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Table 3 Studies that applied the GRADE approach for rating PEN-relevant outcomes

From: Use of the GRADE approach in health policymaking and evaluation: a scoping review of nutrition and physical activity policies

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
  1. BMI body mass index, LDL low-density lipoprotein, NRSs non-randomized studies, RoB risk of bias, SSB sugar-sweetened beverages
  2. *If more outcomes have been graded, only the seven most important/relevant outcomes per study are presented in this table
  3. **Modified GRADE approach was used. NRSs did not start with “low quality of evidence” but with “high quality of evidence” if NRS study design was the most feasible/optimal one for the intervention