Table 3 Studies that applied the GRADE approach for rating PEN-relevant outcomes
Author | GRADE rating | Outcome | Reason for downgrading |
|---|---|---|---|
Al-Khudairy et al. [23] | ⊕⊕◯◯ Low | Change in BMI | Inconsistency, indirectness |
⊕⊕◯◯ Low | Adverse events | RoB, limited information | |
⊕⊕◯◯ Low | Health-related quality of life | RoB, inconsistency | |
Baker et al. [24] | ⊕⊕◯◯ Low | Physical activity in % (end of intervention to 6 years) and energy expenditure | Inconsistency, imprecision |
⊕⊕⊕⊕ High | Physical activity in % (end of intervention to 3 years, 4 months) | ||
⊕⊕⊕◯ Moderate | Physical activity, average daily minutes of moderate to vigorous (24 months) | Findings based on a single study | |
Balogun et al. [25] | ⊕⊕◯◯ Low | Initiation of breastfeeding | Inconsistency and RoB |
⊕◯◯◯ Very Low | Early initiation of breastfeeding | Inconsistency, RoB, wide CI | |
Crockett et al. [27] | ⊕◯◯◯ Very low | Food purchased from vending machines | Very serious RoB (2 levels), imprecision |
⊕◯◯◯ Very low | Food purchased from a grocery store | NRSs, RoB, indirectness | |
⊕◯◯◯ Very low | Potential harms (high-energy snack foods consumed with misleading low fat/energy labels in laboratory settings) | RoB, Inconsistency, indirectness | |
⊕⊕◯◯ Low | Food purchased in restaurants (labels on menus) | Very serious RoB (2 levels) | |
⊕⊕◯◯ Low | Food consumed in laboratory settings (labels on menus or labels placed on a range of food options) | Imprecision, indirectness | |
⊕⊕◯◯ Low | Food consumed in laboratory settings (single snack food or drink option) | RoB, indirectness | |
Cushing et al. [28] | ⊕⊕⊕◯ Moderate | Overall assessment, diet, physical activity, and smoking | Inconsistency or RoB |
Dobbins et al. [29] | ⊕⊕◯◯ Low | Television viewing, physical activity rates, physical activity duration, mean systolic/diastolic blood pressure, BMI | Inconsistency, imprecision (same reasons for each outcome) |
Elvsaas et al. [31] | ⊕⊕⊕◯ Moderate | BMI 6 months, BMI 12 months, BMI Z score 6 months and BMI Z score 12 months | Inconsistency (same reason for each outcome) |
⊕⊕◯◯ Low | BMI 24 months | Inconsistency, imprecision | |
⊕⊕⊕⊕ High | BMI Z score 24 months | ||
Freak-Poli et al. [34]* | Workplace pedometer programs vs. alternative physical activity program: | ||
⊕⊕◯◯ Low | Physical activity | RoB, imprecision | |
⊕⊕◯◯ Low | BMI | RoB, imprecision | |
⊕⊕◯◯ Low | Systolic blood pressure | RoB, imprecision | |
⊕⊕◯◯ Low | LDL cholesterol | RoB, imprecision | |
Workplace pedometer programs compared to no intervention: | |||
⊕◯◯◯ Very low | Physical activity | NRSs, RoB | |
⊕◯◯◯ Very low | BMI | RoB, imprecision, inconsistency | |
⊕⊕◯◯ Low | Systolic blood pressure | RoB, imprecision, inconsistency | |
Hodder et al. [37] | For all intervention types: | ||
⊕◯◯◯ Very low | Short-term impact (< 12 months) child vegetable intake | Inconsistency, RoB, imprecision | |
⊕◯◯◯ Very low | Short-term impact on cost-effectiveness and unintended adverse events | RoB, imprecision, publication bias (same reasons for each outcome) | |
Intervention: child nutrition education | |||
⊕⊕◯◯ Low | Short-term impact child vegetable intake | RoB, imprecision | |
Hollands et al. [38] | ⊕⊕⊕◯ Moderate | Consumption (in general, among adults and among children), selection without purchase (in general and among adults) | RoB (same reason for each outcome) |
⊕⊕◯◯ Low | Selection without purchase among children | RoB, imprecision | |
Langford et al. [39] | ⊕⊕⊕◯ Moderate | Obesity or overweight or body size | Inconsistency |
⊕⊕◯◯ Low | Nutrition | Inconsistency, RoB | |
⊕⊕⊕◯ Moderate | Body image or eating disorder | RoB | |
⊕⊕◯◯ Low | Physical activity, alcohol, substance use, sexual health | Inconsistency, RoB (same reasons for each outcome) | |
Martin et al. [41] | ⊕⊕⊕◯ Moderate | Effect of lifestyle interventions | RoB |
⊕⊕⊕◯ Moderate | Effect of physical activity/sedentary behavior interventions | RoB | |
⊕⊕⊕◯ Moderate | Effect of physical activity interventions | RoB | |
⊕⊕◯◯ Low | Effect of sedentary behavior interventions | Imprecision, RoB | |
McLaren et al. [43] | ⊕◯◯◯ Very low | Salt intake in grams per day (overall, men and women) | NRSs, inconsistency, RoB |
NICE (physical activity) [45]*,** | ⊕⊕◯◯ Low | Total physical activity as measured by total time spent in physical activity | NRSs**, RoB, imprecision |
⊕⊕◯◯ Low | Total sedentary time as measured by the total time spent sitting | NRSs**, RoB, imprecision | |
⊕◯◯◯ Very low | Changes to transport as measured by % of car drivers switching to public transport | NRSs**, RoB (2×), imprecision | |
⊕◯◯◯ Very low | Active travel as measured by the average time spent in active commuting | NRSs**, RoB (2×), imprecision | |
⊕◯◯◯ Very low | Physical activity in everyday life as measured by the average time spent in recreational walking and cycling | NRSs**, RoB (2×), imprecision | |
⊕⊕◯◯ Low | Changes to transport as measured by changes in proportion of journeys to work made by active travel (proximity) | NRSs**, RoB, indirectness | |
⊕◯◯◯ Very low | Public transport use (as a proxy of physical activity) as measured by bus use | NRSs**, RoB (2×), imprecision | |
Oakman et al. [46] | ⊕⊕⊕◯ Moderate | Effect of individually focused workplace interventions on work ability | RoB |
⊕◯◯◯ Very low | Effect of multilevel focused workplace interventions on work ability | RoB (2 levels), imprecision | |
Shrestha et al. [51]* | |||
⊕⊕◯◯ Low | Sit-stand desks without information | RoB, imprecision | |
⊕◯◯◯ Very low | Treadmill desk with counseling | Imprecision, RoB (2 levels) | |
⊕⊕◯◯ Low | Workplace policy changes (walking strategies) | RoB, imprecision | |
⊕⊕◯◯ Low | Workplace policy changes (short vs. long break) | Imprecision, RoB | |
⊕⊕◯◯ Low | Information, feedback, and counseling | Imprecision, RoB | |
⊕⊕◯◯ Low | Prompts combined with information | Imprecision, RoB | |
⊕◯◯◯ Very low | Multi-component intervention | Imprecision, RoB, inconsistency | |
Verweij et al. [54]* | ⊕⊕⊕◯ Moderate | Bodyweight (physical activity and diet, follow-up 6–18 months) | Inconsistency |
⊕⊕◯◯ Low | Bodyweight (phyical activity, follow-up 2––12 months) | RoB, imprecision | |
⊕⊕⊕◯ Moderate | BMI (physical activity and diet, follow-up 6–18 months) | RoB | |
⊕⊕◯◯ Low | BMI (physical activity, follow-up 2–12 months) | RoB imprecision | |
⊕⊕⊕◯ Moderate | Body fat (physical activity and diet, follow-up 6-9 months) | Imprecision | |
⊕⊕◯◯ Low | Waist circumference (physical activity and diet, follow-up 24 weeks to 1 year) | Inconsistency, imprecision | |
⊕◯◯◯ Very low | Waist–hip ratio (cm) (physical activity and diet; follow-up 3–18 months) | Only one study available | |
von Philipsborn et al. [49]* | ⊕⊕⊕◯ Moderate | Traffic-light labeling on SSB sales | NRSs, upgraded for magnitude of effect |
⊕◯◯◯ Very low | Improved access to drinking water in schools on SSB intake | RoB, NRSs, imprecision | |
⊕⊕⊕◯ Moderate | Price-increase on SSB sales | NRSs, upgraded for dose-response gradient and magnitude of effect | |
⊕◯◯◯ Very low | Voluntary food and beverage industry initiatives to improve the nutritional quality of the whole food supply on SSB sales | NRSs, RoB | |
⊕⊕◯◯ Low | Healthier default beverages in children’s menus in restaurants on SSB sales | NRS, upgraded for magnitude of effect, downgraded for RoB | |
⊕⊕⊕◯ Moderate | Government food benefit programs with incentives for buying fruit and vegetables and restrictions on the purchase of SSB | RoB | |
⊕⊕⊕◯ Moderate | Improved access to low-calorie beverages in the home environment on SSB intake | RoB | |
WHO (potassium) [56]* | |||
⊕◯◯◯ Very low | Cardiovascular disease | NRSs, imprecision | |
⊕⊕◯◯ Low | Stroke | NRSs | |
⊕◯◯◯ Very low | Coronary heart disease | NRSs, imprecision | |
⊕◯◯◯ Very low | All-cause mortality | Only one study, imprecision | |
⊕⊕⊕⊕ High | Resting systolic blood pressure | ||
⊕⊕⊕⊕ High | Total cholesterol | ||
⊕⊕⊕⊕ High | Plasma noradrenaline | ||
WHO (primary health-care) [55] | ⊕◯◯◯ Very low | BMI with dietary intervention (children aged 0–18 years) | NRSs, indirectness |
⊕◯◯◯ Very low | BMI with dietary and/or physical activity interventions (children aged 0–5 years) | NRSs, indirectness | |
⊕◯◯◯ Very low | BMI with physical activity interventions (children aged 0–18 years) | NRSs, indirectness | |
⊕◯◯◯ Very low | BMI with physical activity interventions (children aged 0–5 years) | NRSs, indirectness | |
⊕⊕◯◯ Low | BMI with specialist setting for treatment | Very serious indirectness | |
WHO (sodium) [57]* | |||
⊕◯◯◯ Very low | Cardiovascular disease (indicates increased risk with increased sodium intake) | NRSs, imprecision | |
⊕⊕⊕◯ Moderate | Cardiovascular disease (indicates decreased risk with decreased sodium intake) | Imprecision | |
⊕◯◯◯ Very low | Stroke | NRSs, inconsistency | |
⊕◯◯◯ Very low | Coronary heart disease | NRSs, imprecision | |
⊕◯◯◯ Very low | All-cause mortality | NRSs, inconsistency | |
⊕⊕⊕⊕ High | Resting systolic blood pressure | ||
⊕⊕⊕⊕ High | Total cholesterol | Not downgraded due to imprecision because follow-up did not cross threshold of relevance of benefit or harm | |
WHO (sugar intake) [58]* | Effect for reduction in free sugars in adults and children on: | ||
⊕⊕⊕◯ Moderate | Bodyweight (follow-up 10 weeks to 8 months) | RoB | |
⊕⊕⊕◯ Moderate | Dental caries (follow-up 10 weeks to 8 months) | NRSs, upgraded for large effect size | |
Effect of an increase in free sugars intake in adults: | |||
⊕⊕⊕◯ Moderate | Bodyweight (follow-up 2 weeks to 6 months) | Potential publication bias | |
⊕⊕⊕◯ Moderate | Dental caries (follow-up 1–8 years) | NRSs, upgraded for large effect size | |
Effect of a reduction in free sugars intake in children: | |||
⊕⊕⊕◯ Moderate | BMI (follow-up 16 to 52 weeks) | Inconsistency | |
⊕⊕⊕◯ Moderate | Dental caries (follow-up 1–8 years) | NRSs, upgraded for large effect size | |
Effect of an increase in free sugars intake in children: | |||
⊕⊕◯◯ Low | Overweight in children | NRSs |