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Chronic Disease
Program Planning:
Discussing Review-
Level Evidence
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What’s the evidence?
 Booth, M., O’Brodovich, H., Finegood, D. (2004). Addressing
childhood obesity: The evidence for action. Ottawa, ON: Canadian
Institutes of Health Research, Institute of Nutrition, Metabolism
and Diabetes.
 Shiell, A., Spilchak, P., Ladhani, N., Hawe, P., Lorenzetti, D. (2008).
A systematic review of population health approaches to prevent type II
diabetes: Report to the Public Health Agency of Canada. Calgary, AB:
Population Health Intervention Research Centre (PHIRC).
 O’Brien, K., Nixon, S., Tynan, A.M., Glazier, R.H. (2010). Aerobic
exercise interventions for adults living with HIV/AIDS. Cochrane
Database of Systematic Reviews, Issue 8, Art. No.: CD001796.
 Farmer, A.P., Legare, F., Grimshaw, J., Harvey, E., McGowan, J.L.,
et al. (2008). Printed educational materials: Effects on professional
practice and health care outcomes. Cochrane Database of Systematic
Reviews, Issue 3, Art. No.: CD004398.

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This webinar has been made possible with support from the
Canadian Institutes of Health Research
Welcome!
Chronic Disease
Program Planning:
Discussing Review-
Level Evidence
You will be placed on hold until the webinar begins.
The webinar will begin shortly, please remain on the line.

The Health Evidence Team
Maureen Dobbins Kara DeCorby Daiva Tirilis
Scientific Director Administrative Director Research Coordinator
Tel: 905 525-9140 ext 22481 Tel: (905) 525-9140 ext. 20461 Tel: (905) 525-9140 ext. 20460
E-mail: dobbinsm@mcmaster.ca E-mail: kdecorby@health-evidence.ca E-mail: dtirilis@health-evidence.ca
Lori Greco Heather Husson Robyn Traynor Lyndsey McRae
Knowledge Broker Project Manager Research Coordinator Research Assistant

What is www.health-evidence.ca?
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inform
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1. Saves you time
2. Relevant & current evidence
3. Transparent process
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Meetings, Planning &
Dissemination Project
CIHR Funded MOP-238541

CIHR-Funded Reviews
 Booth, M., O’Brodovich, H., Finegood, D. (2004). Addressing
childhood obesity: The evidence for action. Ottawa, ON: Canadian
Institutes of Health Research, Institute of Nutrition, Metabolism
and Diabetes.
 Shiell, A., Spilchak, P., Ladhani, N., Hawe, P., Lorenzetti, D. (2008).
A systematic review of population health approaches to prevent type II
diabetes: Report to the Public Health Agency of Canada. Calgary, AB:
Population Health Intervention Research Centre (PHIRC).
 O’Brien, K., Nixon, S., Tynan, A.M., Glazier, R.H. (2010). Aerobic
exercise interventions for adults living with HIV/AIDS. Cochrane
Database of Systematic Reviews, Issue 8, Art. No.: CD001796.
 Farmer, A.P., Legare, F., Grimshaw, J., Harvey, E., McGowan, J.L.,
et al. (2008). Printed educational materials: Effects on professional
practice and health care outcomes. Cochrane Database of Systematic
Reviews, Issue 3, Art. No.: CD004398.

Evaluation
Please check your email for the evaluation
survey link after the webinar.
It take 5 minutes to complete!
If you’ve been watching with someone else and did
not personally register for the webinar, please
e-mail Jennifer McGugan at mcgugj@mcmaster.ca
to be sent the survey.

Questions?

Summary Statement:
Booth (2004)

Overall Considerations
Considerations for Public Health Practice
Conclusions from Health Evidence General Implications
Interventions that showed improvement in Public health should support:
obesity outcomes promoted: • programs that focus on diet + exercise
• consumption of a healthier diet plus • physical activity behavior change and dietary
exercise (vs. diet only) change interventions for school children
• increased physical activity in and out-of- • behavior modification with both diet and
school physical activity strategies
• healthier diet among school-aged children
• behaviour modification strategies alongside Due to a current lack of evidence, public health
strategies to improve diet and physical programs should not include:
activity • a focus on specific elements of dietary
interventions
Evidence is not conclusive enough to support: • dietary interventions for pre-school aged
• dietary interventions children or minorities
• dietary change interventions for preschool- • reinforcement after obesity treatment
aged children or minorities • a focus on modifying factors including age,
• reinforcement after obesity treatment setting, duration, or initial weight, as a way
• modifying factors (age, duration, etc.) to modify obesity outcomes

Overall Considerations
Considerations for Public Health Practice
Conclusions from Health Evidence General Implications
No impact on obesity outcomes were Due to a lack of effectiveness, public health
observed for interventions on: should also avoid focus on:
• dietary change • cardiovascular risk factor interventions to
• cardiovascular risk factor reduction modify obesity outcomes
• primary prevention programs for obesity • primary prevention programs for obesity
• lifestyle exercise strategies • lifestyle exercise programs
• parental involvement
No current evidence to inform how public
No review-level evidence was identified to health should address obesity treatment in
address treatment of obesity in minority minority groups, and programs for these groups
groups. should be evaluated and evaluations shared.

Interpreting the Evidence
Prevention of obesity (6 SR including 34 studies + 6 narrative
reviews; mostly low to moderate quality)
What’s the evidence? Implications for practice & policy
No impact of obesity OR cardiovascular • Public health decision makers should not
prevention interventions on adiposity rely on either obesity prevention or
• Systematic review evidence (4 reviews for cardiovascular prevention programs for
which citation analysis was possible): does decreasing adiposity, given the current
not support obesity prevention programs evidence from both systematic and
(i.e. several school-based) for the reduction narrative reviews.
of adiposity. (7/26 studies identified a
reduction in adiposity)
• Systematic review evidence (1 review – 16
studies): Cardiovascular prevention
programs were not effective in decreasing
adiposity (7/77 showed a positive impact).
• Narrative review evidence (6 reviews):
insufficient evidence for obesity prevention
as an adiposity reduction measure.

Interpreting the Evidence
Diet vs. Diet and Exercise (5 reviews)
What’s the evidence? Implications for practice & policy
• Exercise programs combined with a dietary • Public Health decision makers should
intervention offered some improvement in promote diet and exercise together (as
adiposity (6 of 10 studies); however the opposed to diet alone) for the secondary
extent to which benefits are sustained in prevention of obesity, and evaluate whether
long term is unclear) long-term benefits are realized.

Interpreting the Evidence
Dietary Interventions (1 meta-analysis (17 studies) + 1 review
of a single study)
What’s the evidence? Implications for practice & policy
• No impact of specific elements of dietary • Based on two SRs of fair quality, there is
interventions on weight loss. insufficient evidence to recommend any
specific elements of dietary interventions
for obesity reduction.

Interpreting the Evidence
Physical Activity (PA) Behaviour Change (8 reviews)
What’s the evidence? Implications for practice & policy
• PA during school hours – high quality • Public health should promote PA behaviour
review evidence (4 reviews) shows that change interventions to increase PA during
school-based interventions are effective in school hours. Programs should be evaluated
increasing PA during school hours. to determine whether PA outside school
• PA outside school hours – there is some hours is increased.
(mixed) evidence that school-based • Evaluations conducted by public health
interventions increase PA outside school should ideally include long-term follow up
hours. into adulthood.

Interpreting the Evidence
Strategies to promote dietary change (7 SR + 5 narrative
reviews; analysis according to behaviour change model)
What’s the evidence? Implications for practice & policy
• Preschool children: 7/10 studies in 2 SRs • Public health should not rely on either
offer mixed evidence that does not behavioural or knowledge-based
conclusively support specific behavioural or approaches to improve preschool children’s
knowledge-based strategies to change food- dietary behaviour.
related behaviour (e.g. touch/smell/taste • Public health should use and evaluate
new foods, modeling, repeated exposures) behaviourally-based approaches to improve
• School-based: 42/59 studies in 6 reviews dietary behaviour in school-based programs.
showed some improvement in dietary • Public health should evaluate efforts to
behaviour that was more closely attributed improve dietary behaviour in minority
to behaviourally-based approaches rather populations in order to contribute to the
than knowledge-based approaches. evidence base available.
Descriptions of strategies are not provided.
• Minority Populations: 1 low-quality
review offered no definitive conclusions
that dietary interventions are effective.

Interpreting the Evidence
Strategies Lifestyle Exercise Strategies (3 reviews citing the
same 3 studies + 1 meta-analysis)
What’s the evidence? Implications for practice & policy
• Lifestyle exercise was distinct from other • Public Health decision makers should not
exercise programs in that it (1) includes rely on lifestyle exercise to decrease
activities of daily living, (2) includes caloric childhood obesity. However, public health
expenditure in small increments throughout should consider other possible benefits to
the day, and (3) no prescribed intensity. be derived from the promotion of lifestyle
• No impact on childhood obesity compared exercise.
to either no exercise or other exercise,
based on the meta-analysis incorporating
the widest range of evidence.

Interpreting the Evidence
Parental Involvement (4 reviews (13 studies) + 1 meta-analysis)
What’s the evidence? Implications for practice & policy
• Parental involvement interventions varied, • Public health should not focus on parental
with only one study directed solely at involvement strategies as a way to improve
parents. A range of interventions were childhood obesity treatment.
aimed at both children and parents to
varying degrees. Intervention elements are
not well described; but tend to be family-
oriented and include homework
assignments, and parents motivating their
children.
• No impact on childhood obesity treatment,
even though there is good evidence in this
topic area

Interpreting the Evidence
Behaviour Modification Strategies (2 reviews of 9 studies + 1
meta-analysis)
What’s the evidence? Implications for practice & policy
• Little information provided regarding the • Behaviour modification strategies should be
nature of behaviour modification strategies considered for use with dietary and physical
used. activity interventions, and ideally with all
• Improvement in obesity status when three strategies combined, in aiming to
behaviour modification strategies were used improve obesity status.
with dietary and physical activity strategies • Public health should not focus on self-
in the short-term. Behaviour modification, control training as an additional strategy for
dietary AND physical activity strategies reducing obesity in children.
together demonstrated greater treatment
effect than behaviour modification and
either dietary or PA.
• No impact of additional or “add-on” self-
control training on obesity status.

Interpreting the Evidence
Reinforcement (1 review)
What’s the evidence? Implications for practice & policy
• A single, small (15 subjects) study of fair • There is limited evidence at this time to
quality in one review showed that periodic support the provision of reinforcement
reinforcement after obesity treatment following obesity treatment programs
enhanced weight loss

Interpreting the Evidence
Factors Influencing Obesity Prevention
What’s the evidence? Implications for practice & policy
• There is a very limited evidence examining • Based on evidence available at this time,
the effect of setting, duration of treatment public health should not focus on modifying
and initial weight status upon which to factors such as: setting, duration of
assess the impact on obesity outcomes. treatment, age, and initial weight status to
improve obesity outcomes. It is possible
that relationships between these factors
and obesity may exist; however, they are
unclear at this time.

Overall Considerations
Considerations for Public Health Practice
Conclusions from Health Evidence General Implications
Interventions that showed improvement in Public health should support:
obesity outcomes promoted: • programs that focus on diet + exercise
• consumption of a healthier diet plus • physical activity behavior change and dietary
exercise (vs. diet only) change interventions for school children
• increased physical activity in and out-of- • behavior modification with both diet and
school physical activity strategies
• healthier diet among school-aged children
• behaviour modification strategies alongside Due to a current lack of evidence, public health
strategies to improve diet and physical programs should not include:
activity • a focus on specific elements of dietary
interventions
Evidence is not conclusive enough to support: • dietary interventions for pre-school aged
• dietary interventions children or minorities
• dietary change interventions for preschool- • reinforcement after obesity treatment
aged children or minorities • a focus on modifying factors including age,
• reinforcement after obesity treatment setting, duration, or initial weight, as a way
• modifying factors (age, duration, etc.) to modify obesity outcomes

Overall Considerations
Considerations for Public Health Practice
Conclusions from Health Evidence General Implications
No impact on obesity outcomes were Due to a lack of effectiveness, public health
observed for interventions on: should also avoid focus on:
• dietary change • cardiovascular risk factor interventions to
• cardiovascular risk factor reduction modify obesity outcomes
• primary prevention programs for obesity • primary prevention programs for obesity
• lifestyle exercise strategies • lifestyle exercise programs
• parental involvement
No current evidence to inform how public
No review-level evidence was identified to health should address obesity treatment in
address treatment of obesity in minority minority groups, and programs for these groups
groups. should be evaluated and evaluations shared.

Questions?

Summary Statement:
Shiell (2008)

Overall Considerations
Considerations for Public Health Practice
Conclusions from Health Evidence General Implications
School-based interventions led to: The most current, rigorous evidence does not
• no effects on physical activity, nutrition, BMI, support school-based interventions to reduce
fruit and vegetable intake, energy from fat, Type II diabetes or its risk factors. Findings from
total serum cholesterol, and VO2 Max less rigorous studies do support the use of
(rigorous studies) school-based interventions.
• improvements in triglycerides, physical
activity, systolic and diastolic blood Community-based interventions are currently
pressure, percentage body fat, smaller recommended for increasing physical activity.
increase in BMI, and waist circumference
among boys Worksite-based interventions are suggested for
increasing smoking cessation rates.
Community-based interventions led to:
• increase in self-reported physical activity There is limited, good quality evidence. Results
should be applied cautiously to public health
Worksite-based interventions led to: practice, and any associated public health
• increase in smoking cessation rates programs need to evaluate the impact of these
interventions.

Interpreting the Evidence
School-based interventions (5 RCTs of high quality, 6 quasi-
experimental of moderate quality)
What’s the evidence? Implications for practice & policy
Among studies of moderate methodological • Given evidence is mixed (rigorous studies
quality, a statistically significant impact was generally report no effect, lower quality
observed on: studies report significant effects), school-
• Triglycerides, blood pressure, percentage based interventions may not be an effective
body fat, participation in rigorous physical public health strategy for reducing Type II
activity, waist circumference, and(less of an diabetes and its risk factors.
increase in BMI compared to usual care. • Given some interventions affect boys and
• Some effects observed among girls only and girls differently, careful consideration of the
others among boys only. different facilitators and barriers to physical
activity among boys and girls is needed, if
Among the most rigorous studies: these interventions are implemented.
• No impact on physical activity, diet, total
serum cholesterol,VO2 Max, or BMI.

Interpreting the Evidence
Community-based interventions (1 study; moderate quality)
What’s the evidence? Implications for practice & policy
• One studies of moderate methodological • Community-based interventions are
quality, statistically significant impact was supported for increasing physical activity.
observed on self-reported physical activity. Results should be interpreted cautiously as
physical activity was measured through self-
report, which may overestimate the true
treatment effect.
• These findings must be re-evaluated as
more rigorous evidence emerges.

Interpreting the Evidence
Worksite-based interventions (1 study; moderate quality)
What’s the evidence? Implications for practice & policy
• One study of moderate methodological • Worksite-based interventions are
quality found a statistically significant recommended for increasing smoking
increase in smoking cessation rate (OR 1.38; cessation rates.
95% CI 1.05-1.81). • These findings must be re-evaluated as
more rigorous evidence emerges.

Overall Considerations
Considerations for Public Health Practice
Conclusions from Health Evidence General Implications
School-based interventions led to: The most current, rigorous evidence does not
• no effects on physical activity, nutrition, BMI, support school-based interventions to reduce
fruit and vegetable intake, energy from fat, Type II diabetes or its risk factors. Findings from
total serum cholesterol, and VO2 Max less rigorous studies do support the use of
(rigorous studies) school-based interventions.
• improvements in triglycerides, physical
activity, systolic and diastolic blood Community-based interventions are currently
pressure, percentage body fat, smaller recommended for increasing physical activity.
increase in BMI, and waist circumference
among boys Worksite-based interventions are suggested for
increasing smoking cessation rates.
Community-based interventions led to:
• increase in self-reported physical activity There is limited, good quality evidence. Results
should be applied cautiously to public health
Worksite-based interventions led to: practice, and any associated public health
• increase in smoking cessation rates programs need to evaluate the impact of these
interventions.

Questions?

Summary Statement:
O’Brien (2010)

Overall Considerations
Considerations for Public Health Practice
Conclusions from Health Evidence General Implications
Immunologic/virologic The overall findings suggest that:
• significant impact on CD4 count (interval • the promotion of aerobic exercise, while
aerobic exercisers) resulting in improvements for a small
• no impact: CD4 count, CD4%, and viral number of outcomes, does not positively
load (all other types of exercise) impact most outcomes, and may not be an
Cardiopulmonary effective public health strategy for this
• improvement in VO2 Max population.
• no impact: max. heart rate or exercise time • various formats of aerobic exercise did not
Strength positively and significantly impact
• improvements in strength (exercisers) immunologic/virologic outcomes, most
Weight and Body composition cardiopulmonary outcomes, and strength
• decrease in body fat (aerobic exercisers) measures
• increased change in leg muscle (aerobic • given improvements on VO2 Max, percent
exercise plus progressive resistive training) body fat, and depression in HIV patients,
• no change in body weight, BMI, waist or hip promotion of exercise may be supported
circumference, waist-to-hip ratio, fat mass If implemented, the impact of aerobic exercise
Psychological promotion on this population should be
• improvement in depression-dejection evaluated within the local context.

Interpreting the Evidence
Immunologic/Virologic Outcomes (14 RCTs)
What’s the evidence? Implications for practice & policy
• A statistically significant impact on CD4 • Generally the evidence does not support
count was observed in the interval aerobic public health allocating resources to
group compared to non-exercisers (69.58 promote aerobic exercise among HIV
cell/mm3, 95% CI, 14.08 – 125.09, P=0.01) (2 populations for the purpose of improving
studies). CD4 count, CD4%, or viral load.
• No impact on change in CD4 count, CD4%,
and viral load for all other combinations of
exercise versus no exercise.

Interpreting the Evidence
Cardiopulmonary (14 RCTs)
What’s the evidence? Implications for practice & policy
• A statistically significant improvement in • Exercise promotion is supported as a public
VO2 Max was observed among aerobic health intervention among HIV populations
exercisers vs. non-exercisers (2.63 if improvements in VO2 Max are of greatest
Ml/kg/min, 95% CI, 1.19 – 4.07); constant interest.
aerobic exercisers vs. non-exercisers (2.40 • However, improvements in maximum heart
Ml/kg/min, 95% CI 0.82-3.99); heavy rate and exercise time should not be
intensity vs. moderate intensity (4.30 expected.
Ml/kg/min, 95% CI 0.67 – 7.98).
• No impact on maximum heart rate or
exercise time.

Interpreting the Evidence
Strength (6 RCTs)
What’s the evidence? Implications for practice & policy
• Meta-analysis not conducted due to • While meta-analysis was not possible, the
variation in strength measures. 5 of 6 evidence suggests that exercise promotion
individual studies reported statistically is supported to achieve improved strength
significant improvements in strength among HIV populations.
measures between exercisers and non-
exercisers.

Interpreting the Evidence
Weight and Body Composition (9 RCTs)
What’s the evidence? Implications for practice & policy
• Statistically significant decrease in percent • While the majority of outcomes related to
body fat (-1.12%, 95% CI -2.18 to -0.07), weight and body composition were not
increase in change in leg muscle area impacted by aerobic exercise, improvement
(4.79cm2, 95% CI 2.04 to 7.54). in percent body fat suggests promotion of
• No impact on change in mean body weight, aerobic exercise among HIV populations
waist circumference, hip circumference, may be an important public health strategy.
waist-to-hip ratio, change in body mass
index, change in fat mass.

Interpreting the Evidence
Psychological (9 RCTs)
What’s the evidence? Implications for practice & policy
• Statistically significant improvement in • The evidence suggests the promotion of
depression-dejection scale in exercisers vs. aerobic exercise among HIV populations for
non-exercisers (7.68, 95% CI -13.47 to improving depression-dejection measure.
-1.90).

Overall Considerations
Considerations for Public Health Practice
Conclusions from Health Evidence General Implications
Immunologic/virologic The overall findings suggest that:
• significant impact on CD4 count (interval • the promotion of aerobic exercise, while
aerobic exercisers) resulting in improvements for a small
• no impact: CD4 count, CD4%, and viral number of outcomes, does not positively
load (all other types of exercise) impact most outcomes, and may not be an
Cardiopulmonary effective public health strategy for this
• improvement in VO2 Max population.
• no impact: max. heart rate or exercise time • various formats of aerobic exercise did not
Strength positively and significantly impact
• improvements in strength (exercisers) immunologic/virologic outcomes, most
Weight and Body composition cardiopulmonary outcomes, and strength
• decrease in body fat (aerobic exercisers) measures
• increased change in leg muscle (aerobic • given improvements on VO2 Max, percent
exercise plus progressive resistive training) body fat, and depression in HIV patients,
• no change in body weight, BMI, waist or hip promotion of exercise may be supported
circumference, waist-to-hip ratio, fat mass If implemented, the impact of aerobic exercise
Psychological promotion on this population should be
• improvement in depression-dejection evaluated within the local context.

Questions?

Summary Statement:
Farmer(2008)

Overall Considerations
Considerations for Public Health Practice
Conclusions from Health Evidence General Implications
Printed educational materials (PEMs) compared to Currently available evidence does not
no intervention led to: support the use of PEMs by public health as
• small negative change in patient outcomes, with a means to improve both professional
the effects being of limited clinical significance practice and patient outcomes.
• no improvement in professional practice
outcomes Decision makers may consider including
a single intervention (e.g. educational PEMs as part of a multi-faceted
workshops or outreach) resulted in: intervention, although this will require
• a small change in some professional practice and rigorous evaluation.
patient outcomes
• non-significant changes in continuous outcomes Although there is currently insufficient
evidence related to the circumstances and
No studies were found comparing PEMs as part of a contexts in which PEMs work best, future
multifaceted intervention to other multifaceted projects re-explore this literature in
interventions. planning PEM campaigns.
Unable to determine specific circumstances and
contexts in which PEMs are most effective.

Interpreting the Evidence
PEMs compared to no intervention (4 cluster randomized
trials, 3 RCTs, 10 interrupted time series (ITS) studies)
What’s the evidence? Implications for practice & policy
• Small deterioration of patient outcomes across • Public health decision makers should not
3 studies (median standard ES -0.004 to - consider PEMs to improve professional
0.20), with uncertain clinical significance. practice.
• No impact on professional practice outcomes • Given the impact of PEMs on patient
for categorical process outcomes (e.g. x-ray outcomes was minimal at best, PEMs may
requests, prescribing and smoking cessation not be an optimal use of public health
activities) and continuous process outcomes resources.
(e.g. medication change, x-rays requests per
practice).

Interpreting the Evidence
PEMs as one component of any intervention compared to a
single intervention (1 RCT)
What’s the evidence? Implications for practice & policy
• A single RCT showed a small positive impact • When using PEMs as one component of a
on professional practice outcomes (median larger intervention, public health decision
absolute risk difference 0.5 in favour of makers should not invest heavily in PEMs
PEMs), with the 2 other trials reporting non- to improve professional practice OR
significant effects. patient outcomes. However, the
• A single RCT showed a small positive impact currently-available evidence is limited.
on categorical patient outcomes for smoking
cessation (median standardized effect -0.2%).
• No impact on continuous patient outcomes
(e.g. screening, return to work, quit smoking).

Overall Considerations
Considerations for Public Health Practice
Conclusions from Health Evidence General Implications
Printed educational materials (PEMs) compared to Currently available evidence does not
no intervention led to: support the use of PEMs by public health as
• small negative change in patient outcomes, with a means to improve both professional
the effects being of limited clinical significance practice and patient outcomes.
• no improvement in professional practice
outcomes Decision makers may consider including
a single intervention (e.g. educational PEMs as part of a multi-faceted
workshops or outreach) resulted in: intervention, although this will require
• a small change in some professional practice and rigorous evaluation.
patient outcomes
• non-significant changes in continuous outcomes Although there is currently insufficient
evidence related to the circumstances and
No studies were found comparing PEMs as part of a contexts in which PEMs work best, future
multifaceted intervention to other multifaceted projects re-explore this literature in
interventions. planning PEM campaigns.
Unable to determine specific circumstances and
contexts in which PEMs are most effective.

Questions?

Discussion Forum
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Evaluation
Please check your email for the evaluation
link. It take 5 minutes to complete!
If you’ve been watching with someone else and did
not personally register for the webinar, please
e-mail Jennifer McGugan at
mcgugj@mcmaster.ca to be sent the survey.
Thank you for your participation!