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O'Connor EA, Evans CV, Henninger M, Redmond N, Senger CA. Interventions for Weight Management in Children and Adolescents: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 2024; 332:233-248. [PMID: 38888913 DOI: 10.1001/jama.2024.6739] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/20/2024]
Abstract
Importance Body mass index (BMI) of the 95th or greater percentile for age and sex is common among young people, and its prevalence has increased in recent decades. Objective To examine the benefits and harms of weight management interventions initiated in health care settings among children and adolescents with high BMI. Data Sources MEDLINE via Ovid, PsycINFO via Ovid, and the Cochrane Central Registry of Controlled Trials through January 12, 2023; ongoing surveillance through January 26, 2024. Study Selection English-language studies of weight management interventions (behavioral and pharmacologic, including liraglutide, semaglutide, orlistat, and phentermine/topiramate) among children aged 2 to 18 years with high BMI (eg, ≥85th or ≥95th percentile for age and sex) conducted in or recruited from health care settings. Data Extraction and Synthesis One investigator abstracted data; a second checked for accuracy. Outcomes with sufficient evidence for meta-analysis were pooled using random-effects models. Main Outcomes and Measures BMI and other weight-related outcomes, cardiometabolic measures, quality of life, physical activity, dietary pattern scores, and harms. Results Fifty-eight randomized clinical trials (RCTs) were included (N = 10 143). Behavioral interventions were associated with small reductions in BMI and other weight outcomes after 6 to 12 months (28 RCTs [n = 4494]; mean difference in change between groups, -0.7 [95% CI, -1.0 to -0.3]). Larger effects were seen in interventions with higher contact hours and that offered physical activity sessions. Reporting was sparse for outcomes other than BMI, with few significant findings. Semaglutide and phentermine/topiramate had the largest effects on BMI (eg, 1 RCT [n = 201] for semaglutide; mean difference, -6.0 [95% CI, -7.3 to -4.6]). The very few studies that evaluated outcomes after medication discontinuation showed immediate weight regain. Gastrointestinal adverse effects were common with liraglutide, semaglutide, and orlistat. Serious adverse effects were rare, but no studies had follow-up longer than 17 months. Conclusions and Relevance In the short term, weight management interventions led to lower BMI in children and adolescents, with no evidence of serious harm. Evidence is lacking about how weight management interventions affect BMI beyond 1 year and after medication discontinuation and about longer-term effects on other outcomes.
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Affiliation(s)
- Elizabeth A O'Connor
- Kaiser Permanente Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
| | - Corinne V Evans
- Kaiser Permanente Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
| | - Michelle Henninger
- Kaiser Permanente Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
| | - Nadia Redmond
- Kaiser Permanente Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
| | - Caitlyn A Senger
- Kaiser Permanente Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
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Bradley M, Melchor J, Carr R, Karjoo S. Obesity and malnutrition in children and adults: A clinical review. OBESITY PILLARS (ONLINE) 2023; 8:100087. [PMID: 38125660 PMCID: PMC10728708 DOI: 10.1016/j.obpill.2023.100087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 09/05/2023] [Accepted: 09/05/2023] [Indexed: 12/23/2023]
Abstract
Background In the U.S., children and adults are consuming more low-nutrient foods with added sugar and excess fats as compared to healthy, high-quality calories and micronutrients. This diet is increasing the prevalence of malnutrition and nutritional deficiencies, despite high calorie intake. This is a review of the common micronutrient deficiencies, the risk factors for malnutrition, dietary plans, and the health consequences in children and adults with obesity in the U.S. Methods This clinical review of literature was performed on the MEDLINE (PubMed) search engine. A total of 1391 articles were identified and after review, a total of 130 were found to be most pertinent. Discussion The most common micronutrient deficiencies found in patients with obesity were vitamin A, thiamine (B1), folate (B9), cobalamin (B12), vitamin D, iron, calcium, and magnesium, especially prior and after bariatric surgery. Diets that produced the most weight reduction also further puts these individuals at risk for worsening malnutrition. Malnutrition and micronutrient deficiencies can worsen health outcomes if not properly managed. Conclusion Adequate screening and awareness of malnutrition can improve the health outcomes in patients with obesity. Physiologic changes in response to increased adiposity and inadequate intake increase this population's risk of adverse health effects. Malnutrition affects the individual and contributes to worse public health outcomes. The recommendations for screening for malnutrition are not exclusive to individuals undergoing bariatric procedures and can improve the health outcomes of any patient with obesity. However, clearly, improved nutritional status can assist with metabolism and prevent adverse nutritional outcomes post-bariatric surgery. Clinicians should advise on proper nutrition and be aware of diets that worsen deficiencies.
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Affiliation(s)
- Morgan Bradley
- Florida State University College of Medicine, 1115 W Call St, Tallahassee, FL, 32304, USA
| | - Julian Melchor
- Florida State University College of Medicine, 1115 W Call St, Tallahassee, FL, 32304, USA
| | - Rachel Carr
- Florida State University College of Medicine, 1115 W Call St, Tallahassee, FL, 32304, USA
| | - Sara Karjoo
- Florida State University College of Medicine, 1115 W Call St, Tallahassee, FL, 32304, USA
- Johns Hopkins All Children's Hospital, 601 5th St. S. Suite 605, St. Petersburg, FL, 33701, USA
- University of South Florida Morsani College of Medicine, 560 Channelside Drive MDD 54, Tampa, FL, 33602, USA
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Strączek K, Horodnicka-Józwa A, Szmit-Domagalska J, Jackowski T, Safranow K, Petriczko E, Walczak M. Impact of One-Year Dietary Education on Change in Selected Anthropometric and Biochemical Parameters in Children with Excess Body Weight. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:11686. [PMID: 36141955 PMCID: PMC9517116 DOI: 10.3390/ijerph191811686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 09/08/2022] [Accepted: 09/12/2022] [Indexed: 06/16/2023]
Abstract
Obesity is regarded as a civilization disease that increases mortality and the risk of cardiovascular complications. In Poland, the prevalence of excess body weight in the paediatric population has been steadily increasing. The consequences of excess body weight in the developmental age population affect children's health and destabilize their development. Appropriate dietary interventions are the main non-invasive methods of preventing and treating obesity. They should be aimed at the whole family, optimally with the use of simple tools such as the Healthy Eating Pyramid. Due to the increasing prevalence of excess body weight in the developmental age population and the problems with the treatment of this condition, studies were undertaken in order to determine the impact of a dietary intervention on anthropometric and biochemical parameters in children with excess body weight. A total of 68 (72.3%) children completed the study. Based on BMI SDS, 59 (86.8%) were diagnosed with obesity and 9 (13.2%) with overweight. After the completion of the one-year dietary educational program, a significant improvement in weight loss, waist and hip circumference, as well as the value of the WHtR index was demonstrated. There was also a significant increase in the percentage of muscle tissue and a decrease in the content of adipose tissue in the bodies of examined children. A significant improvement in the parameters of carbohydrate metabolism, and almost all parameters of lipid metabolism, except for total cholesterol. A significant (by 28.0%) reduction in the incidence of fatty liver was also noted. No influence of dietary education on arterial blood pressure was observed.
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Affiliation(s)
- Kamilla Strączek
- Department of Pediatrics, Endocrinology, Diabetology, Metabolic Diseases and Cardiology of the Developmental Age, Pomeranian Medical University, 71-252 Szczecin, Poland
| | - Anita Horodnicka-Józwa
- Department of Pediatrics, Endocrinology, Diabetology, Metabolic Diseases and Cardiology of the Developmental Age, Pomeranian Medical University, 71-252 Szczecin, Poland
| | - Justyna Szmit-Domagalska
- Department of Pediatrics, Endocrinology, Diabetology, Metabolic Diseases and Cardiology of the Developmental Age, Pomeranian Medical University, 71-252 Szczecin, Poland
| | - Tomasz Jackowski
- Department of Pediatrics, Endocrinology, Diabetology, Metabolic Diseases and Cardiology of the Developmental Age, Pomeranian Medical University, 71-252 Szczecin, Poland
| | - Krzysztof Safranow
- Department of Biochemistry and Medical Chemistry, Pomeranian Medical University, 70-111 Szczecin, Poland
| | - Elżbieta Petriczko
- Department of Pediatrics, Endocrinology, Diabetology, Metabolic Diseases and Cardiology of the Developmental Age, Pomeranian Medical University, 71-252 Szczecin, Poland
| | - Mieczysław Walczak
- Department of Pediatrics, Endocrinology, Diabetology, Metabolic Diseases and Cardiology of the Developmental Age, Pomeranian Medical University, 71-252 Szczecin, Poland
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Jia SS, Liu Q, Allman-Farinelli M, Partridge SR, Pratten A, Yates L, Stevens M, McGill B. The Use of Portion Control Plates to Promote Healthy Eating and Diet-Related Outcomes: A Scoping Review. Nutrients 2022; 14:nu14040892. [PMID: 35215542 PMCID: PMC8874720 DOI: 10.3390/nu14040892] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 02/16/2022] [Accepted: 02/18/2022] [Indexed: 01/17/2023] Open
Abstract
The role of portion control plates in achieving healthy diets is unclear. The aim of this scoping review was to systematically map findings from peer reviewed and grey literature to provide evidence for the use of portion control plates to promote healthy eating and nutrition-related knowledge in children and adults. A secondary aim was to review the design characteristics of portion control plates. The search was conducted in four databases, including Medline, CINAHL, Embase, and PsycInfo, and grey literature sources following the PRISMA scoping review guidelines. A total of 22 articles comprising 23 intervention studies and 8 from grey literature were included. It was found that the various two-dimensional and three-dimensional portion control plates examined were effective tools for better portion size selection in healthy children and adults. Most portion control plates dedicated half the plate to vegetables, a quarter to protein, and a quarter to carbohydrates. The use of portion control plates in nutrition interventions appears to promote weight loss among those with overweight and obesity and/or type 2 diabetes. However, portion control plates were mostly used as part of multicomponent interventions and the effectiveness of the portion control plate as a stand-alone educational resource or portion control tool alone was uncertain. Further interventional research is indicated to investigate portion plates as tools to improve dietary behaviours and food consumption at the population level.
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Affiliation(s)
- Si Si Jia
- Engagement and Co-Design Research Hub, School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney 2006, Australia;
- Correspondence: ; Tel.: +61-2-8627-1697
| | - Qingzhou Liu
- Charles Perkins Centre, School of Life and Environmental Sciences, Faculty of Science, The University of Sydney, Sydney 2006, Australia;
| | - Margaret Allman-Farinelli
- Charles Perkins Centre, Sydney Nursing School, Faculty of Medicine and Health, The University of Sydney, Sydney 2006, Australia;
| | - Stephanie R. Partridge
- Engagement and Co-Design Research Hub, School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney 2006, Australia;
- Charles Perkins Centre, Sydney Nursing School, Faculty of Medicine and Health, The University of Sydney, Sydney 2006, Australia;
- Prevention Research Collaboration, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney 2006, Australia;
| | - Amy Pratten
- New South Wales Ministry of Health, Centre for Population Health, St Leonards, Sydney 2065, Australia; (A.P.); (L.Y.); (M.S.)
| | - Lisa Yates
- New South Wales Ministry of Health, Centre for Population Health, St Leonards, Sydney 2065, Australia; (A.P.); (L.Y.); (M.S.)
| | - Matthew Stevens
- New South Wales Ministry of Health, Centre for Population Health, St Leonards, Sydney 2065, Australia; (A.P.); (L.Y.); (M.S.)
| | - Bronwyn McGill
- Prevention Research Collaboration, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney 2006, Australia;
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Vargas-Alvarez MA, Navas-Carretero S, Palla L, Martínez JA, Almiron-Roig E. Impact of Portion Control Tools on Portion Size Awareness, Choice and Intake: Systematic Review and Meta-Analysis. Nutrients 2021; 13:nu13061978. [PMID: 34207492 PMCID: PMC8229078 DOI: 10.3390/nu13061978] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 05/12/2021] [Accepted: 05/15/2021] [Indexed: 02/04/2023] Open
Abstract
Portion control utensils and reduced size tableware amongst other tools, have the potential to guide portion size intake but their effectiveness remains controversial. This review evaluated the breadth and effectiveness of existing portion control tools on learning/awareness of appropriate portion sizes (PS), PS choice, and PS consumption. Additional outcomes were energy intake and weight loss. Published records between 2006–2020 (n = 1241) were identified from PubMed and WoS, and 36 publications comparing the impact of portion control tools on awareness (n = 7 studies), selection/choice (n = 14), intake plus related measures (n = 21) and weight status (n = 9) were analyzed. Non-tableware tools included cooking utensils, educational aids and computerized applications. Tableware included mostly reduced-size and portion control/calibrated crockery/cutlery. Overall, 55% of studies reported a significant impact of using a tool (typically smaller bowl, fork or glass; or calibrated plate). A meta-analysis of 28 articles confirmed an overall effect of tool on food intake (d = –0.22; 95%CI: –0.38, –0.06; 21 comparisons), mostly driven by combinations of reduced-size bowls and spoons decreasing serving sizes (d = –0.48; 95%CI: –0.72, –0.24; 8 comparisons) and consumed amounts/energy (d = –0.22; 95%CI: –0.39, –0.05, 9 comparisons), but not by reduced-size plates (d = –0.03; 95%CI: –0.12, 0.06, 7 comparisons). Portion control tools marginally induced weight loss (d = –0.20; 95%CI: –0.37, –0.03; 9 comparisons), especially driven by calibrated tableware. No impact was detected on PS awareness; however, few studies quantified this outcome. Specific portion control tools may be helpful as potentially effective instruments for inclusion as part of weight loss interventions. Reduced size plates per se may not be as effective as previously suggested.
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Affiliation(s)
- M. Angeles Vargas-Alvarez
- Center for Nutrition Research, University of Navarra, 31008 Pamplona, Spain; (M.A.V.-A.); (S.N.-C.)
- Department of Nutrition, Food Science and Physiology, Faculty of Pharmacy and Nutrition, University of Navarra, 31008 Pamplona, Spain;
| | - Santiago Navas-Carretero
- Center for Nutrition Research, University of Navarra, 31008 Pamplona, Spain; (M.A.V.-A.); (S.N.-C.)
- Department of Nutrition, Food Science and Physiology, Faculty of Pharmacy and Nutrition, University of Navarra, 31008 Pamplona, Spain;
- Navarra Institute for Health Research (IdiSNa), 31008 Pamplona, Spain
- CIBERobn, Obesity and Nutrition, Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Luigi Palla
- Department of Public Health and Infectious Diseases, University of Rome La Sapienza, 00185 Rome, Italy;
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | - J. Alfredo Martínez
- Department of Nutrition, Food Science and Physiology, Faculty of Pharmacy and Nutrition, University of Navarra, 31008 Pamplona, Spain;
- CIBERobn, Obesity and Nutrition, Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Eva Almiron-Roig
- Center for Nutrition Research, University of Navarra, 31008 Pamplona, Spain; (M.A.V.-A.); (S.N.-C.)
- Department of Nutrition, Food Science and Physiology, Faculty of Pharmacy and Nutrition, University of Navarra, 31008 Pamplona, Spain;
- Navarra Institute for Health Research (IdiSNa), 31008 Pamplona, Spain
- Correspondence: ; Tel.: +34-948-425-600
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Mead E, Brown T, Rees K, Azevedo LB, Whittaker V, Jones D, Olajide J, Mainardi GM, Corpeleijn E, O'Malley C, Beardsmore E, Al‐Khudairy L, Baur L, Metzendorf M, Demaio A, Ells LJ. Diet, physical activity and behavioural interventions for the treatment of overweight or obese children from the age of 6 to 11 years. Cochrane Database Syst Rev 2017; 6:CD012651. [PMID: 28639319 PMCID: PMC6481885 DOI: 10.1002/14651858.cd012651] [Citation(s) in RCA: 215] [Impact Index Per Article: 30.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Child and adolescent overweight and obesity has increased globally, and can be associated with significant short- and long-term health consequences. This is an update of a Cochrane review published first in 2003, and updated previously in 2009. However, the update has now been split into six reviews addressing different childhood obesity treatments at different ages. OBJECTIVES To assess the effects of diet, physical activity and behavioural interventions (behaviour-changing interventions) for the treatment of overweight or obese children aged 6 to 11 years. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, LILACS as well as trial registers ClinicalTrials.gov and ICTRP Search Portal. We checked references of studies and systematic reviews. We did not apply any language restrictions. The date of the last search was July 2016 for all databases. SELECTION CRITERIA We selected randomised controlled trials (RCTs) of diet, physical activity, and behavioural interventions (behaviour-changing interventions) for treating overweight or obese children aged 6 to 11 years, with a minimum of six months' follow-up. We excluded interventions that specifically dealt with the treatment of eating disorders or type 2 diabetes, or included participants with a secondary or syndromic cause of obesity. DATA COLLECTION AND ANALYSIS Two review authors independently screened references, extracted data, assessed risk of bias, and evaluated the quality of the evidence using the GRADE instrument. We contacted study authors for additional information. We carried out meta-analyses according to the statistical guidelines in the Cochrane Handbook for Systematic Reviews of Interventions. MAIN RESULTS We included 70 RCTs with a total of 8461 participants randomised to either the intervention or control groups. The number of participants per trial ranged from 16 to 686. Fifty-five trials compared a behaviour-changing intervention with no treatment/usual care control and 15 evaluated the effectiveness of adding an additional component to a behaviour-changing intervention. Sixty-four trials were parallel RCTs, and four were cluster RCTs. Sixty-four trials were multicomponent, two were diet only and four were physical activity only interventions. Ten trials had more than two arms. The overall quality of the evidence was low or very low and 62 trials had a high risk of bias for at least one criterion. Total duration of trials ranged from six months to three years. The median age of participants was 10 years old and the median BMI z score was 2.2.Primary analyses demonstrated that behaviour-changing interventions compared to no treatment/usual care control at longest follow-up reduced BMI, BMI z score and weight. Mean difference (MD) in BMI was -0.53 kg/m2 (95% confidence interval (CI) -0.82 to -0.24); P < 0.00001; 24 trials; 2785 participants; low-quality evidence. MD in BMI z score was -0.06 units (95% CI -0.10 to -0.02); P = 0.001; 37 trials; 4019 participants; low-quality evidence and MD in weight was -1.45 kg (95% CI -1.88 to -1.02); P < 0.00001; 17 trials; 1774 participants; low-quality evidence.Thirty-one trials reported on serious adverse events, with 29 trials reporting zero occurrences RR 0.57 (95% CI 0.17 to 1.93); P = 0.37; 4/2105 participants in the behaviour-changing intervention groups compared with 7/1991 participants in the comparator groups). Few trials reported health-related quality of life or behaviour change outcomes, and none of the analyses demonstrated a substantial difference in these outcomes between intervention and control. In two trials reporting on minutes per day of TV viewing, a small reduction of 6.6 minutes per day (95% CI -12.88 to -0.31), P = 0.04; 2 trials; 55 participants) was found in favour of the intervention. No trials reported on all-cause mortality, morbidity or socioeconomic effects, and few trials reported on participant views; none of which could be meta-analysed.As the meta-analyses revealed substantial heterogeneity, we conducted subgroup analyses to examine the impact of type of comparator, type of intervention, risk of attrition bias, setting, duration of post-intervention follow-up period, parental involvement and baseline BMI z score. No subgroup effects were shown for any of the subgroups on any of the outcomes. Some data indicated that a reduction in BMI immediately post-intervention was no longer evident at follow-up at less than six months, which has to be investigated in further trials. AUTHORS' CONCLUSIONS Multi-component behaviour-changing interventions that incorporate diet, physical activity and behaviour change may be beneficial in achieving small, short-term reductions in BMI, BMI z score and weight in children aged 6 to 11 years. The evidence suggests a very low occurrence of adverse events. The quality of the evidence was low or very low. The heterogeneity observed across all outcomes was not explained by subgrouping. Further research is required of behaviour-changing interventions in lower income countries and in children from different ethnic groups; also on the impact of behaviour-changing interventions on health-related quality of life and comorbidities. The sustainability of reduction in BMI/BMI z score and weight is a key consideration and there is a need for longer-term follow-up and further research on the most appropriate forms of post-intervention maintenance in order to ensure intervention benefits are sustained over the longer term.
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Affiliation(s)
- Emma Mead
- Teesside UniversityHealth and Social Care InstituteMiddlesbroughUKTS1 3BA
| | - Tamara Brown
- Teesside UniversityHealth and Social Care InstituteMiddlesbroughUKTS1 3BA
- Durham University Queen's CampusSchool of Medicine, Pharmacy and HealthDurhamUKTS17 6BH
| | - Karen Rees
- Warwick Medical School, University of WarwickDivision of Health SciencesCoventryUKCV4 7AL
| | - Liane B Azevedo
- Teesside UniversityHealth and Social Care InstituteMiddlesbroughUKTS1 3BA
| | - Victoria Whittaker
- Teesside UniversityHealth and Social Care InstituteMiddlesbroughUKTS1 3BA
| | - Dan Jones
- Teesside UniversityHealth and Social Care InstituteMiddlesbroughUKTS1 3BA
| | - Joan Olajide
- Teesside UniversityHealth and Social Care InstituteMiddlesbroughUKTS1 3BA
| | - Giulia M Mainardi
- School of Medicine, University of São PauloDepartment of Preventive MedicineSão PauloBrazilCEP 01246 903
| | - Eva Corpeleijn
- University Medical Centre GroningenDepartment of EpidemiologyHanzeplein 1GroningenNetherlands9713 GZ
| | - Claire O'Malley
- Durham University Queen's CampusSchool of Medicine, Pharmacy and HealthDurhamUKTS17 6BH
| | | | - Lena Al‐Khudairy
- Warwick Medical School, University of WarwickDivision of Health SciencesCoventryUKCV4 7AL
| | - Louise Baur
- The University of SydneyDepartment of Paediatrics and Child HealthLocked Bag 4001WestmeadAustraliaNSW 2145
| | - Maria‐Inti Metzendorf
- Institute of General Practice, Medical Faculty of the Heinrich‐Heine‐University DüsseldorfCochrane Metabolic and Endocrine Disorders GroupMoorenstr. 5DüsseldorfGermany40225
| | | | - Louisa J Ells
- Teesside UniversityHealth and Social Care InstituteMiddlesbroughUKTS1 3BA
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