Defining success in adult obesity management: A systematic review and framework synthesis of clinical practice guidelines

Obesity is a chronic and complex disease affecting millions of people worldwide. Currently, there is no standard definition of success for the management of obesity. We set out to complete a synthesis of clinical practice guidelines for obesity management for adult populations, aiming to provide both a quantitative descriptive and qualitative analysis of definitions of success in clinical practice guidelines. An electronic search retrieved 4477 references. Sixteen clinical practice guidelines were included after screening and full‐text review. We coded definitions of success 147 times across the included guidelines. No standard or explicit definition of success was identified in the guidelines but rather success was implicitly defined. We developed three themes describing how success was defined in the clinical practice guidelines: Knowledge‐based decision making; management of expectations; and the perception of control. The review reinforced that success is an inherently subjective and complex concept. Defining success is limited by existing studies that focus on weight loss and would benefit from additional research on different outcomes. Equally, the relationship between people living with obesity and their clinicians should be further explored to understand how defining success is controlled, discussed and framed in a clinical setting.


| INTRODUCTION
2][3][4] The prevalence of obesity has continuously increased over the past decades, with estimates that by 2030, 20% of the world's population will be considered to be living with obesity. 5,6Currently, there is no standard definition of successful management of obesity.
A definition of success is needed to establish a standard by which to evaluate the efficacy or value of management programmes.
Commissioners need definitions of success to create assessable standards to ensure healthcare services provide valuable management programmes, an example being the National Obesity Audit and other commissions established to ensure the quality of care available to those living with obesity.Hospitals rely on definitions of success to identify value-based treatments, and the current lack of consensus for the definition of successful obesity management is demonstrated in the wide range of outcomes used to represent or evaluate effectiveness.Pharmaceutical companies are currently tasked with both defining relevant outcomes for obesity medications and demonstrating their medication's efficacy risking biased outcomes.Finally, in clinical practice, without a shared opinion of successful management, there is a risk of individuals losing trust in their clinicians or developing frustration with the management programme.For obesity research to provide positive change to the current healthcare landscape, we must endeavour to provide a comprehensive understanding of success within the obesity management pathway.

| OBJECTIVE
We set out to understand how success is defined and currently framed by systematically reviewing clinical practice guidelines for obesity management for adults.

| Design
This is a framework synthesis of clinical guidelines for obesity management, which includes a quantitative descriptive analysis of themes relating to success. 7Clinical guidelines, as per the Institute of Medicine (IOM), are 'systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances'. 8We selected clinical practice guidelines as they are written for the target audience of clinicians but also audiences across the healthcare system including but not limited to clinicians, allied health and social care professionals, policymakers and payers (of healthcare). 9We used a systematic search to identify all relevant guidelines and a framework synthesis to incorporate both an inductive and deductive analytical approach to understanding success. 7protocol was registered in advance on the Open Science Framework (10.17605/OSF.IO/CTRHM).The review was reported following PRISMA guidelines for systematic reviews 10 and ENTREQ guidance for qualitative syntheses 11 (Tables S2 and S3).

| Terminology
For the purpose of this review, the terms 'management' and 'treatment' were considered interchangeable as both terms were used across the included guidelines.Various titles were used to denote healthcare professional across the guidelines, this review will use the term 'clinicians'.People living with obesity were referred to as 'patients' within the guidelines; therefore, this review will use the term 'patients' when discussing results.

| Search strategy
We retrieved guidelines through a systematic search of the following electronic databases in October 2020.A follow-up search was completed in November 2021 and September 2023.The search strategy included Medical subject heading terms for obesity and text words for clinical practice guidelines and was adapted for each database (see Table S1).

| Eligibility criteria
We included clinical practice guidelines or consensus statements for the treatment or management of obesity in adults (e.g., 18 years or older or as per local regulations).Eligible clinical practice guidelines or statements were those that met the definition of clinical practice guidelines defined by IOM.We did not set any criteria for the year of publishing nor did we exclude guidelines that had been redacted by the respective country.If multiple guidelines from a single source or country existed, we included the most recent edition.We excluded guidelines for specific population groups (e.g., veterans) or for children and adolescents, as defined by the respective country.Only guidelines in the English language were included.

| Screening
Two reviewers (N.J.H. and W.J.) independently screened references based on the title and abstract, and two reviewers (N.J.H. and Z.A.) independently completed the full-text review of all references, which met the eligibility criteria or where abstracts were not available.Disagreements were resolved through discussion.We documented the record of screening and full-text review with the aid of the online software Covidence 12 for references identified in the PubMed search and using Excel for references identified from searches in the Guideline and National Guideline databases.One reviewer (N.J.H.) compiled all included references from the three database searches into Excel.

| Quality appraisal
We did not conduct an appraisal of the included guidelines for bias or overall quality as it was not deemed relevant to support the exploratory nature of the review.The purpose of the review was to understand how success was defined across guidelines and guidelines were not excluded based on quality.Aspects of quality appraisal were included to evaluate the impact on success: status of the guideline (i.e., redacted [Y/N]) and the quality of evidence that supported definitions of success.

| Data extraction and management
We imported a copy of each included guideline into the qualitative data analysis software NVIVO. 13The primary reviewer (N.J.H.) conducted data extraction and coding of the included guidelines.We extracted and recorded the following information for the included guidelines: respective country or region, year, status (i.e., redacted [Y/N]), methodology, scope or purpose, and stakeholders involved in development (Table 2).Guidelines were then coded in their entirety according to the preliminary framework (Table 1).

| Data synthesis
N.J.H. completed the primary coding (line-by-line) with input and discussion with other reviewers.The codes were identified in-text, extracted and indexed against the preliminary framework as per a framework synthesis, from which both the descriptive quantitative analysis and themes were derived. 7When a new concept was developed, we amended the framework.We analysed the coded text to quantify the frequency and presence of success within and across guidelines and used the charted and indexed codes to support thematic development.
The primary reviewer developed the preliminary framework during protocol development in discussion with the other reviewers, as no relevant framework or theory existed.The framework consists of two concepts: (i) how success was defined and (ii) how the definition of success was developed (Table 1).Statements of advice, recommendations, aims or goals were considered constructs of 'definitions of success' and coded as such.We further categorized the codes by how each definition of success was 'measured' (e.g., weight loss and health outcome).Study characteristics, quality of evidence, stakeholder perspectives and methodology were all constructs of 'developing the definition of success'.These categories reflect the concepts reviewers use when conducting systematic reviews and appraising included studies. 14 per the study aim, we quantitatively analysed the extracted codes to determine the frequency of coded definitions of success across the guidelines using NVIVO.We charted and indexed the codes against the framework to identify patterns, which informed how success was defined in the guidelines.The identified patterns helped develop themes that related to answering the overall research question. 15| RESULTS

| Included guidelines
A total of 4477 references (3656:72:749) were identified in the electronic search (PubMed: Guideline database: National database), of which 126 were eligible for full-text review.We exclude 93 (83:7:3) of these references with reason.We collated all references from the three databases and, thereafter, excluded an additional 18 guidelines.
Of the three guideline preface/summaries, one guideline was identified, and the remaining two were summaries of already included guidelines.We included a total of 16 guidelines in the final review (Figure 1).The included guidelines were composed of guidelines from a total of 12 countries, one global guideline 16 and one European guideline. 17idelines were published between 2000 and 2020.Two guidelines were no longer applicable for use in clinical practice having been rescinded. 18,19No updated guidelines were identified in either country (Scotland and Australia).The NICE (UK) guidelines from 2014 were included, and since completing the search have been revised in 2023. 20An overview of the included guidelines with a short description of scope, purpose and methodology is provided in Table 2.

| Descriptive analysis of success
We included all guidelines identified by the systematic review in the analysis.We coded a total of 147 statements of success across the guidelines (Table 3).These statements are considered definitions of success for this review.Of the 147 definitions, 13 were explicitly defined management goals, 90 were guideline recommendations and 24 were statements describing a failure to achieve success (coded as 'opposite of success') (Table 4).
The statements of success coded across the guidelines were also categorised by the measure of success: behavioural change, health outcome, body composition, weight loss undefined, weight loss defined or weight maintenance.The most common measures of success were defined as weight loss (e.g., % body weight) or health outcome (Table 4).
The statements of success were categorized by the type of treatment they referred to bariatric surgery, lifestyle interventions or pharmacotherapy.When the statement referred to any type of treatment or all treatments, it was categorized as obesity management, and when no treatment was specified, the statement was categorized as undefined.
'Lifestyle interventions' and 'obesity management' were associated with definitions of success most often.We identified definitions of success measured by weight loss (defined) for all treatment types.
We coded the measure of health outcomes as the primary measure of success of 'obesity management', followed by weight loss (defined) and weight maintenance.

| Themes
We developed three themes describing how success was defined in clinical practice guidelines: Knowledge-based decision-making, management of expectations and the perception of control.Quotations from the guidelines are included to support the descriptions of the themes.

| Knowledge-based decision making
Knowledge-based decision-making consisted of the activity of gathering and evaluating evidence to construct a decision for how to define success, it reflects that success is not an absolute but rather made up by existing evidence and beliefs.The theme consisted of three subthemes: the evaluation of evidence, the ability to evaluate evidence and the evidence itself.

Evaluation of evidence
Determining criteria for success reflected the process of evaluating the available evidence to appropriately decide what would constitute success.
The guidelines stated that evidence included cited studies, the guideline The guidelines suggested that conditions of the individual such as 'stress level' would affect what could be considered success, but how the condition should be considered for was not clarified.In the above example, the guideline has considered a 'realistic goal' as one related to the 'patient's physical condition'; 5%-10% weight loss reduces comorbidities (e.g., physical condition).There is no reference to the other limitations or conditions, and the numerically defined weight loss goal is somewhat at odds with the notion of 'personalized goals'.

The ability to evaluate evidence
The ability to evaluate and understand knowledge correctly was necessary to make appropriate decisions, including how to define success, described as 'Health literacy'.The guidelines insinuated that clinicians had the capability of making these decisions, whereas the individual had limited health literacy and was, therefore, incapable, positioning the clinician as the decision-maker.
The term 'health literacy' refers to a person's ability to obtain, process, understand and act on basic health information and services to make appropriate health decisions (Ministry of Health 2010).
Evaluating evidence reflected the ability to make decisions considering the most robust evidence.This was further facilitated by the guidelines themselves, providing an evaluation of the evidence alongside the recommendations and aligning terminology to these evaluations.Most guidelines used GRADE, a framework and tool for evaluating the quality of evidence for making recommendations. 33finition of actionable verbs used in the recommendations (Canadian, G4).In the Canadian guideline(G4), the choice of actionable verbs was associated with levels of evidence giving more clout to the evidence considered of higher quality.

Evidence
The evidence used to create the guidelines was itself a limiting factor as defining success in the guidelines was invariably based on the outcomes and availability of existing evidence.
Because the existing literature is based mainly on weight-loss outcomes, several recommendations in this guideline are weight-loss centred.(Canadian, G4).
It was made explicit in this Canadian guideline(G4) that existing evidence is based mainly on weight loss and as such, recommendations in the guidelines reflect a weight-loss-centred approach reflected in success being seen as measurable as weight-loss outcomes.This was reflected in the measures of success throughout all the guidelines (Table 4 and Figures 2-4).Four of the six measures of Health care providers should talk with their patients and agree on realistic expectations (Canada, G4).
Health practitioners should develop their ability to assist people with different levels of health literacy (New Zealand, G10).
The guidelines suggested that individuals with higher health literacy would have expectations based on clinically relevant evidence ('proven health benefits') rather than unrealistic, media reports primarily focused on weight-loss outcomes.The phrasing implied the expectations of clinicians were those that reflected a true understanding of what evidence had proven.
Although a modest 5% to 10% weight loss has proven health benefits, it often does not provide the cosmetic benefit that patients are looking for.This results in a mismatch between the patient's goals for weight loss and what diet and exercise can realistically achieve.(Endocrine, G5).
T A B L E 3 Number of definitions of success across all included guidelines.

Guideline and country
Definitions of success coded for (N) The mismatch between expectations was framed as attributable to the unrealistic expectations held by patients rather than just a difference of opinion, these expectations were considered scientifically unsound, unrealistic, and driven by cosmetic wishes reinforced by media reports of 'success stories' rather than realistic, proven health benefits.

| The perception of control
Control encompassed the perception or reality of being responsible for deciding how to define success.The act of deciding successrather than any subsequent outcome-was the ultimate demonstration of control and would implicitly determine how success was defined.
Some of the guidelines firmly positioned the clinician as in control, but recognized that patients had a role to play in their self-management.In the quotations below, we see terminology that reflects the underlying assumption that the professional is in control.In the first, the statement 'let the patient choose' implies the individual patient cannot do so without permission.In the second, the same guideline highlights the various roles and differing expertise.In the third, it is seen as necessary for both to reach a joint agreement on whether the patient losing weight is an appropriate goal.It seems that control and choice are managed by the clinician and put into practice by giving the individual specific choices.Devolving control to patients, however, was only in terms of certain aspects of healthcare, and always in alignment with clinicians' views and support.
…it is fundamental to let the patient choose the area they feel able to make behavioural changes.
The patient is considered his/her own expert and chooses the area for behaviour modification with the T A B L E 4 Measure of success across all definitions of success.support of his/her GP or obesity expert (European, G6).
The expert Panel advises (expert opinion) that the clinician and patient agree on whether weight loss is appropriate.(AHA TOS, G2).
As noted in the second quotation above, the clinician and patient were described as experts in different areas, putting them in control of specific aspects of management.Clinicians were framed as experts on obesity and were encouraged to use this expertise to reframe, redefine and alter how patients considered their success.This was The possible achievement of success was framed as related to how the patient perceived the value of the planned change or intervention and the clinician's perception of the patient's ability to make a change.

| DISCUSSION
This review and synthesis aimed to explore how success was defined in clinical practice guidelines for obesity management.As anticipated, we did not identify a standard, unequivocal definition of success in obesity management across the guidelines.We did not identify any inconsistencies across the guidelines, Singapore (G14) had the highest number of success definitions coded; this was a result of a large number of recommendations listed.Despite this, they were largely similar in content to the other guidelines.
The descriptive analysis demonstrated that success was not explicitly defined but rather described as goals or recommendations,  or endpoints, such as weight loss (e.g., % body weight, kg) and health outcomes.This was expected as these endpoints are typically used in clinical practice and can be easily assessed and further extrapolated for further analysis to evaluate association with other clinical outcomes (e.g., reduction in risk for cardiovascular disease risk). 33,34Furthermore, these measures reflect that most obesity management programmes focus on weight outcomes as obesity itself is defined by excessive weight.The three themes demonstrated that success was constructed as an interpretation of evidence in an interaction between the clinician and individual living with obesity (Table 5).
Although the guidelines included patients, i.e., people living with obesity, as target audiences, they were largely aimed at clinicians, and the language and content reflected this.The language used to describe success impacts how success is understood and often the language in the guidelines when referring to 'success' was subjective, including terms such as 'realistic' or 'appropriate'.The use of subjective language can lead to misinterpretation of the guidelines and potentially lead the reader to interpret a contradicted meaning that was intended.Furthermore, the term 'failure', coded from the guidelines, warrants further consideration for how language with negative connotations impacts the individuals' own perception of their obesity management journey. 35e definition of success was limited by the existing evidence; success was mostly defined by the clinical endpoints and outcomes.
As explicitly stated in both AACE (G1) and Canadian (G4) guidelines, existing evidence in obesity management is weight-related and the content of the guidelines and information used to define success reflected weight-related evidence.Therefore, although guidelines included non-weight outcomes such as quality of life or mental health (G4), they were outweighed by the evidence available to support weight-related outcomes.This skew reflected the lack of patient perspectives across most guidelines as much of the evidence had yet to incorporate the new insights from patient-reported outcomes.There is a need for more inclusion of qualitative research investigating the perspectives of the patients.
Recognizing the role clinicians have in interpreting and handling the non-evidence-based narrative around obesity is difficult, 36  further compound the lack of clarity of success in practice.This is not to suggest that the use of evidence-based practice is wrong but to highlight the need to consider the implications of language when discussing obesity management and be cognisant of the interaction between individuals and clinicians.This review demonstrates a complex interaction between the individuals living with obesity and the clinician providing guidance and recommendations; questioning who is deemed to be truly in control.

| Implications
We observed that success was primarily described in terms of clinical endpoints and outcomes, and although the use of health outcomes, rather than weight loss alone is the first step in creating a more holistic understanding of success, more evidence supporting qualitative non-weight outcomes is needed.8][39][40] Within practice, there are numerous examples of the improvement of the construct of 'success'; as outlined by the use of 'Best Weight' developed by Arya Mitra Sharma and Yoni Freedhoff, and in the prioritised value of psychological aspects in dialogue. 40It is also demonstrated in the pilot to apply the Canadian guideline, which incorporates more holistic aspects of success, to other countries (Chile and Ireland). 41Thus, as our understanding of obesity, clinical outcomes and PROs continue to evolve, so too must our understanding and language around 'success'.The review clearly demonstrates that 'success' consists of more than evidence alone and the implications of this are important if to adequately evaluate the provision of obesity management.
Although not within the remit of this review, further evaluation of the classification of obesity should be taken to understand how the definition of obesity itself may have implications on our understanding of success.

| STRENGTHS AND LIMITATIONS
A limitation of this review is that the search is out-of-date.Continually scoping of new guidelines has shown that since the search the NICE CG189 Guideline has been revised (July 2023) to include revised recommendations on surgical interventions, the revision was not evaluated to have implications on these findings.
Clinical practice is not limited to the latest research but is also affected by historical perceptions-the inclusion of both current and redacted guidelines ensured a comprehensive overview of guidelines.
We used established systematic review methodologies to identify all relevant clinical practice guidelines and included a comprehensive search across multiple databases.
A mixed methods approach was used for the analysis of the codes identified from the framework synthesis.In addition to coding and indexing for theme development, quantitative analysis and presentation of the codes were derived and used to support the development of themes.A framework synthesis was used as it includes both inductive and deductive approaches to understanding the data.An iterative approach allowed us to amend the framework as the analysis progressed. 42There was no a priori framework available to use to support this analysis as no similar research had been completed before this review.[45] The guidelines included in the review were limited to those in the English language; this resulted in the exclusion of 10 guidelines.
The results should be considered with this in mind.Guidelines for adolescents or other specific populations were excluded as what may be constituted as success would likely be specific to the population and not applicable further.
We did not formally review the quality of the guidelines as the nature of this review was exploratory and to identify how success was defined in each, as opposed to evaluating the quality of the guideline.
As clinicians are the target audience of guidelines, clinical judge-

••
PubMed electronic database • International guideline databases: National guideline databases: National Institute for Health and Care Excellence (NICE) Scottish Intercollegiate Guidelines Network Australian Clinical Practice Guidelines Canadian Task Force on Preventative Health Care New Zealand Guidelines Group American Association of Clinical Endocrinologists (AACE) The Obesity Society U.S. Preventive Service Task Force itself, professionals' judgement and the views of patient.The guidelines presented clinicians as decision-makers and facilitators of knowledge dissemination.In the quote below, we see how the professionals are positioned as those 'taking into account' the various aspects of the situation: When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service.(NICE, G9).T A B L E 2 (Continued) national experts from SIGN.Team to develop Guidelines with assistance from Scientific Committee.Review of relevant evidence-based scientific literature.Tools to help practicing doctors to manage obese patients.Members of Working Group consisted of clinicians and academics.G15 United Arab Emirates 32 2018 Multi-disciplinary panel of international and regional experts.Panel considered a number of international guidelines on obesity as baseline references including AACE and ACE.Members reviewed references and relevant literature and developed recommendations.Panel reviewed recommendations and circulated with external stakeholders.Set of recommendations for clinicians.To be used in local context.Of interest to clinicians in other GCC countries.Authors consisted of clinicians G16 World Gastroenterology organisation (WGO) 16 2011 WGO Guidelines Committee Review team and external experts including peer review.Practice guidelines for global applicability.Review team consisted of experts (e.g., clinicians and academics) The clinicians were expected to consider the evidence presented in the guideline, in combination with the patients' health needs, preferences and values.Clinicians were to review the evidence as it related to the patient's obesity-related comorbidities to determine what definition of success was appropriate, and the targets (e.g., success) were altered to reflect the confines of their illness.Beyond physical comorbidities, the clinician was tasked with considering the psychological factors when determining success.It is appropriate to set realistic, personalised goals that take into account the patient's physical condition, motivational level, social support, stress level and other psychological factors.Often normalisation of BMI is not a realistic goal.Instead, an initial goal of 5-10% weight loss over 6 months will help reduce comorbidities significantly.(Singapore, G14).
success are directly (weight loss defined or undefined, weight management) or indirectly (body composition) related to weight loss.4.3.2| Management of expectations Management of expectations demonstrated that success was a reflection of what was expected and only considered achieved if expectations were met; success, therefore, reflected the balance between clinician and individual's expectations.The guidelines presented variation in terms of what constituted the clinicians' expectations compared with individuals' expectations.These variances were often presented as problematic, differences in expectations could result in emotional consequences for the individual.It was often stated that both needed to reach an agreement.While weight loss of 5-10% of original weight constitutes medically defined success and has clear health benefits, it may still leave the patient with a sense of frustration and even failure.(Singapore, G14).People often have unrealistic expectations of how much weight loss is feasible, which can be reinforced by media reports of weight loss 'success stories'.(Australia, G3).The terms 'realistic' and 'unrealistic' were used to reinforce the insinuation that patients had naive expectations about their obesity management and, therefore, it was the clinician's role to manage expectations or reframe them.As discussed in the previous theme, the clinician's role involves knowledge dissemination, including the interpretation and presentation of evidence, which has a part to play in expectation management.Ensuring effective communication with individuals with different levels of health literacy was assumed to aid in ensuring individuals living with obesity understand the evidence and develops realistic expectations for obesity management.

2 4
IntervenƟons Pharmacotherapy Obesity Management Overall Undefined F I G U R E 3 Definitions of success by type of management across each included guideline.Measure of success associated with type of management across all included guidelines.An example of theme development.specifically where guidelines encouraged a focus on health improvement rather than aesthetic change: note the final quote in the previous theme, which stated that '[weight loss] does not provide the cosmetic benefit that patients are looking for'.The principal outcome and therapeutic target in the treatment of obesity should be to improve the health of the patient by preventing or treating weight-related complications using weight loss, not the loss of body weight per se (AACE, G1).Helpful actions in primary care consultations to mitigate anti-fat stigma include … redefining success as healthy behaviour change regardless of body size or weight (Canada, G4).By giving the clinicians the responsibility to reframe patient's expectations, they were given control and positioned as the arbiters of success.As described in an earlier theme, clinicians based their decisions on the knowledge available (see 4.3.1).Some of this knowledge was what they perceived about the individual.They may perceive an individual as motivated to lose weight or motivated to make a behavioural change and, thereby, define the measure of success (weight loss or behaviour change) by their perception of the individuals' capabilities.There are 3 keys to potential success: 1 The perceived importance of change must be high.2 The patient feels confident in his/her ability to change behaviour.3 This change is a priority the patient.It's the right moment to do it.(European, G6).
or implied when describing what was considered a failure: the opposite of success.The definitions of success most commonly used throughout the guidelines were those that reflected clinical outcomes T A B L E 5 Number of definitions of success associated with the type of management across all included guidelines.
ment was not described.The reviewers undertaking this synthesis were not clinicians and had limited perspectives of clinical judgement in practice.It is unknown if clinical judgement varies by patient population or disease area and if that has any impact on success beyond what was derived by the reviewers.Further, a limitation of using clinical practice guidelines to reflect clinical practice is that clinical judgement goes beyond what is included in practice guidelines and recommendations within these guidelines may not provide a true picture of obesity management.46 7 | CONCLUSIONThis review was exploratory in nature, setting out to understand how success is defined and framed.Our review reinforces that success in obesity management is an inherently subjective and complex concept reflected in the lack of a standard or explicit definition in obesity management guidelines.Defining success was seen as an activity that largely fell to clinicians.Clinicians were encouraged to take account of individual needs and values while limiting the definitions to the existing data.Success was framed by the perceptions of who was in control of making decisions for how to define success.The review demonstrates how the choice of language can impact both the perception and interpretation of the guidelines.More research is needed to understand how language impacts the relationship between individuals living with obesity and clinicians and to investigate how control is perceived in practice.Future research in obesity management should continue to focus on outcomes beyond weight loss to support the development of more holistic definitions of success.AUTHOR CONTRIBUTIONS Nicole Juul-Hindsgaul, Anne-Marie Boylan, Jamie Hartmann-Boyce and David Nunan were involved with the conception of the review.NJ carried out the electronic search, screening of references and preliminary analysis of data.Nicole Juul-Hindsgaul and Zahra Alalwani completed the full-text screening.All authors were involved in writing and reviewing the paper and had final approval of the submitted and published versions.
Overview of included guidelines including description of methods, scope and stakeholders involved in development.
Committee chair was expert with guideline development processes without specific expertise in the prevention and management of obesity.Committee members had relevant experience with obesity management (e.g., academics) Consumer representation was sought.Public consultation (e.g., health departments, nongovernment organisations, health services and individuals) Executive and steering committee with broad expertise (e.g., clinicians).Committee include person living with obesity (PwO).Engagement with indigenous community members.Authors include experts in field of obesity management (e.g., clinicians and academics) G7 Germany 26 2014 Expert group for Guideline development.Literature search and evaluation of evidence using German Agency for Quality in Medicine.Selection and evaluation of studies were conducted in accordance with SIGN.Recommendations Not described Expert Group made up of experts from medical societies and organisations (e.g., clinicians and academics) T A B L E 2 (Continued) 2004 Systematic review of relevant published literature (up to 2004).Included other reports SIGN and AACE/ACE.Treatment strategies have been graded based on the levels of evidence.Guideline initiated by the Malaysian Association for the Study of Obesity and the Malaysian Endocrine and Metabolic Society.Guideline to assist healthcare providers to better diagnose and manage overweight and obese patients.Guidelines are consistent with other similar guidelines and are developed with the expectation of improving the overall health care system in Malaysia.Committee members made up of experts in the field of obesity management (e.g., clinicians and academics) American Association of Clinical Endocrinology; ACE, American College of Endocrinology; AHA, American Heart Association; ACC, American College of Cardiology; TOS, The Obesity Society; NICE, National Institute for Health and Care Excellence; SIGN, Scottish Intercollegiate Guidelines Network; UAE, United Arab Emirates; WGO, World Gastroenterology Organisation.
a Definitions of success that were explicitly related to obesity management overall regardless of intervention type chosen.R. b Undefined treatment was unclear for which treatment was meant.