HomeCirculationVol. 129, No. 25_suppl_22013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults Open AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplementary MaterialsOpen AccessResearch ArticlePDF/EPUB2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in AdultsA Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society Michael D. Jensen, MD, Donna H. Ryan, MD, Caroline M. Apovian, MD, FACP, Jamy D. Ard, MD, Anthony G. Comuzzie, PhD, Karen A. Donato, SM, Frank B. Hu, MD, PhD, FAHA, Van S. Hubbard, MD, PhD, John M. Jakicic, PhD, Robert F. Kushner, MD, Catherine M. Loria, PhD, FAHA, Barbara E. Millen, DrPH, RD, Cathy A. Nonas, MS, RD, F. Xavier Pi-Sunyer, MD, MPH, June Stevens, PhD, Victor J. Stevens, PhD, Thomas A. Wadden, PhD, Bruce M. Wolfe, MD and Susan Z. Yanovski, MD Michael D. JensenMichael D. Jensen , Donna H. RyanDonna H. Ryan , Caroline M. ApovianCaroline M. Apovian , Jamy D. ArdJamy D. Ard , Anthony G. ComuzzieAnthony G. Comuzzie , Karen A. DonatoKaren A. Donato , Frank B. HuFrank B. Hu , Van S. HubbardVan S. Hubbard , John M. JakicicJohn M. Jakicic , Robert F. KushnerRobert F. Kushner , Catherine M. LoriaCatherine M. Loria , Barbara E. MillenBarbara E. Millen , Cathy A. NonasCathy A. Nonas , F. Xavier Pi-SunyerF. Xavier Pi-Sunyer , June StevensJune Stevens , Victor J. StevensVictor J. Stevens , Thomas A. WaddenThomas A. Wadden , Bruce M. WolfeBruce M. Wolfe and Susan Z. YanovskiSusan Z. Yanovski Originally published12 Nov 2013https://doi.org/10.1161/01.cir.0000437739.71477.eeCirculation. 2014;129:S102–S138is corrected byCorrectionOther version(s) of this articleYou are viewing the most recent version of this article. Previous versions: January 1, 2013: Previous Version 1 Table of ContentsPreamble and Transition to ACC/AHA Guidelines to Reduce Cardiovascular Risk S1031. Introduction/Scope of Guideline S1041.1. Rationale for Updating Obesity Clinical Guidelines S1061.2. CQ-Based Approach S1071.3. Organization of the Panel S1071.4. Document Review and Approval S1082. Obesity Recommendations and Algorithm S1082.1. Summary of Evidence-Based Recommendations S1082.2. Chronic Disease Management Model for Primary Care of Patients With Overweight and Obesity—Treatment Algorithm S1083. CQs and Corresponding ESs S1103.1. CQ1: Statement of the Question S1173.1.1. Weight Loss and Risk of Diabetes S1173.1.2. Weight Loss and Impact on Cholesterol/Lipid Profile S1183.1.3. Weight Loss and Hypertension Risk S1183.2. CQ2: Statement of the Question S1183.2.1. Current BMI Cutpoints and CVD-Related Risk and All-Cause Mortality S1193.2.2. Areas of Insufficient Evidence With Regard to Cutpoints for BMI and for Waist Circumference S1193.3. CQ3: Statement of the Question S1203.3.1. Overall Dietary Intervention and Composition—Creating Reduced Dietary Energy Intake S1203.3.2. Overall Dietary Intervention and Composition—Pattern of Weight Loss Over Time With Dietary Intervention S1203.3.3. Low-Fat Approaches S1213.3.4. Higher-Protein Approaches (25% to 30% of Energy) S1213.3.5. Low-Carbohydrate Approaches (<30 g/d) S1213.3.6. Complex Versus Simple Carbohydrates S1213.3.7. Glycemic Load Dietary Approaches S1213.3.8. Dietary Patterns (Mediterranean Style, Vegetarian, and Other Dietary Pattern Approaches) S1213.3.9. Meal Replacement and Adding Foods to Liquid Diets S1213.3.10. Very–Low–Calorie Diet Approaches S1213.4. CQ4: Statement of the Question S1223.4.1. Description of the Diet, Physical Activity, and Behavior Therapy Components in High-Intensity, On-Site Lifestyle Interventions S1223.4.2. Comprehensive Interventions Compared With Usual Care, Minimal Care, or No-Treatment Control S1223.4.3. Efficacy/Effectiveness of Electronically Delivered, Comprehensive Interventions in Achieving Weight Loss S1233.4.4. Efficacy/Effectiveness of Comprehensive, Telephone-Delivered Lifestyle Interventions in Achieving Weight Loss S1233.4.5. Efficacy/Effectiveness of Comprehensive Weight Loss Programs in Patients Within a Primary Care Practice Setting Compared With Usual Care S1233.4.6. Efficacy/Effectiveness of Commercial-Based, Comprehensive Lifestyle Interventions in Achieving Weight Loss S1233.4.7. Efficacy/Effectiveness of Very–Low-Calorie Diets as Used as Part of a Comprehensive Lifestyle Intervention in Achieving Weight Loss S1233.4.8. Efficacy/Effectiveness of Comprehensive Lifestyle Interventions in Maintaining Lost Weight S1233.4.9. Characteristics of Lifestyle Intervention Delivery That May Affect Weight Loss: Intervention Intensity S1233.4.10. Characteristics of Lifestyle Intervention Delivery That May Affect Weight Loss or Weight Loss Maintenance: Individual Versus Group Treatment S1243.4.11. Characteristics of Lifestyle Intervention Delivery That May Affect Weight Loss or Weight Loss Maintenance: On-Site Versus Electronically Delivered Interventions S1243.5. CQ5: Statement of the Question S1243.5.1. Component 1: Efficacy S1253.5.2. Component 2: Predictors S1263.5.3. Component 3: Complications S1263.5.3.1. Laparoscopic Adjustable Gastric Banding S1263.5.3.2. Roux-En-Y Gastric Bypass S1263.5.3.3. Biliopancreatic Diversion S1263.5.3.4. Laparoscopic Sleeve Gastrectomy S1274. Gaps in Evidence and Future Research Needs S1274.1. CQ1 (Benefits of Weight Loss) S1274.2. CQ2 (Risks of Overweight and Obesity) S1274.3. CQ3 (Dietary Interventions for Weight Loss) S1274.4. CQ4 (Lifestyle Interventions for Weight Loss) S1274.5. CQ5 (Surgical Procedures for Weight Loss) S128References S128Appendix 1. Author Relationships With Industry and Other Entities (Relevant) S133Appendix 2. Expert Reviewer Relationships With Industry and Other Entities S137Appendix 3. Abbreviations S138Preamble and Transition to ACC/AHA Guidelines to Reduce Cardiovascular RiskThe goals of the American College of Cardiology (ACC) and the American Heart Association (AHA) are to prevent cardiovascular diseases (CVD); improve the management of people who have these diseases through professional education and research; and develop guidelines, standards, and policies that promote optimal patient care and cardiovascular health. Toward these objectives, the ACC and AHA have collaborated with the National Heart, Lung, and Blood Institute (NHLBI) and stakeholder and professional organizations to develop clinical practice guidelines for assessment of cardiovascular risk, lifestyle modifications to reduce cardiovascular risk, management of blood cholesterol in adults, and management of overweight and obesity in adults.In 2008, the NHLBI initiated these guidelines by sponsoring rigorous systematic evidence reviews for each topic by expert panels convened to develop critical questions (CQs), interpret the evidence, and craft recommendations. In response to the 2011 report from the Institute of Medicine on the development of trustworthy clinical guidelines,1 the NHLBI Advisory Council recommended that the NHLBI focus specifically on reviewing the highest-quality evidence and partner with other organizations to develop recommendations.2,3 Accordingly, in June 2013 the NHLBI initiated collaboration with the ACC and AHA to work with other organizations to complete and publish the 4 guidelines noted above and make them available to the widest possible constituency. Recognizing that the Expert Panels/Work Groups did not consider evidence beyond 2011 (except as specified in the methodology), the ACC, AHA, and collaborating societies plan to begin updating these guidelines starting in 2014.The joint ACC/AHA Task Force on Practice Guidelines (Task Force) appointed a subcommittee to shepherd this transition, communicate the rationale and expectations to the writing panels and partnering organizations, and expeditiously publish the documents. The ACC/AHA and partner organizations recruited a limited number of expert reviewers for fiduciary examination of content, recognizing that each document had undergone extensive peer review by representatives of the NHLBI Advisory Council, key federal agencies, and scientific experts. Each writing panel responded to comments from these reviewers. Clarifications were incorporated where appropriate, but there were no substantive changes because the bulk of the content was undisputed.Although the Task Force led the final development of these prevention guidelines, they differ from other ACC/AHA guidelines. First, as opposed to an extensive compendium of clinical information, these documents are significantly more limited in scope and focus on selected CQs on each topic based on the highest-quality evidence available. Recommendations were derived from randomized trials, meta-analyses, and observational studies evaluated for quality and were not formulated when sufficient evidence was not available. Second, the text accompanying each recommendation is succinct, summarizing the evidence for each question. The Full Panel/Work Group Reports include more detailed information about the evidence statements (ESs) that serve as the basis for recommendations. Third, the format of the recommendations differs from other ACC/AHA guidelines. Each recommendation has been mapped from the NHLBI grading format to the ACC/AHA Classification of Recommendation/Level of Evidence (COR/LOE) construct (Table 1) and is expressed in both formats. Because of the inherent differences in grading systems and the clinical questions driving the recommendations, alignment between the NHLBI and ACC/AHA formats is in some cases imperfect. Explanations of these variations are noted in the recommendation tables, where applicable.Table 1. Applying Classification of Recommendation and Level of EvidenceTable 1. Applying Classification of Recommendation and Level of EvidenceIn consultation with NHLBI, the policies adopted by the writing panels to manage relationships of authors with industry and other entities (RWI) are outlined in the methods section of each panel report. These policies were in effect when this effort began in 2008 and throughout the writing process and voting on recommendations, until the process was transferred to ACC/AHA in 2013. In the interest of transparency, the ACC/AHA requested that panel authors resubmit RWI disclosures as of July 2013. Relationships relevant to this guideline are disclosed in Appendix 1. None of the ACC/AHA expert reviewers had relevant RWI (Appendix 2). See Appendix 3 for a list of abbreviations used in this guideline.Systematic evidence reports and accompanying summary tables were developed by the expert panels and NHLBI. The guideline was reviewed by the ACC/AHA Task Force and approved by the ACC Board of Trustees, the AHA Science Advisory and Coordinating Committee, and The Obesity Society. In addition, ACC/AHA sought endorsement from other stakeholders, including professional organizations. It is the hope of the writing panels, stakeholders, professional organizations, NHLBI, and Task Force that the guidelines will garner the widest possible readership for the benefit of patients, providers, and the public health.These guidelines are meant to define practices that meet the needs of patients in most circumstances and are not a replacement for clinical judgment. The ultimate decision about care of a particular patient must be made by the healthcare provider and patient in light of the circumstances presented by that patient. As a result, situations might arise in which deviations from these guidelines may be appropriate. These considerations notwithstanding, in caring for most patients, clinicians can employ the recommendations confidently to reduce the risks of atherosclerotic CVD events.See Tables 2 and 3 for an explanation of the NHLBI recommendation grading methodology.Table 2. NHLBI Grading of the Strength of RecommendationsGradeStrength of Recommendation*AStrong recommendationThere is high certainty based on evidence that the net benefit† is substantial.BModerate recommendationThere is moderate certainty based on evidence that the net benefit is moderate to substantial, or there is high certainty that the net benefit is moderate.CWeak recommendationThere is at least moderate certainty based on evidence that there is a small net benefit.DRecommendation againstThere is at least moderate certainty based on evidence that there is no net benefit or that risks/harms outweigh benefits.EExpert opinion (“There is insufficient evidence or evidence is unclear or conflicting, but this is what the Work Group recommends.”)Net benefit is unclear. Balance of benefits and harms cannot be determined because of no evidence, insufficient evidence, unclear evidence, or conflicting evidence, but the Work Group thought it was important to provide clinical guidance and make a recommendation. Further research is recommended in this area.NNo recommendation for or against (“There is insufficient evidence or evidence is unclear or conflicting.”)Net benefit is unclear. Balance of benefits and harms cannot be determined because of no evidence, insufficient evidence, unclear evidence, or conflicting evidence, and the Work Group thought no recommendation should be made. Further research is recommended in this area.*In most cases, the strength of the recommendation should be closely aligned with the quality of the evidence; however, under some circumstances, there may be valid reasons for making recommendations that are not closely aligned with the quality of the evidence (eg, strong recommendation when the evidence quality is moderate, such as smoking cessation to reduce CVD risk or ordering an ECG as part of the initial diagnostic work-up for a patient presenting with possible MI). Those situations should be limited and the rationale explained clearly by the Work Group.†Net benefit is defined as benefits minus risks/harms of the service/intervention.CVD indicates cardiovascular disease; ECG, electrocardiogram; MI, myocardial infarction; and NHLBI, National Heart, Lung, and Blood Institute.Table 3. NHLBI Quality Rating of the Strength of EvidenceType of EvidenceQuality Rating*Well-designed, well-executed† RCT that adequately represent populations to which the results are applied and directly assess effects on health outcomes.Meta-analyses of such studies.Highly certain about the estimate of effect. Further research is unlikely to change our confidence in the estimate of effect.HighRCT with minor limitations‡ affecting confidence in, or applicability of, the results.Well-designed, well-executed nonrandomized controlled studies§ and well-designed, well-executed observational studies‖.Meta-analyses of such studies.Moderately certain about the estimate of effect. Further research may have an impact on our confidence in the estimate of effect and may change the estimate.ModerateRCT with major limitations.Nonrandomized controlled studies and observational studies with major limitations affecting confidence in, or applicability of, the results.Uncontrolled clinical observations without an appropriate comparison group (eg, case series, case reports).Physiological studies in humans.Meta-analyses of such studies.Low certainty about the estimate of effect. Further research is likely to have an impact on our confidence in the estimate of effect and is likely to change the estimate.Low*In some cases, other evidence, such as large all-or-none case series (eg, jumping from airplanes or tall structures), can represent high- or moderate-quality evidence. In such cases, the rationale for the evidence rating exception should be explained by the Work Group and clearly justified.†“Well-designed, well-executed” refers to studies that directly address the question; use adequate randomization, blinding, and allocation concealment; are adequately powered; use intention-to-treat analyses; and have high follow-up rates.‡Limitations include concerns with the design and execution of a study that result in decreased confidence in the true estimate of the effect. Examples of such limitations include but are not limited to: inadequate randomization, lack of blinding of study participants or outcome assessors, inadequate power, outcomes of interest that are not prespecified for the primary outcomes, low follow-up rates, and findings based on subgroup analyses. Whether the limitations are considered minor or major is based on the number and severity of flaws in design or execution. Rules for determining whether the limitations are considered minor or major and how they will affect rating of the individual studies will be developed collaboratively with the methodology team.§Nonrandomized controlled studies refer to intervention studies where assignment to intervention and comparison groups is not random (eg, quasi-experimental study design).‖Observational studies include prospective and retrospective cohort, case-control, and cross-sectional studies.NHLBI indicates National Heart, Lung, and Blood Institute; and RCT, randomized controlled trial.1. Introduction/Scope of GuidelineMore than 78 million adults in the United States were obese in 2009 and 2010.4 Obesity raises the risk of morbidity from hypertension, dyslipidemia, type 2 diabetes mellitus (diabetes), coronary heart disease (CHD), stroke, gallbladder disease, osteoarthritis, sleep apnea and respiratory problems, and some cancers. Obesity is also associated with increased risk of all-cause and CVD mortality. The biomedical, psychosocial, and economic consequences of obesity have substantial implications for the health and well-being of the US population.According to the 1998 “Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults—The Evidence Report,”5 overweight is defined as a body mass index (BMI) of 25 kg/m2 to 29.9 kg/m2 and obesity as a BMI of ≥30 kg/m2. Current estimates are that 69% of adults are either overweight or obese, with approximately 35% obese.6 These latest data from the National Health and Nutrition Examination Surveys indicate that for both men and women, obesity estimates for 2009 and 2010 did not differ significantly from estimates for 2003 to 2008 and that increases in the prevalence rates of obesity appear to be slowing down or leveling off.6 Nevertheless, overweight and obesity continue to be highly prevalent, especially in some racial and ethnic minority groups, as well as in those with lower incomes and less education. Overweight and obesity are major contributors to chronic diseases in the United States and present a major public health challenge. Compared with normal-weight individuals, obese patients incur 46% higher inpatient costs, 27% more physician visits and outpatient costs, and 80% higher spending on prescription drugs.7 The medical care costs of obesity in the United States are staggering. In 2008 dollars, these costs totaled about $147 billion.7The Expert Panel was first convened in September 2008 by the NHLBI in cooperation with the National Institute of Diabetes and Digestive and Kidney Diseases to update the 1998 Clinical Guidelines Report.5 The Expert Panel considered new evidence related to key issues on overweight and obesity evaluation and treatment, particularly in individuals with other risk factors for CVD and diabetes. The key issues identified included the appropriateness of the current BMI and waist circumference cutpoints that are used for determining risk in overweight and obese adults across diverse populations; the impact of weight loss on risk factors for CVD and type 2 diabetes, as well as CVD morbidity and mortality; optimal behavioral, dietary intervention, and other lifestyle treatment approaches for weight loss and weight loss maintenance; and benefits and risks of various bariatric surgical procedures. The Expert Panel’s ultimate goal was to systematically develop ESs and recommendations for 5 CQs to assist clinicians in primary care. The recommendations are based on evidence from a rigorous systematic review and synthesis of recently published medical literature.This guideline is based on the Full Panel Report, which is provided as an online-only data supplement to the guideline. The Full Panel Report contains background and additional material related to content, methodology, evidence synthesis, rationale, and references and is supported by the NHLBI Systematic Evidence Review, which can be found at http://www.nhlbi.nih.gov/guidelines/obesity/ser/. Refer to the “2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults,” “2013 AHA/ACC Guideline on Lifestyle Management to Reduce Cardiovascular Risk,” and “2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk”8–10 for topics outside the scope of the 2013 AHA/ACC/TOS Obesity Guideline.1.1. Rationale for Updating Obesity Clinical GuidelinesThe NHLBI, in cooperation with the National Institute of Diabetes and Digestive and Kidney Diseases, released the 1998 “Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults—The Evidence Report”11 as a systematic review of the published scientific literature found in MEDLINE from January 1980 to September 1997 on important topics reviewed by the Expert Panel. The published literature was evaluated to determine appropriate treatment strategies that would constitute evidence-based clinical guidelines on overweight and obesity. The San Antonio Cochrane Center assisted in literature abstraction and in organizing the data into evidence tables, and a methodology consultant worked with the Expert Panel to develop ESs and recommendations.In 2005, the NHLBI initiated the process to update the overweight/obesity guidelines and convened stakeholder groups to provide input on what should be the next-generation guideline development process. The resulting recommendations were used to design the process. To continually improve the quality and impact of the guidelines, the process was updated to assure rigor and minimize bias through the use of strict, evidence-based methodologies to guide the development of ESs and recommendations based on a systematic review of the biomedical literature for a specific period of time.1.2. CQ-Based ApproachThe Expert Panel began its deliberations by developing 23 possible CQs, and after considerable discussion, narrowed the possibilities to 5 targeted CQs. Questions were chosen to aid primary care practitioners (PCPs) and providers who frequently work with obese patients to identify patients at health risk of weight-related comorbidities and to update them on the benefits and risks of weight loss achieved by various approaches. Examples of CQs that were not included for this review included consideration of genetics of obesity, binge-eating disorders, pharmacotherapy, and cost-effectiveness of interventions to manage obesity. For each of the chosen CQs, Expert Panel members reviewed the final list of included and excluded articles, along with the quality ratings, and had the opportunity to raise questions and appeal the ratings to the methodology team. The team then reexamined these articles and presented their rationale for either keeping or changing the quality rating of the articles. Expert Panel members also played a key role in examining the evidence tables and summary tables to be certain the data from each article were accurately displayed.The body of the present report is organized by CQ and the following information is included for each CQ:The rationale for its selection is provided, and methods are described.The body of evidence is summarized, and ESs are presented, which include a rating for quality and a supportive narrative summary.Recommendations and their strength are accompanied by a narrative summary of how the recommendation was derived from the evidence and a discussion of issues considered by the Expert Panel in formulating the recommendation.CQ1 and CQ2 were chosen to help providers determine the appropriate criteria to guide a weight loss recommendation. CQ1 addresses the expected health benefits of weight loss as a function of the amount and duration of weight loss. CQ2 addresses the health risks of overweight and obesity and seeks to determine if the current waist circumference cutpoints and the widely accepted BMI cutpoints defining persons as overweight (BMI 25–29.9 kg/m2) and obese (BMI ≥30 kg/m2) are appropriate for population subgroups. Because patients are interested in popular diets that are promoted for weight loss and see the PCP as an authoritative source of information, CQ3 asks which dietary intervention strategies are effective for weight loss efforts. CQ4 seeks to determine the efficacy and effectiveness of a comprehensive lifestyle approach (diet, physical activity, and behavior therapy) to achieve and maintain weight loss. CQ5 seeks to determine the efficacy and safety of bariatric surgical procedures, including benefits and risks. CQ5 also seeks to determine patient and procedural factors that may help guide decisions to enhance the likelihood of maximum benefit from surgery for obesity and related conditions.1.3. Organization of the PanelIn 2007, the NHLBI sought nominations for panel membership that would ensure adequate representation of key specialties and appropriate expertise. The NHLBI staff reviewed the nominees and selected potential chairs and co-chairs for the panels. A Guidelines Executive Committee was formed, consisting of the chairs from each of the 3 panels (obesity, high blood pressure [BP], and high blood cholesterol) and 3 cross-cutting working groups (lifestyle, risk assessment, and implementation). This committee worked with the NHLBI to select panel members from the list of nominees.The Obesity Expert Panel comprised 15 members and 3 ex-officio members, including individuals with specific expertise in psychology, nutrition, physical activity, bariatric surgery, epidemiology, internal medicine, and other clinical specialties. The full Obesity Expert Panel met 23 times throughout the years (5 times face-to-face and 18 times via Webinar). Expert Panel chairs asked all members to disclose any conflicts of interest to the full Expert Panel in advance of the deliberations; members with conflicts were asked to recuse themselves from voting on any aspect of the guideline for which a conflict might exist. Each of the 5 CQs had working groups consisting of a leader and various Expert Panel members who met via conference calls to discuss all aspects of the CQ; to review the list of included and excluded articles along with the quality ratings; to review the evidence tables and summary tables; and to develop spreadsheets, ESs, resulting recommendations, and research/evidence gaps. Expert Panel members had the opportunity to raise questions about the included and excluded articles, submit additional articles that were not identified in the original search, appeal the quality ratings on articles, and question articles that were excluded. Each working group presented their findings to the full Expert Panel for all final decisions on ESs and recommendations, including the strength of the evidence.The evidence-based process followed most of the standards from the Institute of Medicine’s report, Clinical Practice Guidelines We Can Trust.1 The process had support from a methodology contractor and a systematic review and general support contractor and included the following steps:Constructed CQs relevant to clinical practice.Identified (a priori) inclusion/exclusion (I/E) criteria for each CQ.Developed a literature search strategy, based on I/E criteria, for each CQ.Executed a systematic electronic search of the published literature from relevant bibliographic databases for each CQ. The date range for the overall literature search was from January 1998 to December 2009. Because CQ1 and CQ2 used systematic reviews and meta-analyses, the literature search included those published from January 2000 to October 2011. CQ3 and CQ4 added major randomized controlled trials (RCTs) published after 2009 with >100 people per treatment arm. CQ5 added some major studies published after 2009 that met the I/E criteria.Screened, by 2 independent reviewers, thousands of abstracts and full-text articles returned from the search to identify relevant original articles, systematic reviews, and meta-analyses. Rigorous validation procedures were applied to ensure that the selected articles met the pre-established detailed I/E criteria before being included in the final review results.Determined, by 2 independent raters on the methodology team, the quality of each included study (good, fair, and poor).Abstracted relevant information from the included studies into an electronic central repository database using common templates and types of data elements.Constructed detailed evidence tables, which organized the data from the abstraction database.Analyzed the evidence tables and constructed summary tables, which display the evidence in a manageable format to answer specific parts of each CQ.Used summary tables to develop ESs for each CQ. The quality of evidence for each ES was graded as high, moderate, or low on the basis of scientific methodology, scientific strength, and consistency of results. For CQ1 and CQ2, spreadsheets with relevant data from systematic reviews and meta-analyses were developed rather than summary tables.Used the graded ESs to write clinical recommendations, and graded the strength of each recommendation. Recommendations were graded as Strong Recommendation (Grade A), Moderate Recommendation (Grade B), Weak Recommendation (Grade C), Recommendation Against (Grade D), Expert Opinion (Grade E), or No Recommendation For or Against (Grade N).Performed G
