or mum*3 or father* or dad*3
or grandparent* or grandmother* or grandfather* or grandad* or sister* or brother* or sibling*
or twin*1) adj3 (identif* or refer* or sign-post* or signpost* or transfer* or recruit* or evaluat*
or advic* or diagnos*)).ti,ab. (1487)
32 ((family* or famili* or parent* or grandparent* or mother* or mum*3 or father* or dad*3
or grandparent* or grandmother* or grandfather* or grandad* or sister* or brother* or sibling*
or twin*1) and (identif* or refer* or sign-post* or signpost* or transfer* or recruit* or evaluat*
or advic* or diagnos*)).hw. (516)
33 ((barrier* or facilitat* or hinder* or block* or obstacle* or restrict* or restrain* or obstruct*
or impede* or delay* or constrain* or hindrance or enhance* or encourag* or support* or
promot* or optimiz* or optimis* or motivat* or incentiv* or persuad* or persuasion or intend*
or intention or counsel* or hesitan* or attrition) adj1 (identif* or refer* or sign-post* or
signpost* or transfer* or recruit* or detect* or advic* or intervent* or diagnos*)).ti,ab. (1637)
34 ((barrier* or facilitat* or hinder* or block* or obstacle* or restrict* or restrain* or obstruct*
or impede* or delay* or constrain* or hindrance or enhance* or encourag* or support* or
promot* or optimiz* or optimis* or motivat* or incentiv* or persuad* or persuasion or intend*
or intention or counsel* or hesitan* or attrition) and (identif* or refer* or sign-post* or
signpost* or transfer* or recruit* or detect* or advic* or intervent* or diagnos*)).hw. (559)
35 ((increas* or improv* or rais* or higher or decreas* or reduc* or poor* or low or lower or
drop* or withdraw* or quit* or likely or unlikely or positiv* or negativ* or influen*) adj1 (identif*
or refer* or sign-post* or signpost* or transfer* or recruit* or detect* or advic* or intervent* or
diagnos*)).ti,ab. (1706)

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Overweight and obesity management: preventing, assessing and managing overweight and
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36 ((increas* or improv* or rais* or higher or decreas* or reduc* or poor* or low or lower or

drop* or withdraw* or quit* or likely or unlikely or positiv* or negativ* or influen*) and (identif*
or refer* or sign-post* or signpost* or transfer* or recruit* or detect* or advic* or intervent* or
diagnos*)).hw. (359)
37 ((home* or resident*) adj3 (identif* or refer* or sign-post* or signpost* or transfer* or
recruit* or detect* or advic* or intervent* or diagnos*)).ti,ab. (1037)
38 ((home* or resident*) and (identif* or refer* or sign-post* or signpost* or transfer* or
recruit* or detect* or advic* or intervent* or diagnos*)).hw. (261)
39 ((carer* or social-work* or health-visit*) adj3 (identif* or refer* or sign-post* or signpost*
or transfer* or recruit* or detect* or advic* or intervent* or diagnos*)).ti,ab. (1064)
40 ((carer* or social-work* or health-visit*) and (identif* or refer* or sign-post* or signpost*
or transfer* or recruit* or detect* or advic* or intervent* or diagnos*)).hw. (519)
41 ((survey* or audit* or questionnaire* or framework*) adj3 (identif* or refer* or sign-post*
or signpost* or transfer* or recruit* or detect* or advic* or intervent* or diagnos*)).ti,ab. (1794)
42 ((survey* or audit* or questionnaire* or framework*) and (identif* or refer* or sign-post*
or signpost* or transfer* or recruit* or detect* or advic* or intervent* or diagnos*)).hw. (960)
43 or/15-42 (29198)
44 14 and 43 (143)
45 (2000* or 2001* or 2002* or 2003* or 2004* or 2005* or 2006* or 2007* or 2008* or
2009* or 2010* or 2011* or 2012* or 2013* or 2014* or 2015* or 2016* or 2017* or 2018* or
2019* or 2020* or 2021* or 2022*).up. (425108)
46 44 and 45 (143)
47 limit 46 to english (143)

Database name: SPP

1 (obes* or preobese* or overweight* or over-weight*).ti,ab. (1072)
2 (obes* or preobese* or overweight* or over-weight*).hw. (891)
3 or/1-2 (1277)
4 (weight* adj1 (loss* or management* or reduc* or lifestyle* or life-style* or control* or
health*) adj2 (servic* or intervent* or program* or plan* or refer* or scheme* or treatment* or
trial* or therap* or clinic* or session*)).ti,ab. (54)
5 ((weight* adj1 (loss* or management* or reduc* or lifestyle* or life-style* or control* or
health*)) and (servic* or intervent* or program* or plan* or refer* or scheme* or treatment* or
trial* or therap* or clinic* or session*)).hw. (6)
6 or/4-5 (59)
7 3 and 6 (51)
8 ((obes* or preobes* or overweight* or over-weight*) adj2 (loss* or management* or
reduc* or lifestyle* or life-style* or control* or health* or prevent*) adj2 (servic* or intervent* or

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obesity: identifying overweight and obesity in children, young people and adults FINAL
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program* or plan* or refer* or scheme* or treatment* or trial* or therap* or clinic* or

session*)).ti,ab. (23)
9 ((obes* or preobes* or overweight* or over-weight*) and (loss* or management* or
reduc* or lifestyle* or life-style* or control* or health* or prevent*) and (servic* or intervent* or
program* or plan* or refer* or scheme* or treatment* or trial* or therap* or clinic* or
session*)).hw. (254)
10 or/8-9 (270)
11 ((obes* or preobese* or overweight* or over-weight*) adj1 (detect* or identif* or
diagnos*) adj3 (refer* or sign-post* or signpost* or transfer* or recruit* or evaluat* or advic* or
diagnos*)).ti,ab. (0)
12 (((obes* or preobese* or overweight* or over-weight*) and (detect* or identif* or
diagnos*)) adj3 (refer* or sign-post* or signpost* or transfer* or recruit* or evaluat* or advic*
or diagnos*)).hw. (5)
13 or/11-12 (5)
14 7 or 10 or 13 (303)
15 ((opportun* or holistic* or routine* or consultat* or appointment* or checkup* or check-
up*) adj3 (identif* or refer* or signpost* or sign-post* or transfer* or recruit* or detect* or
advic* or intervent* or diagnos*)).ti,ab. (977)
16 ((opportun* or holistic* or routine* or consultat* or appointment* or checkup* or check-
up*) and (identif* or refer* or signpost* or sign-post* or transfer* or recruit* or detect* or
advic* or intervent* or diagnos*)).hw. (648)
17 (case-find* or active-case*).ti,ab. (125)
18 (case-find* or active-case*).hw. (0)
19 (self-refer* or self-report* or self-diagnos* or self-evaluat* or self-manag*).ti,ab. (4509)
20 (self-refer* or self-report* or self-diagnos* or self-evaluat* or self-manag*).hw. (36)
21 ((clinician* or physician* or doctor* or nurse*1 or pharmacy* or pharmacies* or
pharmacist* or consultant* or practition* or primary-care* or dietician* or nutritionist* or GP*1
or HCP*1) adj3 (identif* or refer* or signpost* or sign-post* or transfer* or recruit* or detect*
or advic* or intervent* or diagnos*)).ti,ab. (1537)
22 ((clinician* or physician* or doctor* or nurse*1 or pharmacy* or pharmacies* or
pharmacist* or consultant* or practition* or primary-care* or dietician* or nutritionist* or GP*1
or HCP*1) and (identif* or refer* or signpost* or sign-post* or transfer* or recruit* or detect* or
advic* or intervent* or diagnos*)).hw. (1149)
23 ((medical* or health or healthcare or clinical*) adj2 (staff* or team* or provide* or
agenc*) adj3 (identif* or refer* or sign-post* or signpost* or transfer* or recruit* or detect* or
advic* or intervent* or diagnos*)).ti,ab. (145)
24 (((medical* or health or healthcare or clinical*) and (staff* or team* or provide* or
agenc*)) adj3 (identif* or refer* or sign-post* or signpost* or transfer* or recruit* or detect* or
advic* or intervent* or diagnos*)).hw. (189)

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25 (screen* adj3 (identif* or refer* or sign-post* or signpost* or transfer* or recruit* or

detect* or advic* or intervent* or diagnos*)).ti,ab. (595)
26 (screen* and (identif* or refer* or sign-post* or signpost* or transfer* or recruit* or
detect* or advic* or intervent* or diagnos*)).hw. (465)
27 ((school* or highschool* or primaryschool* or preschool* or nurser* or universit* or
educat* or pupil* or teach* or student*) adj3 (identif* or refer* or sign-post* or signpost* or
transfer* or recruit* or detect* or advic* or intervent* or diagnos*)).ti,ab. (3252)
28 ((school* or highschool* or primaryschool* or preschool* or nurser* or universit* or
educat* or pupil* or teach* or student*) and (identif* or refer* or sign-post* or signpost* or
transfer* or recruit* or detect* or advic* or intervent* or diagnos*)).hw. (4280)
29 ((Setting-based or communit* or clinic-based or work-based or workplace*) adj3
(identif* or refer* or sign-post* or signpost* or transfer* or recruit* or evaluat* or advic* or
diagnos*)).ti,ab. (2034)
30 ((Setting-based or communit* or clinic-based or work-based or workplace*) and (identif*
or refer* or sign-post* or signpost* or transfer* or recruit* or evaluat* or advic* or
diagnos*)).hw. (3626)
31 ((family* or famili* or parent* or grandparent* or mother* or mum*3 or father* or dad*3
or grandparent* or grandmother* or grandfather* or grandad* or sister* or brother* or sibling*
or twin*1) adj3 (identif* or refer* or sign-post* or signpost* or transfer* or recruit* or evaluat*
or advic* or diagnos*)).ti,ab. (3200)
32 ((family* or famili* or parent* or grandparent* or mother* or mum*3 or father* or dad*3
or grandparent* or grandmother* or grandfather* or grandad* or sister* or brother* or sibling*
or twin*1) and (identif* or refer* or sign-post* or signpost* or transfer* or recruit* or evaluat*
or advic* or diagnos*)).hw. (4741)
33 ((barrier* or facilitat* or hinder* or block* or obstacle* or restrict* or restrain* or obstruct*
or impede* or delay* or constrain* or hindrance or enhance* or encourag* or support* or
promot* or optimiz* or optimis* or motivat* or incentiv* or persuad* or persuasion or intend*
or intention or counsel* or hesitan* or attrition) adj1 (identif* or refer* or sign-post* or
signpost* or transfer* or recruit* or detect* or advic* or intervent* or diagnos*)).ti,ab. (2234)
34 ((barrier* or facilitat* or hinder* or block* or obstacle* or restrict* or restrain* or obstruct*
or impede* or delay* or constrain* or hindrance or enhance* or encourag* or support* or
promot* or optimiz* or optimis* or motivat* or incentiv* or persuad* or persuasion or intend*
or intention or counsel* or hesitan* or attrition) and (identif* or refer* or sign-post* or
signpost* or transfer* or recruit* or detect* or advic* or intervent* or diagnos*)).hw. (3318)
35 ((increas* or improv* or rais* or higher or decreas* or reduc* or poor* or low or lower or
drop* or withdraw* or quit* or likely or unlikely or positiv* or negativ* or influen*) adj1 (identif*
or refer* or sign-post* or signpost* or transfer* or recruit* or detect* or advic* or intervent* or
diagnos*)).ti,ab. (1357)
36 ((increas* or improv* or rais* or higher or decreas* or reduc* or poor* or low or lower or
drop* or withdraw* or quit* or likely or unlikely or positiv* or negativ* or influen*) and (identif*
or refer* or sign-post* or signpost* or transfer* or recruit* or detect* or advic* or intervent* or
diagnos*)).hw. (930)
37 ((home* or resident*) adj3 (identif* or refer* or sign-post* or signpost* or transfer* or
recruit* or detect* or advic* or intervent* or diagnos*)).ti,ab. (2110)

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38 ((home* or resident*) and (identif* or refer* or sign-post* or signpost* or transfer* or

recruit* or detect* or advic* or intervent* or diagnos*)).hw. (2611)
39 ((carer* or social-work* or health-visit*) adj3 (identif* or refer* or sign-post* or signpost*
or transfer* or recruit* or detect* or advic* or intervent* or diagnos*)).ti,ab. (2720)
40 ((carer* or social-work* or health-visit*) and (identif* or refer* or sign-post* or signpost*
or transfer* or recruit* or detect* or advic* or intervent* or diagnos*)).hw. (5135)
41 ((survey* or audit* or questionnaire* or framework*) adj3 (identif* or refer* or sign-post*
or signpost* or transfer* or recruit* or detect* or advic* or intervent* or diagnos*)).ti,ab. (1337)
42 ((survey* or audit* or questionnaire* or framework*) and (identif* or refer* or sign-post*
or signpost* or transfer* or recruit* or detect* or advic* or intervent* or diagnos*)).hw. (1189)
43 or/15-42 (39739)
44 14 and 43 (72)
45 (2000* or 2001* or 2002* or 2003* or 2004* or 2005* or 2006* or 2007* or 2008* or
2009* or 2010* or 2011* or 2012* or 2013* or 2014* or 2015* or 2016* or 2017* or 2018* or
2019* or 2020* or 2021* or 2022*).up. (275101)
46 44 and 45 (69)

Database name: Cochrane: CDSR and CENTRAL

#1 MeSH descriptor: [Weight Reduction Programs] this term only 849
#2 MeSH descriptor: [Obesity] explode all trees 15271
#3 MeSH descriptor: [Overweight] explode all trees 18120
#4 (obes* or preobes* or overweight* or over-weight*):ti,ab 45929
#5 {or #2-#4} 48507
#6 (weight* NEAR/1 (loss* or management* or reduc* or lifestyle* or life-style* or control*
or health*) NEAR/2 (servic* or intervent* or program* or plan* or refer* or scheme* or
treatment* or trial* or therap* or clinic* or session*)):ti,ab 6423
#7 #5 and #6 5092
#8 ((obes* or preobes* or overweight* or over-weight*) NEAR/2 (loss* or management*
or reduc* or lifestyle* or life-style* or control* or health* or prevent*) NEAR/2 (servic* or
intervent* or program* or plan* or refer* or scheme* or treatment* or trial* or therap* or clinic*
or session*)):ti,ab 1344
#9 #1 or #7 or #8 6557
#10 MeSH descriptor: [Obesity] explode all trees and with qualifier(s): [diagnosis - DI,
prevention & control - PC] 2192
#11 MeSH descriptor: [Overweight] this term only and with qualifier(s): [diagnosis - DI,
prevention & control - PC] 498

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#12 ((obes* or preobese* or overweight* or over-weight*) NEAR/1 (detect* or identif* or

diagnos*) NEAR/3 (refer* or sign-post* or signpost* or transfer* or recruit* or evaluat* or
advic* or diagnos*)):ti,ab 85
#13 {or #10-#12} 2547
#14 #9 or #13 8387
#15 MeSH descriptor: [Referral and Consultation] this term only 2010
#16 MeSH descriptor: [Remote Consultation] this term only 387
#17 MeSH descriptor: [Diagnostic Self Evaluation] this term only 214
#18 MeSH descriptor: [Appointments and Schedules] explode all trees 1123
#19 ((opportun* or holistic* or routine* or consultat* or appointment* or checkup* or check-
up*) NEAR/3 (identif* or refer* or signpost* or sign-post* or transfer* or recruit* or detect* or
advic* or intervent* or diagnos*)):ti,ab 6628
#20 (case-find* or active-case*):ti,ab 529
#21 MeSH descriptor: [Self Care] this term only 4327
#22 MeSH descriptor: [Self-Management] this term only 621
#23 (self-refer* or self-report* or self-diagnos* or self-evaluat* or self-manag*):ti,ab
42933
#24 MeSH descriptor: [Health Personnel] explode all trees 9998
#25 MeSH descriptor: [Attitude of Health Personnel] this term only 2006
#26 MeSH descriptor: [Professional-Family Relations] this term only 223
#27 MeSH descriptor: [Professional-Patient Relations] this term only 792
#28 ((clinician* or physician* or doctor* or nurse or nurses or pharmacy* or pharmacies*
or pharmacist* or consultant* or practition* or primary-care* or dietician* or nutritionist* or GP
or GPs or HCP or HCPs) NEAR/3 (identif* or refer* or signpost* or sign-post* or transfer* or
recruit* or detect* or advic* or intervent* or diagnos*)):ti,ab 17082
#29 ((medical* or health or healthcare or clinical*) NEAR/2 (staff* or team* or provide* or
agenc*) NEAR/3 (identif* or refer* or sign-post* or signpost* or transfer* or recruit* or detect*
or advic* or intervent* or diagnos*)):ti,ab 1167
#30 MeSH descriptor: [Mass Screening] this term only 3339
#31 (screen* NEAR/3 (identif* or refer* or sign-post* or signpost* or transfer* or recruit* or
detect* or advic* or intervent* or diagnos*)):ti,ab 7988
#32 MeSH descriptor: [School Health Services] this term only 1536
#33 MeSH descriptor: [School Nursing] this term only 83
#34 ((school* or highschool* or primaryschool* or preschool* or nurser* or universit* or
educat* or pupil* or teach* or student*) NEAR/3 (identif* or refer* or sign-post* or signpost* or
transfer* or recruit* or detect* or advic* or intervent* or diagnos*)):ti,ab 22564

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#35 ((Setting-based or communit* or clinic-based or work-based or workplace*) NEAR/3

(identif* or refer* or sign-post* or signpost* or transfer* or recruit* or evaluat* or advic* or
diagnos*)):ti,ab 4019
#36 MeSH descriptor: [Family] explode all trees 10243
#37 ((family* or famili* or parent* or grandparent* or mother* or mum or mums or mummy
or mummies or father* or dad or dads or daddy or daddies or grandparent* or grandmother*
or grandfather* or grandad* or sister* or brother* or sibling* or twin or twins) NEAR/3 (identif*
or refer* or sign-post* or signpost* or transfer* or recruit* or evaluat* or advic* or
diagnos*)):ti,ab 5190
#38 ((barrier* or facilitat* or hinder* or block* or obstacle* or restrict* or restrain* or
obstruct* or impede* or delay* or constrain* or hindrance or enhance* or encourag* or
support* or promot* or optimiz* or optimis* or motivat* or incentiv* or persuad* or persuasion
or intend* or intention or counsel* or hesitan* or attrition) NEAR/1 (identif* or refer* or sign-
post* or signpost* or transfer* or recruit* or detect* or advic* or intervent* or diagnos*)):ti,ab
12806
#39 ((increas* or improv* or rais* or higher or decreas* or reduc* or poor* or low or lower
or drop* or withdraw* or quit* or likely or unlikely or positiv* or negativ* or influen*) NEAR/1
(identif* or refer* or sign-post* or signpost* or transfer* or recruit* or detect* or advic* or
intervent* or diagnos*)):ti,ab 19919
#40 MeSH descriptor: [Home Nursing] explode all trees 299
#41 MeSH descriptor: [Home Care Services] this term only 1926
#42 ((home* or resident*) NEAR/3 (identif* or refer* or sign-post* or signpost* or transfer*
or recruit* or detect* or advic* or intervent* or diagnos*)):ti,ab 6530
#43 ((carer* or social-work* or health-visit*) NEAR/3 (identif* or refer* or sign-post* or
signpost* or transfer* or recruit* or detect* or advic* or intervent* or diagnos*)):ti,ab 659
#44 ((survey* or audit* or questionnaire* or framework*) NEAR/3 (identif* or refer* or sign-
post* or signpost* or transfer* or recruit* or detect* or advic* or intervent* or diagnos*)):ti,ab
6677
#45 {or #15-#44} 146979
#46 #14 and #45 2707
#47 "conference":pt or (clinicaltrials or trialsearch):so 582582
#48 #46 not #47 with Cochrane Library publication date Between Jan 2000 and Jan 2022,
in Cochrane Reviews 17
#49 #46 not #47 with Publication Year from 2000 to 2022, in Trials 2053

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Cost-effectiveness searches

Main search – Databases

• Database • No.
• Date • Database
• Database segment or of results
searched Platform
version downloaded

• Medline • OVID • 1946 to

• 01/02/2022 January 31, • 162
2022

• Medline in • 01/02/2022 • OVID • 1946 to

process January 31, • 1
2022

• Medline • 01/02/2022 • OVID • January

• 3
ePub ahead 31, 2022

• Embase • OVID • 1974 to

• 02/02/2022 2022 February • 111
01

• Econlit • 1886 to
• 02/02/2022 • OVID January 27, • 1
2022

• NHS EED • 02/02/2022 • CRD • N/A • 51

• INAHTA • 02/02/2022 • INAHTA • N/A • 61

Search strategy history

Database name: Medline

1 Weight Reduction Programs/ (2670)
2 exp *obesity/ or overweight/ or Obesity Management/ (186743)
3 (obes* or preobese* or overweight* or over-weight*).ti,ab. (310583)
4 or/2-3 (337899)
5 (weight* adj1 (loss* or management* or reduc* or lifestyle* or life-style* or control* or
health*) adj2 (servic* or intervent* or program* or plan* or refer* or scheme* or treatment* or
trial* or therap* or clinic* or session*)).ti,ab. (11461)
6 4 and 5 (8971)
7 ((obes* or preobes* or overweight* or over-weight*) adj2 (loss* or management* or
reduc* or lifestyle* or life-style* or control* or health* or prevent*) adj2 (servic* or intervent* or

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program* or plan* or refer* or scheme* or treatment* or trial* or therap* or clinic* or

session*)).ti,ab. (3241)
8 1 or 6 or 7 (13130)
9 exp *Obesity/di, pc or *Overweight/di, pc (14986)
10 ((obes* or preobese* or overweight* or over-weight*) adj1 (detect* or identif* or
diagnos*) adj3 (refer* or sign-post* or signpost* or transfer* or recruit* or evaluat* or advic* or
diagnos*)).ti,ab. (437)
11 or/9-10 (15295)
12 8 or 11 (26420)
13 "referral and consultation"/ or remote consultation/ or diagnostic self evaluation/ or exp
"Appointments and Schedules"/ (101516)
14 ((opportun* or holistic* or routine* or consultat* or appointment* or checkup* or check-
up*) adj3 (identif* or refer* or signpost* or sign-post* or transfer* or recruit* or detect* or
advic* or intervent* or diagnos*)).ti,ab. (48303)
15 (case-find* or active-case*).ti,ab. (6244)
16 self care/ or self-management/ (38777)
17 (self-refer* or self-report* or self-diagnos* or self-evaluat* or self-manag*).ti,ab.
(183752)
18 exp Health Personnel/ or "Attitude of Health Personnel"/ or professional-family
relations/ or professional-patient relations/ (666942)
19 ((clinician* or physician* or doctor* or nurse*1 or pharmacy* or pharmacies* or
pharmacist* or consultant* or practition* or primary-care* or dietician* or nutritionist* or GP*1
or HCP*1) adj3 (identif* or refer* or signpost* or sign-post* or transfer* or recruit* or detect*
or advic* or intervent* or diagnos*)).ti,ab. (84102)
20 ((medical* or health or healthcare or clinical*) adj2 (staff* or team* or provide* or
agenc*) adj3 (identif* or refer* or sign-post* or signpost* or transfer* or recruit* or detect* or
advic* or intervent* or diagnos*)).ti,ab. (6020)
21 Mass Screening/ (111788)
22 (screen* adj3 (identif* or refer* or sign-post* or signpost* or transfer* or recruit* or
detect* or advic* or intervent* or diagnos*)).ti,ab. (76415)
23 school health services/ or school nursing/ (22318)
24 ((school* or highschool* or primaryschool* or preschool* or nurser* or universit* or
educat* or pupil* or teach* or student*) adj3 (identif* or refer* or sign-post* or signpost* or
transfer* or recruit* or detect* or advic* or intervent* or diagnos*)).ti,ab. (64973)
25 ((Setting-based or communit* or clinic-based or work-based or workplace*) adj3
(identif* or refer* or sign-post* or signpost* or transfer* or recruit* or evaluat* or advic* or
diagnos*)).ti,ab. (22366)
26 exp Family/ (346922)

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27 ((family* or famili* or parent* or grandparent* or mother* or mum*3 or father* or dad*3

or grandparent* or grandmother* or grandfather* or grandad* or sister* or brother* or sibling*
or twin*1) adj3 (identif* or refer* or sign-post* or signpost* or transfer* or recruit* or evaluat*
or advic* or diagnos*)).ti,ab. (63458)
28 ((barrier* or facilitat* or hinder* or block* or obstacle* or restrict* or restrain* or obstruct*
or impede* or delay* or constrain* or hindrance or enhance* or encourag* or support* or
promot* or optimiz* or optimis* or motivat* or incentiv* or persuad* or persuasion or intend*
or intention or counsel* or hesitan* or attrition) adj1 (identif* or refer* or sign-post* or
signpost* or transfer* or recruit* or detect* or advic* or intervent* or diagnos*)).ti,ab. (64484)
29 ((increas* or improv* or rais* or higher or decreas* or reduc* or poor* or low or lower or
drop* or withdraw* or quit* or likely or unlikely or positiv* or negativ* or influen*) adj1 (identif*
or refer* or sign-post* or signpost* or transfer* or recruit* or detect* or advic* or intervent* or
diagnos*)).ti,ab. (125630)
30 Home Nursing/ or Home Care Services/ (42873)
31 ((home* or resident*) adj3 (identif* or refer* or sign-post* or signpost* or transfer* or
recruit* or detect* or advic* or intervent* or diagnos*)).ti,ab. (17829)
32 ((carer* or social-work* or health-visit*) adj3 (identif* or refer* or sign-post* or signpost*
or transfer* or recruit* or detect* or advic* or intervent* or diagnos*)).ti,ab. (2130)
33 ((survey* or audit* or questionnaire* or framework*) adj3 (identif* or refer* or sign-post*
or signpost* or transfer* or recruit* or detect* or advic* or intervent* or diagnos*)).ti,ab.
(37594)
34 or/13-33 (1818655)
35 12 and 34 (6944)
36 limit 35 to english language (6738)
37 animals/ not humans/ (4918000)
38 36 not 37 (6722)
39 limit 38 to ed=20000101-20221231 (6478)
40 Cost-Benefit Analysis/ (88239)
41 (cost* and ((qualit* adj2 adjust* adj2 life*) or qaly*)).tw. (13141)
42 ((incremental* adj2 cost*) or ICER).tw. (13549)
43 (cost adj2 utilit*).tw. (5156)
44 (cost* and ((net adj benefit*) or (net adj monetary adj benefit*) or (net adj health adj
benefit*))).tw. (1688)
45 ((cost adj2 (effect* or utilit*)) and (quality adj of adj life)).tw. (17922)
46 (cost and (effect* or utilit*)).ti. (30136)
47 or/40-46 (99896)
48 39 and 47 (162)

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FINAL

Database name: Medline in process

1 Weight Reduction Programs/ (0)
2 exp *obesity/ or overweight/ or Obesity Management/ (0)
3 (obes* or preobese* or overweight* or over-weight*).ti,ab. (3660)
4 or/2-3 (3660)
5 (weight* adj1 (loss* or management* or reduc* or lifestyle* or life-style* or control* or
health*) adj2 (servic* or intervent* or program* or plan* or refer* or scheme* or treatment* or
trial* or therap* or clinic* or session*)).ti,ab. (119)
6 4 and 5 (85)
7 ((obes* or preobes* or overweight* or over-weight*) adj2 (loss* or management* or
reduc* or lifestyle* or life-style* or control* or health* or prevent*) adj2 (servic* or intervent* or
program* or plan* or refer* or scheme* or treatment* or trial* or therap* or clinic* or
session*)).ti,ab. (46)
8 1 or 6 or 7 (125)
9 exp *Obesity/di, pc or *Overweight/di, pc (0)
10 ((obes* or preobese* or overweight* or over-weight*) adj1 (detect* or identif* or
diagnos*) adj3 (refer* or sign-post* or signpost* or transfer* or recruit* or evaluat* or advic* or
diagnos*)).ti,ab. (7)
11 or/9-10 (7)
12 8 or 11 (132)
13 "referral and consultation"/ or remote consultation/ or diagnostic self evaluation/ or exp
"Appointments and Schedules"/ (0)
14 ((opportun* or holistic* or routine* or consultat* or appointment* or checkup* or check-
up*) adj3 (identif* or refer* or signpost* or sign-post* or transfer* or recruit* or detect* or
advic* or intervent* or diagnos*)).ti,ab. (558)
15 (case-find* or active-case*).ti,ab. (40)
16 self care/ or self-management/ (0)
17 (self-refer* or self-report* or self-diagnos* or self-evaluat* or self-manag*).ti,ab. (2156)
18 exp Health Personnel/ or "Attitude of Health Personnel"/ or professional-family
relations/ or professional-patient relations/ (0)
19 ((clinician* or physician* or doctor* or nurse*1 or pharmacy* or pharmacies* or
pharmacist* or consultant* or practition* or primary-care* or dietician* or nutritionist* or GP*1
or HCP*1) adj3 (identif* or refer* or signpost* or sign-post* or transfer* or recruit* or detect*
or advic* or intervent* or diagnos*)).ti,ab. (728)
20 ((medical* or health or healthcare or clinical*) adj2 (staff* or team* or provide* or
agenc*) adj3 (identif* or refer* or sign-post* or signpost* or transfer* or recruit* or detect* or
advic* or intervent* or diagnos*)).ti,ab. (69)

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obesity: identifying overweight and obesity in children, young people and adults FINAL
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21 Mass Screening/ (0)

22 (screen* adj3 (identif* or refer* or sign-post* or signpost* or transfer* or recruit* or
detect* or advic* or intervent* or diagnos*)).ti,ab. (1045)
23 school health services/ or school nursing/ (0)
24 ((school* or highschool* or primaryschool* or preschool* or nurser* or universit* or
educat* or pupil* or teach* or student*) adj3 (identif* or refer* or sign-post* or signpost* or
transfer* or recruit* or detect* or advic* or intervent* or diagnos*)).ti,ab. (611)
25 ((Setting-based or communit* or clinic-based or work-based or workplace*) adj3
(identif* or refer* or sign-post* or signpost* or transfer* or recruit* or evaluat* or advic* or
diagnos*)).ti,ab. (228)
26 exp Family/ (0)
27 ((family* or famili* or parent* or grandparent* or mother* or mum*3 or father* or dad*3
or grandparent* or grandmother* or grandfather* or grandad* or sister* or brother* or sibling*
or twin*1) adj3 (identif* or refer* or sign-post* or signpost* or transfer* or recruit* or evaluat*
or advic* or diagnos*)).ti,ab. (572)
28 ((barrier* or facilitat* or hinder* or block* or obstacle* or restrict* or restrain* or obstruct*
or impede* or delay* or constrain* or hindrance or enhance* or encourag* or support* or
promot* or optimiz* or optimis* or motivat* or incentiv* or persuad* or persuasion or intend*
or intention or counsel* or hesitan* or attrition) adj1 (identif* or refer* or sign-post* or
signpost* or transfer* or recruit* or detect* or advic* or intervent* or diagnos*)).ti,ab. (789)
29 ((increas* or improv* or rais* or higher or decreas* or reduc* or poor* or low or lower or
drop* or withdraw* or quit* or likely or unlikely or positiv* or negativ* or influen*) adj1 (identif*
or refer* or sign-post* or signpost* or transfer* or recruit* or detect* or advic* or intervent* or
diagnos*)).ti,ab. (1467)
30 Home Nursing/ or Home Care Services/ (0)
31 ((home* or resident*) adj3 (identif* or refer* or sign-post* or signpost* or transfer* or
recruit* or detect* or advic* or intervent* or diagnos*)).ti,ab. (171)
32 ((carer* or social-work* or health-visit*) adj3 (identif* or refer* or sign-post* or signpost*
or transfer* or recruit* or detect* or advic* or intervent* or diagnos*)).ti,ab. (21)
33 ((survey* or audit* or questionnaire* or framework*) adj3 (identif* or refer* or sign-post*
or signpost* or transfer* or recruit* or detect* or advic* or intervent* or diagnos*)).ti,ab. (399)
34 or/13-33 (8039)
35 12 and 34 (27)
36 limit 35 to english language (27)
37 animals/ not humans/ (0)
38 36 not 37 (27)
39 limit 38 to dt=20000101-20221231 (27)
40 Cost-Benefit Analysis/ (0)

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41 (cost* and ((qualit* adj2 adjust* adj2 life*) or qaly*)).tw. (190)

42 ((incremental* adj2 cost*) or ICER).tw. (163)
43 (cost adj2 utilit*).tw. (71)
44 (cost* and ((net adj benefit*) or (net adj monetary adj benefit*) or (net adj health adj
benefit*))).tw. (27)
45 ((cost adj2 (effect* or utilit*)) and (quality adj of adj life)).tw. (228)
46 (cost and (effect* or utilit*)).ti. (277)
47 or/40-46 (421)
48 39 and 47 (1)

Database name: Medline ePub ahead

1 Weight Reduction Programs/ (0)
2 exp *obesity/ or overweight/ or Obesity Management/ (0)
3 (obes* or preobese* or overweight* or over-weight*).ti,ab. (5844)
4 or/2-3 (5844)
5 (weight* adj1 (loss* or management* or reduc* or lifestyle* or life-style* or control* or
health*) adj2 (servic* or intervent* or program* or plan* or refer* or scheme* or treatment* or
trial* or therap* or clinic* or session*)).ti,ab. (249)
6 4 and 5 (169)
7 ((obes* or preobes* or overweight* or over-weight*) adj2 (loss* or management* or
reduc* or lifestyle* or life-style* or control* or health* or prevent*) adj2 (servic* or intervent* or
program* or plan* or refer* or scheme* or treatment* or trial* or therap* or clinic* or
session*)).ti,ab. (66)
8 1 or 6 or 7 (227)
9 exp *Obesity/di, pc or *Overweight/di, pc (0)
10 ((obes* or preobese* or overweight* or over-weight*) adj1 (detect* or identif* or
diagnos*) adj3 (refer* or sign-post* or signpost* or transfer* or recruit* or evaluat* or advic* or
diagnos*)).ti,ab. (16)
11 or/9-10 (16)
12 8 or 11 (242)
13 "referral and consultation"/ or remote consultation/ or diagnostic self evaluation/ or exp
"Appointments and Schedules"/ (0)
14 ((opportun* or holistic* or routine* or consultat* or appointment* or checkup* or check-
up*) adj3 (identif* or refer* or signpost* or sign-post* or transfer* or recruit* or detect* or
advic* or intervent* or diagnos*)).ti,ab. (1168)
15 (case-find* or active-case*).ti,ab. (119)

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16 self care/ or self-management/ (0)

17 (self-refer* or self-report* or self-diagnos* or self-evaluat* or self-manag*).ti,ab. (5760)
18 exp Health Personnel/ or "Attitude of Health Personnel"/ or professional-family
relations/ or professional-patient relations/ (0)
19 ((clinician* or physician* or doctor* or nurse*1 or pharmacy* or pharmacies* or
pharmacist* or consultant* or practition* or primary-care* or dietician* or nutritionist* or GP*1
or HCP*1) adj3 (identif* or refer* or signpost* or sign-post* or transfer* or recruit* or detect*
or advic* or intervent* or diagnos*)).ti,ab. (2149)
20 ((medical* or health or healthcare or clinical*) adj2 (staff* or team* or provide* or
agenc*) adj3 (identif* or refer* or sign-post* or signpost* or transfer* or recruit* or detect* or
advic* or intervent* or diagnos*)).ti,ab. (209)
21 Mass Screening/ (0)
22 (screen* adj3 (identif* or refer* or sign-post* or signpost* or transfer* or recruit* or
detect* or advic* or intervent* or diagnos*)).ti,ab. (1837)
23 school health services/ or school nursing/ (0)
24 ((school* or highschool* or primaryschool* or preschool* or nurser* or universit* or
educat* or pupil* or teach* or student*) adj3 (identif* or refer* or sign-post* or signpost* or
transfer* or recruit* or detect* or advic* or intervent* or diagnos*)).ti,ab. (2099)
25 ((Setting-based or communit* or clinic-based or work-based or workplace*) adj3
(identif* or refer* or sign-post* or signpost* or transfer* or recruit* or evaluat* or advic* or
diagnos*)).ti,ab. (605)
26 exp Family/ (0)
27 ((family* or famili* or parent* or grandparent* or mother* or mum*3 or father* or dad*3
or grandparent* or grandmother* or grandfather* or grandad* or sister* or brother* or sibling*
or twin*1) adj3 (identif* or refer* or sign-post* or signpost* or transfer* or recruit* or evaluat*
or advic* or diagnos*)).ti,ab. (1451)
28 ((barrier* or facilitat* or hinder* or block* or obstacle* or restrict* or restrain* or obstruct*
or impede* or delay* or constrain* or hindrance or enhance* or encourag* or support* or
promot* or optimiz* or optimis* or motivat* or incentiv* or persuad* or persuasion or intend*
or intention or counsel* or hesitan* or attrition) adj1 (identif* or refer* or sign-post* or
signpost* or transfer* or recruit* or detect* or advic* or intervent* or diagnos*)).ti,ab. (1960)
29 ((increas* or improv* or rais* or higher or decreas* or reduc* or poor* or low or lower or
drop* or withdraw* or quit* or likely or unlikely or positiv* or negativ* or influen*) adj1 (identif*
or refer* or sign-post* or signpost* or transfer* or recruit* or detect* or advic* or intervent* or
diagnos*)).ti,ab. (2855)
30 Home Nursing/ or Home Care Services/ (0)
31 ((home* or resident*) adj3 (identif* or refer* or sign-post* or signpost* or transfer* or
recruit* or detect* or advic* or intervent* or diagnos*)).ti,ab. (467)
32 ((carer* or social-work* or health-visit*) adj3 (identif* or refer* or sign-post* or signpost*
or transfer* or recruit* or detect* or advic* or intervent* or diagnos*)).ti,ab. (110)

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33 ((survey* or audit* or questionnaire* or framework*) adj3 (identif* or refer* or sign-post*

or signpost* or transfer* or recruit* or detect* or advic* or intervent* or diagnos*)).ti,ab. (1172)
34 or/13-33 (19459)
35 12 and 34 (49)
36 limit 35 to english language (49)
37 animals/ not humans/ (0)
38 36 not 37 (49)
39 limit 38 to dt=20000101-20221231 (49)
40 Cost-Benefit Analysis/ (0)
41 (cost* and ((qualit* adj2 adjust* adj2 life*) or qaly*)).tw. (469)
42 ((incremental* adj2 cost*) or ICER).tw. (406)
43 (cost adj2 utilit*).tw. (207)
44 (cost* and ((net adj benefit*) or (net adj monetary adj benefit*) or (net adj health adj
benefit*))).tw. (57)
45 ((cost adj2 (effect* or utilit*)) and (quality adj of adj life)).tw. (637)
46 (cost and (effect* or utilit*)).ti. (631)
47 or/40-46 (1219)
48 39 and 47 (3)

Database name: Embase

1 weight loss program/ (2801)

2 exp *obesity/ or obesity management/ (265216)
3 (obes* or preobese* or overweight* or over-weight*).ti,ab. (523498)
4 or/2-3 (573633)
5 (weight* adj1 (loss* or management* or reduc* or lifestyle* or life-style* or control* or
health*) adj2 (servic* or intervent* or program* or plan* or refer* or scheme* or treatment* or
trial* or therap* or clinic* or session*)).ti,ab. (19724)
6 4 and 5 (14575)
7 ((obes* or preobes* or overweight* or over-weight*) adj2 (loss* or management* or
reduc* or lifestyle* or life-style* or control* or health* or prevent*) adj2 (servic* or intervent* or
program* or plan* or refer* or scheme* or treatment* or trial* or therap* or clinic* or
session*)).ti,ab. (4951)
8 1 or 6 or 7 (20292)
9 exp obesity/di, pc (29015)

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Overweight and obesity management: preventing, assessing and managing overweight and
obesity: identifying overweight and obesity in children, young people and adults FINAL
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10 ((obes* or preobese* or overweight* or over-weight*) adj1 (detect* or identif* or

diagnos*) adj3 (refer* or sign-post* or signpost* or transfer* or recruit* or evaluat* or advic* or
diagnos*)).ti,ab. (858)
11 or/9-10 (29694)
12 8 or 11 (47701)
13 patient referral/ or teleconsultation/ or self evaluation/ or consultation/ or hospital
management/ (342954)
14 ((opportun* or holistic* or routine* or consultat* or appointment* or checkup* or check-
up*) adj3 (identif* or refer* or signpost* or sign-post* or transfer* or recruit* or detect* or
advic* or intervent* or diagnos*)).ti,ab. (82114)
15 (case-find* or active-case*).ti,ab. (8887)
16 self care/ (66793)
17 (self-refer* or self-report* or self-diagnos* or self-evaluat* or self-manag*).ti,ab.
(281838)
18 exp health care personnel/ or exp health personnel attitude/ or human relation/ or
professional-patient relationship/ (1927227)
19 ((clinician* or physician* or doctor* or nurse*1 or pharmacy* or pharmacies* or
pharmacist* or consultant* or practition* or primary-care* or dietician* or nutritionist* or GP*1
or HCP*1) adj3 (identif* or refer* or signpost* or sign-post* or transfer* or recruit* or detect*
or advic* or intervent* or diagnos*)).ti,ab. (146534)
20 ((medical* or health or healthcare or clinical*) adj2 (staff* or team* or provide* or
agenc*) adj3 (identif* or refer* or sign-post* or signpost* or transfer* or recruit* or detect* or
advic* or intervent* or diagnos*)).ti,ab. (10251)
21 mass screening/ (58508)
22 (screen* adj3 (identif* or refer* or sign-post* or signpost* or transfer* or recruit* or
detect* or advic* or intervent* or diagnos*)).ti,ab. (126848)
23 school health services/ or school nursing/ (17785)
24 ((school* or highschool* or primaryschool* or preschool* or nurser* or universit* or
educat* or pupil* or teach* or student*) adj3 (identif* or refer* or sign-post* or signpost* or
transfer* or recruit* or detect* or advic* or intervent* or diagnos*)).ti,ab. (107250)
25 ((Setting-based or communit* or clinic-based or work-based or workplace*) adj3
(identif* or refer* or sign-post* or signpost* or transfer* or recruit* or evaluat* or advic* or
diagnos*)).ti,ab. (34584)
26 exp family/ (547607)
27 ((family* or famili* or parent* or grandparent* or mother* or mum*3 or father* or dad*3
or grandparent* or grandmother* or grandfather* or grandad* or sister* or brother* or sibling*
or twin*1) adj3 (identif* or refer* or sign-post* or signpost* or transfer* or recruit* or evaluat*
or advic* or diagnos*)).ti,ab. (99574)

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Overweight and obesity management: preventing, assessing and managing overweight and
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28 ((barrier* or facilitat* or hinder* or block* or obstacle* or restrict* or restrain* or obstruct*

or impede* or delay* or constrain* or hindrance or enhance* or encourag* or support* or
promot* or optimiz* or optimis* or motivat* or incentiv* or persuad* or persuasion or intend*
or intention or counsel* or hesitan* or attrition) adj1 (identif* or refer* or sign-post* or
signpost* or transfer* or recruit* or detect* or advic* or intervent* or diagnos*)).ti,ab. (106198)
29 ((increas* or improv* or rais* or higher or decreas* or reduc* or poor* or low or lower or
drop* or withdraw* or quit* or likely or unlikely or positiv* or negativ* or influen*) adj1 (identif*
or refer* or sign-post* or signpost* or transfer* or recruit* or detect* or advic* or intervent* or
diagnos*)).ti,ab. (207074)
30 exp home care/ (80814)
31 ((home* or resident* or residenc*) adj3 (identif* or refer* or sign-post* or signpost* or
transfer* or recruit* or detect* or advic* or intervent* or diagnos*)).ti,ab. (30988)
32 ((carer* or social-work* or health-visit*) adj3 (identif* or refer* or sign-post* or signpost*
or transfer* or recruit* or detect* or advic* or intervent* or diagnos*)).ti,ab. (3639)
33 ((survey* or audit* or questionnaire* or framework*) adj3 (identif* or refer* or sign-post*
or signpost* or transfer* or recruit* or detect* or advic* or intervent* or diagnos*)).ti,ab.
(63836)
34 or/13-33 (3600798)
35 12 and 34 (11979)
36 limit 35 to english language (11484)
37 nonhuman/ not human/ (4925871)
38 36 not 37 (11437)
39 (letter or editorial or conference abstract or conference paper or conference proceeding
or "conference review").pt. (7005464)
40 38 not 39 (8901)
41 limit 40 to dc=20000101-20221231 (8555)
42 cost utility analysis/ (10889)
43 (cost* and ((qualit* adj2 adjust* adj2 life*) or qaly*)).tw. (26094)
44 ((incremental* adj2 cost*) or ICER).tw. (26699)
45 (cost adj2 utilit*).tw. (9634)
46 (cost* and ((net adj benefit*) or (net adj monetary adj benefit*) or (net adj health adj
benefit*))).tw. (2703)
47 ((cost adj2 (effect* or utilit*)) and (quality adj of adj life)).tw. (31821)
48 (cost and (effect* or utilit*)).ti. (51253)
49 or/42-48 (80857)
50 41 and 49 (111)

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Database name: Econlit

1 (obes* or preobese* or overweight* or over-weight*).ti,ab. (2470)
2 (weight* adj1 (loss* or management* or reduc* or lifestyle* or life-style* or control* or
health*) adj2 (servic* or intervent* or program* or plan* or refer* or scheme* or treatment* or
trial* or therap* or clinic* or session*)).ti,ab. (18)
3 1 and 2 (12)
4 ((obes* or preobes* or overweight* or over-weight*) adj2 (loss* or management* or
reduc* or lifestyle* or life-style* or control* or health* or prevent*) adj2 (servic* or intervent* or
program* or plan* or refer* or scheme* or treatment* or trial* or therap* or clinic* or
session*)).ti,ab. (20)
5 3 or 4 (30)
6 ((obes* or preobese* or overweight* or over-weight*) adj1 (detect* or identif* or
diagnos*) adj3 (refer* or sign-post* or signpost* or transfer* or recruit* or evaluat* or advic* or
diagnos*)).ti,ab. (0)
7 5 or 6 (30)
8 ((opportun* or holistic* or routine* or consultat* or appointment* or checkup* or check-
up*) adj3 (identif* or refer* or signpost* or sign-post* or transfer* or recruit* or detect* or
advic* or intervent* or diagnos*)).ti,ab. (1041)
9 (case-find* or active-case*).ti,ab. (42)
10 (self-refer* or self-report* or self-diagnos* or self-evaluat* or self-manag*).ti,ab. (3790)
11 ((clinician* or physician* or doctor* or nurse*1 or pharmacy* or pharmacies* or
pharmacist* or consultant* or practition* or primary-care* or dietician* or nutritionist* or GP*1
or HCP*1) adj3 (identif* or refer* or signpost* or sign-post* or transfer* or recruit* or detect*
or advic* or intervent* or diagnos*)).ti,ab. (412)
12 ((medical* or health or healthcare or clinical*) adj2 (staff* or team* or provide* or
agenc*) adj3 (identif* or refer* or sign-post* or signpost* or transfer* or recruit* or detect* or
advic* or intervent* or diagnos*)).ti,ab. (21)
13 (screen* adj3 (identif* or refer* or sign-post* or signpost* or transfer* or recruit* or
detect* or advic* or intervent* or diagnos*)).ti,ab. (171)
14 ((school* or highschool* or primaryschool* or preschool* or nurser* or universit* or
educat* or pupil* or teach* or student*) adj3 (identif* or refer* or sign-post* or signpost* or
transfer* or recruit* or detect* or advic* or intervent* or diagnos*)).ti,ab. (2602)
15 ((Setting-based or communit* or clinic-based or work-based or workplace*) adj3
(identif* or refer* or sign-post* or signpost* or transfer* or recruit* or evaluat* or advic* or
diagnos*)).ti,ab. (694)
16 ((family* or famili* or parent* or grandparent* or mother* or mum*3 or father* or dad*3
or grandparent* or grandmother* or grandfather* or grandad* or sister* or brother* or sibling*
or twin*1) adj3 (identif* or refer* or sign-post* or signpost* or transfer* or recruit* or evaluat*
or advic* or diagnos*)).ti,ab. (1403)

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17 ((barrier* or facilitat* or hinder* or block* or obstacle* or restrict* or restrain* or obstruct*

or impede* or delay* or constrain* or hindrance or enhance* or encourag* or support* or
promot* or optimiz* or optimis* or motivat* or incentiv* or persuad* or persuasion or intend*
or intention or counsel* or hesitan* or attrition) adj1 (identif* or refer* or sign-post* or
signpost* or transfer* or recruit* or detect* or advic* or intervent* or diagnos*)).ti,ab. (1549)
18 ((increas* or improv* or rais* or higher or decreas* or reduc* or poor* or low or lower or
drop* or withdraw* or quit* or likely or unlikely or positiv* or negativ* or influen*) adj1 (identif*
or refer* or sign-post* or signpost* or transfer* or recruit* or detect* or advic* or intervent* or
diagnos*)).ti,ab. (2256)
19 ((home* or resident*) adj3 (identif* or refer* or sign-post* or signpost* or transfer* or
recruit* or detect* or advic* or intervent* or diagnos*)).ti,ab. (378)
20 ((carer* or social-work* or health-visit*) adj3 (identif* or refer* or sign-post* or signpost*
or transfer* or recruit* or detect* or advic* or intervent* or diagnos*)).ti,ab. (14)
21 ((survey* or audit* or questionnaire* or framework*) adj3 (identif* or refer* or sign-post*
or signpost* or transfer* or recruit* or detect* or advic* or intervent* or diagnos*)).ti,ab. (2399)
22 or/8-21 (16030)
23 7 and 22 (1)
24 limit 23 to (yr="2000 -Current" and english) (1)

Database name: NHS EED

1 MeSH DESCRIPTOR weight reduction programs 39
2 MeSH DESCRIPTOR Obesity EXPLODE ALL TREES 1025
3 MeSH DESCRIPTOR overweight 172
4 MeSH DESCRIPTOR obesity management 0
5 (obes* or preobese* or overweight* or over-weight*) 1620
6 #2 OR #3 OR #4 OR #5 1625
7 (weight* adj1 (loss* or management* or reduc* or lifestyle* or life-style* or control* or
health*) adj2 (servic* or intervent* or program* or plan* or refer* or scheme* or treatment* or
trial* or therap* or clinic* or session*)) 255
8 #6 AND #7 200
9 ((obes* or preobes* or overweight* or over-weight*) adj2 (loss* or management* or reduc*
or lifestyle* or life-style* or control* or health* or prevent*) adj2 (servic* or intervent* or
program* or plan* or refer* or scheme* or treatment* or trial* or therap* or clinic* or session*))
161
10 #1 OR #8 OR #9 335
11 ((obes* or preobese* or overweight* or over-weight*) adj1 (detect* or identif* or diagnos*)
adj3 (refer* or sign-post* or signpost* or transfer* or recruit* or evaluat* or advic* or
diagnos*)) 2

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12 (#10 OR #11) IN NHSEED FROM 2000 TO 2022 51

Database name: INAHTA

1 "Weight Reduction Programs"[mh] 9
2 "Obesity"[mhe] 232
3 "Overweight"[mh] 15
4 "Obesity Management"[mh] 8
5 (obes* or preobese* or overweight* or over-weight*) [Title] 263
6 #2 or #3 or #4 or #5 315
7 ((weight* AND (loss* or management* or reduc* or lifestyle* or life-style* or control* or
health*) AND (servic* or intervent* or program* or plan* or refer* or scheme* or treatment* or
trial* or therap* or clinic* or session*)))[Title] 32
8 #7 and #6 32
9 (((obes* or preobes* or overweight* or over-weight*) AND (loss* or management* or
reduc* or lifestyle* or life-style* or control* or health* or prevent*) AND (servic* or intervent*
or program* or plan* or refer* or scheme* or treatment* or trial* or therap* or clinic* or
session*)))[Title] 64
10 #1 or #8 or #9 65
11 (((obes* or preobese* or overweight* or over-weight*) AND (detect* or identif* or
diagnos*) AND (refer* or sign-post* or signpost* or transfer* or recruit* or evaluat* or advic*
or diagnos*)))[Title] 2
12 #10 or #11 67
13 #12 FROM 2000 TO 2022 65
14 #13 English Language 61

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Appendix C - Quantitative and qualitative evidence study

selection
A joint search was conducted for review questions on identification and uptake (RQ1.3 and
RQ1.4). The joint search also covered children, young people and adults.

Records identified Records identified Records identified

through database through updated through reference
searching database search checking
(n = 19,474) (n = 1,630) (n = 3)

Records screened at title and abstract Records excluded

(n = 21,107) (n=20,685)

Records assigned to
other reviews
(n=285*)
Records relevant to identification question *36 studies were
assigned to both reviews
(n = 137)

Children and young people Adults

Full text articles Records excluded Full text articles

assessed for (n=108) assessed for
eligibility eligibility
Quantitative (n=52)
Conference abstract (n=7)
Quantitative studies Quantitative studies
Review (n=9)
= 55 Intervention (n=8) = 20
Comparator (n=1)
Qualitative studies = Study design (n=25) Qualitative studies =
69 Outcomes (n=2) 26
Qualitative (n=56)
Conference abstract (n=8)
Review (n=3)
Country (n=16)
No qualitative data (n=8)
Studies included in Irrelevant topics (n=16) Studies included
Participant age (n=3)
review Study design (n=2)
in review

Quantitative studies = Quantitative studies

3 =3

Qualitative studies = Qualitative studies =

13 8

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Appendix D – Evidence tables

Quantitative evidence
Children and young people

Bailey-Davis, 2017
Bibliographic Bailey-Davis, Lisa; Peyer, Karissa L; Fang, Yinan; Kim, Jae-Kwang; Welk,
Reference Greg J; Effects of Enhancing School-Based Body Mass Index Screening
Reports with Parent Education on Report Utility and Parental Intent To
Modify Obesity Risk Factors.; Childhood obesity (Print); 2017; vol. 13 (no.
2); 164-171

Study details
Trial Not detailed
registration
number
and/or trial
name
Study type Randomised controlled trial (RCT)
Study location Convenience sample of schools in Pennsylvania, USA
Study setting A convenience sample of schools.
Study dates 2012 - 2013
Sources of NIH grant (5R21HD067803).
funding
Inclusion Children 5-10 years old
criteria
Intervention(s) Active case finding via SBMIS: school-based body mass index screening,
for the purpose of providing parents with annual assessments of their
child’s weight status with an explanation of the results, recommended
follow-up actions, and education on healthy eating and active living.

Active case finding+ via SBMIS+: reports enhanced with education that
included an online link for parents to self-assess and learn about strategies
to reduce the risk of childhood obesity
Comparator Comparison of interventions
Outcome Referral to weight management service
measures
Parent response to report:

- "Report provided information or access to resources aimed at promoting

healthy lifestyles"

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- "Report prompted you to visit a healthcare provider or registered dietitian

about your child’s weight status"
Number of 6356 surveys were sent out
participants
Duration of The surveys were sent 4-6 weeks after the parents received the SBMIS or
follow-up SBMIS+ reports
Loss to 1745 (27%) of 6535 surveys were returned
follow-up
Methods of Responses to questions were coded ‘‘1 = Yes’’ and ‘‘0 = No.’’
analysis

Study arms
Active case finding + (N = 738)
School-based body mass index screening (SBMIS). This was enhanced with
education that included an online link for parents to self-assess and learn about
strategies to reduce the risk of childhood obesity

Active case finding (N = 731)

School-based body mass index screening (SBMIS).

Characteristics

Study-level characteristics
Characteristic Study (N = 1469)
% Female n = 742 ; % = 51

Sample size
Mean age (SD) 5-6 years old: 446, 7-8: 502, 9-10: 521

Custom value

Arm-level characteristics
Characteristic Active case finding + (N = 738) Active case finding (N = 731)
Ethnicity White 90%, Black 4%, Hispanic 4%, White 86%, Black 2%, Hispanic 7%,
Asian, 1%, American Indian/Alaskan Asian, 3%, American Indian/Alaskan
Custom value Native/Pacific I 1%, Other 0% Native/Pacific I 1%, Other 1%

Critical appraisal - Cochrane Risk of Bias tool (RoB 2.0) Cluster trials
Section Question Answer
Overall bias and Risk of bias High
Directness judgement (Due to issues with randomisation and missing
outcome data)

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Section Question Answer

Overall bias and Overall Directness Partially applicable
Directness (Unclear if participants were referred to a weight
management service)

Chomitz, 2003
Bibliographic Chomitz, Virginia R; Collins, Jessica; Kim, Juhee; Kramer, Ellen;
Reference McGowan, Robert; Promoting healthy weight among elementary school
children via a health report card approach.; Archives of pediatrics &
adolescent medicine; 2003; vol. 157 (no. 8); 765-72

Study details
Trial Not reported
registration
number
and/or trial
name
Study type Randomised controlled trial (RCT)
Study location Schools in Cambridge, USA
Study setting Four predominantly English- or Spanish-speaking elementary schools
agreed to participate in the intervention.
Study dates Undertaken in 2001
Sources of This study was supported by the Institute for Community Health and
funding Cambridge Public Schools, Cambridge, USA
Inclusion Children 5-14 years old
criteria
Intervention(s) For PI and GI groups, the package of intervention materials included an
introductory letter and a 1-page general-information sheet with tips for
healthy living, including the slogan "2-1-5," developed to promote the
following daily recommendations: 2 hours or less of television or videos, 1
hour of physical activity, and 5 servings of fruits and vegetables. Other tips
and resources for healthy living and managing overweight were based on
existing materials, including a return-addressed stamped postcard of
suggestions for community- or school-based obesity-prevention
approaches for families to check off and return, and a directory of physical
activity options available to families in the locality.

The PI group also received the personalized health report card of the
children's height, weight, and weight status (overweight, at risk for
overweight, healthy weight, and underweight), fitness test results, and
interpretive information. The materials referred parents with children
outside the healthy weight range to follow up with their primary health care
provider or their school nurse.
Comparator No health report card

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Outcome Number of children and young people identified as overweight or obese

measures
Parents correctly identifying their children's weight status

Referral to weight management service

Seek medical service for overweight children

Number of 1131 families
participants
Duration of 6 weeks of phone calls after intervention. Unclear how many or any more
follow-up specificity of when they occurred.
Loss to 50% of families completed telephone interviews after the intervention. 45%
follow-up PI, 52% GI, 54%, control group.
Methods of All analyses were stratified by the child's overweight or healthy weight
analysis status, because weight status was independently associated with
implementation and outcome measures

Study arms
Active case finding+ (N = 481)
PI: Family group receiving personal information intervention using a health report
card

Active case finding (N = 451)

GI: Family groups in the general-information intervention (GI)

Control (N = 464)
Family groups receiving no intervention

Characteristics

Study-level characteristics
Characteristic Study (N = 1131)
% Female 50%

Custom value
Mean age (SD) 98.5 (empty data)

Mean (SD)

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Arm-level characteristics
Characteristic Active case finding+ Active case finding (N Control (N = 464)
(N = 481) = 451)
BMI Underweight: 1%, Underweight: 0%, Underweight: 1%,
healthy weight: 53%, at healthy weight: 46%, at healthy weight: 48%, at
Custom value risk of overweight: 9%, risk of overweight: 14%, risk of overweight: 13%,
overweight: 37% overweight: 40%% overweight: 39%%
Ethnic group White: 44%, African White: 50%, African White: 40%, African
American: 28%, American: 24%, American: 26%,
Custom value Hispanics: 24%, Others: Hispanics: 16%, Others: Hispanics: 27%, Others:
4% 10% 7%

Critical appraisal - Cochrane Risk of Bias tool (RoB 2.0) Normal RCT
Section Question Answer
Overall bias Risk of bias High
and Directness judgement (Concerns about randomisation, concealment, lack of
blinding, and missing outcome data.)
Overall bias Overall Partially applicable
and Directness Directness (Outcome parents correctly identifying their children's weight
partially applicable to review. Outcome parents seek
medical service for overweight children partially applicable to
review.)

Madsen, 2021
Bibliographic Madsen, Kristine A; Thompson, Hannah R; Linchey, Jennifer; Ritchie,
Reference Lorrene D; Gupta, Shalika; Neumark-Sztainer, Dianne; Crawford, Patricia
B; McCulloch, Charles E; Ibarra-Castro, Ana; Effect of School-Based Body
Mass Index Reporting in California Public Schools: A Randomized Clinical
Trial.; JAMA pediatrics; 2021; vol. 175 (no. 3); 251-259

Study details
Trial ClinicalTrials.gov Identifier: NCT02088086
registration
number
and/or trial
name
Study type Cluster randomised controlled trial

79 schools, rather than individuals, randomised

Study location USA
Study setting 79 schools in California, USA
Study dates 2014-2017

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Sources of This study was funded by grant R01HD074759 from the National Heart,
funding Lung, and Blood Institute of the National Institutes of Health (NIH).
Inclusion Children 8-13 years old
criteria
Intervention(s) School staff assessed BMI each spring among students in both intervention
groups. Parents of students in the active case finding + group were sent a
BMI report each in Autumn during the 2 years study
Comparator No BMI screening
Outcome Adverse events
measures
Number of 28,641
participants
Duration of 3 years
follow-up
Loss to 14,273 (50%) did not return complete survey data
follow-up

Study arms

Active case finding + (N = 10041)

BMI screening and reporting

Active case finding (N = 10441)

BMI screening only

Usual care (N = 8159)

No screening

Characteristics

Arm-level characteristics
Characteristic Active case finding + Active case finding (N Usual care (N = 8159)
(N = 10041) = 10441)
% Female 48.1% 49.3% 49.2%

Custom value
% of children Grade 3: 40%, 4: 22%, Grade 3: 35%, 4: 20%, Grade 3: 0%, 4: 43%, 5:
in each grade 5: 9%, 6: 16%, 7: 12% 5: 9%, 6: 22%, 7: 15% 9%, 6: 22%, 7: 25%

Custom value
Race / Hispanic: 57%, Asian: Hispanic: 63%, Asian: Hispanic: 56%, Asian:
Ethnicity 18%, 11%, African_American: 18%,

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Characteristic Active case finding + Active case finding (N Usual care (N = 8159)
(N = 10041) = 10441)
Custom value African_American: 5%, 10%, White: 15%, Other African_American: 8%,
White: 17%, Other 4% 2% White: 15%, Other 4%
% weight Underweight: 22%, Underweight: 22%, Underweight: 23%,
category healthy weight: 53%, healthy weight: 51%, healthy weight: 51%,
overweight: 20%, overweight: 22%, overweight: 21%,
Custom value Obese: 5% Obese: 5% Obese: 5%

Critical appraisal - GDT Crit App - Cochrane Risk of Bias tool (RoB 2.0) Cluster trials
Section Question Answer
Overall bias and Risk of bias High
Directness judgement (Due to variations in the treatment groups and due
to the scale of the missing data)
Overall bias and Overall Directly applicable
Directness Directness

Adults

Lee, 2009
Bibliographic Lee, Nam-Ju; Chen, Elizabeth S; Currie, Leanne M; Donovan, Mary; Hall,
Reference Elizabeth K; Jia, Haomiao; John, Rita Marie; Bakken, Suzanne; The effect
of a mobile clinical decision support system on the diagnosis of obesity
and overweight in acute and primary care encounters.; ANS. Advances in
nursing science; 2009; vol. 32 (no. 3); 211-21

Study details
Trial 1R01 NR008903
registration
number
and/or trial
name
Study type Randomised controlled trial (RCT)
Study location New York, USA
Study setting master’s program at the Columbia University School of Nursing
Study dates January 1, 2006 – August 31, 2006
Sources of National Institute of Nursing Research
funding

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Inclusion Nurses
criteria
(registered nurses completing advanced practice nurse (master’s level)
training in 2 nurse practitioner specialties (acute care and family))

Enrolled in the master’s program at the Columbia University School of

Nursing
Intervention(s) In the application used by the experimental group (the personal digital
assistant-based clinical decision support system for obesity), the screening
process includes a reminder to screen; entering height, weight, and waist
circumference; automatic calculation of body mass index, assessing
potential confounders to accurate interpretation of body mass index, and
documentation of number of obesity related risk factors. Also, the clinical
decision support system provides nurses with information based on
guidelines through a context specific link, which we call an info button. For
example, if a nurse clicks on the info button next to waist circumference,
content related to the association of high waist circumference and obesity
and the cut-off point for high risk in waist circumference are presented. On
the basis of the results of screening, the clinical decision support system
generates an obesity-related diagnosis, and nurses can document the
patient’s weight management goal.
Comparator The personal digital assistant-based clinical log without decision support
features for obesity. In regards to the diagnosis and management of
obesity and overweight, the clinical log supports entering of height and
weight; selection of an obesity related diagnoses from a pick-list of
diagnoses for “Weight-related Condition”; and selection of plan of care
items from pick-lists for diagnostics, procedures, prescriptions, teaching
and counselling, and referrals. The content related to diagnoses and plan
of care is the same as in the decision support system, however, the content
is not tailored by obesity diagnosis or organized accordingly by plan of care
categories
Outcome Diagnosis of overweight/obesity
measures
Missed diagnosis
Number of The study sample comprised 1874 encounters: 807 (46%) experimental
participants group encounters entered by 13 nurses and 997 control group encounters
entered by 16 nurses.
Duration of n/a
follow-up
Loss to n/a
follow-up
Methods of Independent sample t test for continuous variables and chi-square or
analysis Fisher exact statistics for categorical data were used for comparisons of
demographic and encounter information in the experimental and control
groups. All statistical tests were 2-sided and considered statistically
significant if P values were less than or equal to .05. We conducted an ad
hoc power analysis for 2-sided chi-square test and alpha of .05 to examine
whether there were sufficient encounters to test differences between

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experimental and control groups. Given the number of encounters of 807

and 997 in the experimental and control group, respectively, there is 80%
power to detect a relative risk of 1.44, assuming the baseline proportion of
the encounter with obesity-related diagnosis was as low as 10%.
Additional Participants were described as being the nurses rather than the patients in
comments this study

Study arms

Clinical decision support system (N = 13)

1874 patients visiting 13 nurses

Clinical log without decision support (N = 16)

997 patients visiting 16 nurses

Characteristics

Arm-level characteristics
Characteristic clinical decision support system clinical log without decision
(N = 13) support (N = 16)
% Female 58.4 57.3

Nominal
Mean age 47.8 (17.88) 47.16 (16.95)
(SD)

Mean (SD)
BMI 28.77 (8.93) 28.23 (6.71)

Mean (SD)
Weight (lbs) 169.45 (45.81) 168.67 (41.87)

Mean (SD)

Critical appraisal - Cochrane Risk of Bias tool (RoB 2.0) Normal RCT
Section Question Answer
Overall bias and Risk of bias Moderate (Some moderate concerns about
Directness judgement ransomisation and deviations from the intended
interventions)
Overall bias and Overall Indirectly applicable
Directness Directness (USA demographics differ from UK population)

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Tang, 2012
Bibliographic Tang, Joyce W; Kushner, Robert F; Cameron, Kenzie A; Hicks, Brent;
Reference Cooper, Andrew J; Baker, David W; Electronic tools to assist with
identification and counseling for overweight patients: a randomized
controlled trial.; Journal of general internal medicine; 2012; vol. 27 (no. 8);
933-9

Study details
Trial Not stated
registration
number
and/or trial
name
Study type Randomised controlled trial (RCT)
Study location Chicago, USA
Study setting This study was conducted at the Northwestern Medical Faculty Foundation
(NMFF) GIM clinic (Chicago, IL), an academic clinic with 40 physicians and
a volume of >60,000 patient visits yearly. The clinic is supported by a
commercial EHR (EpicCare, Epic Systems Corporation, Verona, WI).
Study dates March 19–September 20, 2010
Sources of Dr. Tang was supported by an institutional award from the Agency for
funding Health care Research and Quality,
Inclusion People who are obese or overweight
criteria
• Patients with BMI 27–29.9 kg/m2
• Age range:
• Patients 18-65
• Visited a physician during the study period

Doctors

• Physicians who saw patients for at least 8 hours per week

Intervention(s) Intervention physicians received access to a tool set including: 1) a point-

of-care alert for overweight; 2) a counselling template to help patients make
an action plan; and 3) an order set to assist with entry of overweight as a
diagnosis and to order relevant handouts.

A point-of-care alert for overweight was designed as a passive prompt

within the patient’s medical record (Fig. 2). Upon viewing the alert,
physicians were directed to open the counselling template (Fig. 3), which
supported evidence-based weight-related counselling through goal-setting
and action planning.17,18 The template guided physicians through
assessing the patient’s rated importance of weight management, setting a

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target weight, selecting from a list of specific strategies to control weight,

and assessing the patient’s confidence to adhere to the selected strategies.
The template included a list of effective strategies for weight loss often
overlooked by physicians (e.g., logging diet and use of meal
replacements).19 After completing the template, physicians could open an
order set that facilitated entry of overweight as a diagnosis, imported the
template information into the physician note, and enabled ordering of
handouts specific to a patient’s chosen goals
Comparator Usual care
Outcome Documentation of weight status
measures
BMI

Diagnosis of overweight/obesity

Patients were categorized as receiving a diagnosis of overweight if

overweight was listed as an encounter diagnosis or problem in the
assessment and plan

Counselling for overweight

Documentation of weight-specific counselling was categorized based on

presence or absence of a documented recommendation for weight loss or
maintenance.

Intervention tool use

Frequency

Participants self-report of intervention experience

Intervention Physician Perspectives Regarding the EHR Tool and Self-

reported Outcomes Among Patients Counselled Using EHR Tools
Number of Physicians who saw patients for at least 8 hours per week were
participants approached for participation and informed consent (n=35). Eligible patients
were adults ages 18–65 who had a visit with a consenting physician during
the 6-month study period (March 19–September 20, 2010), and whose
most recently measured weight and height corresponded to a calculated
BMI 27–29.9 kg/m2.

Intervention: 15 physicians, 958 patients.

Control: 15 physicians, 1156 patients.

Duration of 6 months
follow-up

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Loss to 0 loss
follow-up
Methods of Descriptive statistics were used to characterize all outcomes. Baseline
analysis characteristics for patients of intervention and control physicians were
compared using chi-square or t-tests as appropriate. We used logistic
regression to compare frequency of diagnosis and counselling for
overweight among intervention and control groups. P values were adjusted
for clustering of patients within physicians’ practices; the intra-class
correlation coefficient was 0.11 for documented diagnosis of overweight
and 0.07 for weight specific counselling. Examples of representative
qualitative responses are presented. Qualitative comments from patient
interviews were reviewed by a single individual (JT). Specific factors
contributing to the usefulness of the counselling were individually noted
and tallied if mentioned by multiple participants.

Study arms
Intervention (N = 15)
15 physicians seeing 958 patients, using the intervention tools.

Usual care (N = 15)

15 physicians seeing 1156 patients, with usual care.

Characteristics
Study-level characteristics
Characteristic Study (N = )
Intervention 48.5

Nominal
Control 54.5
Control

Nominal
Intervention 46.4 (10.8)

Mean (SD)
Control 46.8 (12)

Mean (SD)
Intervention 28.2 (2.5)

Mean (SD)
Control 28.4 (1.3)

Mean (SD)

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Characteristic Study (N = )
Intervention 48.5

Nominal
Control 56.5

Nominal

Critical appraisal - GDT Crit App - Cochrane Risk of Bias tool (RoB 2.0) Normal RCT
Section Question Answer
Overall bias and Risk of bias Low (No serious concerns identified)
Directness judgement
Overall bias and Overall Directness Indirectly applicable
Directness (USA demographics differ from those in the
UK)

Wee, 2016
Bibliographic Wee, Christina C.; Baer, Heather J.; Orav, Endel J.; DeVito, Katerina;
Reference Burdick, Elisabeth; Williams, Deborah H.; Wright, Adam; Bates, David W.;
Use of electronic health records for addressing overweight and obesity in
rimary care: Results from a cluster-randomized controlled trial; Journal of
General Internal Medicine; 2016; vol. 31 (no. 2suppl1); 452-s453

Study details
Secondary This record represents a conference abstract. Data extraction has been
publication of done using the full text project report available at:
another https://digital.ahrq.gov/ahrq-funded-projects/use-electronic-health-records-
included addressing-overweight-and-obesity-primary-care
study- see
primary study
for details

Trial AHRQ/ K01 HS019789

registration
number
and/or trial
name
Study type Cluster randomised controlled trial
Study location Boston, USA
Study setting primary care practices at Brigham and Women’s Hospital (BWH).

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Study dates December 2011 - December 2012

Sources of the Agency for Healthcare Research and Quality and the Boston Nutrition
funding Obesity Research Center
Inclusion People who are obese or overweight
criteria
BMI >=25 (for diagnosis outcome only)

Age range:

Over 20

Visited a physician during the study period

Exclusion Visited a physician who saw less than 50 patients during the study period
criteria
Intervention(s) New electronic health record tools implemented:

1. Reminders to measure height and weight. If a patient had no

measure of height and/or no measure of weight in the LMR within
the past year, a reminder would appear on the summary screen,
asking the provider to enter a height and/or weight for the patient.
The LMR automatically calculates BMI from patients’ most recent
height and weight entries; therefore, any patient with both height
and weight should have a BMI.
2. An alert asking providers whether they want to add overweight or
obesity to the problem list, for patients with BMI 25-29.9 or ≥ 30
kg/m2 , respectively. The alert would appear as a pop-up screen,
and the provider would have the option to add overweight or obesity
or to dismiss the alert (Figure 1). This alert was added to an existing
clinical alerting system, introduced in May 2010, which was
designed to improve the completeness of electronic problem list
documentation for 17 other conditions
3. Reminders with tailored management recommendations, based on
patients’ BMI and other risk factors (e.g., hypertension,
hyperlipidemia, type 2 diabetes) included on the problem list or
identified from medications or laboratory results.34 For each patient
with BMI ≥ 25, one reminder would appear on the summary screen
with a recommendation that was based on the NIH guidelines
(Table 1).12 4)
4. A Weight Management screen with several features, including tools
to help providers assess patients’ motivation to lose weight,
calculate and set a 6-month weight loss goal, refer patients to other
resources (e.g., nutritionist or medically-monitored weight loss
program), and access more information

Comparator The new features were activated for clinics in the intervention group and
were not activated for clinics in the control group.
Outcome Documentation of weight status
measures

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Diagnosis of overweight/obesity
Number of Documentation outcome: A total of 60,244 eligible patients had visits during
participants Phase 1 of the intervention period (26,481 in the intervention group and
33,763 in the control group)

Diagnosis outcome: a total of 35,665 eligible patients with BMI ≥ 25 kg/m2

had visits during Phase 2 of the intervention period (14,779 in the
intervention group and 20,886 in the control group).

Duration of 12 months
follow-up
Loss to Not stated
follow-up
Methods of All statistical analyses were conducted using SAS version 9.4 (SAS
analysis Institute Inc., Cary, NC). We compared changes in documentation of BMI in
the LMR from the pre-intervention period to Phase 1 for patients who had
visits in the intervention and control clinics, using mixed-effects logistic
regression models (SAS PROC GLIMMIX) to account for the within-clinic
and within-provider correlation. We used a similar approach to compare
changes in diagnosis and management of overweight and obesity from the
preintervention period to Phase 2 for patients with BMI ≥ 25 kg/m2 who had
visits in the intervention and control clinics.
Additional Peer review uncertain, as the document does not match the search record.
comments

Study arms
New EHR tools used (N = 26481)
26481 patients visiting 11 clinics, 14779 with a BMI >=25

No change to EHR (N = 33763)

33763 patients visiting 12 clinics, 20886 with a BMI >=25

Characteristics
Arm-level characteristics
Characteristic New EHR tools used (N = 26481) No change to EHR (N = 33763)
% Female 68.6 60.8

Critical appraisal - Cochrane Risk of Bias tool (RoB 2.0) Cluster trials
Section Question Answer
Overall bias and Risk of bias Moderate (Some moderate concerns about the
Directness judgement randomisation process and deviations from the intended
interventions)

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Section Question Answer

Overall bias and Overall Indirectly applicable (USA demographics differ from UK
Directness Directness population)

Qualitative evidence
Children and young people

Avis, 2016
Bibliographic Avis, Jillian L S; Komarnicki, Angela; Farmer, Anna P; Holt, Nicholas L;
Reference Perez, Arnaldo; Spence, Nicholas; Ball, Geoff D C; Tools and resources
for preventing childhood obesity in primary care: A method of evaluation
and preliminary assessment.; Patient education and counseling; 2016; vol.
99 (no. 5); 769-75

Study Characteristics
Study type Semi structured interviews
Aim of To pilot-test a mixed methods approach to evaluate tools and resources (TRs)
study that healthcare providers (HCPs) use for preventing childhood obesity in
primary care, and report a preliminary descriptive assessment of commonly-
used TRs
Theoretical None stated
approach
Study Alberta, Canada
location
Study Primary Care
setting
Study dates Not provided
Sources of the Canadian Institutes of Health Research (JA), Alberta Innovates—Health
funding Solutions (JA, AP), and the Women and Children’s Health Research Institute
Data Our semi-structured interview guide (Supplementary material) included 13
collection questions with follow-up examples and probes. The guide was developed by
(i) identifying and evaluating relevant literature, (ii) organizing questions
thematically (e.g., context, likability), and (iii) confirming the inclusion and
exclusion of concepts and questions with team members (AK, AP). At the end
of each interview, participants were asked by interviewers (JA, AK) to self-rate
the suitability of each TR on a 10-point Likert scale (1[not suitable]–10[very
suitable]), with the option to rate by increments of 0.5. This question was used
to quantify participants’ perceptions of an intangible concept

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Method and Interviews were audio-recorded and submitted to The Comma Police
process of (www.commapolice.com) for transcription. Interviews were transcribed within
analysis 5–7 business days of data collection to facilitate concurrent data collection
and analysis. Data saturation was reached when no new information emerged
from the interviews. Transcribed data were imported into NVivo 10 (QSR,
Melbourne, Australia) for management, which was followed by inductive
thematic data analysis [23]. Once interviews were checked alongside their
corresponding audio-recording for accuracy and completeness, each
transcript was read to become familiar with the data; a broad-based coding
system was then developed. This coding scheme was used to understand the
relationships between various groupings and concepts. After each interview
was coded, categories were grouped under general themes, and a written
description was constructed to explain each theme. To enhance
methodological rigor, the coding scheme was reviewed by a colleague (AP)
and formally discussed with two additional researchers (NH, GB) to ensure
accuracy and completeness.
Population Participants were purposefully sampled to achieve diversity in experience and
and sample expertise, which we believed would offer rich, in-depth, and multifaceted
collection perspectives on their use of TRs. Participants were recruited (Fig. 1) through
their professional affiliations with Alberta Health Services, the University of
Alberta, and the Edmonton Oliver Primary Care Network. Snowball sampling
was used to continue recruitment of participants until data saturation was
achieved. Participants who identified as eligible for study participation were
recruited by telephone or email. One week prior to scheduled interviews,
participants were contacted to complete an online survey (SurveyMonkey
Inc.) that queried their clinical discipline, years of experience in clinical
practice, information about the TRs they used for childhood obesity
prevention, and of the TRs they listed, which ones were used for patient
education and clinical support purposes.
Inclusion Healthcare professionals
Criteria
Directly involved in weight management

Involved in child measurement

Clinical experience

at least 2 years

Used tools and resources

at least 3
Relevant 1. Purpose of use
themes 1. 1. Need for clinical support
1. 1a. Assessment & monitoring [1a] One of our clinics or
locations we do more of a health promotion, so just a
quick screening. So . . . plotting the child on the graph .
. . to continue to monitor their weight and their height
and their growth. [KIN1]

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2. 1b. Communication with families [1b] So I guess I use

tools to support discussions that I might be having with
families around nutrition and weight management in the
pediatric setting, so yeah primarily to support like in
discussion. [RD8]
3. 1c. Enhance credibility, confidence & competency [1c]
It’s great to have formal guidelines just to know that
you’re doing what is recommended, just that
reassurance . . . and then also if a parent decides, you
know that doesn’t seem reasonable at all, then I can
pull it up and say well this is what it is, right? [RD4]
2. 2. Need for families
1. 2a. Education [2a] Yeah, I think just to provide more
education to the families and to the children. I think it’s
used as a good reference guide for when people go
home. [RN3]
2. 2b. Facilitate behavior change [2b] People walk out the
door and forget what we told them from a practical,
physical perspective so those tools are there to support
the behaviour when they’re not with us. [KIN3]
2. Logistical factors
1. 1. Awareness
1. 1a. Top-down process [1a] We do have updates from
Alberta Health Services so when they do have some
new tools or information or journals or articles, they do
send it to us. [RD7]
2. 1b. Bottom-up process [1b] Like really if you weren’t
following all the blogs and reading research, you might
not even know about the 5As and that’s one of the ones
that’s most discussed and researched. [RN1]
2. 2. Accessibility
1. 2. Access is impacted by cost, distribution, and
production [1b] I’ve looked for my tools, so just
searching a lot on the Internet. I’ve been following a few
blogs, which have been helpful [KIN4] [2] For myself I’d
have to purchase a lot of them so that’s the biggest
thing so we have to look at cost in our clinics as well. If
cost is an issue, then we might not have the resources.
[KIN5]
3. Decision to use
1. 1. Expected suitability
1. 1a. Age of child [1a] I think it’s clinical judgement right?
So if they’re teenagers, sometimes they want to read
the ones that are not Peds focused, ’cause they don’t
identify themselves as kids. [RN1]
2. 1b. Culture, language & literacy level [1b] So I mean I
love them but they’re only for certain families, okay? I
mean they have to be able to read well, you know
definitely not for someone whose English is a second
language. [RD3]
3. 1c. Motivation & readiness to change [1c] So it depends
on how engaged the family is in terms of their

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willingness to change and their willingness to cooperate

as a family . . . so, for example, like I won’t always pull
out the growth chart because I don’t want the view to be
very skewed on focusing just on weight and he’s
overweight and stuff like that. [RD9]
4. 1d. Specific parental concerns [1d] Well, it’s very
different for every tool right that we use, so depending
on the issues that the family may have, like they don’t
get enough fruits and vegetables in their diet, then you
would choose a tool that would help boost their fruits
and vegetables and gives them ways how to do it.
[RD5]
2. 2. Experienced suitability
1. 2a. Usability (for self and families) [2a] It’s easy to get
out the rip-off version, the one-page version . . . is very
easy to use, and you can scribble on it. [MD2]
2. 2b. Usefulness (for self and families) [2b] I guess in
terms of it [tool], it is a good, little, quick, cheap thing,
but not crazy effective because I haven’t looked at it in
a while and because I feel like I just have that in my
back pocket already. But if I had a co-worker that was
seeing an overweight patient for weight management,
and they were panicking about, “I don’t know what to
do,” I could hand them this and say, this will help you.
[KIN2]

Critical appraisal - CASP qualitative checklist

Section Question Answer
Overall risk of bias and relevance Overall risk of bias Low
Overall risk of bias and relevance Relevance Relevant

Dam, 2019
Bibliographic Dam, Rinita; Robinson, Heather Anne; Vince-Cain, Sarah; Heaton, Gill;
Reference Greenstein, Adam; Sperrin, Matthew; Hassan, Lamiece; Engaging parents
using web-based feedback on child growth to reduce childhood obesity: a
mixed methods study.; BMC public health; 2019; vol. 19 (no. 1); 300

Study Characteristics
Study type Focus Groups

Interviews

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Aim of to investigate how effectively CHAMP engaged parents and supported

study reductions in childhood obesity, with a view to building an evidence base for
parent-only, online feedback interventions
Theoretical Ellis and Hogard’s three-pronged “trident” model as a theoretical framework.
approach
Study Manchester, UK
location
Study Schools
setting
Study dates 2016/2017
Sources of This work was commissioned by Manchester University NHS Foundation
funding Trust (MFT) and funded by Health Education England working across the
North West. The research was undertaken by the Health eResearch Centre
(HeRC), which is funded by the Medical Research Council (MRC)
Data Parents were invited to participate in focus group discussions and/or
collection individual semi-structured interviews, depending on their preference. To
increase flexibility and maximise opportunities for recruitment, we provided
the participants with a choice of being interviewed in person or over the
telephone. Focus groups took place in a private room at the school and
typically lasted 60 min; interviews took place at the school and/or over the
telephone and lasted up to 30 min. RD led the facilitation of the focus groups
with LH acting as co-facilitator. RD carried out one-to-one and telephone
interviews. All participants were asked to complete a short questionnaire to
capture demographic information about them and their family. Topic guides
were used to guide discussions, exploring topics including: views on healthy
growth; views on the annual weighing and measuring programme; awareness
and experiences of the CHAMP programme; and perceived impacts (see
Additional file 1 Topic guide for parents). Key personnel were interviewed
individually, typically at their place of work (see Additional file 2 Topic guide
for staff ). Topics explored included views on organisational approaches to
combat childhood obesity, knowledge and experience of the CHAMP
programme and ideas for future improvements. Data collection continued until
saturation was reached, with interviewees providing no substantively new
information. All focus groups and interviews were audio (digitally) recorded
with the consent of participants, and transcribed verbatim
Method and Data were imported into NVivo software (version 11) and analysed
process of thematically [28]. Data were coded using a priori framework developed from
analysis our existing understanding of the key issues. Coding then developed
iteratively, with comparisons made between different stakeholders to further
refine our understanding of key outcomes and processes. LH was the second
coder who coded four transcripts (out of a total of 20 transcripts) – specifically,
a transcript from one focus group discussion that took place with five parents,
a transcript from a one-to-one parent semi-structured interview, a transcript
from a one-to-one semi-structured interview with a Head of school and a
transcript from a one-to-one semi-structured interview with an NHS/public
health manager. Emerging findings were discussed at team meetings to
resolve discrepancies and refine themes

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Population Focus group and interview participants were drawn from six primary schools
and sample in Manchester, selected to cover the range of prevalence of deprivation, BMI
collection category and CHAMP website registration. Purposive sampling strategies
were used to recruit from two broad groups: (a) parents/carers (n = 18); and
(b) healthcare and school staff (n = 11). A group of parents at a local school
that did not take part in the qualitative element of the study provided public
involvement input into study design including recruitment strategies,
participant information and dissemination strategies.

Family liaison workers working within the schools were guided to recruit a
diverse sample of parents with respect to demographics (including gender,
ethnicity and family size) and prior awareness of the CHAMP website.
Maximum variation sampling and snowball sampling techniques were used to
identify participants with relevant experiences and ensure a sufficiently
diverse sample

Of the 63,337 children in our sample, 45.0% (n = 28,530) had been measured
once, 39.5% (n = 25,024) had measurements spanning two academic years
and 15.4% (n = 9783) had measurements taken for three or more academic
years between 2013/14 and 2016/17
Inclusion • Child participated in the National Child Measurement Programme;
Criteria eligible during 2016/2017
• Location: Manchester
• Age: Over 16
• Healthcare professionals
• Parent/guardian
• School staff;
• Heads of school (or acting Heads),
• School Health Assistants
• NHS and public health senior managers with a role relevant to
commissioning and/or delivering childhood obesity related services
• English language

Relevant 1. Engagement with annual weighing and measuring: Most parents

themes interviewed (16 out of 18) stated that they were aware of the
measuring and weighing process. “It’s good to know where you stand,
where you can… If there’s a problem, you can sort it out, instead of
just sitting without knowing anything”
2. Engagement with the CHAMP website: the process by which parents
became aware of, and subsequently accessed the CHAMP website
was inconsistent
3. Associations between CHAMP registration and changes in child BMI:
arents readily described a range of measures that they were using to
support their children to be healthy. "It was a real concern for the
school, they were monitoring the weight, thinking of activities that she

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could do. It was stressful for us, so that’s when we started looking into
it."
4. Psychological impacts of CHAMP on families. "“She’s only nine, nearly
ten at the end of the day. I think it’s young to be worrying about weight
because she’s going through puberty now. So her body is going to be
changing.”"
1. judgement of parenting: Parents may feel judged or reassured,
depending on the BMI result
2. Increased reflection and monitoring: CHAMP can prompt
parents to stop, reflect and monitor
3. Psychological impacts on children: Concern about children
worrying over weight from a young age

Critical appraisal - CASP qualitative checklist

Section Question Answer
Overall risk of bias and relevance Overall risk of bias Low
Overall risk of bias and relevance Relevance Relevant

Gainsbury, 2018
Bibliographic Gainsbury, Alexa; Dowling, Sally; 'A little bit offended and slightly
Reference patronised': parents' experiences of National Child Measurement
Programme feedback.; Public health nutrition; 2018; vol. 21 (no. 15);
2884-2892

Study Characteristics
Study type Focus Groups

Semi-structured
Aim of To develop a descriptive account of parents’ experiences of written feedback
study from the National Child Measurement Programme (NCMP), based on primary
data collected from semi-structured focus groups.
Theoretical Critical realist perspective
approach
Study South West England
location
Study Community
setting
Study dates Unspecified. Children entered the National Child Measurement Programme in
2014/15 and 2015/16.

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Sources of This research received no specific grant from any funding agency in the
funding public, commercial or not-for-profit sectors. Part of author's MSc in Public
Health which was funded by Health Education England SW.
Data All focus groups were audio-recorded and followed a semi-structured
collection schedule (Box 1). This was developed by both authors based on study
objectives with further input provided by the local NCMP manager, who
wished to use study findings to inform future communications with parents.
The schedule included open questions and prompts to stimulate conversation
while also enabling discussion to grow organically. Discussions lasted
between 55 and 77 min and group size ranged from three to six participants.
We decided to hold mixed outcome groups and not stratify participants
according to their child’s weight status. This approach enabled the study to
observe how healthy and overweight feedback is assimilated and discussed
within the same social contexts.
Method and Recordings of focus group discussions were transcribed verbatim, reviewed
process of for accuracy by A.G. and imported into the qualitative data analysis software
analysis NVivo version 10. Analysis identified themes and patterns relating to parents’
experience of NCMP feedback. Analysis followed the framework set out by
Braun and Clarke: data familiarisation, initial code generation, searching for
themes, review of themes, defining and naming themes and finally producing
a report. Extracts are coded according to the category of feedback
participants reported to have received regarding their index child (underweight
(UW), healthy weight (HW), overweight (OW) or very over-weight (VOW)),
their child’s gender (male (M) or female (F)) and the number of the focus
group that the parent attended (FG1–4)
Population Participants were recruited directly through advertisement and then via
and sample snowballing once volunteers had made contact. Via this approach two focus
collection groups were formed out of existing peer groups (‘natural groups’). A further
two focus groups (‘study-established’ groups) comprised of direct recruits with
no social connection.

Eighteen parents participated in the study, including seventeen birth parents

and one adoptive parent. The majority of parents who participated in the
groups were female (n 15) and both natural groups were comprised only of
women.
Inclusion Child participated in the National Child Measurement Programme
Criteria
in 2014/15 and 2015/16

Parents
Exclusion None reported
criteria
Relevant 1. Peer collaboration in the rejection of overweight feedback: Healthy
themes weight recipients in the natural groups were more likely to trivialise the
impact of receiving healthy feedback; receipt of overweight feedback
was generally reported in overwhelmingly negative terms. "If I was you
I would have been fuming because none of your children are obese,
so I would have been furious."

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2. The shared process of ‘othering’ by participants based on

characteristics other than weight feedback in their understanding of
childhood obesity and the NCMP’s perceived target audience. "What
we’re saying is it’s impacting the wrong people because the
responsible ones are having sleepless nights about it and the
irresponsible ones are ignoring it"

Critical appraisal - CASP qualitative checklist

Section Question Answer
Overall risk of bias and relevance Overall risk of bias Low
Overall risk of bias and relevance Relevance Highly relevant

Hardy, 2019
Bibliographic Hardy, Kelly; Hooker, Leesa; Ridgway, Lael; Edvardsson, Kristina;
Reference Australian parents' experiences when discussing their child's overweight
and obesity with the Maternal and Child Health nurse: A qualitative study.;
Journal of Clinical Nursing; 2019; vol. 28 (no. 1920); 3610-3617

Study Characteristics
Study type Interviews
Aim of To explore parents’ experiences when discussing child overweight issues with
study the Maternal and Child Health nurse
Theoretical None stated
approach
Study Victoria, Australia
location
Study Primary care: child and family health nurses (termed Maternal and Child
setting Health [MCH] nurses) provide free, universal, primary health care to infants,
children and their families.
Study dates June 2017
Sources of Not stated
funding
Data All interviews were conducted in June 2017 by the first author, at a location of
collection the participant's choice. Prior to the interview, women were emailed details of
the study, consent forms for signing and information on withdrawing from the
study if they wished. The following topics were discussed during interviews.
How child overweight/obesity was identified and addressed during the
consultation and the subsequent parent's reaction; advice given by the MCH
nurse; barriers and facilitators for discussing weight with the MCH nurse; and

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how parents perceive the MCH nurse's role in the management of weight
issues in children, in relation to support offered from other
professions/sources. Additional probing questions were used when needed to
encourage participants to discuss the topics at length. Interviews were
recorded with the consent of each participant. Each interview lasted between
11 and 32 (mean 20) minutes and was transcribed verbatim. No identifiable
information was collected or documented during the interviews
Method and Data analysis did not commence until all interviews were completed. The
process of transcribed interviews were analysed using the inductive thematic method of
analysis data analysis recommended by Green et al. (2007). The transcripts were read
and reread to get a sense of the meaning of the experience for the participant,
during which recurring themes emerged. Analysis involved inductive coding of
all interview transcripts (KH). Using word processing and spreadsheet
software, manual coding was facilitated by using separate colours for each
interview. The process involved back and forth movement between text,
codes and categories. KH inductively coded all transcripts, with double coding
of a small sample by remaining authors. All authors met regularly to discuss
coding and emerging themes. KH, LH and KE finalised the categories into
three final themes. The final themes were generated beyond simple
categorisation—to consideration of the links between the interview data
findings and our methodological (lived experience) approach. For example,
simple codes/categories such as “words to avoid,” “bringing up the topic” and
“failure to ask” were interpreted in the context of child obesity discussions to
become the important theme of MCH nurse communication with parents.
Research processes were documented in a clear audit trail, which included
development of a comprehensive data analysis code book and processes of
member checking of data. The COREQ guidelines were used to ensure rigour
in conduct and reporting of the research
Population The study involved a snowball sampling method for participants using
and sample Facebook and word of mouth, where parents were invited to partake in semi
collection structured interviews. Parents were included if they had a child aged 2–5
years that had been identified as overweight or obese by the MCH nurse. No
other inclusion or exclusion criteria applied. Interested parents contacted the
first author by phone and were then emailed about the study. The snowball
sampling meant that participants who contacted with the researcher were
asked to refer other parents on, if they met the inclusion criteria. All parents
who contacted the researcher met the inclusion criteria. Interviews were
planned by phone and participants nominated a place and time for the
interview. Sample size was determined by the number of participants
responding to the study and the time limited scope of the project. Ten mothers
with a child aged between 2 and 5 years responded to the call for participants
and were recruited. No fathers sought to participate. A researcher's
background can significantly influence the research process, findings and
framing of conclusions (Malterud, 2001). In this study, the interviewer (KH) is
a midwife and new graduate child health nurse who has a developing
knowledge base, insight and experience in the nursing role. KH disclosed her
professional status but had no previous relationship with participants. Regular
reflection and team discussions assisted KH to check assumptions,
motivations and systematically attend to the knowledge constructed.

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The sociodemographic characteristics of the 10 women who participated in

the study are described in Table 1. The majority of women were aged
between 30–35 years, were well educated, working part time, married and of
Caucasian background.
Inclusion Parents
Criteria
Child is overweight/obese

Child’s age: 2-5 years

Relevant 1. Maternal and Child Health nurse communication: participants
themes described communication challenges faced by nurses when
addressing weight concerns. According to the participants, MCH
nurses either did not discuss the child's identified issue or lacked the
communication skills to discuss it adequately. "The opening is there to
discuss weight, food, activity when you're actually weighing and
measuring the child"
2. Parent's perspectives on child overweight and obesity: Elements
included their own previous understanding of the problem, their
partner's reaction and how they personally felt about the issue. "I felt
as though the health nurse was blaming me, that was exactly how it
felt"
3. Role of the Health Care Practitioner: Participant views varied on the
MCH nurse's role in discussing weight management. The majority of
mothers felt it was to offer evidence‐based information and support
when discussing children's weight, while not being judgemental.
"Established relationships encourage easier communication"

Critical appraisal - CASP qualitative checklist

Section Question Answer
Overall risk of bias and relevance Overall risk of bias Low
Overall risk of bias and relevance Relevance Relevant

Jachyra, 2018
Bibliographic Jachyra, Patrick; Anagnostou, Evdokia; Knibbe, Tara Joy; Petta,
Reference Catharine; Cosgrove, Susan; Chen, Lorry; Capano, Lucia; Moltisanti,
Lorena; McPherson, Amy C.; Weighty Conversations: Caregivers',
Children's, and Clinicians' Perspectives and Experiences of Discussing
Weight-Related Topics in Healthcare Consultations; Autism Research;
2018; vol. 11 (no. 11); 1500-1510

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Study Characteristics
Study type Interviews
Aim of to examine the perspectives and experiences of children with ASD, their
study caregivers, and HCPs around discussing weight-related topics in healthcare
consultations
Theoretical Interpretive phenomenological analysis (IPA) approach
approach
Study Toronto, Canada
location
Study Canadian children’s rehabilitation hospital
setting
Study dates Not provided
Sources of Centre for Leadership in Child Development with support from Holland
funding Bloorview Kids Rehabilitation Hospital Foundation
Data Individual, in-depth, and in-person semi-structured interviews were conducted
collection with children, caregivers, and HCPs. Separate interview guides were used for
each stakeholder group. Questions were designed to elicit discussion about
their experiences and perceptions of discussing weight-related topics in
healthcare consultations. Consistent with our IPA approach, questions were
open-ended and flexible in nature to understand the everyday practices and
experiences of weight-related conversations in the clinic setting (Jachyra,
Atkinson, & Washiya, 2015; Jachyra, Atkinson, & Gibson, 2014; Jachyra et
al., 2018). Children and caregivers were interviewed in their homes (see
Jachyra et al., 2018) as previous research has shown that it positions them as
experts of this particular social space, and they can utilize their surrounding
environment to illustrate a point they are making (Teachman & Gibson, 2013).
Acknowledging the potentially sensitive nature of the research topic,
caregivers were interviewed without the presence of their child to provide
them with a safe space to speak openly about their child’s weight and clinical
encounters. During children’s interviews, caregivers had the option to be
present to help support, and potentially prompt their child to speak about a
particular clinical experience. Some children were completely independent in
sharing their perspectives and experiences, while others required some
prompting to remind the child about clinical experiences. Interviews with
HCPs were conducted at the children’s hospital. Interviews were conducted
by a research coordinator who had expertise in qualitative methodology and
previous experience interviewing children, caregivers, and HCPs about
weight-related topics. All interviews were audio recorded, and transcribed
verbatim.
Method and Given the iterative nature of qualitative research, data generation and
process of analysis occurred concurrently, and was guided by our IPA approach. Three
analysis members of the research team (PJ, TJ, AMC) read all of the transcripts and
the remaining team members each read a selection of transcripts. To begin
analysis, each transcript was first read and reread to be immersed in the data.
When reading each transcript, line by line descriptive (content), language use
(type and use of vernacular), and conceptual (possible
meanings/interpretations) annotations (codes) of the text were made in the
margins (Smith et al., 2009). Initially, three lists of annotations were generated

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from children, caregivers, and HCPs, and each were examined separately.
The annotations and interview notes then were clustered, compared and
contrasted across the interviews to examine patterns, and connections to map
out interrelationships between the interviewees. Throughout analysis, we
drew on “negative cases” (known as outliers in quantitative research), which
are codes and themes that deviate and/or contradict the defining plotline and
characteristics of an emerging theme (Phoenix & Orr, 2017). These
inconsistencies in the analysis served as a valuable resource to explore the
contradictions across participants’ accounts, and served to test our
interpretations of the data. This iterative process enabled the development of
themes, which were grouped if they were similar in nature. Drawing on a
higher level of abstraction, the themes were descriptively labelled, and
verbatim quotations were utilized to support the themes. Several strategies
were used to facilitate the conduct of high quality qualitative research and
analysis (Smith & McGannon, 2017): varied expertise on the research team
(all members of the study team had experience working with children with
ASD, and also represented clinical and research expertise in paediatrics,
dietetics, nursing, rehabilitation science, medicine, psychology, and early
childhood education); use of a reflexive dialogue; use of multiple coders and
analysts; analytic memos within the transcripts, a consistent epistemological
approach; and peer examinations about the process and developing
interpretations of the data
Population Multiple stakeholder perspectives were sought to elicit a contextualized and
and sample nuanced understanding of weight related communication. Children, their
collection caregivers, and HCPs at a large Canadian children’s rehabilitation hospital
were recruited using purposive sampling (Etikan, Musa, & Alkassim, 2016).
This approach was used to obtain “information rich cases” for the
phenomenon being studied, that is, those with experiences of discussing
weight management in healthcare settings related to ASD. With this sampling
frame in mind, eligibility criteria for a child’s participation in the study were: a
diagnosis of ASD as per DSM-5 criteria (American Psychiatric Association,
2013) and supported by the Autism Diagnostic Observation Schedule (Lord,
Rutter, Dilavore, et al., 2012); aged 10–18 years; verbal fluency in English;
attending the tertiary psycho-pharmacology clinic and currently being
prescribed psychotropic medications; and Body Mass Index greater than the
85th percentile (Center for Disease Control, 2016). Caregivers of these
children were also invited to take part in an interview as part of the study if
they were the primary caregiver for the child, and were able to communicate
in English. Finally, HCPs who worked in the psycho-pharmacology clinic were
also invited to participate in an individual interview.

The study included 21 participants. Eight children (4 male, 4 female) aged

11–17 years; eight caregivers (6 mothers and 2 fathers); and five HCPs (2
paediatricians, 2 nurses, and 1 neurologist) participated
Inclusion Healthcare professionals
Criteria
Overweight/obese; Body Mass Index greater than the 85th percentile

Parent/guardian

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English language

Child’s age: 10-18 years

Children had a diagnosis of autism and were attending a clinic. This included
children attending the tertiary psycho-pharmacology clinic and currently being
prescribed psychotropic medications
Relevant 1. Caregivers’ and Children’s Clinical Encounters
themes 2. HCPs Reflect upon Clinical Practice
3. Establishing a Therapeutic Partnership

Critical appraisal - CASP qualitative checklist

Section Question Answer
Overall risk of bias and relevance Overall risk of bias Low
Overall risk of bias and relevance Relevance Relevant

Jones, 2014
Bibliographic Jones, Kay M; Dixon, Maureen E; Dixon, John B; GPs, families and
Reference children's perceptions of childhood obesity.; Obesity research & clinical
practice; 2014; vol. 8 (no. 2); e140-8

Study Characteristics
Study type Semi structured interviews
Aim of To explore perceptions and experiences of treating childhood obesity of (i)
study GPs, (ii) families involved in a childhood obesity study in general practice’ and
(iii) families not involved in the project, but who had concerns about childhood
obesity.
Theoretical None stated
approach
Study Australia
location
Study Primary care - GP practices
setting
Study dates 2009
Sources of Commonwealth Government through the General Practice Clinical Research
funding Programme (Round 2) — Priority Driven Research Grants administered by
NHMRC
Data Supported by the literature, a semi-structured schedule was developed to
collection address the aims (Table 1). Data were collected from GPs during workshops
and from families during face-to-face or telephone interviews. All interviews

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were conducted in 2009. Workshops lasted approximately 1.5—2 h and

interviews approximately 30—45 min. All interviews were audio-taped and
transcribed verbatim.
Method and Data were thematically analysed independently by two investigators (KJ, MD).
process of Key themes were compared and when there was a difference of opinion,
analysis issues were discussed until agreement was reached. Data are reported under
the five themes that emerged from the data analysis. Generally, numbers are
not used to describe data, but where relevant, numbers are used.
Population A convenience sample was recruited from the 10 GPs and 15 families
and sample involved in the study for the purpose of exploring GPs’ perceptions and
collection experiences of treating childhood obesity and families and children’s
perceptions, concerns and experiences of treating childhood obesity [47,48].
GPs were invited to participate during education workshops and to invite the
families involved in this project to participate in a semi-structured interview. All
10 GPs (100% response rate) and eight of the 15 families agreed and
participated (53% response rate). In addition, families not involved in this
project were recruited via advertisements placed in local newspapers inviting
them to participate in an interview; four families responded and all participated
in an interview (100% response rate). The purpose of interviewing the second
cohort of families was to explore whether their perceptions, concerns and
experiences of treating childhood obesity were similar or different to families
who were involved in the project. GPs and families were compensated for
their involvement in this project.

Of the 12 interviews, eight were conducted face-to-face and four by

telephone. Children were present at five of the eight face-to-face interviews.
Two of the children were from ‘study’ families and three were from ‘non-study’
families. Children commented during four interviews. Two children from one
non-study family were present at one of the face-to-face interviews. No
children were present and/or participated in the four telephone interviews. The
group comprised eight females and five males with an age range of 8—16
years
Inclusion GPs
Criteria
Participants in larger study

Parent/guardian

Children
Relevant 1. Raising the topic (of obesity)
themes 1. GPs: GPs used a range of approaches including ‘‘clinical
impression triggers’’ (GP1) ‘‘a gentle, subtle approach’’ (GP5),
in a ‘‘non-confrontational way’’ (GP6) and ensuring to ‘‘always
include the family in the child’s management plan’’
2. Families: participants described the GP as being ‘‘more
interested in the children’s life and wellbeing and has a better
understanding of the family unit’’
2. Frustrations experienced by the GPs and families

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1. GPs: issues around family dynamics and/or a lack of

compliance and follow up, particularly when parents give in to
children’s demands were frustrating for the GPs
2. Families: few mentioned practice-based issues, such as
whether the nurse or other staff spent more time with the child.
Change of staff was an issue for one family, ‘‘we started seeing
one nurse, she left, and there was a period where there was
nobody else’’
3. Support available for GPs to provide to families and/or anticipated by
families
1. GPs: All GPs reported that specialists including the Royal
Children’s Hospital, allied health professionals such as
dietitians and psychologists, community programmes and sport
such as football, hockey, cycling, affiliations with schools, and
gymnasiums were available in the various areas where the
GPs were located.
2. Families: The eight families involved in the project reported
changes in how they managed their child’s weight as a
consequence of their involvement
4. Successes from involvement in the project
1. GPs: GPs’ felt there were significant successes from
involvement in the project which were both practice and patient
related.
2. Families: For families involved the most important changes
were related to sedentary behaviour and physical activity), food
and portion size and children asking questions
5. Sustaining improvements — the GPs’ and family’s perspectives
1. GPs: Sustaining improvement revolved around continuing to
‘‘measure the children regularly’’ and ‘‘educate them to have a
healthy diet’’ ensuring a ‘‘more methodical approach’’
2. Families: Study families identified issues for sustaining
improvement of weight management for their child as including
‘‘ancillary staff [in the practice] helping, perhaps a dietitian
could have helped’

Critical appraisal - CASP qualitative checklist

Section Question Answer
Overall risk of Overall risk High (Minimal information provided in the methods, so cannot
bias and of bias judge data collection method or research design. Data analysis
relevance does not appear to be rigorous. )
Overall risk of Relevance Relevant
bias and
relevance

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McPherson, 2018
Bibliographic McPherson, A. C; Knibbe, T. J; Oake, M; Swift, J. A; Browne, N; Ball, G.
Reference D. C; Hamilton, J; "Fat is really a four-letter word": Exploring weight-
related communication best practices in children with and without
disabilities and their caregivers.; Child: Care, Health and Development;
2018; vol. 44 (no. 4); 636-643

Study Characteristics
Study type Interviews
Aim of To present the findings of a recent scoping review to children with and without
study disabilities and their caregivers for their reactions; and to explore the
experiences and perceptions of the children and their caregivers regarding
weight‐related communication best practices
Theoretical Inductive thematic analysis from a relativist ontologic approach was
approach undertaken using a systematic, iterative approach
Study Ontario, Canada
location
Study Paediatric hospitals
setting
Study dates January–May 2016.
Sources of Canadian Institutes of Health Research (Funding reference: 132037).
funding
Data Separate focus groups were conducted with children and caregivers at the
collection two hospitals with individual interviews offered as alternatives. After verbal
consent was obtained, a lay summary of the scoping review findings was sent
to participants prior to their focus group/ interview. Written informed consent
(and assent, when appropriate) was obtained in‐person prior to data
collection. All participants completed a short demographic questionnaire.
Three members of the research team (A. C. M., T. J. K., M. O.) led the focus
groups/interviews using a semi structured interview guide. We convened a
Research Advisory Group to guide our original scoping review, comprising
clinicians, caregivers of children with overweight or obesity, and researchers.
The Research Advisory Group helped develop the interview guides, which
clustered into three main sections considered to be clinically meaningful: (a)
Who should participate in weight‐ related discussions?; (b) When and how
should the topic of weight be broached?; and (c) What terminology should be
used? Summarized findings for each of the three sections were briefly
reviewed with participants, who were then invited to discuss their
experiences, including where the existing literature did or did not resonate
with those experiences. The discussions took approximately 1 hr
Method and All discussions were digitally recorded, professionally transcribed and
process of managed using NVivo (v10). Inductive thematic analysis from a relativist
analysis ontologic approach was undertaken using a systematic, iterative approach
(Fade & Swift, 2011). The data were read separately several times by all
authors and emerging themes and patterns identified, from which a flexible
coding system was created and applied to the data (by T. J. K.) and checked
(by A. C. M.). Discrepancies were resolved through discussion. Coding

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ceased when it no longer added anything substantial to the overall analysis

(Braun & Clarke, 2006). Sections of text assigned the same code were
grouped, and a consolidated list of master themes produced and supported
by verbatim quotations (all names are pseudonyms). The lists of master
themes from children and caregivers were examined separately, then
compared and contrasted to explore varying perspectives. Data from focus
groups and individual interviews were combined after examining transcripts
and finding little difference in data patterns (Lambert & Loiselle, 2008).
Characteristics such as child age and presence of disability were considered
when analysing the data, in order to understand the context within which
participants derived meaning from their experiences (Dierckx, Gastmans,
Bryon, & Denier, 2012). Dissenting views and “negative cases” were included
where appropriate (Shenton, 2004). An audit trail of key analytical decisions
was documented throughout the analysis. Methodological rigour was ensured
by regular team discussions about the process and the ideas emerging from
the data, and we provide detailed accounts to convey the contexts within
which the discussions took place (termed “thick description”) to enhance
credibility and assist with the transferability of the data (Shenton, 2004).
Member checking was not employed as it was inconsistent with our relativist
ontologic position (Fade & Swift, 2011). Responses to the demographic
questionnaires were analysed descriptively using SPSS (v21). A
supplementary file contains information required for reporting of qualitative
studies using the “Consolidated Criteria for Reporting Qualitative Studies
(COREQ)” (Tong, Sainsbury, & Craig, 2007)
Population Children and their caregivers (i.e., parents and guardians) were recruited
and sample purposively from two large paediatric hospitals in Ontario, Canada.
collection Participants were either attending a tertiary‐level weight management clinic
for typically developing adolescents or receiving rehabilitation services from a
hospital that serves children with conditions including cerebral palsy, spina
bifida, autism spectrum disorder (ASD), and acquired brain injury. A maximum
variation sampling strategy was used in relation to age, gender, and medical
condition/diagnosis (Sandelowski, 2000). Child eligibility criteria were (a) aged
7–18 years; (b) have an interest in healthy lifestyles and weight management;
and (c) able to communicate in English. Children were excluded if they had
(a) severe cognitive impairments or (b) major co‐morbid psychiatric illness
(e.g., severe depression and anxiety) that impacted their ability to participate
in a discussion. Primary caregivers of children who met eligibility criteria and
could communicate in English were also recruited. Research ethics approval
was obtained from both hospitals.

Eighteen children (nine boys, nine girls; age: 14.0 ± 2.6 years) and 21
caregivers (17 mothers, one step‐father, three other caregivers) participated
in eight focus groups and seven interviews (Table 1). Two child and two
caregiver focus groups were held with participants recruited from the weight
management program (n = 11 children, n = 12 caregivers); the remaining
participants were recruited from the rehabilitation hospital (n = 7 children, n =
9 caregivers).
Inclusion Parent/guardian; and children
Criteria

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English language

Child’s age: 7-18 years

Interested in weight management

Exclusion History of psychological illness
criteria
Learning disability or condition
Relevant 1. Who should participate in weight‐related discussions? "If it was an
themes appointment and I knew it was going to be about [weight], I would ask
my Mom if I would not have to go to the appointment so I wouldn't
have to hear about it. "
1. Is everyone on the same page?
2. The triadic relationship
2. When and how should the topic of weight be broached? "I feel like
weight loss should be discussed only in certain areas, like, I don't feel
like all your doctors should be like … why don't you lose some weight"
1. Timing: A delicate balance
2. The clinical imperative
3. The blame and shame game
3. What terminology should be used? "For some people, if they hear [the
word] obese they may think “oh this is more serious than I thought, this
is something that I need to do something about,” right?"
1. Fat is a four‐letter word
2. Visual materials: Benefits and unintended consequences

Critical appraisal - CASP qualitative checklist

Section Question Answer
Overall risk of bias Overall risk of Moderate (Some concerns about the relationship
and relevance bias between the researcher and participants)
Overall risk of bias Relevance Relevant
and relevance

Sjunnestrand, 2019
Bibliographic Sjunnestrand, My; Nordin, Karin; Eli, Karin; Nowicka, Paulina; Ek, Anna;
Reference Planting a seed - child health care nurses' perceptions of speaking to
parents about overweight and obesity: a qualitative study within the STOP
project.; BMC public health; 2019; vol. 19 (no. 1); 1494

Study Characteristics
Study type Interviews

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Aim of to explore CHC nurses’ perceptions of speaking to parents about children’s

study overweight/obesity and of their role in referring children to treatment for
overweight/ obesity
Theoretical realist approach
approach
Study Stockholm, Sweden
location
Study child health care (CHC) centers
setting
Study dates 2010–2012
Sources of The STOP project received funding from the European Union’s Horizon 2020
funding research and innovation programme under Grant Agreement No. 774548.
Data Data were collected using individual, semi-structured interviews. All interviews
collection were conducted by the first author, MS, as part of a Master’s degree.
Interviews took place over the telephone, except one that was held in the
nurse’s office due to the nurse’s preference for an in person interview. The
interviews were audio recorded and transcribed verbatim by MS and a trained
journalist. Field notes were made during the interviews. The interviews
followed an interview guide developed by MS in consultation with an expert
group (all female). The expert group consisted of main supervisor AE, a
postdoctoral fellow in early childhood obesity treatment, co-supervisor PN, a
professor in Communication of Dietetics, and co-supervisor KN, a paediatric
nurse and research assistant. All three experts have extensive experience of
talking to families about overweight and obesity and have worked closely with
child health professionals in different settings to improve overweight and
obesity care. The interview questions aimed to capture CHC nurses’
experiences of communicating with parents about their children’s overweight,
and to identify the nurses’ perceived barriers and facilitators to referring
children to obesity treatment (see Table 1). The interviewer asked all
questions to all nurses, as well as individualized follow-up questions based on
each nurse’s responses. The questions were pilot tested using cognitive
interviews with two CHC nurses and then revised for a final version. During
these cognitive interviews, think-aloud and verbal probing techniques were
used. Think-aloud is a technique where the participant is encouraged to
verbalize how she/he reasons when answering the questions and verbal
probing refers to follow-up questions asked by the interviewer. Both
techniques enable the researcher to identify strategies used by the participant
when she/he attempts to answer the question to gain a better understanding
of the cognitive processes evoked by the questions. It was emphasized that
the participants were free to express their own thoughts and to raise
additional issues during the interviews. Questions that did not provide
comprehensive answers or did not capture what was intended were removed
or rephrased. For example, the question “When do you usually address
children’s overweight?” was removed because the answer was given in a
previous question. In another example, the question “Do you feel that the
children’s weight status is perceived as a problem for parents?” was changed
to “When do parents seek help for their child’s obesity?” In addition, some
words were changed or added to questions in order to soften the tone. The
final version of the interview guide consisted of 14 open-ended questions. The

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reporting of this study follows the COnsolidated criteria for REporting

Qualitative research (COREQ) checklist
Method and The interviews were analysed using thematic analysis, following a realist
process of approach. This approach allowed us to focus on the experiences the
analysis participants described, ascertain the meanings they assigned to these
experiences, and relate these to the everyday realities of working in CHCs .
The transcribed interviews were read and re-read by MS and KN and coded
by MS using an inductive approach, without being limited to a preexisting
coding frame . Thus, identified themes were associated with the participants’
responses rather than directly linked to the specific questions asked. MS
noted initial ideas that emerged while reading through the interviews, to
identify an overall pattern. MS then placed relevant textual entities into a new
document and coded these. MS, AE and KN met weekly to follow the
progress of analysis and discuss the coding. Once the coding was completed,
MS, AE and KN sorted the codes into different themes and subthemes.
Themes were identified on semantic level (i.e., each theme reflected content
explicit in the data). Lastly, all identified themes were organized in a table.
Population Participants were recruited through a purposive sampling approach. First, an
and sample invitation letter explaining the aim and content of the study was sent by email
collection to all registered CHC nurses employed in Stockholm County (n = 442).
Nurses who wanted to participate in the study were asked to contact the
research group. No nurses responded to this letter. As the next step, the first
author, MS, visited 15 CHC centers, most of which were located in areas with
a high prevalence of childhood overweight and obesity, and provided
information about the study in person to all nurses at each CHC center. All
nurses who attended those meetings were invited to participate in an
interview. In addition, nurses (n = 24) from 8 of the visited 15 CHC centers
were individually approached by phone. The nurses who declined
participation reported they had limited experience of addressing children’s
overweight to parents. Nurses who wanted to participate were sent an
informed consent form by mail and were asked to send the signed original
back to the research group. The interviews were then scheduled for a date
and time that suited the nurses.

A total of 17 CHC nurses representing 10 CHC (all female with an average

working experience of 6.7 years (SD ± 4.9 years)) were interviewed.
Inclusion Nurses
Criteria
Relevant 1. The relationship between the nurse and the parent: Nurses
themes emphasized the importance of developing and maintaining trusting
relationships with parents, and interacted carefully with parents to
raise awareness of child overweigh
1. Afraid to burn bridges
2. Plant a seed
2. Glitch in the system: Nurses identified several organizational factors
that interfered with their ability to communicate with parents about
children’s weights and offer them appropriate support. The subthemes
focus on organizational and relational factors in the healthcare system
1. Working together

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2. Improving structures and maintaining knowledge

Critical appraisal - CASP qualitative checklist

Section Question Answer
Overall risk of bias Overall risk of Moderate (Some concerns about the recruitment
and relevance bias strategy, participants were not initially willing)
Overall risk of bias Relevance Relevant
and relevance

Syrad, 2015
Bibliographic Syrad, H; Falconer, C; Cooke, L; Saxena, S; Kessel, A. S; Viner, R; Kinra,
Reference S; Wardle, J; Croker, H; 'Health and happiness is more important than
weight': A qualitative investigation of the views of parents receiving written
feedback on their child's weight as part of the National Child Measurement
Programme.; Journal of Human Nutrition and Dietetics; 2015; vol. 28 (no.
1); 47-55

Study Characteristics
Study type Semi structured interviews
Aim of to explore parental perceptions of overweight children and associated health
study risks after receiving National Child Measurement Programme (NCMP) weight
feedback
Theoretical theory of planned behaviour
approach
Study England, UK
location
Study Primary Care
setting
Study dates 2010–2011
Sources of National Institute for Health Research (NIHR) under its Programme Grants for
funding Applied Research programme [RP-PG-0608-10035 – The Paediatric
Research in Obesity Multi-modal Intervention and Service Evaluation
(PROMISE) programme].
Data An interview schedule was developed by two of the authors, and consisted of
collection open-ended questions, with prompts used as required, to explore parents’
perceptions of their child’s weight and health (for interview schedule, see
Appendix A). For the present study, we focused on responses to questions
specifically about reactions to NCMP written feedback and behaviour change
after receiving feedback. Example items included ‘Do you agree/disagree with
the feedback?’ and ‘Is there anything that would help you to make changes to
your child’s diet?’. Parents provided written consent before participation. On

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average, interviews lasted 30 min, with face-to-face interviews in the parents’

homes lasting 10 min longer than telephone interviews. Interviews were
audiotaped using a digital voice recorder. Interviews were conducted by one
researcher with considerable experience in conducting qualitative interviews
with parents of school-aged children
Method and Interviews were transcribed verbatim and reviewed for accuracy. A thematic
process of analysis was carried out using the qualitative data analysis software package
analysis NVIVO (Bazeley & Jackson, 2013). Braun & Clarke (2006) suggest that
thematic analysis can be approached in an essentialist/ realist way, in which
the experiences, meanings and the reality of participants are reported, or in a
constructionist way, which explores the ways that experiences are the effects
of a range of discourses within society. It was acknowledged that parental
views of NCMP feedback will be influenced by social factors, such as culture,
history and language (Willig, 2008), and so, for the present study, a
constructionist framework was used, focusing at a latent/interpretative level
on the underlying views, assumptions and conceptualisations of parents
receiving overweight feedback about their child. Transcripts were read and re-
read, and initial codes were drawn from the data. These codes were collated
into themes, in close discussion with three of the authors, and a coding frame
was developed. One researcher conducted and analysed all the interviews,
and themes were driven by her preconceptions, with the research question in
mind when conducting and analysing the interviews. Therefore, an
epistemological strategy was taken because the researcher’s interest in the
research area, and a view to potentially improve the NCMP feedback and
other services involving parents of overweight and obese children, would
have introduced some degree of subjectivity. This subjectivity was important
because different parents would inevitably respond to the NCMP feedback in
different ways; however, to account for this, one in five transcripts was
randomly selected to be coded by a second researcher who was provided
with the raw transcripts and coding frame. This inter-rater reliability aimed to
check agreement with the themes and ensure that both researchers deduced
similar themes from the transcripts. Minor changes to terminology were made,
although there were no changes to the emerging themes
Population Parents were recruited from five National Health Service (NHS) Primary Care
and sample Trusts enrolled in the NCMP programme in England in 2010–2011 as part of
collection a larger study aiming to evaluate the impact of NCMP feedback. The study
methods have been previously reported in detail (Falconer et al., 2012). This
qualitative study recruited parents of overweight or obese children purposely
on the basis of their response to a pre- and post-NCMP feedback survey,
which was sent to all parents with children involved in the NCMP from 2010 to
2011. This questionnaire assessed parents’ awareness that their child’s
weight might pose a risk to their health: the primary outcome of the main
study. Responses were obtained for 1844 parents, of whom 285 were parents
of obese and overweight children, and therefore eligible for interview. Of
these, we aimed to recruit 50 parents, of whom an equal proportion had and
had not indicated awareness that their child’s weight might pose a risk to their
health. Parents were selected from different socioeconomic and ethnic
backgrounds to obtain views across a range of social circumstances, and an
equal proportion of parents with children aged 4–5 years and 10–11 years
was selected. Because we were interested in the views of all parents with
children in the NCMP, we did not exclude anyone with a child that may have

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not been following a typical development trajectory (e.g. as a result of a

disability). Parents were sent a written invitation to participate and, if parents
did not contact us to decline participation, this letter was followed up by a
maximum of three phone calls, carried out during the day and evening to
minimise selection bias.
Inclusion Child participated in the National Child Measurement Programme during
Criteria 2010-2011

Participants in larger study

Pre- and post NCMP feedback survey, which was sent to all parents with
children involved in the NCMP from 2010 to 2011

Parent/guardian of children aged 4-11; child is overweight/obese

Relevant 1. Broad definitions of healthy: Parents reported that they placed more
themes importance on their child’s emotional and physical health than weight:
‘I see it more as being healthy as opposed to being you’re too fat or
you’re too thin’
2. Inherited/acquired factors: When asked why they thought their child
had been classified as overweight, the most common explanation was
that the child had puppy fat: ‘I look at him and I see puppy fat, I don’t
see overweight fat, I think they’re two different things’
3. Appearance: Some parents therefore agreed their child was
overweight, and perceived them to look overweight: ‘She looks fat'
4. Cultural influence: Although not commonly commented on, some
parents of non-white ethnicity described a disparity between
‘traditional’ British views of overweight and those of their culture where
being overweight was more acceptable

Critical appraisal - CASP qualitative checklist

Section Question Answer
Overall risk of bias and relevance Overall risk of bias Low
Overall risk of bias and relevance Relevance Relevant

Toftemo, 2013
Bibliographic Toftemo, Ingun; Glavin, Kari; Lagerlov, Per; Parents' views and
Reference experiences when their preschool child is identified as overweight: A
qualitative study in primary care.; Family Practice; 2013; vol. 30 (no. 6);
719-723

Study Characteristics
Study type Interviews

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Aim of To explore parents’ views and experiences when health professionals identify
study their preschool child as overweight.
Theoretical None stated
approach
Study Eastern Norway
location
Study Well child clinics
setting
Study dates March–September 2012
Sources of the Norwegian Committee on Research in General Practice, a division of the
funding Norwegian College of General Practice
Data Parents gave their informed consent to participate in semi-structured
collection interviews conducted by the first author; she is a GP with a speciality in family
medicine (Norwegian Medical Association). The other authors have PhDs
applying qualitative methods. The interviews took place at the families’ local
WCC during March–September 2012, no <4 weeks after consultation at the
WCCs. The interviews lasted 45–75 minutes. An interview guide was used
during each interview. The main topics included the parents’ experiences at
the WCC, their perceptions of their child’s weight and their own weight and
the family’s relationship within their extended family and with kindergarten.
Interviews were recorded digitally and transcribed verbatim by the first author
Method and Sound tracks were listened to, and transcriptions were read by all three
process of authors who worked together on the qualitative analysis through discussions
analysis Transcripts were imported into the software package ATLAS.ti (atlasti. com).
Qualitative data were analysed through systematic text condensation as
described by Malterud.10 Analysis followed these steps: (i) reading transcripts
and listening to sound tracks to obtain an overall impression; (ii) identifying
and coding for units of meaning, representing different aspects parents
experienced when their child was identified as overweight; (iii) condensing
and summarizing contents of each coded group and (iv) generalizing
descriptions and concepts summarized into subcategories and then into main
themes.
Population To this study, we recruited parents of preschool children with an ISO-BMI of
and sample 25 or above. GPs and public health nurses at seven WCCs in the eastern
collection rural part of Norway informed parents about the study, and handed out written
invitations. These WCCs were located within 150 km from the hometown of
the first author enabling visits by car. They covered all children with varying
socioeconomic background in the area. During the recruitment period of
6 months, 4 of the WCCs were able to recruit participants: mothers of 9
children and both parents of 1 child. The families were ethnic Norwegian and
had at least one grandparent living in the same county. All children were
healthy and attended kindergarten.

Inclusion Parent/guardian
Criteria
Child is overweight/obese; BMI>25

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Child’s age: Pre-school

Relevant 1. Parents’ feelings and concerns when being told that their child is
themes overweight: Parents reported that overweight was a thoroughly difficult
issue to discuss. They presented themselves and their children as
easily hurt. Most parents did not consider their child to be overweight.
This theme comprised three subcategories:
1. (i) parents being vulnerable;
2. (ii) relationship with the child;
3. (iii) conceptions about the child
2. Motivational factors: All parents accepted that they were mainly
responsible for their child attaining normal growth. However, they
expressed a desire to receive support from primary health care,
kindergarten and grandparents. Participants noted several
disadvantages and bad experiences in relation to overweight. This
theme comprised three subcategories:
1. (i) consequences of overweight;
2. (ii) dialogue with health professionals;
3. (iii) relationships with significant others.

Critical appraisal - CASP qualitative checklist

Section Question Answer
Overall risk of bias Overall risk of Moderate (Concerns that there was not enough detail
and relevance bias on the methods and the sample size was small)
Overall risk of bias Relevance Relevant
and relevance

Turner, 2016
Bibliographic Turner, Gillian L; Owen, Stephanie; Watson, Paula M; Addressing
Reference childhood obesity at school entry: Qualitative experiences of school
health professionals.; Journal of Child Health Care; 2016; vol. 20 (no. 3);
304-313

Study Characteristics
Study type Focus Groups

Semi structured interviews

Open ended questionnaires

Aim of To explore the practice of school health professionals in addressing childhood
study obesity at school entry, with a view to explaining potential reasons for low
referral rates and understanding how the role of school health professionals
can be optimised to address childhood obesity at an early age.

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Theoretical None stated

approach
Study North-West England, UK
location
Study Schools
setting
Study dates October 2012 and July 2013
Sources of This research received no specific grant from any funding agency in the
funding public, commercial or not-for-profit sectors.

This study formed part of Gillian Turner’s MSc dissertation

Data Mixed qualitative methods (semi-structured interviews, focus groups and
collection questionnaires) were used to gather perspectives of staff in different roles.
Semi-structured interviews were used to capture the experiences of Ms (n=3),
who operated in different geographical areas of the city. Conversely
SNs/CHPs operated in geographical teams and shared a common frame of
reference (SEA delivery), therefore focus groups were used to promote peer
interaction and explore the shared and diverse experiences of addressing
child weight (Kidd and Parshall, 2000). Two focus groups were conducted
with SNs (n=12) and two focus groups with CHPs (n=6), organised by
geographical area to take place during office hours. SNs (n=4) and CHPs
(n=1) who were unavailable to attend focus groups completed an open-ended
e-mail questionnaire. Questions for all methods were focussed around the
research questions, with additional probes as appropriate (see supplementary
resources 1, 2 & 3 for full schedules). Although each interview/focus group
had key themes, the conversation was driven by participant experiences,
allowing the emergence of inductive themes beyond those already identified
in the nursing literature (Steele et al., 2011). To enhance the trustworthiness
of data, participants were assured of their anonymity and encouraged to air
their honest views, even if their opinions were different from others. All focus
groups were facilitated by PW with assistance from either GT or SO.
Interviews were conducted by SO or PW.
Method and Interviews and focus groups were audio-recorded, transcribed verbatim and
process of imported (along with the questionnaires) into the QSR NVivo 10 qualitative
analysis software programme for analysis. A thematic analysis (Braun and Clarke,
2006) was conducted by GT, with frequent debriefing sessions with PW to
debate emerging themes and review coding decisions. After reading and re-
reading transcripts for familiarisation, text was coded into broad themes
aligned with each research question. Coded text was scrutinised for patterns
and similarities, and grouped together to form inductive themes which were
then reviewed and further refined. When coding the focus group data,
interaction between participants was preserved to ensure viewpoints were
considered in the context of the surrounding conversation (Kidd and Parshall,
2000)
Population The study was conducted in a large city in the North-West of England with
and sample high levels of socio-economic deprivation. Prevalence of childhood obesity
collection was higher than the national average, with 28.6% of children overweight or
obese at reception age (compared with 22.2% nationally, Health and Social
Care Information Centre, 2013). The school health service was grouped into

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three geographical areas, each with a service manager (M) plus smaller
teams made up of school nurses (SN, registered nurses with caseload
responsibilities) and child health practitioners (CHP, registered nurses who
supported school nurses in the delivery of care, but did not hold caseload
responsibilities). All Ms, SNs and CHPs employed in the study location
between October 2012 and July 2013 were eligible to take part. Invites were
e-mailed directly to Ms and to team leaders (SNs) who distributed invites
amongst SNs/CHPs (estimated to be 45-55 staff). The inclusion of staff in
different roles was deemed important as stakeholders differ with regards to
perceptions of childhood obesity (Staniford et al., 2011). Twenty-six staff (25
females, 1 male) consented to participate, including three Ms (one from each
geographical area), 16 SNs and 7 CHPs. Number of years in current roles
ranged from one month to 13 years.
Inclusion School staff
Criteria
A service manager (M) plus smaller teams made up of school nurses (SN,
registered nurses with caseload responsibilities) and child health practitioners
(CHP, registered nurses who supported school nurses in the delivery of care,
but did not hold caseload responsibilities

Involved in child measurement

Employed in study locations

Relevant 1. Perceived role and current practice: Participants viewed health
themes promotion as an important part of the school health professional’s role
2. lack of capacity: Participants felt their ability to support children who
were overweight was limited by reduced staffing levels and the
requirement to cover for other colleagues “We have sickness and
absence, we have annual leave, we have other commitments”,
3. lack of clear protocols: Participants were not aware of any written
protocols within the school health service related to childhood obesity
“there’s no clarity on what we should be doing…I don’t know about
anyone else but I don't know any clear guidelines”
4. Challenges of engaging parents: Participants described how parents
often failed to engage “the ones that really need it don't access it”,
5. Confidence in addressing weight issues: Participants expressed mixed
levels of confidence in addressing weight issues with families. "We’re
not trained formally, you’re not confident in what you’re delivering you
know”
6. Training: There was a strong feeling amongst participants that training
related to childhood obesity was insufficient. "I didn’t have formal
training, but you’re learning as you go along”

Additional Questionnaire data included as it is combined with focus groups and

information interviews

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Critical appraisal - CASP qualitative checklist

Section Question Answer
Overall risk of bias and relevance Overall risk of bias Low
Overall risk of bias and relevance Relevance Relevant

Adults

Atlantis, 2021
Bibliographic Atlantis, Evan; John, James Rufus; Fahey, Paul Patrick; Hocking,
Reference Samantha; Peters, Kath; Clinical usefulness of brief screening tool for
activating weight management discussions in primary cARE (AWARE): A
nationwide mixed methods pilot study.; PloS one; 2021; vol. 16 (no. 10);
e0259220

Study Characteristics
Study type Semi structured interviews
Aim of To assess the clinical usefulness of a new screening tool based on the
study Edmonton Obesity Staging System (EOSS) for activating weight management
discussions in general practice
Theoretical None stated
approach
Study South Australia, New South Wales, Queensland, Victoria, and Western
location Australia
Study General practice
setting
Study dates Not stated
Sources of iNova Pharmaceuticals (Australia) Pty Ltd (https://inovapharma.com/), in
funding partnership with the National Association of Clinical Obesity Services
Incorporated (https://www.nacos.org.au/) and Western Sydney University.
Data We collected qualitative data from GP participants soon after they had
collection completed all the study tasks in most of their patients enrolled in the study
and from patient participants soon after (no more than two weeks apart) their
second appointment. To explore GP and patient participants’ perspectives of
the feasibility and applicability of the tool in general practice, we utilised semi-
structured interviews. The interviews included a set of open-ended questions
generated prior to the interview to uncover different perspectives (S2
Appendix). One author (JRJ) conducted the interviews after receiving expert
training by another author with extensive experience in qualitative interviewing
(KP). He used prompt questions to gain a deeper understanding of
participants’ perspectives or to clarify aspects of their narratives. We sought to
complete the interviews within 10 to 15 minutes to minimise study burden.
Additionally, we sent the interview questions to some patients who had

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requested them via a text message prior to their scheduled interview. All
interviews were audio-recorded for accurate verbatim transcription
Method and The audio-recordings were transcribed verbatim using the online Otter.ai
process of software and imported into Microsoft Word documents for data management.
analysis We adopted Braun and Clarke’s six phase method of thematic analysis to
ensure rigour in the analytic process. The first phase identified by Braun and
Clarke is familiarisation with the interview data. This involved immersion in the
data by repeatedly listening to the audio-recordings while reading and re-
reading the interview transcripts. The second and third phases consisted of
identifying patterns and meanings, organising these into initial codes, and
then generating broad themes and sub-themes. The fourth phase of analysis
involved reviewing the data set to ensure themes are coherent and supported
by the data and the fifth phase involved further development and refinement
of the themes and sub-themes. Transcripts were independently reviewed and
analysed by authors (JRJ, KP, EA) and themes were discussed and further
developed until consensus was reached. In the sixth and final phase of
analysis, final themes integrated relevant extracts from participants’
transcripts with the guiding narrative to authentically convey their
experiences.
Population GP participants: The GP participants were recruited via the authors
and sample professional networks, namely the National Association for Clinical Obesity
collection Services (NACOS) and Healthed, using a promotional flyer seeking
expressions of interest “to participate in paid research testing a brief
screening tool to help them initiate discussions about obesity with their
patients.”. They received payment of $250 (Australian dollars) per patient
recruited and completed, to partially compensate them for the extra study
tasks over and above standard care.

Patient participants: The GPs recruited the study patients from their practices.
Patients were not reimbursed for their participation in the study.

We used purposive sampling to ensure participants had relevant experience

with the phenomenon of interest. Despite the nature of the present pilot study,
we anticipated that the small target sample sizes for collecting GP and patient
participants’ perspectives would be adequate to provide credible and
trustworthy preliminary evidence of the feasibility and applicability of the
EOSS-2 Risk Tool in general practice. For instance, expert opinions argue
that sample size targets for qualitative research have no firm lower bounds. It
has been suggested that sample sizes between one and 12 may be most
efficient for homogeneous populations and up to 30 for heterogeneous
populations. Interviews with patients continued until no new information was
revealed and data saturation was reached.

Five GPs participated and enrolled 25 patients. One GP recruited one patient
only, whereas the other GPs recruited six patients each. Nineteen (76%)
patients were aged 45 years or more, five (20%) were male, and 20 (80%)
were classified as having obesity.
Inclusion GPs: Practicing and able to recruit patient participants
Criteria

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Patients: Overweight/obese; eligible for weight management

Age: 18-65 years

Capacity to give informed consent

Exclusion Pregnant or planning to become pregnant during the study; breastfeeding or
criteria currently lactating

History of psychological illness

Learning disability or condition

Condition such as to interfere with the patient’s ability to understand the

requirements of the study
Relevant 1. GP recognition of obesity as a health priority: Most GP participants
themes had a special interest in obesity and an excellent understanding of its
importance. "I usually try to attend all the webinars and everything I
can get. "
2. Obesity stigma: Most of the GPs pointed to the usefulness of the tool
in discussing weight related issues with their patients, as it helped
them initiate health based and non-judgmental unbiased conversations
with their patients. "you can just show them the test. See you are high
risk. So let’s talk about this time to change."
3. Patient health literacy: The GP participants reported that the tool had
increased the level of awareness and understanding of weight related
health risks. "My knowledge has improved 100%, that a lot of things
are linked to it, like having surgeries, that the recovery from the
surgery could impact your weight gain"
4. Patient motivation for self-management: The application of the EOSS-
2 Risk Tool motivated patients to focus on self-management their
weight related complications. "I’m more confident that I can lose
weight. She’s [GP] there to help and refer me to the people that can
help me as well."
5. Applicability and scalability: There was consensus among most GPs
that the EOSS-2 Risk Tool was easy to use, relevant to a range of
their patient groups, and possibly scalable in general practice. "Yes.
CVD risk calculator, diabetes risk calculator, we only use this and K10
score and this kind of thing. We use it a general screening. It just
[needs to] become more coincided. And to make it more organized if
you have got something visible."

Critical appraisal - CASP qualitative checklist

Section Question Answer
Overall risk of bias Overall risk of High (Due to potential conflict of interest: the tool
and relevance bias being tested was developed by the research team)
Overall risk of bias Relevance Relevant
and relevance

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Beeken, 2021
Bibliographic Beeken, Rebecca J.; Scott, Anna M.; Sims, Rebecca; Cleo, Gina;
Reference Glasziou, Paul; Thomas, Rae; Clifford, Helen; A Community Jury on
initiating weight management conversations in primary care; Health
expectations : an international journal of public participation in health care
and health policy; 2021; vol. 24 (no. 4); 1450-1458

Study Characteristics
Study type Focus Groups

'Community jury' structure which imitates a courtroom jury decision making

process and guides discussions towards forming a consensus and group
'verdict'
Aim of To elicit the views of people with overweight and obesity about the role of
study GPs in initiating conversations about weight management.
Theoretical None stated
approach
Study Unspecified region, Australia
location
Study Conducted through Taverner Research using a random-generated landline
setting and location known mobile sample drawn from SamplePages
Study dates 10-11 March 2018
Sources of This work was supported by an Endeavour Award and a Yorkshire Cancer
funding Research University Academic Fellowship awarded to Dr Beeken. Dr Scott is
supported by an NHMRC Centre for Research Excellence (# 1044904), Dr
Thomas and Ms Sims are supported by an NHMRC Program grant (#
1106452), and Professor Glasziou is supported by a NHMRC Research
Fellowship (#1080042)
Data All sessions except for the final deliberation were facilitated by an
collection experienced facilitator and researcher, who had conducted work in the field of
obesity/weight management. The facilitator ensured equal participation,
recorded questions and noted participant concerns. Two observers took notes
on participant comments, affect and participation, except during the final
confidential deliberation. To not lead or bias the jurors towards a specific
recommendation, only jury group members were present during private
deliberations. On Day 1, following written consent, participants completed a
brief survey to assess their comprehension of the topic and attitudes prior to
receiving information. Four experts with clinical, research and public health
expertise, each presented 20-minute voice over PowerPoint presentations
followed by a telephone question–and-answer session with the jurors. As
background, the first expert provided a scientific overview of obesity; the
second presented on the available resources and services for weight
management in the local region. The third and fourth experts presented
opposing views on whether GPs should initiate conversations with patients
about weight management. Participants were provided with hand-outs of the

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presentations and the experts’ biographies. Participants commenced

facilitated discussions after the presentations and broke for the day. On Day
2, participants shared overnight reflections and, where needed, re-questioned
the experts by telephone. Participants then deliberated in private until a
consensus or impasse was reached and presented their decisions on the two
questions to the facilitator and other researchers. Postsurveys were
administered to participants prior to CJ completion
Method and CJ proceedings were audiotaped and transcribed. Reasons for the jury
process of recommendation were analysed by two researchers using thematic analysis.
analysis
Population Recommendations for the composition of CJs suggest a sample size between
and sample 12 and 25 is appropriate.18 We were therefore aiming to recruit 15
collection participants to allow for some dropout and ensure there were sufficient people
to encourage a wide ranging, but manageable, discussion, where all voices
would be heard.19 We were seeking to obtain the views of ‘consumers’ (the
affected public),17 as these would be most relevant to GPs considering this
issue. Therefore, we recruited participants over 18 years with a body mass
index ≥25 (calculated from self-reported height and weight). We excluded
anyone unable to provide informed consent due to mental incapacity, or
unable to speak or understand English. We recruited participants from a
region in Australia through Taverner Research using a random-generated
landline and location known mobile sample drawn from SamplePages. This
sample frame had the potential to cover 80% or more of the population in the
region. Compared with an online panel or market research database, recruits
were therefore less likely to have been exposed to research and people
without internet could be included. We requested roughly equal numbers of
men and women, and where possible, a range of education levels and ages.
Using the random generated and location known telephone numbers,
Taverner Research contacted potential participants and, without coercion or
pressure, asked respondents whether they would be willing to receive more
information about the study. Interested participants were checked by Taverner
Research for eligibility, and given further details about the study, including an
explanatory statement containing details about the nature and purpose of the
CJ alongside contact details for the research team in case they had any
queries, and a consent form. If potential participants agreed to take part after
reading this sheet, and having had the opportunity to contact the research
team with any queries, then they were asked to sign a consent form.
Participants were asked to either send the consent form in advance, or bring
a hardcopy on the day of jury. Written consent was obtained from all
participants before commencing the CJ. CJ participants received two $100 gift
cards as reimbursement for their time.

Of the 13 participants recruited, 11 (5 males and 6 females) attended the CJ

weekend. No explanations were provided for nonattendance. Mean age of
attendees was 47 years (SD 20); median BMI was 29.1 (IQR 26.6-31.6). All
jurors had completed high school and a majority had some post-high school
education
Inclusion Location: specific region
Criteria

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Overweight/obese; BMI>=25

Over 18 years

General public
Exclusion Learning disability or condition
criteria
Unable to provide written consent

Limited/no English
Relevant 1. Community Jury decision, GP initiating conversation on weight
themes management: The jury found the original first question problematic and
opted to change it to ‘Should GPs discuss lifestyle, health, and weight
management, with their patients?
2. Jury's rationale for changing the question: The jury felt it was important
that weight management be considered as just one aspect of overall
health as part of a holistic approach to care. "? So, it’s not as focused
on weight, but it’s also looking at all of the factors that are contributing
to the overweight or obese situation? "
3. Jury's rationale for verdict: Jurors unanimously agreed a GP was the
most appropriate person to discuss weight management with an
individual as they could be objective. "everyone trusts their doctor, to a
certain degree. They trust they’re educated, they trust they’ve seen it
all"

Critical appraisal - CASP qualitative checklist

Section Question Answer
Overall risk of Overall risk High (Concerns about the approach to data collection. Too
bias and of bias rigid to address the research question adequately and
relevance minimal information on data analysis method)
Overall risk of Relevance Relevant
bias and
relevance

Blackburn, 2015
Bibliographic Blackburn M; Stathi A; Keogh E; Eccleston C; Raising the topic of
Reference weight in general practice: perspectives of GPs and primary care
nurses.; BMJ open; 2015; vol. 5 (no. 8)

Study Characteristics
Study type Semi structured interviews
Aim of To explore general practitioners’ (GPs) and primary care nurses’ perceived
study barriers to raising the topic of weight in general practice

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Theoretical Theoretical Domains Framework (TDF)

approach
Study South West of England, UK
location
Study General practices located in one primary care trust
setting
Study dates January and February 2013
Sources of Wiltshire Public Health
funding
Data A flexible interview schedule was developed based on the TDF domains and
collection a review of empirical research literature concerning barriers to health
professional prevention and management of obesity in primary care (see
online supplementary additional file 2). The topic guide for the interviews
began by asking participants about the factors that triggered them to broach
discussions about weight loss. The remainder of the questions focused on the
theoretical domains, to gain insight into factors hindering discussion about
weight loss. Prior to interviews, the questions were piloted with three GPs and
two primary care nurses, to assess clarity and focus of the interview schedule,
and refined as appropriate. Face-to-face individual interviews were conducted
by the lead researcher (MB), at a time and place to suit the participant.
Interview locations included general practice offices, the University of Bath
and participants’ homes. Interviews lasted between 30 and 90 min.
Participants were encouraged to express the barriers most salient to them
and prompted to expand on views when deemed appropriate by the
researcher. Interviews were digitally audiorecorded, and then transcribed
verbatim by the lead researcher and an external agency with transcription
expertise.
Method and Audio recordings were transcribed verbatim in Microsoft Word and then
process of uploaded to NVivo (V.10) for coding and data organisation. A period of
analysis familiarisation with the data set by the lead researcher was followed by a
process of coding whereby a priori themes directed by the interview topic
guide, unexpected emergent themes and recurring viewpoints were identified.
A deductive approach to content analysis34 was used to code the data to the
TDF framework, whereby data were reviewed for content and correspondence
to identified categories of the TDF.31 The manifest and latent content were
both examined.35 36 The TDF coding framework developed by Heslehurst et
al31 was used to ensure code names were matched to the appropriate
domains. The accuracy of this initial coding, derived from a subset of the data,
was checked by other members of the research team, and then used to guide
the indexing of the remaining transcripts. Following the mapping of codes to
the domains of the TDF, the lower order themes were charted and organised
into three salient higher order themes that manifest within the whole data set.
This process was facilitated by drawing on principles of thematic analysis37
and additional behaviour change theory designed to guide the grouping of
domains in the TDF into broader components.38 At the final stage of data
analysis, the derived themes for GPs and nurses were compared, and
similarities and differences were identified. Analysis was a recursive process
that developed over time, with the lead researcher continually revisiting the
data set and theoretical literature before arriving at the final themes

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Population Purposive sampling was used to recruit a heterogeneous sample of GPs and
and sample nurses working within one primary care trust in the South West of England.
collection Study information was provided at a practice manager meeting, and emails
outlining the study were sent to 58 GP surgeries and to a network of sessional
GPs in the local authority. This resulted in 13 GPs and 14 nurses agreeing to
be interviewed after receiving further details about the study. Snowball
sampling was also used to recruit participants; four GPs and three nurses
were approached, either in person or via email, and all agreed to be
interviewed. Prior to taking part in the study, participants were informed that
interviews would involve discussion about views of obesity, role and efficacy
beliefs, and the challenges involved in raising the topic of weight in general
practice. Participants were recruited until no new information and
understanding from the interviews occurred.32 33 As a token of appreciation,
participants were offered the opportunity to claim practice level
reimbursement for their time.

Of the 17 GPs interviewed, 5 were partners, 6 were salaried (1 of whom was

a GP assistant) and 6 were locums. Of the 17 nurses interviewed, 3 were
nurse practitioners. Nursing roles varied widely: six nurses specialised in
diabetes care (3 of whom also carried out general practice nurse duties),
three nurses specialised in chronic obstructive pulmonary disease and
asthma (2 of whom also carried out general practice nurse duties), four
nurses worked in emergency and minor illness roles (1 of whom also carried
out general practice nurse duties), and four nurses were identified as having a
generalist practice nurse role. Respondents came from rural, semirural and
urban practices.
Inclusion GPs
Criteria
Exclusion None reported
criteria
Relevant 1. Knowledge: Lacking content knowledge of guidelines, Not recognising
themes obesity as a complex medical problem, Uncertainty about raising the
topic routinely
2. Skills: Uncertainty about how to raise the topic sensitively. Uncertainty
about how to raise the topic when patient is not consulting with related
problem
3. Beliefs about consequences: Potential to damage the doctor–patient
relationship, Concern that patient will feel alienated and disengage
from healthcare, Beliefs about negative responses, Potential to ‘open
a can of worms'
4. Beliefs about capabilities: Feeling ineffective at helping patients with
weight loss
5. Motivation: Desire to maintain a positive, non-judgemental relationship
with patient
6. Competing goals: Prioritising other areas of patient care, Prioritising
other public health concerns
7. Emotion: Fear of upsetting patients, Feeling awkward/uncomfortable
raising the issue, Hopelessness, Frustration

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8. Professional role and identification: Threat to professional reputation,

Impact of own weight status, Personal feelings about advocating
weight loss
9. GP practice and available resources: Having time to open up a
sensitive issue, Feeling as if there’s nothing to offer patients, No
continuity of care with patients
10. Social influences: Adhering to the patient’s agenda, Perceptions about
patient receptiveness to advice

Critical appraisal - CASP qualitative checklist

Section Question Answer
Overall risk of bias and relevance Overall risk of bias Low
Overall risk of bias and relevance Relevance Highly relevant

Doherty, 2019
Bibliographic Doherty, Alison J; Jones, Stephanie P; Chauhan, Umesh; Gibson,
Reference Josephine M E; Healthcare practitioners' views and experiences of
barriers and facilitators to weight management interventions for adults with
intellectual disabilities.; Journal of applied research in intellectual
disabilities : JARID; 2019; vol. 32 (no. 5); 1067-1077

Study Characteristics
Study type Semi structured interviews
Aim of To explore GPs and other HCPs’ views and experiences of barriers and
study facilitators to providing evidence-based weight management interventions for
adults with intellectual disabilities
Theoretical None stated
approach
Study Lancashire, North-West England.
location
Study General practice
setting
Study dates Between April 2016 and November 2016
Sources of None stated
funding
Data Semi-structured, face-to-face interviews were held with GPs and other HCPs
collection involved in obesity identification and or the provision of evidence-based
weight management interventions for all adults (including adults with, and
without, intellectual disabilities) in Lancashire, North-West England. The

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research team comprised a lead researcher and two other researchers with
knowledge and experience of conducting qualitative research.

A study topic guide for the semi-structured interviews was developed by the
lead researcher with the support of the other researchers. The guide
contained 16 questions designed to explore how HCPs recognise obesity in
adults with intellectual disabilities, and how they manage weight management
interventions for such individuals. The study topic guide’s questions included,
for example, whether HCPs incurred anything that helped or hindered them
from discussing obesity and weight management with people who have
intellectual disabilities, from offering and or delivering weight management
interventions to this population, and if they had accessed or needed any
training, guidelines or other resources for weight management interventions
involving this population. Digital audio-recordings made of the semi-structured
interviews lasted an average of 28 minutes per interview (range 13 - 52
minutes).
Method and Digital audio-recordings of the interviews were transcribed by an independent
process of researcher from within the lead researcher’s institutional faculty. The
analysis transcriptions were checked for accuracy by the lead researcher. Mays &
Pope’s (2000) application of reflexivity was applied by the research team.
Reflexivity involves being sensitive to the ways in which the subjectivities of
researchers affect the data collection and analysis. The application of
reflexivity in this study involved the lead researcher undertaking the primary
analysis followed by a second member of the research team independently
analysing a sample of the transcripts. The transcriptions were analysed using
thematic analysis. Reading, re-reading, and open coding of each individual
transcript was firstly undertaken to explore the data, and then themes within
and between all the individual transcriptions were compared using constant
comparison techniques. Potential themes and sub-themes were identified by
hand and then by using NVivo (v11) software by the lead researcher. A
second independent researcher similarly analysed a sample of the transcripts.
A thematic coding framework was produced by the lead researcher to aid the
analysis. Key themes identified by the lead researcher in the analysis were
verified with the second independent researcher. A third researcher from the
team reviewed and critiqued the emerging themes attributed by the first two
researchers. Any discrepancies were discussed and reviewed by the research
team to reach a consensus agreement.
Population A combination of purposive and snowball sampling was selected as the most
and sample practical approach. Clinical Commissioning Groups (CCGs) who are
collection responsible for the planning and commissioning of health care services for
their local area, were approached by the lead researcher and asked to send
information about the research study to GPs’ Practices. The lead researcher
also contacted local authorities in Lancashire by email requesting information
about their commissioned weight management services. The researchers
intended to recruit up to 20 participants, however 6 of the 20 potential
participants who were approached and provided with information declined.

14 practitioners (7 GPs, one GP nurse and 6 other HCPs) were interviewed

in GPs’ Practices and other venues used in the delivery of weight
management services and interventions (e.g. leisure centres).

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Inclusion GPs, Nurses, Healthcare professionals, health facilitators, physiotherapists

Criteria and dietitians

Location: Lancashire

Directly involved in weight management

Exclusion None reported
criteria
Relevant 1. Communication: GPs experience challenges in communicating the
themes subject of weight management with individuals with intellectual
disabilities, and that these challenges are compounded if the carers or
support workers are overweight or obese themselves and or if
individuals with intellectual disabilities do not always have the support
of the same carer or support worker. “I’m aware that there’s a lot of
easy-to-read information out there but we don’t really have that [in
general practice].”
2. Knowledge: This study identified a need to raise GPs’ knowledge and
awareness of locally available weight management interventions for
adults with intellectual disabilities and, thereby, improve referrals to
such services. “Weight management services? I don’t think we’ve got
any weight management services I am afraid.”
3. Support: GPs and other HCPs value continuity of caring support for
people with intellectual disabilities who have weight management
needs, including carers’ involvement in weight management
interventions for this population. “We try to encourage the parents or
the support workers and carers to actually be part of the groups"
4. Resources: Resources - including training for HCPs - are required to
facilitate weight management discussions between HCPs and people
with intellectual disabilities. However, this study’s findings suggest that
some GPs may not to be sufficiently motivated or incentivised to
participate in weight management training for this population group.
“You’ve got to improve their access to a lot of services available,
specialised interventions for their needs.”
5. External factors: This study’s findings add to other studies’ arguments
for weight management interventions for people with intellectual
disabilities that are tailored to address the wider environment,
demographic and socio-economic issues surrounding this population.
"I think its environmental more than anything…they’re just getting
dragged off to McDonald’s and things…”
6. Motivation: Motivation for weight management may be a challenge for
some individuals with intellectual disabilities and it is acknowledged
that there may be conflicts between carers and people with intellectual
disabilities which may affect motivation for weight loss. “You’ve got to
be really motivated…if some course comes up about obesity, that’s
the last thing I’m gonna go to. Whereas if there’s a course on new
treatments in hypertension or new treatments in epilepsy or… that’s
what I’m gonna go to.”

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Critical appraisal - CASP qualitative checklist

Section Question Answer
Overall risk of bias Overall risk of Low
and relevance bias
Overall risk of bias Relevance Partially relevant (the aim was focused on weight
and relevance management more than identification)

Glenister, 2017
Bibliographic Glenister KM; Malatzky CA; Wright J; Barriers to effective conversations
Reference regarding overweight and obesity in regional Victoria.; Australian family
physician; 2017; vol. 46 (no. 10)

Study Characteristics
Study type Semi structured interviews
Aim of To examine how GPs in rural areas talk about overweight and obesity with
study their patients, specifically to identify key barriers to effective conversations
Theoretical None stated
approach
Study Victoria, Australia
location
Study Rural GP practices
setting
Study dates Not provided
Sources of The federal Department of Health’s Rural Health Multidisciplinary Training
funding Program.
Data Semi-structured interviews were undertaken with GPs and patients located in
collection two of the four regional Victorian locations of the preceding community health
survey (populations of 50,000 and 27,000, each with nine general practices).
A total of seven GPs and seven patients across the two sites participated in
audiorecorded, face-to-face interviews with one researcher (sociologist or
biomedical scientist)

Participants were asked about:

• how often weight is discussed during consultations

• how discussions are initiated

• what kind of advice is provided

• barriers to effective conversations

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Method and The resulting data were then coded separately by each researcher for
process of thematic analysis. Researchers shared and discussed the initial coding of
analysis data before engaging in an iterative process of re-coding, categorising and
identifying broad themes
Population To recruit GPs, a plain language statement explaining the project was sent via
and sample email to all general practices in the two towns. GPs who were interested then
collection contacted the researchers directly. Patients were recruited via a flyer outlining
the project, which was displayed in several public places, including
gymnasiums, health clinics and public service noticeboards. A total of seven
GPs and seven patients across the two sites participated.
Inclusion GPs
Criteria
Patients
Exclusion None reported
criteria
Relevant 1. Lack of effective treatment options
themes 2. Uncertainty about appropriate language
3. Lack of time
4. Impact of rurality on difficult conversations
5. Importance of mutual trust and rapport for weight-related
conversations
6. Concern about patient readiness
7. Patients’ mental health and impact of stigma
8. Lack of effective and individualised treatment and/or referral options
9. Lack of regular weight measurement
10. Uncomplicated obesity

Critical appraisal - CASP qualitative checklist

Section Question Answer
Overall risk of Overall risk High (Concerns due to there being very little information on
bias and of bias the methods used and because the summary of the
relevance themes does not match the full descriptions)
Overall risk of Relevance Relevant
bias and
relevance

Gunther, 2012
Bibliographic Gunther, Stephen; Guo, Fenglin; Sinfield, Paul; Rogers, Stephen; Baker,
Reference Richard; Barriers and enablers to managing obesity in general practice: a
practical approach for use in implementation activities.; Quality in primary
care; 2012; vol. 20 (no. 2); 93-103

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Study Characteristics
Study type Semi structured interviews
Aim of To uncover and describe barriers and enablers to implementing NICE’s
study recommendations on the management of obesity in adults in general practice,
using practical qualitative methods.
Theoretical None stated
approach
Study East Midlands, UK
location
Study Primary care
setting
Study dates December 2009 to March 2010
Sources of National Institute for Health Research Collaboration for Leadership in Applied
funding Health Research and Care – Leicestershire, Northamptonshire and Rutland
Data Interviews were conducted between December 2009 and March 2010 and
collection lasted between 20 and 45 minutes each. The interview schedule was
designed to be practical, being delivered and analysed by staff with relatively
limited research expertise in order to reflect an approach feasible to replicate
in routine practice. An interview schedule containing open-ended questions
with prompts was developed by the research team to guide semi-structured
interviews. Health professionals were asked what factors hinder or help them
in identifying and managing patients who are overweight or obese. Patients
were asked about the barriers and enablers to obtaining support from the
practice, and what services they were aware of to support them with their
weight reduction. In addition to the interview questions, information on age,
gender, marital status and duration of employment of practitioners were
collected. Participant information leaflets were provided prior to the interviews,
and those giving consent to take part were interviewed individually at a place
of their own preference. All health professionals were interviewed at their
practices. Patients were interviewed either at their homes or at their local
practice. Interviews were recorded, transcribed verbatim and entered into
Nvivo 814 for data management. The researchers took field notes during the
interview to record any issues in need of further exploration.15 SG, a health
professional, conducted 14 interviews and FG, a health services researcher,
conducted nine.
Method and Reflecting the practical nature of the study, a thematic framework approach
process of was used to analyse the data. The thematic framework was created, drawing
analysis from issues reported in the literature on barriers and enablers to the
implementation of guidelines. SG and FG familiarised themselves with the
data separately, identifying additional emergent themes and sub-themes
which were coded. SG and FG coded, mapped and interpreted the data to
provide explanations of the findings. To test the understanding of the data, the
two researchers met to agree the final themes and subthemes which were
then tested through discussions with researchers at the university to agree
codes that were subsequently incorporated, and to ensure appropriate
methodology was adopted. Analyses revealed good agreement between the
two researchers to develop the final model and they were content with the
methods used

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Population We used purposive sampling by asking the obesity leads in each PCT to
and sample identify five practices with different levels of commitment to obesity, indicated
collection by different levels of recording of body mass index (BMI) from quality and
outcomes framework data from each PCT. We sought a mix of rural and
urban practices and set a provisional quota sample of 12 healthcare
professionals (one GP and one practice nurse from each participating general
practice) and 8–10 patients (one or two from each participating general
practice who had experience of weight management from the practice) to
enable us to capture a range of views, recognising that some practices would
not participate. From those practices agreeing to take part, health
professionals were recruited by the researchers, and patients who had
experienced weight management support from the practice were recruited by
their healthcare professional.

Nine general practices (Table 1) were recruited with a total of 14 health

professionals (seven GPs and seven practice nurses; Table 2) and nine
patients (Table 3) being interviewed. On average, health professionals had
spent 10 years working in primary care.
Inclusion GPs, Nurses, Healthcare professionals
Criteria
Location: East Midlands PCTs

Patients who had experienced weight management conversations in the

practice
Exclusion None reported
criteria
Relevant 1. Patient themes: "‘You need to trust someone. Sometimes you don’t
themes get the same nurse and sometimes you don’t see the same person"
1. Motivation: Family support, empowered patient, good
relationship with health professional
2. Patient experience: Endless loop of failure. Patient requiring a
trigger
3. Stigma: View obesity as their own fault, in denial about being
obese
4. Cost of services: additional costs
2. Practitioner themes: "‘You can lead a horse to water but you can’t stop
it eating cream cakes.’"
1. Consultation with patients: Lack of counselling skills, limited
time with patients
2. Consistency of approach: Lack of consistency of approach
across the practice
3. Not the practitioner’s responsibility: helplessness in patients
not interested, frustration by lack of support, practitioners
wanting patients to take responsibility
4. Confident practitioner: Practitioner being overweight or obese,
trying to tackling co-morbidities
3. Service themes: "‘They have reduced the number of dietary services
in the whole of [x], so it’s very difficult to actually refer somebody"
1. Commissioning process: Embedding obesity into the quality
and outcomes framework

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2. Support services: Peer support groups within a practice,

supporting patients earlier, other agencies supporting the
practice, multi-component one-stop shop, professional feeling
confident to refer to services

Critical appraisal - CASP qualitative checklist

Section Question Answer
Overall risk of bias and relevance Overall risk of bias Low
Overall risk of bias and relevance Relevance Highly relevant

Holmgren, 2019
Bibliographic Holmgren, Marianne; Sandberg, Magnus; Ahlstrom, Gerd; To initiate the
Reference conversation-Public health nurses' experiences of working with obesity in
persons with mobility disability.; Journal of Advanced Nursing; 2019; vol.
75 (no. 10); 2156-2166

Study Characteristics
Study type Interviews
Aim of To develop a theory explaining how public health nurses accomplish and
study adapt counselling in lifestyle habits to decrease obesity in people with mobility
disability
Theoretical Grounded theory
approach
Study Southern Sweden
location
Study Primary health care centres
setting
Study dates September 2017–February 2018
Sources of This work was supported by a programme grant from Forte (the Swedish
funding Research Council for Health, Working Life and Welfare), number 2010‐1828.
This work was also supported by a grant from the Faculty of Medicine, Lund
University (Date of decision 2017‐11‐13)
Data In total, ten face‐to face interviews were conducted at the PHNs’ workplace,
collection except one that was conducted at Lund University. Interviewing, analysing
and coding occurred in an iterative process in accordance with GT by Glaser
(Glaser, 1978, 1998) by the first author (MH). All interviews were digitally
recorded and lasted be‐ tween 33‐66 min. The study began with three
interviews (Interview step 1, Table 1) and, was thereafter analysed by open
coding, which means coding the participants’ own words, line by line. These
three interviews included three open questions: ‘What is your experience with

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meeting persons with MD?’ Followed by: ‘What is your experience with
treating obesity when you meet a person with MD?’ And ‘In which way would
you work with lifestyle counselling and tailoring obesity treatment to people
with MD.’ To process the PHNs’ narratives from the interviews, open coding
conceptualizes the underlying pattern of a set of empirical indicators in the
data. Open coding includes questioning the data and the narratives during the
analysis. Memos, which are the interviewers’ thoughts that appear during the
analysis and are a core ingredient in GT (Glaser, 1978), were written
throughout the analysis to capture new questions and angles. The open
coding of the first three interviews generated more refined interview
questions.
Method and After the first three interviews were analysed, another three interviews were
process of performed (Interview step 2, Table 1). These three interviews were performed
analysis one at a time with an analysis phase between the interviews where the raw
data were coded. Further new questions emerged that were used in later
interviews, for example: ‘In what way is it difficult to discuss obesity with the
patient?,’ ‘How does the discussion differ if the patients have MD?’ and ‘How
can you facilitate addressing the problem? The codes generated concepts,
which were compared continuously during the analysis to ensure that the data
and the concepts were related to each other and through this process, the
core concept emerged. When the main concern to initiate the conversation
and the core concept public health nurses facilitators to communicate lifestyle
changes emerged, the next phase of selective coding began. The core
concept explains how participants resolve their main concern (Glaser, 1998).
During the selective coding, only those indicators that were related to the
main concern in sufficiently significant ways were used
Population A purposeful selection of PHNs with a specialist education in public health on
and sample master level from both rural and urban PHCC in southern Sweden were
collection made. The last author (GA) sent a letter with information about the study to
medical directors at PHCCs asking for permission to contact the PHNs who
were most experienced in healthy lifestyle interventions for people with MD.
Twenty‐six medical directors were contacted and asked to recommend PHNs
suitable to interview. The first author (MH) then sent an information letter to
these PHNs who were thereafter contacted by telephone in a week, received
additional verbal in‐ formation and were asked if they had any questions and if
they were willing to participate in the study. The participants were nine female
and one male PHNs, aged 40–58, with work experience between 3–22 years
Inclusion Nurses
Criteria
Location: primary care region in southern Sweden

Experienced with care of disabled patients

Exclusion None reported
criteria
Relevant 1. Person‐centeredness in the situation: "I try to personalize, try to scan
themes that person's ability to do and that you give advices based on that"
1. Needs and conditions
2. Continuous
3. Related to medical issues

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2. Experience and knowledge: "think the more years you have worked,
the easier it is for you to dare and find opportunities where it would be
appropriate to initiate it…"
1. Years of experiences
2. Educated in motivating interviewing
3. Strengthening conditions: "Is it the doctor who wants it or is it the
patient? It is first and foremost important in all behavioral changes"
1. Motivation
2. Responsibility
3. Group physical activity
4. Access to other professionals: "… you have to have multi‐professional
collaboration with physiotherapist and dietician"
1. Physiotherapist
2. Dietician
3. Physicians
5. Prioritization in everyday work: "..a lot is given low priority and this is
such a thing – lifestyle habits. It is after all, the first choice in all
treatment with regard to osteoarthritis, hypertension, obesity."
1. Resources
2. Management
3. Time

Critical appraisal - CASP qualitative checklist

Section Question Answer
Overall risk of bias and relevance Overall risk of bias Low
Overall risk of bias and relevance Relevance Relevant

Phillips, 2014
Bibliographic Phillips, Katie; Wood, Fiona; Kinnersley, Paul; Tackling obesity: the
Reference challenge of obesity management for practice nurses in primary care.;
Family practice; 2014; vol. 31 (no. 1); 51-9

Study Characteristics
Study type Semi structured interviews
Aim of To use qualitative semi-structured interviews to explore how practice nurses
study manage obesity within primary care and to identify good practice and explore
barriers to achieving effective management
Theoretical None stated
approach
Study South Wales, UK
location

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Study Local Health Boards

setting
Study dates Not stated
Sources of This project was not externally funded
funding
Data Semi-structured face-to-face interviews were conducted with 18 practice
collection nurses in South Wales

Following a literature review and discussion within the research team of the
aims of the project, we designed an interview schedule (Appendix 1)
incorporating a diagram based on a tool previously used in body-morph
research (21). The body-morph diagram was used to facilitate discussion of
which patients the practice nurse would approach. The diagram showed lines
of Caucasian women and men with body sizes ranging from underweight to
obese in sequence. Participants were asked to focus on the overweight end
of the spectrum and discuss who they would counsel in a variety of situations.
The interview schedule was piloted with a practice nurse and two questions
adapted. The final interview schedule was piloted with another practice nurse
and data from this interview were incorporated into the data analysis.
Method and Interviews were conducted, anonymized and transcribed by KP. Thematic
process of analysis was adopted for analysis. A field diary and research diary were kept
analysis during data collection and informed inductive development of data themes as
the interviews progressed. Data immersion during transcription and reading of
all interviews also aided theme development. Provisional themes of ‘who is
being counselled?’, ‘how is counselling being approached and done?’ and
‘what counselling is given?’ were generated. Transcripts were read again by
KP, FW and PK and themes validated. Data were then coded under these
major themes, with subnodes agreed and modified iteratively. NVivo was
used to manage data by constructing an accessible code book to assist in
coding and extraction during analysis. Node labels and definitions were
discussed before inputting data into NVivo in order to tighten definitions and
explicate themes from each other as much as possible. When 10 of the
interviews had been coded by KP, and FW used the coding stripes function in
NVivo to check for appropriate standard of coding
Population Nurses were included in the sample frame if they were a practice nurse
and sample currently working in either Cwm Taf Local Health Board (LHB) or Cardiff and
collection Vale University Health Board (UHB). Health care in Wales is organized by 7
LHBs, each responsible for a geographical area of the country. The two LHBs
chosen provide care for two geographically neighbouring areas in South
Wales; Cardiff and Vale UHB covers the urban capital city and a mix of
coastal and rural areas with varying affluence, and Cwm Taf LHB covers a
different population including isolated ex-mining populations in the South
Wales Valleys. The mix of patient populations afforded through sampling from
these two LHBs was chosen to add breadth to the experience nurses would
have. There were no age, gender, or experience sampling criteria and nurses
who had extra qualifications to become ‘nurse practitioners’ with consulting
and prescribing roles were eligible for recruitment, given their background of
practice nursing and continued exposure to obesity management. More than
one nurse from each practice was eligible to participate. No financial incentive

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was given. We sent an e-mail to the lead nurses for each LHB and asked
them to disseminate it to all practice nurses in the area. In Cwm Taf, KP
attended a teaching afternoon for all nurses in the locality. Interested nurses
contacted the research team by e-mail or phone.

The Townsend Score (a measure to calculate deprivation based on multiple

personal and societal factors) was used to describe the relative deprivation of
each practice population recruited. Data accessed from Public Health Wales
Observatory were used to assign a score to each practice that a nurse was
recruited from, based on the postcode of the practice. Scores in Wales range
from −7.64 (the least deprived area) to 11.93 (the most deprived score). We
assessed data saturation after 16 interviews and made a decision to continue
recruiting to 18 interviews due to the relative under-representation of affluent
areas in Cwm Taf.

A total of 18 nurses across the two health boards agreed to participate. Of the
18 nurses, 11 worked in Cardiff and Vale UHB (out of all nurses in the area,
this is a response rate of 7%) and 7 worked in Cwm Taf LHB (response rate
8%). All participants were female. Sixteen percent of participants had
<5 years of experience, 16% had 5–10 years of experience, 61% had 10–
20 years of experience and 5% had >20 years of experience. Five
participants (28%) had nurse practitioner roles above their practice nurse
duties.
Inclusion Location:
Criteria
Cardiff and Vale UHB and Cwm Taf LHB
Exclusion None reported
criteria
Relevant 1. Who are nurses discussing weight with?: "I’ll look at them and think
themes sometimes ‘well, you’re really not that bad’ but that is compared to
what I’m dealing with in my weight management clinic"
1. Who is primary care seeing?
2. Opportunities to discuss weight with patients
3. Priority patients to target
2. How are nurses discussing weight?: "...But nearly at 35 stone no one
is doing anything and it’s perceived that he can’t stop but nobody can
help. You can’t say ‘you know, you should eat less"
1. Approaching the subject
2. Relationships with patients
3. Risk language used in discussion with different groups of
patients
4. Strategies for discussing weight with patients
5. Guiding or directing patients to making lifestyle changes
6. Monitoring patients
3. What is being discussed with patients?: "So if they, ‘I don’t know what
I’m doing’ then you kind of make it to suit – you know, you go back to
basics. Right, we’ll do a food diary, we’ll do this week, I give them little
goals"
1. Dietary advice given

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2. Exercise advice given

Critical appraisal - CASP qualitative checklist

Section Question Answer
Overall risk of bias and relevance Overall risk of bias Low
Overall risk of bias and relevance Relevance Highly relevant

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Appendix E – Forest plots

Children and young people

Advanced active case finding (report card with personal information intervention)
versus active case finding (report card with general information intervention)
Number of children and young people identified as overweight

Referral to weight management services

Advanced active case finding (report card with personal information intervention)
versus usual care (no report card)

Number of children and young people identified as overweight

Referral to weight management services

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Active case finding (report card with general information intervention) versus usual
care (no report card)

Number of children and young people identified as overweight

Referral to weight management services

All Active case finding (screening with parent report and no parent report) versus
usual care (no screening)

Adverse events: Peer teasing (Higher value reflects increased teasing)

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Adverse events: Peer weight talk (Higher value reflects increased talk)

Adverse events: teacher weight talk (Higher value reflects increased talk)

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Advanced active case finding (screening with parent report) versus active case finding
(screening with no parent report) or usual care (no screening)

Adverse events: Family weight teasing (Higher value reflects increased teasing)

Adverse events: Family encourages dieting at 1 year follow up (Higher value reflects
increasing encouragement)

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Adverse events: Family encourages dieting at 2 years follow up (Higher value reflects
increasing encouragement to diet to control weight)

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Adverse events: Family weight talk at 1 year follow up (Higher value reflects increasing talk)

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Adverse events: Family weight talk at 2 year follow up (Higher value reflects increasing talk)

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Adults
Opportunistic identification using electronic tools vs usual care with no tool use

Diagnosis of overweight/obesity: Number of adults identified as overweight or obese from the

total number of patient consultations

(a) It is unclear if Wee 2010 has statistically accounted for clustering

Missed diagnoses: Number of patients with BMI≥25 who were not diagnosed with
overweight/obesity

(b) It is unclear if Wee 2010 has statistically accounted for clustering

(c) A random effects model was selected due to the use of different types of tool in each study, which would be expected to
produce heterogeneous effects.

Documentation of BMI: Number of patients whose BMI was recorded from the total number
of patient consultations

(d) It is unclear if Wee 2010 has statistically accounted for clustering

Weight counselling: The number of patients who received weight counselling during their
appointment from the total number of patient consultations

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Appendix F – GRADE and CERQual tables

GRADE tables
Children and young people

Table 20: Advanced active case finding (report card with personal information intervention) versus active case finding (report card with
general information intervention)

Quality assessment No of patients Effect

Quality Importance
Active case finding +
No of Risk of Other Relative
Design Inconsistency Indirectness Imprecision versus active case Control Absolute
studies bias considerations (95% CI)
finding
Number of children and young people identified as overweight or obese (follow-up 0-6 weeks; assessed with: Parents correctly identifying their children's weight status)
11 randomised very no serious serious4 very serious5 none 25/57 41.1% RR 1.08 (0.72 to 33 more per 1000 ⊕ΟΟΟ
trials serious2 inconsistency3 (43.9%) 1.62) (from 115 fewer VERY LOW CRITICAL
to 255 more)
Referral to weight management service (follow-up 0-6 weeks; assessed with: Parents seek medical service for overweight children)
1 randomised very no serious serious6 no serious none 14/57 7% RR 3.64 (1.39 to 185 more per ⊕ΟΟΟ CRITICAL
trials serious2 inconsistency3 imprecision (24.6%) 9.5) 1000 (from 27 VERY LOW
more to 595
more)

1
Chomitz 2003
2
Downgraded by 2 increments because the majority of the evidence was at very high risk of bias
3
Single study- inconsistency not applicable.
4
Indirect assessment of the number of children and young people identified as overweight or obese
5
Downgraded by 2 increments as the confidence interval crossed both MIDs (0.8. 1.25)
6
Considered indirect evidence as it was unclear if they went on to referral to weight management service

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Table 21: Advanced active case finding (report card with personal information intervention) versus usual care (no report card)

Quality assessment No of patients Effect

Quality Importance
Active case
No of Risk of Other Relative
Design Inconsistency Indirectness Imprecision finding + versus Control Absolute
studies bias considerations (95% CI)
usual care
Number of children and young people identified as overweight or obese (follow-up 0-6 weeks; assessed with: Parents correctly identifying their children's weight status)
11 randomised very no serious serious4 Serious6 none 25/57 22.9% RR 1.95 (1.16 218 more per 1000 ⊕ΟΟΟ
trials serious2 inconsistency3 (43.9%) to 3.28) (from 37 more to VERY LOW CRITICAL
522 more)
Referral to weight management service (follow-up 0-6 weeks; assessed with: Parents seek medical service for overweight children)
11 randomised very no serious serious5 Serious6 none 14/57 8% RR 2.91 (1.19 153 more per 1000 ⊕ΟΟΟ
trials serious2 inconsistency3 (24.6%) to 7.08) (from 15 more to VERY LOW CRITICAL
486 more)
1
Chomitz 2003
2
Downgraded by 2 increments because the majority of the evidence was at very high risk of bias
3
Single study- inconsistency not applicable
4
Indirect assessment of the number of children and young people identified as overweight or obese
5
Considered indirect evidence as it was unclear if they went on to referral to weight management service
6
Downgraded by 1 increment as the confidence interval crossed one MID (0.8, 1.25)

Table 22: Active case finding (report card with general information intervention) versus usual care (no report card)

Quality assessment No of patients Effect

Quality Importance
Active case
No of Risk of Other Relative
Design Inconsistency Indirectness Imprecision finding versus Control Absolute
studies bias considerations (95% CI)
usual care
Number of children and young people identified as overweight or obese (follow-up 0-6 weeks; assessed with: Parents correctly identifying their children's weight status)
11 randomised very no serious serious4 serious5 none 30/74 22.9% RR 1.8 (1.08 183 more per 1000 ⊕ΟΟΟ
trials serious2 inconsistency3 (40.5%) to 3) (from 18 more to VERY LOW CRITICAL
458 more)
Referral to weight management service (follow-up 0-6 weeks; assessed with: Parents seek medical service for overweight children)
11 randomised very no serious serious6 very serious7 none 5/74 8% RR 0.8 (0.26 16 fewer per 1000 ⊕ΟΟΟ
trials serious2 inconsistency3 (6.8%) to 2.5) (from 59 fewer to VERY LOW CRITICAL
120 more)
1
Chomitz 2003
2
Downgraded by 2 increments because the majority of the evidence was at very high risk of bias
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3
Single study- inconsistency not applicable
4
Indirect assessment of the number of children and young people identified as overweight or obese
5
Downgraded by 1 increment as the confidence interval crossed one MID (0.8, 1.25)
6
Considered indirect evidence as it was unclear if they went on to referral to weight management service
7
Downgraded by 2 increments as the confidence interval crossed both MIDs (0.8, 1.25)

Table 23: All Active case finding (screening with parent report and no parent report) versus usual care (no screening)

Quality assessment No of patients Effect

Quality Importance
Active case
No of Risk of Other Relative
Design Inconsistency Indirectness Imprecision finding + / active Control Absolute
studies bias considerations (95% CI)
case finding
Adverse events: peer teasing (follow-up 1 years; measured with: Peer weight teasing index. 1-5 “never” to “almost every day”; range of scores: 1-5; Better indicated by lower values)
11 randomised very no serious no serious no serious none 204826 81596 - MD 0.01 higher ⊕⊕ΟΟ
trials2 serious3 inconsistency4 indirectness imprecision5 (0.02 lower to 0.04 LOW IMPORTANT
higher)
Adverse events: peer teasing (follow-up 2 years; measured with: Peer weight teasing index. 1-5 “never” to “almost every day”; range of scores: 1-5; Better indicated by lower values)
11 randomised very no serious no serious no serious none 204826 81596 - MD 0.02 lower ⊕⊕ΟΟ
trials2 serious3 inconsistency4 indirectness imprecision7 (0.07 lower to 0.03 LOW IMPORTANT
higher)
Adverse events: peer talk (follow-up 1 years; measured with: Peer weight talk index. 1-5 “never” to “almost every day”; range of scores: 1-5; Better indicated by lower values)
11 randomised very no serious no serious no serious none 204826 81596 - MD 0.05 higher ⊕⊕ΟΟ
trials2 serious3 inconsistency4 indirectness imprecision8 (0.01 to 0.09 LOW IMPORTANT
higher)
Adverse events: peer talk (follow-up 2 years; measured with: Peer weight talk index. 1-5 “never” to “almost every day”; range of scores: 1-5; Better indicated by lower values)
11 randomised very no serious no serious no serious none 204826 81596 - MD 0.00 higher ⊕⊕ΟΟ
trials2 serious3 inconsistency4 indirectness imprecision5 (0.07 lower to 0.07 LOW IMPORTANT
higher)
Adverse events: teacher weight talk (follow-up 1 years; measured with: "Teachers talk about my weight or size": 1-5 Never to almost every day; range of scores: 1-5; Better indicated by lower
values)
11 randomised very no serious no serious no serious none 204826 81596 - MD 0.01 lower ⊕⊕ΟΟ
trials2 serious3 inconsistency4 indirectness imprecision9 (0.03 lower to 0.01 LOW IMPORTANT
higher)
Adverse events: teacher weight talk (follow-up 2 years; measured with: "Teachers talk about my weight or size": 1-5 Never to almost every day; range of scores: 1-5; Better indicated by lower
values)
11 randomised very no serious no serious no serious none 204826 81596 - MD 0.00 lower ⊕⊕ΟΟ
trials2 serious3 inconsistency4 indirectness imprecision8 (0.04 lower to 0.04 LOW IMPORTANT
higher)
1
Madsen 2021
2
Cluster randomised trial
3
Downgraded by 2 increments because the majority of the evidence was at very high risk of bias
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4
Single study- inconsistency not applicable
5
Calculated SD of comparison group =2.71. MID calculated as 0.5 of the SD in comparison group= 1.355
6
Number of students in the arm - Study does not report number of clusters
7
Calculated SD of comparison group=3.61. MID calculated as 0.5 of the SD in comparison group= 1.805
8
Calculated SD of comparison group = 1.81. MID calculated as 0.5 of the SD in comparison group = 0.905
9
Calculated SD of comparison group = 0.90. MID calculated as 0.5 of the SD in comparison group = 0.45

Table 24: Advanced active case finding (screening with parent report) versus active case finding (screening with no parent report) or
usual care (no screening)

Quality assessment No of patients Effect

Quality Importance
Active case
No of Risk of Other Active case Relative
Design Inconsistency Indirectness Imprecision finding / Absolute
studies bias considerations finding + (95% CI)
usual care
Adverse events: family weight teasing (follow-up 1 years; measured with: My family teases or makes fun of me because of my weight. 1-5 Never to almost every day; range of scores: 1-5; Better
indicated by lower values)
11 randomised very no serious no serious no serious none 100416 186006 - MD 0.01 lower ⊕⊕ΟΟ
trials2 serious3 inconsistency4 indirectness imprecision5 (0.04 lower to 0.02 LOW IMPORTANT
higher)
Adverse events: family weight teasing (follow-up 2 years; measured with: My family teases or makes fun of me because of my weight. 1-5 Never to almost every day; range of scores: 1-5; Better
indicated by lower values)
11 randomised very no serious no serious no serious none 100416 186006 - MD 0.01 lower ⊕⊕ΟΟ
trials2 serious3 inconsistency4 indirectness imprecision7 (0.06 lower to 0.04 LOW IMPORTANT
higher)
Adverse event: family encourages dieting in children who consider themselves as underweight (follow-up 1 years; measured with: Family encourages dieting. 1 to 4 Not at all to very much;
range of scores: 1-4; Better indicated by lower values)
11 randomised very no serious no serious serious8 none 100419 186009 - MD 0.03 higher ⊕ΟΟΟ
trials2 serious3 inconsistency4 indirectness (0.07 lower to 0.13 VERY LOW IMPORTANT
higher)
Adverse event: family encourages dieting in children who consider themselves as underweight (follow-up 2 years; measured with: Family encourages dieting. 1 to 4 Not at all to very much;
range of scores: 1-4; Better indicated by lower values)
11 randomised very no serious no serious serious8 none 100419 186009 - MD 0.01 higher ⊕ΟΟΟ
trials2 serious3 inconsistency4 indirectness (0.15 lower to 0.17 VERY LOW IMPORTANT
higher)
Adverse event: family encourages dieting in children who consider themselves as about the right weight (follow-up 1 years; measured with: Family encourages dieting. 1 to 4 Not at all to very
much; range of scores: 1-4; Better indicated by lower values)
11 randomised very no serious no serious serious8 none 100419 186009 - MD 0.05 lower ⊕ΟΟΟ
trials2 serious3 inconsistency4 indirectness (0.12 lower to 0.02 VERY LOW IMPORTANT
higher)
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Adverse event: family encourages dieting in children who consider themselves as about the right weight (follow-up 2 years; measured with: Family encourages dieting. 1 to 4 Not at all to very
much; range of scores: 1-4; Better indicated by lower values)
11 randomised very no serious no serious serious8 none 100419 186009 - MD 0.07 higher ⊕ΟΟΟ
trials2 serious3 inconsistency4 indirectness (0.03 lower to 0.17 VERY LOW IMPORTANT
higher)
Adverse event: family encourages dieting in children who consider themselves as somewhat overweight (follow-up 1 years; measured with: Family encourages dieting. 1 to 4 Not at all to very
much; range of scores: 1-4; Better indicated by lower values)
11 randomised very no serious no serious serious8 none 100419 186009 - MD 0.03 higher ⊕ΟΟΟ
trials2 serious3 inconsistency4 indirectness (0.08 lower to 0.14 VERY LOW IMPORTANT
higher)
Adverse event: family encourages dieting in children who consider themselves as somewhat overweight (follow-up 2 years; measured with: Family encourages dieting. 1 to 4 Not at all to very
much; range of scores: 1-4; Better indicated by lower values)
11 randomised very no serious no serious serious8 none 100419 186009 - MD 0.11 lower ⊕ΟΟΟ
trials2 serious3 inconsistency4 indirectness (0.28 lower to 0.06 VERY LOW IMPORTANT
higher)
Adverse event: family encourages dieting in children who consider themselves very overweight (follow-up 1 years; measured with: Family encourages dieting. 1 to 4 Not at all to very much;
range of scores: 1-4; Better indicated by lower values)
11 randomised very no serious no serious serious8 none 100419 186009 - MD 0.14 higher ⊕ΟΟΟ
trials2 serious3 inconsistency4 indirectness (0.08 lower to 0.36 VERY LOW IMPORTANT
higher)
Adverse event: family encourages dieting in children who consider themselves very overweight (follow-up 2 years; measured with: Family encourages dieting. 1 to 4 Not at all to very much;
range of scores: 1-4; Better indicated by lower values)
11 randomised very no serious no serious no serious none 100419 186009 - MD 0.44 higher ⊕⊕ΟΟ
trials2 serious3 inconsistency4 indirectness imprecision (0.66 to 0.82 LOW IMPORTANT
higher)
Adverse event: family weight talk in children who consider themselves as underweight (follow-up 1 years; measured with: Family weight-talk index. 1 to 5 Not at all to very much; range of
scores: 1-4; Better indicated by lower values)
11 randomised very no serious no serious no serious none 100419 186009 - MD 0.07 higher ⊕⊕ΟΟ
trials2 serious3 inconsistency4 indirectness imprecision (0.01 to 0.13 LOW IMPORTANT
higher)
Adverse event: family weight talk in children who consider themselves as underweight (follow-up 2 years; measured with: Family weight-talk index. 1 to 5 Not at all to very much; range of
scores: 1-4; Better indicated by lower values)
11 randomised very no serious no serious serious8 none 100419 186009 - MD 0.05 higher ⊕ΟΟΟ
trials2 serious3 inconsistency4 indirectness (0.05 lower to 0.15 VERY LOW IMPORTANT
higher)
Adverse event: family weight talk in children who consider themselves as about the right weight (follow-up 1 years; measured with: Family weight-talk index. 1 to 5 Not at all to very much; range
of scores: 1-4; Better indicated by lower values)
11 randomised very no serious no serious serious8 none 100419 186009 - MD 0.01 lower ⊕ΟΟΟ
trials2 serious3 inconsistency4 indirectness (0.06 lower to 0.04 VERY LOW IMPORTANT
higher)
Adverse event: family weight talk in children who consider themselves as about the right weight (follow-up 2 years; measured with: Family weight-talk index. 1 to 5 Not at all to very much; range
of scores: 1-4; Better indicated by lower values)

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11 randomised very no serious no serious serious8 none 100419 186009 -

MD 0.02 lower ⊕ΟΟΟ
trials2 serious3 inconsistency4 indirectness (0.09 lower to 0.05 VERY LOW IMPORTANT
higher)
Adverse event: family weight talk in children who consider themselves as somewhat overweight (follow-up 1 years; measured with: Family weight-talk index. 1 to 5 Not at all to very much; range
of scores: 1-4; Better indicated by lower values)
11 randomised very no serious no serious serious8 none 100419 186009 - MD 0.04 lower ⊕ΟΟΟ
trials2 serious3 inconsistency4 indirectness (0.11 lower to 0.03 VERY LOW IMPORTANT
higher)
Adverse event: family weight talk in children who consider themselves as somewhat overweight (follow-up 2 years; measured with: Family weight-talk index. 1 to 5 Not at all to very much; range
of scores: 1-4; Better indicated by lower values)
11 randomised very no serious no serious serious8 none 100419 186009 - MD 0.06 higher ⊕ΟΟΟ
trials2 serious3 inconsistency4 indirectness (0.05 lower to 0.17 VERY LOW IMPORTANT
higher)
Adverse event: family weight talk in children who consider themselves as very overweight (follow-up 1 years; measured with: Family weight-talk index. 1 to 5 Not at all to very much; range of
scores: 1-4; Better indicated by lower values)
11 randomised very no serious no serious no serious none 100419 186009 - MD 0.13 higher ⊕⊕ΟΟ
trials2 serious3 inconsistency4 indirectness imprecision (0.01 to 0.25 LOW IMPORTANT
higher)
Adverse event: family weight talk in children who consider themselves as very overweight (follow-up 2 years; measured with: Family weight-talk index. 1 to 5 Not at all to very much; range of
scores: 1-4; Better indicated by lower values)
11 randomised very no serious no serious no serious none 100419 186009 - MD 0.24 lower ⊕⊕ΟΟ
trials2 serious3 inconsistency4 indirectness imprecision (0.47 to 0.01 lower) LOW IMPORTANT
1
Madsen 2021
2
Cluster randomised trial
3
Downgraded by 2 increments because the majority of the evidence was at very high risk of bias
4
Single study- inconsistency not applicable
5
Calculated SD of comparison group = 0.90. MID calculated as 0.5 of the SD in comparison group = 0.45
6
Number of students in the arm - Study does not report number of clusters
7
Calculated SD of comparison group = 1.81. MID calculated as 0.5 of the SD in comparison group = 0.905
8
Downgraded by 1 increment because 95% CI crosses line of no effect. (MID could not be calculated).
9
Total number in arm. Study does not report the number of children in this subgroup

Table 25: Advanced active case finding (report enhanced with education) versus active case finding alone (report alone)

Quality assessment No of patients Effect

Quality Importance
No of Risk of Other Active case Active case Relative
Design Inconsistency Indirectness Imprecision Absolute
studies bias considerations finding + finding (95% CI)
Referral to weight management service (follow-up 0-8 weeks; assessed with: "Report prompted you to visit a healthcare provider or registered dietitian about your child’s weight status")
11 randomised very no serious serious5 very serious6 none - 0% OR 0.8 (0 to -8 ⊕ΟΟΟ
trials2 serious3 inconsistency4 0)7 VERY LOW CRITICAL

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1
Bailey-Davis 2017
2
Cluster randomised trial
3
Downgraded by 2 increments because the majority of the evidence was at very high risk of bias
4
Single study- inconsistency not applicable
5
Considered indirect evidence as it was unclear if they went on to referral to weight management service
6
Downgraded by 2 increments. Confidence interval not reported.
7
Study does not report 95% CI. Study reports p-value of 0.16.
8
Absolute risk not calculable with the outcome data provided

Adults

Table 26: Opportunistic identification using electronic tools vs usual care with no tool use

Quality assessment No of patients Effect

Quality Importance
No of Indirectnes Other Electronic Relative
Design Risk of bias Inconsistency Imprecision Usual care Absolute
studies s considerations record tools (95% CI)
Diagnosis of overweight/obesity (assessed with: number of patients diagnosed, 0 follow up)
31,2,3 randomised serious4 very serious serious5 no serious none 10747/28246 1736/35916 RR 6.61 (3.56 to 271 more per ⊕⊕ΟΟ
trials inconsistency7 imprecision (38%) (4.8%) 12.28) 1000 (from 124 VERY LOW CRITICAL
more to 545
more)
Weight counselling (assessed with: Number of patients who received weight counselling)
13 randomised no serious risk no serious serious5 serious none 53/200 29/200 RR 1.83 (1.22 to 120 more per ⊕⊕⊕Ο
trials of bias inconsistency8 imprecision9 (26.5%) (14.5%) 2.75) 1000 (from 32 LOW CRITICAL
more to 254
more)
Missed diagnosis (assessed with: Number of patients with BMI>=25 who were not diagnosed as overweight/obese)
21,2 randomised serious4 serious serious5 no serious none 4337/14987 19655/2154 RR 0.32 (0.29 to 620 fewer per ⊕⊕ΟΟ
trials inconsistency10 imprecision (28.9%) 8 0.37) 1000 (from 575 VERY LOW CRITICAL
(91.2%) fewer to 648
fewer)
Documentation of BMI (assessed with: Number of patients whose BMI was recorded)
12 randomised serious6 no serious serious5 no serious none 25951/26481 33088/3376 RR 1 (1 to 1) No difference ⊕⊕ΟΟ
trials inconsistency8 imprecision (98%) 3 LOW CRITICAL
(98%)
1
Lee 2009
2
Wee 2010 (cluster RCT)
3
Tang 2012
4
Lee 2009 and Wee 2010 were both rated moderate risk of bias
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5
All studies were rated indirectly applicable as they were conducted in the USA
6
Wee 2010 was rated moderate risk of bias
I = 93%
7 2
8
Single study: Inconsistency is not applicable
9
Confidence interval crossed the MID (0.8, 1.25)
I = 36%
10 2

CERQual tables
Table 27: GRADE-CERQual table for evidence on the effectiveness of approaches in identifying overweight and obesity in children and
young people
Methodologic
Summary of review finding Studies al limitations Relevance Coherence Adequacy Confidence
Barriers in the UK NCMP
Parents were offended by the identification Dam 2019 No concerns No concerns No concerns No concerns High
Gainsbury 2018
Coupe 2022
Parents ignored the identification Gainsbury 2018 No concerns No concerns No concerns No concerns High
Syrad 2015
Turner 2016
Parents disagreed with the identification Dam 2019 No concerns No concerns No concerns No concerns High
Gainsbury 2018
Syrad 2015
Turner 2016
Parents agreed with the identification, but felt Dam 2019 No concerns No concerns No concerns No concerns High
that overweight is not a problem Syrad 2015
Coupe 2022
Staff describe practical limitations on what they Dam 2019 No concerns No concerns Minor No concerns Moderate
can do Turner 2016 concerns5
Coupe 2022
International barriers matching the UK NCMP
Parents were offended by the identification Hardy 2019 Minor Minor No concerns No concerns Moderate
Jachyra 2018 concerns1 concerns3
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Methodologic
Summary of review finding Studies al limitations Relevance Coherence Adequacy Confidence
Jones 2014
McPherson 2018
Sjunnestrand 2019
Toftemo 2013
Eli 2022
Parents ignored the identification Hardy 2019 Minor Minor Serious Serious Very low
Jones 2014 concerns1 concerns3 concerns9 concerns10
Parents disagreed with the identification Hardy 2019 Minor Minor No concerns Minor Moderate
Sjunnestrand 2019 concerns1 concerns3 concerns7
Toftemo 2013
Eli 2022
Parents agreed with the identification, but felt Hardy 2019 Minor Minor Minor Moderate Very low
that overweight is not a problem Jones 2014 concerns1 concerns3 concerns5 concerns8
Toftemo 2013
Eli 2022
Staff describe practical limitations on what they Sjunnestrand 2019 Minor Minor Moderate Minor Very low
can do Jones 2014 concerns1 concerns3 concerns6 concerns7
Hardy 2019

International barriers and facilitators

HCPs provided context for normal weight and Avis 2016 Minor Minor No concerns No concerns Moderate
growth Hardy 2019 concerns1 concerns3
Jones 2014
Sjunnestrand 2019
Toftemo 2013
Eli 2022
HCPs were able to discuss and explain weight Avis 2016 No concerns Minor No concerns No concerns High
issues Hardy 2019 concerns3
Jachyra 2018
Jones 2014
McPherson 2018
Sjunnestrand 2019
Toftemo 2013
Eli 2022

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Methodologic
Summary of review finding Studies al limitations Relevance Coherence Adequacy Confidence
Collaboration with other professionals Hardy 2019 Minor Minor Minor No concerns Moderate
facilitated engagement Jones 2014 concerns1 concerns3 concerns5
McPherson 2018
Sjunnestrand 2019
A trusting relationship between HCP and Avis 2016 No concerns Minor No concerns No concerns High
families was important Hardy 2019 concerns3
Jachyra 2018
Jones 2014
McPherson 2018
Sjunnestrand 2019
Toftemo 2013
Eli 2022
HCPs tailored conversations to the families Avis 2016 No concerns Minor No concerns No concerns High
Hardy 2019 concerns3
Jachyra 2018
Jones 2014
McPherson 2018
Sjunnestrand 2019
Eli 2022
Barriers and facilitators for specific groups
Younger age groups Jones 2014 Moderate Minor Minor No concerns Low
McPherson 2018 concerns2 concerns3 concerns5
Toftemo 2013
Disability and complex health issues Jachyra 2018 Minor Minor No concerns Minor Moderate
McPherson 2018 concerns1 concerns3 concerns7
Autism Jachyra 2018 Minor Minor No concerns Minor Moderate
McPherson 2018 concerns1 concerns3 concerns7
Race and culture Avis 2016 Minor Minor No concerns Moderate Low
Jones 2014 concerns1 concerns3 concerns8
McPherson 2018
1
Finding was downgraded once because it was identified mainly in studies at moderate or high risk of bias
2
Finding was downgraded twice because it was identified mainly in studies at high risk of bias
3
Finding was downgraded once because it was identified mainly in studies that were indirectly or partially relevant
4
Finding was downgraded twice because it was identified mainly in studies that were partially relevant
5
Finding was downgraded once for coherence because the theme did not emerge from all relevant studies, findings were somewhat conflicting, or there was little convincing theoretical explanation

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6
Finding me was downgraded twice for coherence because the theme did not emerge from all relevant studies, findings were directly conflicting, or there was no convincing theoretical explanation
7
Finding was downgraded once for adequacy because of insufficient studies (fewer than 3) or insufficient detail
8
Finding was downgraded twice for adequacy because of both insufficient studies (fewer than 3) and insufficient detail
9
Finding was downgraded three times for coherence because the theme rarely emerged and there was no convincing theoretical explanation
10
Finding was downgraded three times for adequacy because of minimal detail being present in fewer than 3 studies

Table 28: GRADE-CERQual table for evidence on the effectiveness of approaches in identifying overweight and obesity in
adults
Methodologic
Summary of review finding Studies al limitations Relevance Coherence Adequacy Confidence
Barriers and facilitators to identification in general
Healthcare providers felt that tools and guidance Atlantis 2021 No concerns No concerns Minor No concerns Moderate
on identifying overweight were useful, but there Blackburn 2015 concerns5
was often a lack of consistency and availability. Doherty 2019
Glenister
Gunther 2012
Holmgren 2019
Atlantis 2021 No concerns No concerns Minor No concerns Moderate
There were mixed opinions on whether it is a Beeken 2021 concerns5
HCPs responsibility to identify overweight or Blackburn 2015
obese people. Gunther 2012
Holmgren 2019
Phillips 2014
Barriers and facilitators to identification of an individual
Identifying overweight or obesity was seen as a Blackburn 2015 No concerns No concerns No concerns No concerns High
difficult conversation to initiate, so HCPs needed Doherty 2019
to feel confident in their ability to do it well. Gunther 2012
Holmgren 2019

Competing priorities in a clinical interaction often Blackburn 2015 No concerns No concerns No concerns No concerns High
meant that weight was not addressed. Doherty 2019
Glenister
Gunther 2012

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Methodologic
Summary of review finding Studies al limitations Relevance Coherence Adequacy Confidence
Holmgren 2019
Phillips 2014

Opinions varied as to which patients should be Beeken 2021 No concerns No concerns Minor No concerns Moderate
identified and whether a conversation about Blackburn 2015 concerns5
weight should occur for an individual. Glenister
Gunther 2012
Holmgren 2019
Phillips 2014

Barriers and facilitators to raising the topic of weight with a patient

A good relationship between patient and HCP Atlantis 2021 No concerns No concerns No concerns No concerns High
made it easier to initiate a conversation about Beeken 2021
weight. Blackburn 2015
Glenister
Gunther 2012
Holmgren 2019
Phillips 2014

Framing the identification of overweight as a Atlantis 2021 No concerns Minor No concerns No concerns Moderate
general status was less productive than framing Beeken 2021 concerns
identification as a health concern. Doherty 2019
Holmgren 2019
Phillips 2014

Most HCPs considered weight conversations to Atlantis 2021 No concerns No concerns No concerns No concerns High
be challenging due to the stigma of being Beeken 2021
overweight. Blackburn 2015
Glenister
Gunther 2012
Holmgren 2019
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Methodologic
Summary of review finding Studies al limitations Relevance Coherence Adequacy Confidence
Phillips 2014

Barriers and facilitators to discussing weight management

Discussions of weight were dependent on the Atlantis 2021 No concerns No concerns Minor No concerns Moderate
patient’s motivation to engage with weight Gunther 2012 concerns5
management Holmgren 2019
Phillips 2014

HCPs discussed the importance of tailoring Beeken 2021 No concerns No concerns No concerns No concerns High
conversations to the patient they are talking to. Doherty 2019
Gunther 2012
Holmgren 2019
Phillips 2014

HCPs who worked with patients with learning Doherty 2019 No concerns Minor No concerns Moderate Low
disabilities described the additional concerns3 concerns8
considerations when carers or support workers
are involved.

Barriers and facilitators to referral and management

HCPs advised their patients on diet and exercise, Atlantis 2021 No concerns No concerns Minor No concerns Moderate
and helped them to plan their weight Glenister concerns5
management individually. Gunther 2012
Holmgren 2019
Phillips 2014

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Methodologic
Summary of review finding Studies al limitations Relevance Coherence Adequacy Confidence
A referral for weight management was often Blackburn 2015 No concerns No concerns No concerns No concerns High
dependent on whether there are appropriate Doherty 2019
services available to refer patients to. Glenister
Gunther 2012
Holmgren 2019
Phillips 2014
1
Finding was downgraded once because it was identified mainly in studies at moderate or high risk of bias
2
Finding was downgraded twice because it was identified mainly in studies at high risk of bias
3
Finding was downgraded once because it was identified mainly in studies that were indirectly or partially relevant
4
Finding was downgraded twice because it was identified mainly in studies that were partially relevant
5
Finding was downgraded once for coherence because the theme did not emerge from all relevant studies, findings were somewhat conflicting, or there was little convincing theoretical explanation
6
Finding me was downgraded twice for coherence because the theme did not emerge from all relevant studies, findings were directly conflicting, or there was no convincing theoretical explanation
7
Finding was downgraded once for adequacy because of insufficient studies (fewer than 3) or insufficient detail
8
Finding was downgraded twice for adequacy because of both insufficient studies (fewer than 3) and insufficient detail

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Appendix G - Economic evidence study selection

What is the cost-effectiveness of identifying overweight and obesity in children, young people
and adults?

Records identified through database

searching
(n =808)

Records after duplicates removed for

Records excluded
screening
(n = 444)
(n = 444)

Full-text articles assessed for

eligibility
(n = 0)

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Appendix H – Economic evidence tables

No economic evidence was found for these review questions.

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Appendix I – Health economic model

These questions were not prioritised for original economic analysis.

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Appendix J – Excluded studies

Study Code [Reason]

Atlantis, Evan, John, James Rufus, Fahey, Paul Patrick et al. - Not a relevant study design
(2021) Clinical usefulness of brief screening tool for activating
weight management discussions in primary cARE (AWARE): Cross-sectional diagnostic
A nationwide mixed methods pilot study. PloS one 16(10): accuracy
e0259220

Aveyard, Paul, Lewis, Amanda, Tearne, Sarah et al. (2016) - Study does not contain a relevant
Screening and brief intervention for obesity in primary care: a intervention
parallel, two-arm, randomised trial. Lancet (London, England)
388(10059): 2492-2500 Intervention is for uptake, all
participants experienced screening
in the same way.

Bailey-Davis, Lisa, Hosterman, Jennifer, Poulsen, Melissa et - Conference abstract

al. (2020) Clinical screening for food security and lifestyle
behavioral risk to prevent pediatric obesity. Obesity
28(suppl2): 68

Barba, G., Giacco, R., Clemente, G. et al. (2001) The - Not a comparative study
BRAVO project: screening for childhood obesity in a primary
school setting. Nutrition, metabolism, and cardiovascular Ongoing assessment of obesity,
diseases : NMCD 11(4suppl): 103-108 lifestyle, and dietary habits in a
school in Italy

Blane, David N; Macdonald, Sara; O'Donnell, Catherine A - SR - checked

(2020) What works and why in the identification and referral
of adults with comorbid obesity in primary care: A realist
review. Obesity reviews : an official journal of the
International Association for the Study of Obesity 21(4):
e12979

Bonsergent, Emilie, Thilly, Nathalie, Legrand, Karine et al. - No relevent outcomes provided
(2013) Process evaluation of a school-based overweight and
obesity screening strategy in adolescents. Global health Comparative outcomes reported do
promotion 20(2suppl): 76-82 not address identification of
overweight/obesity and co not
match those in the protocol

Bordowitz, Richard; Morland, Kimberly; Reich, Douglas - Not a relevant study design
(2007) The use of an electronic medical record to improve
documentation and treatment of obesity. Family medicine retrospective cross-sectional study
39(4): 274-9

Camp, Nadine L, Robert, Rebecca C, Nash, Jessica E et al. - Not a relevant study design
(2017) Modifying Provider Practice To Improve Assessment
of Unhealthy Weight and Lifestyle in Young Children: Review of electronic record data
Translating Evidence in a Quality Improvement Initiative for
At-Risk Children. Childhood obesity (Print) 13(3): 173-181

Campbell-Scherer, D., Heatherington, M., Klein, D. et al. - Conference abstract

(2017) The 5AsT-MD pilot: Improving education and training
in obesity management in family medicine residents. Obesity
Facts 10(supplement1): 146

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Chau, Sarah, Oldman, Samantha, Ali, Saba et al. (2021) - Comparator in study does not
Online behavioral screener with tailored obesity prevention match that specified in protocol
messages: Application to a pediatric clinical setting. Nutrients
13(1): 1-14 No control group used

Dam, Rinita, Robinson, Heather Anne, Vince-Cain, Sarah et - Not a relevant study design
al. (2019) Engaging parents using web-based feedback on
child growth to reduce childhood obesity: a mixed methods Descriptive data
study. BMC public health 19(1): 300

Davidson, Kamila, Vidgen, Helen, Denney-Wilson, Elizabeth - SR - checked

et al. (2018) How is children's weight status assessed for
early identification of overweight and obesity? - Narrative
review of programs for weight status assessment. Journal of
child health care : for professionals working with children in
the hospital and community 22(3): 486-500

Dennison, Barbara A, Nicholas, Joseph, de Long, Rachel et - Study does not contain a relevant
al. (2009) Randomized controlled trial of a mailed toolkit to intervention
increase use of body mass index percentiles to screen for
childhood obesity. Preventing chronic disease 6(4): a122 Toolkit for doctors to support them
measuring BMI in children versus
no toolkit

Fayter, Debra, Nixon, John, Hartley, Suzanne et al. (2007) A - Not a relevant study design
systematic review of the routine monitoring of growth in
children of primary school age to identify growth-related Diagnostic accuracy review
conditions. Health Technology Assessment 11(22)

Gee, Kevin A (2015) School-Based Body Mass Index - Not a relevant study design
Screening and Parental Notification in Late Adolescence:
Evidence From Arkansas's Act 1220. The Journal of Non-randomised trial
adolescent health : official publication of the Society for
Adolescent Medicine 57(3): 270-6

Gehring, Nicole D, Kebbe, Maryam, Rathwell, Sarah et al. - Not a relevant study design
(2021) Physician-related predictors of referral for
multidisciplinary paediatric obesity management: a retrospective, population-level
population-based study. Family practice 38(5): 576-581 cross-sectional study

Gentile, Natalie, Cristiani, Valeria, Lynch, Brian A et al. - Not a relevant study design
(2016) The effect of an automated point of care tool on
diagnosis and management of childhood obesity in primary retrospective record review
care. Journal of Evaluation in Clinical Practice 22(6): 958-964

Greenberg, Barbara L; Glick, Michael; Tavares, Mary (2017) - SR - checked

Addressing obesity in the dental setting: What can be learned
from oral health care professionals' efforts to screen for
medical conditions. Journal of public health dentistry
77suppl1: 67-s78

Guardi, Jodie N, Aquino, Elizabeth, Larimer, Karen et al. - Not a comparative study
(2020) Lack of Diagnosis and Screening for Pediatric Obesity
in the Retail Health Setting: Implications for Quality This was a retrospective chart
Improvement Measures. Journal of pediatric health care : review investigating the accuracy of
diagnosis of overweight and obesity
in Illinois, USA.

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official publication of National Association of Pediatric Nurse

Associates & Practitioners 34(3): 222-229

Henderson, E J, Ells, L J, Rubin, G P et al. (2015) Systematic - SR - checked

review of the use of data from national childhood obesity
surveillance programmes in primary care: a conceptual
synthesis. Obesity reviews : an official journal of the
International Association for the Study of Obesity 16(11):
962-71

Hillman, Jennifer B; Corathers, Sarah D; Wilson, Stephen E - Not a relevant study design
(2009) Pediatricians and screening for obesity with body
mass index: does level of training matter?. Public health a retrospective review of the
reports (Washington, D.C. : 1974) 124(4): 561-7 medical records

Hudson, Eibhlin; McGloin, Aileen; McConnon, Aine (2012) - Study does not contain a relevant
Parental weight (mis)perceptions: factors influencing parents' intervention
ability to correctly categorise their child's weight status.
Maternal and child health journal 16(9): 1801-9 Focus on parental perception of
weight status

Ikeda, Joanne P, Crawford, Patricia B, Woodward-Lopez, - Review article but not a

Gail et al. (2006) BMI screening in schools: Helpful or systematic review
harmful. Health Education Research 21(6): 761-769

Korhonen, Paivi E; Jarvenpaa, Salme; Kautiainen, Hannu - Not a relevant study design
(2014) Primary care-based, targeted screening programme to
promote sustained weight management. Scandinavian No suitable control group used
journal of primary health care 32(1): 30-6

Lewis, A., Jebb, S., Aveyard, P. et al. (2014) A randomised - Conference abstract
controlled trial to test the effectiveness of a brief intervention
for weight management in primary care. Obesity Reviews
15(suppl2): 148

Lewis, A.L., Aveyard, P., Jolly, K. et al. (2013) A randomised - Conference abstract
controlled trial to test the effectiveness of a brief intervention
for weight management for obese adults in primary care.
Obesity Facts 6(suppl1): 155

Logue, J., O'Donnell, J., Brooksbank, K. et al. (2019) An - Conference abstract

educational intervention to increase referrals of patients with
type 2 diabetes from primary care to weight management
(Small Talk Big Difference): Results of a randomised
controlled trial. Obesity Facts 12(supplement1): 171-172

Lydecker, Janet A and Grilo, Carlos M (2017) The missed - Not a relevant study design
diagnosis and misdiagnosis of pediatric obesity.
Psychotherapy and Psychosomatics 86(3): 173-174 retrospective medical record review

Madsen, Kristine A (2011) School-based body mass index - No relevent outcomes provided
screening and parent notification: a statewide natural
experiment. Archives of pediatrics & adolescent medicine Outcomes linked to BMI z Score
165(11): 987-92

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McGeown, Laura; Ball, Geoff D C; Mushquash, Aislin R - Not a relevant study design
(2021) Is There a Role for Self-Referral in Pediatric Weight
Management?. Childhood obesity (Print) 17(8): 559-562 retrospective medical record review

McLaughlin, Joanna C; Hamilton, Kathryn; Kipping, Ruth - Study does not contain a relevant
(2017) Epidemiology of adult overweight recording and intervention
management by UK GPs: a systematic review. The British
journal of general practice : the journal of the Royal College
of General Practitioners 67(663): e676-e683

Meriaux, Benita Gunnarsson; Hellstrom, Anna-Lena; Marild, - Study does not contain a relevant
Staffan (2008) Identification and follow-up of obesity in ten- intervention
year-old school children. International journal of pediatric
obesity : IJPO : an official journal of the International Interventions were for weight
Association for the Study of Obesity 3(2): 102-8 management. All participants were
screened/identified.

Nguyen, Nam Hoang, Kebbe, Maryam, Peng, Chenhui et al. - Not a relevant study design
(2020) Public health nurse referrals for paediatric weight
management: A nested mixed-methods study. Journal of Descriptive data
clinical nursing 29(1718): 3263-3271

O'Connor, Elizabeth A, Evans, Corinne V, Burda, Brittany U - SR - checked

et al. (2017) Screening for Obesity and Intervention for
Weight Management in Children and Adolescents: Evidence
Report and Systematic Review for the US Preventive
Services Task Force. JAMA 317(23): 2427-2444

O'Connor, Kaitlin Ann, Sahrmann, Julie Marie, Magie, - Not a relevant study design
Richard E et al. (2013) Examining body mass index in an
urban core population: from health screening to physician retrospective chart review.
visit. Clinical pediatrics 52(4): 315-21

O'Grady, Jason S; Thacher, Tom D; Chaudhry, Rajeev - Not a relevant study design
(2013) The effect of an automated clinical reminder on weight
loss in primary care. Journal of the American Board of Family Retrospective analysis of electronic
Medicine : JABFM 26(6): 745-50 medical records

Oetzel, Keri Bolton, Scott, Amy Anixter, McGrath, Jane et al. - Not a comparative study
(2009) School-based health centers and obesity prevention:
Changing practice through quality improvement. Pediatrics This study looked at outcomes
123(suppl): 267-271 linked to Envision New Mexico, a
quality improvement program
utilised at a number of school-
based health centers (SBHCs)

Patel, Anisha I, Madsen, Kristine A, Maselli, Judith H et al. - Not a relevant study design
(2010) Underdiagnosis of pediatric obesity during outpatient
preventive care visits. Academic pediatrics 10(6): 405-9 Survey

Perrin, Eliana M, Jacobson Vann, Julie C, Benjamin, John T - Not a relevant study design
et al. (2010) Use of a pediatrician toolkit to address parental
perception of children's weight status, nutrition, and activity pre-test, post-test study
behaviors. Academic pediatrics 10(4): 274-81

Pollak, Kathryn I, Tulsky, James A, Bravender, Terrill et al. - Study does not contain a relevant
(2016) Teaching primary care physicians the 5 A's for intervention

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discussing weight with overweight and obese adolescents.

Patient Education and Counseling 99(10): 1620-1625 The intervention is teaching primary
care physicians to better
communicate with overweight and
obese adolescents through utilising
a technique called the 5 A's. The
study outcomes are linked to their
future usage of the 5 A's when
speaking to overweight and obese
adolescents.

Queally, Michelle, Doherty, Edel, Matvienko-Sikar, Karen et - Study does not contain a relevant
al. (2018) Do mothers accurately identify their child's intervention
overweight/obesity status during early childhood? Evidence
from a nationally representative cohort study. The Focus on why parents mis-identify
international journal of behavioral nutrition and physical
activity 15(1): 56

Slomka, Juliette, McTigue, Kathleen, Hess, Rachel et al. - Conference abstract

(2011) To refer or not to refer obesity: Are primary care
physicians addressing the question?. Journal of General
Internal Medicine 26(suppl1): 132-s133

Smith, Sharon R., Johnson, Stephanie T., Oldman, - Not a relevant study design
Samantha M. et al. (2019) Pediatric Adapted Liking Survey: A
Novel, Feasible and Reliable Dietary Screening in Clinical Survey
Practice. Caries research 53(2): 153-159

Sturgiss, Elizabeth, Haesler, Emily, Elmitt, Nicholas et al. - Not a relevant study design
(2017) Increasing general practitioners' confidence and self-
efficacy in managing obesity: a mixed methods study. BMJ Survey
open 7(1): e014314

Vaughn, Lisa M, Nabors, Laura, Pelley, Terri J et al. (2012) - Not a relevant study design
Obesity screening in the pediatric emergency department.
Pediatric emergency care 28(6): 548-52 cross-sectional study

Villarosa, Amy R, George, David, Ramjan, Lucie M et al. - SR - checked

(2018) The role of dental practitioners in addressing
overweight and obesity among children: A scoping review of
current interventions and strategies. Obesity research &
clinical practice 12(5): 405-415

Viner, Russell M, Kinra, Sanjay, Christie, Deborah et al. - Not a comparative study
(2020) No title provided.
This is a wide-ranging report
covering overweight and obesity in
children and young people. The
relevant chapter for this review is a
uncontrolled pilot study of
Computer-Assisted Treatment of
CHildren tool (CATCH).

Wake, Melissa (2009) Issues in obesity monitoring, screening - Review article but not a
and subsequent treatment. Current opinion in pediatrics systematic review
21(6): 811-6

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Waring, Molly E, Roberts, Mary B, Parker, Donna R et al. - Study does not contain a relevant
(2009) Documentation and management of overweight and intervention
obesity in primary care. Journal of the American Board of
Family Medicine : JABFM 22(5): 544-52 No intervention tested

Wein, Lawrence M; Yang, Yan; Goldhaber-Fiebert, Jeremy D - Not a relevant study design
(2012) Assessing screening policies for childhood obesity.
Obesity (Silver Spring, Md.) 20(7): 1437-43 Modelling

Whitlock, Evelyn P, Williams, Selvi B, Gold, Rachel et al. - SR - checked

(2005) Screening and Interventions for Childhood
Overweight.

Wylie-Rosett, Judith, Velastegui, Lorena, Grullon, Rosalie et - Conference abstract

al. (2020) Patient recruitment: Insights from the goals for
eating and moving study (GEM); a clusterrct of a health
coaching technology-assisted weight-loss intervention in
primary care. Journal of General Internal Medicine
35(suppl1): 223-s224

Study Code [Reason]

Albury, Charlotte V. A, Ziebland, Sue, Webb, Helena et al. (2021) - Not a relevant study design
Discussing weight loss opportunistically and effectively in family
practice: A qualitative study of clinical interactions using Conversation analysis;
conversation analysis in UK family practice. Family Practice 38(3): observational
321-328

Andrade, Lesley, Moran, Kathy, Snelling, Susan J et al. (2020) - Children under 2 years old
Beyond BMI: a feasibility study implementing NutriSTEP in primary
care practices using electronic medical records (EMRs). Health Cannot separate data for 0-2
promotion and chronic disease prevention in Canada : research, and 2-5 year olds
policy and practice 40(1): 1-10

Arora, A., Rana, K., Manohar, N. et al. (2022) Perceptions and - Does not ask relevant
Practices of Oral Health Care Professionals in Preventing and questions
Managing Childhood Obesity. Nutrients 14(9): 1809
Focus on prevention and
promoting health generally

Asberg, M.; Derwig, M.; Castor, C. (2023) Parents' recalled - Does not ask relevant
experiences of the child centred health dialogue in children with questions
overweight: a qualitative study. BMC health services research
23(1): 289 Engaging children with an
existing diagnosis, not
identification

Asselin, Jodie D., Osunlana, Adedayo, Ogunleye, Ayodele et al. - Conference abstract
(2015) Hidden in plain sight: The embedded nature of obesity in
primary care visits. Canadian Journal of Diabetes 39(suppl1): 53

Bailey-Davis, Lisa, Pinto, Angela Marinilli, Hanna, David J et al. - Country not in the selected
(2022) Qualitative inquiry with primary care providers and range
specialists about adult weight management care and referrals.
Translational behavioral medicine 12(4): 576-584 USA

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Study Code [Reason]

Bailey-Davis, Lisa, Still, Christopher, Hanna, David et al. (2020) - Conference abstract
Provider perspectives on weight management referrals: A
qualitative analysis. Obesity 28(suppl2): 144-145

Berkson, Stephanie S, Espinola, Janice, Corso, Katherine A et al. - Does not contain qualitative
(2013) Reliability of height and weight measurements collected by data
physical education teachers for a school-based body mass index
surveillance and screening system. The Journal of school health
83(1): 21-7

Bradbury, Daisy, Chisholm, Anna, Watson, Paula M et al. (2018) - SR - checked

Barriers and facilitators to health care professionals discussing child
weight with parents: A meta-synthesis of qualitative studies. British
journal of health psychology 23(3): 701-722

Camp, Nadine L, Robert, Rebecca C, Nash, Jessica E et al. (2017) - Country not in the selected
Modifying Provider Practice To Improve Assessment of Unhealthy range
Weight and Lifestyle in Young Children: Translating Evidence in a
Quality Improvement Initiative for At-Risk Children. Childhood USA
obesity (Print) 13(3): 173-181

Clark, E; Tuthill, D; Hingston, E J (2018) Paediatric dentists' - Does not contain qualitative
identification and management of underweight and overweight data
children. British dental journal 225(7): 657-661

Clarke, J, Fletcher, B, Lancashire, E et al. (2013) The views of - SR - checked

stakeholders on the role of the primary school in preventing
childhood obesity: a qualitative systematic review. Obesity reviews :
an official journal of the International Association for the Study of
Obesity 14(12): 975-88

Clarke, Joanne L, Griffin, Tania L, Lancashire, Emma R et al. - Based on an ineligible

(2015) Parent and child perceptions of school-based obesity intervention
prevention in England: a qualitative study. BMC public health 15:
1224 Data was on a weight
management intervention

Croker, Helen; Lucas, Rebecca; Wardle, Jane (2012) Cluster- - Based on an ineligible
randomised trial to evaluate the 'Change for Life' mass media/ intervention
social marketing campaign in the UK. BMC Public Health 12(404)
Intervention for healthy
habits

Cyril, Sheila, Nicholson, Jan M, Agho, Kingsley et al. (2017) - Does not ask relevant
Barriers and facilitators to childhood obesity prevention among questions
culturally and linguistically diverse (CALD) communities in Victoria,
Australia. Australian and New Zealand journal of public health
41(3): 287-293

Cyril, Sheila, Polonsky, Michael, Green, Julie et al. (2017) - Does not ask relevant
Readiness of communities to engage with childhood obesity questions
prevention initiatives in disadvantaged areas of Victoria, Australia.
Australian health review : a publication of the Australian Hospital Focus on obesity at a
Association 41(3): 297-307 community level

Davidson, Kamila, Vidgen, Helen, Denney-Wilson, Elizabeth et al. - Does not ask relevant
(2019) Who is responsible for assessing children's weight status? - questions

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Study Code [Reason]

a qualitative study of health professionals in regional Australia.
BMC public health 19(1): 1196 Speculation rather than
experiences

Farman, R.; Fitzgerald, H.; Radley, D. (2019) Weight management - Conference abstract
provision in a special school: Experiences of disabled children and
their families. Obesity Facts 12(supplement1): 268

Gage, Heather, Erdal, Ebru, Saigal, Priyanka et al. (2012) - Does not contain qualitative
Recognition and management of overweight and obese children: A data
questionnaire survey of general practitioners and parents in
England. Journal of Paediatrics and Child Health 48(2): 146-152

Gillison F; Beck F; Lewitt J (2014) Exploring the basis for parents' - Questionnaire study not
negative reactions to being informed that their child is overweight. required
Public health nutrition 17(5): 987-997

Gray, Lesley; Chamberlain, Rachel; Morris, Caroline (2016) - Country not in the selected
"Basically you wait for an 'in''': community pharmacist views on their range
role in weight management in New Zealand. Journal of primary
health care 8(4): 365-371 New Zealand

Greenwood, Nicola and Lewis, Kiara (2015) Opportunistic health - Based on an ineligible
promotion among overweight children. Nursing children and young intervention
people 27(3): 16-20
Healthy lifestyle promotion

Gutin, Iliya (2022) Not 'putting a name to it': Managing uncertainty in - Country not in the selected
the diagnosis of childhood obesity. Social Science & Medicine 294 range

USA

Helseth, Solvi, Riiser, Kirsti, Holmberg Fagerlund, Bettina et al. - Themes are specific to a
(2017) Implementing guidelines for preventing, identifying and non-UK country
treating adolescent overweight and obesity-School nurses'
perceptions of the challenges involved. Journal of clinical nursing Implementing Norway's
26(2324): 4716-4725 national guidelines

Hersch, Derek E., Uy, Marc James A, Loth, Katie A. et al. (2021) - Country not in the selected
Primary care providers' perspectives on initiating childhood obesity range
conversations: a qualitative study. Family practice 38(4): 460-467
USA

Holden, M.A., Waterfield, J., Whittle, R. et al. (2018) A mixed - Conference abstract
methods exploration of how UK physical therapists address weight
loss among individuals with hip osteoarthritis. Osteoarthritis and
Cartilage 26(supplement1): 324

Isma, Gabriella E, Bramhagen, Ann-Cathrine, Ahlstrom, Gerd et al. - Children under 2 years old
(2013) Obstacles to the prevention of overweight and obesity in the
context of child health care in Sweden. BMC family practice 14: 143 Includes ages 0-6, cannot
separate the data for
different ages.

Jones, A. R, Parkinson, K. N, Drewett, R. F et al. (2011) Parental - Does not ask relevant
perceptions of weight status in children: The Gateshead Millennium questions
Study. International Journal of Obesity 35(7): 953-962
Focus on parental views on
weight

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Study Code [Reason]

Kass, Andrea E, Wang, Annie Z, Kolko, Rachel P et al. (2015) - Does not contain qualitative
Identification as overweight by medical professionals: relation to data
eating disorder diagnosis and risk. Eating behaviors 17: 62-8

Kim, Kyoung Kon, Yeong, Lin-Lee, Caterson, Ian D et al. (2015) - Does not ask relevant
Analysis of factors influencing general practitioners' decision to questions
refer obese patients in Australia: a qualitative study. BMC family
practice 16: 45 Focused on referrals to
surgery

Knafel, R.M., Coddington, J., Sorg, M. et al. (2023) Introduction of a - Not a relevant study design
conversation starter tool to improve health habits in young children.
Journal of pediatric nursing 68: 1-9 Quasi-experimental

Kubik, Martha Young, Story, Mary, Rieland, Gayle et al. (2007) - Country not in the selected
Developing school-based BMI screening and parent notification range
programs: Findings from focus groups with parents of elementary
school students. Health Education & Behavior 34(4): 622-633 USA

Leiter, L A, Astrup, A, Andrews, R C et al. (2015) Identification of - Does not contain qualitative
educational needs in the management of overweight and obesity: data
results of an international survey of attitudes and practice. Clinical
obesity 5(5): 245-55

Moir, Chris and Jones, Virginia (2019) Experience of nurses - Country not in the selected
measuring preschool body mass index for the Health target: Raising range
Healthy Kids. Journal of primary health care 11(3): 275-282
New Zealand

Nguyen, Nam Hoang, Kebbe, Maryam, Peng, Chenhui et al. (2020) - Themes are specific to a
Public health nurse referrals for paediatric weight management: A non-UK country
nested mixed-methods study. Journal of clinical nursing 29(1718):
3263-3271 Canadian referral pathways

O'Donnell, Jennifer E; Foskett-Tharby, Rachel; Gill, Paramjit S - Does not ask relevant
(2017) General practice views of managing childhood obesity in questions
primary care: a qualitative analysis. JRSM Open 8(6)
Focus on managing obesity

O'Shea, Brendan, Ladewig, Emma L, Kelly, Alan et al. (2014) - Does not contain qualitative
Weighing children; parents agree, but GPs conflicted. Archives of data
disease in childhood 99(6): 543-5

Po'e, Eli K, Gesell, Sabina B, Lynne Caples, T et al. (2010) - Country not in the selected
Pediatric obesity community programs: barriers & facilitators toward range
sustainability. Journal of community health 35(4): 348-54
USA

Redsell, Sarah A, Swift, Judy A, Nathan, Dilip et al. (2013) UK - Children under 2 years old
health visitors' role in identifying and intervening with infants at risk
of developing obesity. Maternal & child nutrition 9(3): 396-408

Royall, D., Brauer, P., Dwyer, J.J.M. et al. (2011) Eliciting provider - Conference abstract
and patient perspectives to develop an interdisciplinary obesity
management planning framework in primary care. Canadian
Journal of Diabetes 35(2): 172

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Study Code [Reason]

Schalkwijk, Annemarie A H, Nijpels, Giel, Bot, Sandra D M et al. - Themes are specific to a
(2016) Health care providers' perceived barriers to and need for the non-UK country
implementation of a national integrated health care standard on
childhood obesity in the Netherlands - a mixed methods approach. Implementing the
BMC health services research 16: 83 Netherlands' national
guidelines

Sela, Y.; Grinberg, K.; Nemet, D. (2022) Obstacles Preventing - Country not in the selected
Public Health Nurses from Discussing Children's Overweight and range
Obesity with Parents. Comprehensive child and adolescent nursing
45(4): 425-436 Israel

Smith, S.; Todd, A.; Summerbell, C.D. (2015) What is the impact of - Conference abstract
a community pharmacy-led weight management service for adults
in a deprived urban area in UK? A mixed methods service
evaluation. Obesity Facts 8(suppl1): 125

Steele, Ric G., Wu, Yelena P., Jensen, Chad D. et al. (2011) School - Country not in the selected
Nurses' Perceived Barriers to Discussing Weight With Children and range
Their Families: A Qualitative Approach. Journal of School Health
81(3): 128-137 USA

Sturgiss, Elizabeth, Haesler, Emily, Elmitt, Nicholas et al. (2017) - Based on an ineligible
Increasing general practitioners' confidence and self-efficacy in intervention
managing obesity: a mixed methods study. BMJ open 7(1):
e014314 Weight management
program delivered by GPs

Teixeira, F V; Pais-Ribeiro, J L; Maia, A (2015) A qualitative study - Country not in the selected
of GPs' views towards obesity: are they fighting or giving up?. range
Public health 129(3): 218-25
Portugal

Thorstensson, Stina, Blomgren, Carola, Sundler, Annelie J et al. - Does not ask relevant
(2018) To break the weight gain-A qualitative study on the questions
experience of school nurses working with overweight children in
elementary school. Journal of Clinical Nursing 27(12): e251-e258 Focused on weight
management

Torti, Jacqueline, Luig, Thea, Borowitz, Michelle et al. (2017) The - Does not ask relevant
5As team patient study: patient perspectives on the role of primary questions
care in obesity management. BMC family practice 18(1): 19
Focuses on management in
primary care

Traun, Benjamin D, Flood, Tracy L, Meinen, Amy et al. (2016) A - Country not in the selected
Qualitative Pilot Study of Pediatricians' Approach to Childhood range
Obesity. WMJ : official publication of the State Medical Society of
Wisconsin 115(3): 134-139 USA

Tucker, C.M., Roncoroni, J., Klein, K.G. et al. (2021) Views of Black - Country not in the selected
women patients with obesity on desired and undesired weight- range
focused clinical encounters. Clinical Obesity 11(5): e12468
USA

Viner, Russell M, Kinra, Sanjay, Christie, Deborah et al. (2020) No - Based on an ineligible
title provided. intervention

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Study Code [Reason]

Qualitative component is on
surgical interventions

Wake, Melissa, Campbell, Michele W, Turner, Megan et al. (2013) - Does not contain qualitative
How training affects Australian paediatricians' management of data
obesity. Archives of disease in childhood 98(1): 3-8

Warr, William, Aveyard, Paul, Albury, Charlotte et al. (2021) A - SR - checked

systematic review and thematic synthesis of qualitative studies
exploring GPs' and nurses' perspectives on discussing weight with
patients with overweight and obesity in primary care. Obesity
reviews : an official journal of the International Association for the
Study of Obesity 22(4): e13151

Waterfield, T., Johnston, J., Sweeney, E. et al. (2016) How should - Conference abstract
we approach obesity in the emergency department?. Archives of
Disease in Childhood 101(supplement1): a124

Weidmann, A.E., Marshall, S., Gray, G. et al. (2014) Can - Conference abstract
community pharmacy contribute to weight management? A
qualitative study of the perspectives of the pharmacy team.
International Journal of Pharmacy Practice 22(suppl1): 53

Wills, Wendy J and Lawton, Julia (2015) Attitudes to weight and - Does not ask relevant
weight management in the early teenage years: A qualitative study questions
of parental perceptions and views. Health Expectations: An
International Journal of Public Participation in Health Care & Health Focus on parental opinions
Policy 18(5): 775-783 on weight

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Appendix K – Research recommendations – full details

Research recommendation 1
What approaches are effective and acceptable in identifying overweight, obesity and central adiposity
in adults, children and young people from minority ethnic family backgrounds? [2023]

Why this is important

Review question 1.3 aimed to look particularly at people from black Asian and minority ethnic
family backgrounds, in both adults and children and young people, but the evidence in these
populations was minimal. The majority of the samples in the included evidence were people
from white European or white American family backgrounds, which cannot be directly applied
to other groups as there are established differences in the risks of developing obesity related
health problems. People from minority ethnic family backgrounds are at greater risk at lower
BMI status than white people, therefore direct evidence on this population is needed to make
appropriate recommendations without disadvantaging them.

Rationale for research recommendation

Importance to ‘patients’ or the Identifying overweight obesity and central adiposity appropriately
population for people from minority ethnic family backgrounds is an important
part of offering patient-centred care and reducing the health
inequalities experienced by people in these populations.
Relevance to NICE guidance The lack of evidence has resulted in this guidance being unable to
make strong evidence-based recommendations for this population.
Relevance to the NHS More specific evidence will enable identification to be done
appropriately for people from minority ethnic backgrounds. This
would enable intervention at the right time to reduce the chances of
developing obesity related health conditions. This in turn would
reduce costs and resource use for the NHS.
National priorities High
Current evidence base Minimal representation in mixed population studies. No studies of
people from minority ethnic family backgrounds specifically.
Equality considerations Important for the equitable treatment of people from minority ethnic
family backgrounds.

Modified PICO table

Population Children and young people
• Children and young people aged under 18 years
Where possible, evidence will be stratified by ethnicity:
o White
o Black African/ Caribbean
o Asian (South Asian, Chinese, any other Asian
background)
o Other ethnic groups (Arab, any other ethnic group)
o Multiple/mixed ethnic group

• Parents and carers

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• Staff undertaking identification of children and young people

with overweight or obesity and engaging them in weight
management services.

Adults
• Adults 18 years and over.
Where possible, evidence will be stratified by ethnicity:
o White
o Black African/ Caribbean
o Asian (South Asian, Chinese, any other Asian
background)
o Other ethnic groups (Arab, any other ethnic group)
o Multiple/mixed ethnic group

• Staff undertaking identification of adults with overweight or

obesity and engaging them in weight management services.

Intervention • Opportunistic identification, including but not confined to:

o When registering with GP
o When receiving consultation for health conditions (e.g.,
chronic health conditions)
o During routine check-up/ annual check-up (delivered by
GPs, nurses or pharmacists, social care staff)
o During medication check (e.g., contraception pill check)
o During vaccination appointments
o Visits to secondary care (e.g., outpatient clinics and
emergency departments or physiotherapist
appointments)

• Active case finding (defined as searching systematically for at

risk people, rather than waiting for them to present with
symptoms or signs of active disease). This includes but is not
confined to:
o Review of medical records
o Receiving or received interventions for example brief
physical activity advice (delivered by GPs, nurses,
pharmacists, activity providers)
o audits of other services (e.g. disability services or
endocrinology services)
• Self-identification or referral
• Parent/ carer-initiated identification or referral
• School nurse/ teacher / health visitor / social services-
initiated identification or referrals

Comparator • No intervention/usual care

• Comparison of interventions
Outcome Primary outcomes:
• Number of adults, children and young people identified as
overweight or obese
• Referral to weight management service

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• Health-related quality of life

Secondary outcomes:
• Adverse events:
o Eating disorders or disordered eating
o Stigma (including self-stigma and negative body image
as defined in studies)
Study design • RCTs
• Observational studies (cohort studies)
• Mixed methods studies
Timeframe Commensurate with existing literature
Additional information None

Research recommendation 2
What are the adverse effects of identifying children and young people as living with
overweight or obesity, particularly the risk of disordered eating and eating disorders?

Why this is important

Adverse outcomes are seldom reported in studies of identification of overweight and obesity
in children and young people. These outcomes, however, are of particular concern to parents
and carers of the children and young people who are identified. The committee agreed with
these concerns but felt that more information was needed before this consideration should
alter their recommendations. The risk of developing eating disorders was highlighted and
thus stated explicitly in the question, because young people are particularly vulnerable to
these during their adolescent years.

Rationale for research recommendation

Importance to ‘patients’ or the Qualitative evidence shows that the risk of eating disorders is a
population serious concern for parents and guardians of children with
overweight or obesity.
Relevance to NICE guidance Recommendations made in this guideline are premised on the
assumption of none or negligible harm to patients. It is important to
test this assumption.
Relevance to the NHS There is considerable pressure on children and young people’s
mental health services. Establishing the adverse impacts of
identifying overweight and obesity on mental health will beneficial in
preventing development of these outcomes and in turn the need for
referral to mental health services.
National priorities High
Current evidence base Little direct evidence
Equality considerations None known

Modified PICO table

Population • Children and young people aged under 18 years
• Parents and carers

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• Staff undertaking identification of children and young people

with overweight or obesity and engaging them in weight
management services.

Intervention • Opportunistic identification, including but not confined to:

o When registering with GP
o When receiving consultation for health conditions (e.g.,
chronic health conditions)
o During routine check-up/ annual check-up (delivered by
GPs, nurses or pharmacists, social care staff)
o During medication check (e.g., contraception pill check)
o During vaccination appointments
o Visits to secondary care (e.g., outpatient clinics and
emergency departments or physiotherapist
appointments)

• Active case finding (defined as searching systematically for at

risk people, rather than waiting for them to present with
symptoms or signs of active disease). This includes but is not
confined to:
o Review of medical records
o Receiving or received interventions for example brief
physical activity advice (delivered by GPs, nurses,
pharmacists, activity providers)
o audits of other services (e.g. disability services or
endocrinology services)
• Self-identification or referral
• Parent/ carer-initiated identification or referral
• School nurse/ teacher / health visitor / social services-
initiated identification or referrals

Comparator • No intervention/usual care

Outcome • Adverse events:
o Mental health (low mood, anxiety, etc.)
o Stigma (including self-stigma and negative body image
as defined in studies)
o Disordered eating behaviour (without formal diagnosis)
o Negative impact on quality of life
• Diagnosed eating disorders:
o Anorexia nervosa
o Bulimia
o Binge eating disorder (BED)
o Other specified feeding or eating disorder (OSFED)
o Avoidant/restrictive food intake disorder (ARFID)
Study design • RCTs
• Observational studies (cohort studies)
• Qualitative studies
• Mixed methods studies
Timeframe Short and/or long term

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Additional information None

Research recommendation 3
What is the effectiveness of children and young people using waist-to-height ratio to
measure their own central adiposity and what is the acceptability of this approach
among this population?

Why this is important

Recommendations for adults encouraged using waist-to-height ratio to measure their own
central adiposity, but there was insufficient evidence to recommend this for children and
young people in the same way. This approach to measuring central adiposity has many
benefits, so it is important to understand if it is effective and acceptable in this age group.

Rationale for research recommendation

Importance to ‘patients’ or the Waist to height ratio would be an easier and potentially less
population stigmatising way to identify overweight or obesity in children and
young people, and would allow them the agency to take these
measures themselves.
Relevance to NICE guidance The lack of evidence has resulted in this guidance being unable to
make a strong evidence-based recommendations on this for
children and young people.
Relevance to the NHS Children measuring their own central adiposity would enable them
to be active participants in their healthcare and assist with
identifying overweight and obesity at the right time to reduce the
chances of developing obesity related health conditions. This in
turn would reduce costs and resource use for the NHS.
National priorities High
Current evidence base No studies investigate this type of measurement
Equality considerations None

Modified PICO table

Population • Children and young people aged under 18 years
Where possible, evidence will be stratified by ethnicity:
o White
o Black African/ Caribbean
o Asian (South Asian, Chinese, any other Asian
background)
o Other ethnic groups (Arab, any other ethnic group)
o Multiple/mixed ethnic group

• Parents and carers

• Staff undertaking identification of children and young people
with overweight or obesity and engaging them in weight
management services.

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Intervention • Child’s self-measurement of waist-to-height ratio

Comparator • Standard BMI measurement
• Healthcare professional’s measurement of waist-to-height ratio
Outcome Primary outcomes:
• Accuracy of child’s measurements
• Number of children and young people identified as overweight
or obese
• Health-related quality of life

Secondary outcomes:
• Adverse events:
o Eating disorders or disordered eating
o Stigma (including self-stigma and negative body image
as defined in studies)

Qualitative outcomes:
• Perspectives, experiences, values, preferences, views, beliefs
and considerations about the acceptability of using waist-to-
height ratio
Study design • RCTs
• Observational studies (cohort studies)
• Mixed methods studies
• Qualitative studies
Timeframe Commensurate with existing literature
Additional information None

Research recommendation 4
How do beliefs and attitudes about weight in families and carers affect identification,
uptake and adherence to overweight and obesity management interventions in
adults, children and young people? [2023]

Why this is important

Beliefs and attitudes about weight were highlighted in the qualitative evidence as
important influences on how families and carers felt about their child being identified
as overweight or obese and referred to overweight and obesity management
services. This beliefs and attitudes stem from a range of cultures and backgrounds,

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and understanding how they affect identification and uptake of interventions is crucial
to effective interventions for these.

Rationale for research recommendation

Importance to ‘patients’ or Beliefs and attitudes are important to the people who hold them and
the population addressing them appropriately shapes their experiences of
healthcare.
Relevance to NICE guidance This guideline aims to improve identification uptake and adherence
to interventions, so understanding the beliefs and attitudes that
affect them is crucial to addressing these potential barriers.
Relevance to the NHS Increased uptake of overweight and obesity management
interventions could prevent children and young people from being
exposed to the health risks of weight related comorbidities
National priorities High
Current evidence base Some qualitative evidence has identified that these beliefs and
attitudes exist, but there is little detail available at present.
Equality considerations Some beliefs and attitudes may stem from cultural ideas originating
in communities from minority family backgrounds, therefore it is
important that these are treated sensitively and respectfully.

Modified PICO table

Population • Children and young people living with

overweight or obesity
• Adults living with overweight or obesity
Intervention n/a
Comparator n/a
Outcome Beliefs and attitudes about weight in families
and carers, including perspectives, experiences,
values, preferences, views and considerations
Study design Qualitative
Timeframe Any
Additional information None

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