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      Clinical practice guideline for the diagnosis and treatment of pediatric obesity: recommendations from the Committee on Pediatric Obesity of the Korean Society of Pediatric Gastroenterology Hepatology and Nutrition

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          Abstract

          The Committee on Pediatric Obesity of the Korean Society of Pediatric Gastroenterology, Hepatology and Nutrition newly developed the first Korean Guideline on the Diagnosis and Treatment of Obesity in Children and Adolescents to deliver an evidence-based systematic approach to childhood obesity in South Korea. The following areas were systematically reviewed, especially on the basis of all available references published in South Korea and worldwide, and new guidelines were established in each area with the strength of recommendations based on the levels of evidence: (1) definition and diagnosis of overweight and obesity in children and adolescents; (2) principles of treatment of pediatric obesity; (3) behavioral interventions for children and adolescents with obesity, including diet, exercise, lifestyle, and mental health; (4) pharmacotherapy; and (5) bariatric surgery.

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          2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society.

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            Interventions for preventing obesity in children.

            Prevention of childhood obesity is an international public health priority given the significant impact of obesity on acute and chronic diseases, general health, development and well-being. The international evidence base for strategies that governments, communities and families can implement to prevent obesity, and promote health, has been accumulating but remains unclear. This review primarily aims to update the previous Cochrane review of childhood obesity prevention research and determine the effectiveness of evaluated interventions intended to prevent obesity in children, assessed by change in Body Mass Index (BMI). Secondary aims were to examine the characteristics of the programs and strategies to answer the questions "What works for whom, why and for what cost?" The searches were re-run in CENTRAL, MEDLINE, EMBASE, PsychINFO and CINAHL in March 2010 and searched relevant websites. Non-English language papers were included and experts were contacted. The review includes data from childhood obesity prevention studies that used a controlled study design (with or without randomisation). Studies were included if they evaluated interventions, policies or programs in place for twelve weeks or more. If studies were randomised at a cluster level, 6 clusters were required. Two review authors independently extracted data and assessed the risk of bias of included studies.  Data was extracted on intervention implementation, cost, equity and outcomes. Outcome measures were grouped according to whether they measured adiposity, physical activity (PA)-related behaviours or diet-related behaviours.  Adverse outcomes were recorded. A meta-analysis was conducted using available BMI or standardised BMI (zBMI) score data with subgroup analysis by age group (0-5, 6-12, 13-18 years, corresponding to stages of developmental and childhood settings). This review includes 55 studies (an additional 36 studies found for this update). The majority of studies targeted children aged 6-12 years.  The meta-analysis included 37 studies of 27,946 children and demonstrated that programmes were effective at reducing adiposity, although not all individual interventions were effective, and there was a high level of observed heterogeneity (I(2)=82%).  Overall, children in the intervention group had a standardised mean difference in adiposity (measured as BMI or zBMI) of -0.15kg/m(2) (95% confidence interval (CI): -0.21 to -0.09).  Intervention effects by age subgroups were -0.26kg/m(2) (95% CI:-0.53 to 0.00) (0-5 years), -0.15kg/m(2) (95% CI -0.23 to -0.08) (6-12 years), and -0.09kg/m(2) (95% CI -0.20 to 0.03) (13-18 years). Heterogeneity was apparent in all three age groups and could not explained by randomisation status or the type, duration or setting of the intervention.  Only eight studies reported on adverse effects and no evidence of adverse outcomes such as unhealthy dieting practices, increased prevalence of underweight or body image sensitivities was found.  Interventions did not appear to increase health inequalities although this was examined in fewer studies. We found strong evidence to support beneficial effects of child obesity prevention programmes on BMI, particularly for programmes targeted to children aged six to 12 years. However, given the unexplained heterogeneity and the likelihood of small study bias, these findings must be interpreted cautiously. A broad range of programme components were used in these studies and whilst it is not possible to distinguish which of these components contributed most to the beneficial effects observed, our synthesis indicates the following to be promising policies and strategies:·         school curriculum that includes healthy eating, physical activity and body image·         increased sessions for physical activity and the development of fundamental movement skills throughout the school week·         improvements in nutritional quality of the food supply in schools·         environments and cultural practices that support children eating healthier foods and being active throughout each day·         support for teachers and other staff to implement health promotion strategies and activities (e.g. professional development, capacity building activities)·         parent support and home activities that encourage children to be more active, eat more nutritious foods and spend less time in screen based activitiesHowever, study and evaluation designs need to be strengthened, and reporting extended to capture process and implementation factors, outcomes in relation to measures of equity, longer term outcomes, potential harms and costs.Childhood obesity prevention research must now move towards identifying how effective intervention components can be embedded within health, education and care systems and achieve long term sustainable impacts.  
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              Systems for grading the quality of evidence and the strength of recommendations I: Critical appraisal of existing approaches The GRADE Working Group

              Background A number of approaches have been used to grade levels of evidence and the strength of recommendations. The use of many different approaches detracts from one of the main reasons for having explicit approaches: to concisely characterise and communicate this information so that it can easily be understood and thereby help people make well-informed decisions. Our objective was to critically appraise six prominent systems for grading levels of evidence and the strength of recommendations as a basis for agreeing on characteristics of a common, sensible approach to grading levels of evidence and the strength of recommendations. Methods Six prominent systems for grading levels of evidence and strength of recommendations were selected and someone familiar with each system prepared a description of each of these. Twelve assessors independently evaluated each system based on twelve criteria to assess the sensibility of the different approaches. Systems used by 51 organisations were compared with these six approaches. Results There was poor agreement about the sensibility of the six systems. Only one of the systems was suitable for all four types of questions we considered (effectiveness, harm, diagnosis and prognosis). None of the systems was considered usable for all of the target groups we considered (professionals, patients and policy makers). The raters found low reproducibility of judgements made using all six systems. Systems used by 51 organisations that sponsor clinical practice guidelines included a number of minor variations of the six systems that we critically appraised. Conclusions All of the currently used approaches to grading levels of evidence and the strength of recommendations have important shortcomings.
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                Author and article information

                Journal
                Korean J Pediatr
                Korean J Pediatr
                KJP
                Korean Journal of Pediatrics
                Korean Pediatric Society
                1738-1061
                2092-7258
                January 2019
                27 December 2018
                : 62
                : 1
                : 3-21
                Affiliations
                [1 ]Department of Pediatrics, Chung-Ang University College of Medicine, Chung-Ang University Hospital, Seoul, Korea
                [2 ]Department of Pediatrics, Chonbuk National University Medical School and Hospital, Jeonju, Korea
                [3 ]Department of Pediatrics, Chungbuk National University College of Medicine, Chungju, Korea
                [4 ]Department of Pediatrics, Eulji University School of Medicine, Nowon Eulji Medical Hospital, Seoul, Korea
                [5 ]Department of Pediatrics, Gyeongsang National University Changwon Hospital, Changwon, Korea
                [6 ]Department of Pediatrics, Hanyang University College of Medicine, Seoul, Korea
                [7 ]Department of Pediatrics, Jeju National University Hospital, Jeju, Korea
                [8 ]Department of Pediatrics, Kangwon National University School of Medicine, Chuncheon, Korea
                [9 ]Department of Pediatrics, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
                [10 ]Department of Pediatrics, Korea University College of Medicine, Seoul, Korea
                [11 ]Department of Pediatrics, School of Medicine, Kyungpook National University, Daegu, Korea
                [12 ]Department of Pediatrics, Pusan National University Children’s Hospital, Pusan National University School of Medicine, Yangsan, Korea
                [13 ]Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
                [14 ]Department of Pediatrics, Seoul National University Children’s Hospital, Seoul National University College of Medicine, Seoul, Korea
                [15 ]Department of Pediatrics, Yonsei University College of Medicine, Severance Children’s Hospital, Seoul, Korea
                [16 ]Department of Physical Education, College of Education, Chung-Ang University, Seoul, Korea
                [17 ]Department of Psychiatry, Jeju National University Hospital, Jeju, Korea
                [18 ]Department of Medical Nutrition, Kyung Hee University, Seoul, Korea
                [19 ]Department of Pediatrics, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
                Author notes
                Corresponding author: Hye Ran Yang, MD, PhD Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Seoul National University Bundang Hospital, 82 Gumiro 173beon-gil, Bundang-gu, Seongnam 13620, Korea Tel: +82-31-787-7285 Fax: +82-31-787-4054 E-mail: hryang@ 123456snubh.org / hrlamb2@ 123456snu.ac.kr
                Author information
                http://orcid.org/0000-0002-3423-6922
                Article
                kjp-2018-07360
                10.3345/kjp.2018.07360
                6351800
                30589999
                bbbe7d58-ab0f-4fdd-9893-a8b60b3c9146
                Copyright © 2019 by The Korean Pediatric Society

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 30 November 2018
                : 27 December 2018
                Categories
                Guideline
                Nutrition

                Pediatrics
                guideline,obesity,diagnosis,treatment,child
                Pediatrics
                guideline, obesity, diagnosis, treatment, child

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