I. INTRODUCCIÓN
1.3 Teorías relacionadas al tema
1.3.1 Inteligencia emocional
Aim of the literature search
Three separate literature searches were undertaken to identify studies to answer the following questions: 1. How accurately do measures of childhood obesity predict CVD, diabetes and/or cancer in adulthood? 2. Which simple measure of obesity in children most accurately predicts the tracking of obesity into
adolescence and adulthood?
3. How accurately do simple measures of obesity reflect actual adiposity in children (actual adiposity in terms of ability to correctly classify a child as normal weight, overweight or obese)?
The three search strategies were devised using a combination of indexed subject heading terms and free-text search terms appearing in the title and/or abstract of database records. Search terms were
identified through discussion within the project team, by scanning background literature and‘key articles’
already known to the project team and by browsing database thesauri. The search strategies were peer reviewed for accuracy by other information specialists based at CRD (Lisa Stirk and Melissa Harden). Once the MEDLINE search strategies were agreed and peer reviewed, they were adapted so that they could be used in the other databases. Bibliographic records were managed using EndNote XI bibliographic management software (Thomson Reuters, CA, USA).
Full details of the search strategies, dates of searches and results from all the databases and resources searched are given in Appendix 1.
Concepts of the search strategy
All three search strategies included a set of search terms for the following three concepts:‘obesity’,
‘children’ and a collection of ‘simple anthropometric measures’ (index tests). The ‘obesity’ concept included
search terms for‘adiposity’. As BMI is the most widely used and recognised simple anthropometric
measure for obesity, using this as a search term inevitably increased the sensitivity of the search strategy and the volume of literature retrieved.
The database searches were supplemented with reference checking and citation searching, as well as additional targeted searches for any gaps in the literature identified after screening of the initial set of literature search results.
The search strategy for the question on the prediction of adult morbidities was structured using the following concepts:
(Obesity OR adiposity) AND
AND
(CVD OR diabetes OR cancer)
An initial search to identify only systematic reviews was conducted, and the searches were limited to the Database of Abstracts of Reviews of Effects (DARE), the Cochrane Database of Systematic Reviews (CDSR), the Database of Promoting Health Effectiveness Reviews (DoPHER) and MEDLINE (with a methodological search filter designed to retrieve systematic reviews).
Having assessed the systematic reviews of measures for predicting morbidity in adulthood, the team was able to identify gaps in the literature and decided on the limits for the searches for primary studies. Targeted searches were conducted for the combinations of measures and morbidities shown in Table 1. For the review question on the tracking of obesity, the search strategy was structured using the
following concepts: (Obesity OR adiposity) AND
IT AND
(Tracking OR Cohort studies OR longitudinal studies OR follow-up studies) AND (Children OR adolescents) AND Adults AND Date limit (2007–2013)
TABLE 1 Specification for targeted searches
Measures Morbidities Update from
BMI CVD, diabetes and cancer 2011
SFT CVD and diabetes 2008
SFT Cancer All dates
WC CVD and diabetes 2008
WC Cancer All dates
All other measures CVD, diabetes and cancer All dates
During the initial scoping searches, a systematic review about‘tracking’ of childhood obesity into
adulthood was identified [Singh et al. (2008)],16and it was therefore decided to limit the searches to run
from the date when the searches for this review were completed (2007). The final agreed search strategy was unable to identify one of the Singh review included studies, owing to the absence of any terms for ‘tracking’ or study design in the title or abstract and inadequate subject heading indexing.
The diagnostic accuracy literature searches were designed to identify studies that compared index tests
with reference standards, so both concepts were combined alongside terms for‘obesity’ and ‘children’.
The diagnostic accuracy search strategy was structured using the following concepts: (Obesity OR adiposity) AND (Children OR adolescents) AND Index tests AND Reference standards NOT Animal studies
Initially, the search for studies on the acceptability of simple measures was to be conducted for those tests previously determined to be the most promising measures in terms of predictive accuracy. However, given the lack of non-BMI studies, searches were designed to retrieve qualitative studies about the accessibility and ease of use of the following simple measures of obesity: BMI, SFT, WHR and WHtR. The searches were limited to the following databases: MEDLINE, EMBASE, PsycINFO and Cumulative Index to Nursing and
Allied Health Literature (CINAHL). They were also limited by date range (2008–13).
Resources searched
The literature searches involved searching a wide range of databases. The following databases and resources were searched:
l MEDLINE (OvidSP)
l MEDLINE In-Process & Other Non-Indexed Citations (OvidSP)
l PubMed (National Library of Medicine)
l EMBASE (OvidSP)
l PsycINFO (OvidSP)
l CINAHL (EBSCO)
l CDSR (Wiley Online Library)
l Cochrane Central Register of Controlled Trials (CENTRAL) (Wiley Online Library)
l DARE (CRD interface)
l Health Technology Assessment (HTA) Database (CRD interface)
l NHS Economic Evaluation Database (NHS EED) (CRD interface)
l Science Citation Index (SCI) [ISI Web of Science (WoS)]
l Conference Proceedings Citation Index– Science (CPCI-S) (ISI WoS)
l Trials Register of Promoting Health Interventions [Evidence for Policy and Practice Information and Co- ordinating Centre (EPPI-Centre) interface]
l DoPHER (EPPI-Centre interface)
l Obesity and Sedentary Behaviour Database (EPPI-Centre interface)
l OAIster (http://oaister.worldcat.org/)
l OpenGrey (www.opengrey.eu/).
The following obesity-related organisation websites were searched:
l Public Health England– Obesity Knowledge and Intelligence (previously National Obesity Observatory)
(www.noo.org.uk/)
l Association for the Study of Obesity (www.aso.org.uk/)
l Obesity Learning Centre (www.obesitylearningcentre.org.uk/)
l National Obesity Forum (www.nationalobesityforum.org.uk/)
l British Dietetic Association (www.bda.uk.com/index.html)
l Centre for Diet and Activity Research (CEDAR) (www.cedar.iph.cam.ac.uk/)
l The Nutrition Society (www.nutritionsociety.org/)
l International Association for the Study of Obesity (www.iaso.org/)
l European Association for the Study of Obesity (EASO) (www.easoobesity.org/)
l European Congress on Obesity (www.easo.org/eco2013)
l European Childhood Obesity Group (ECOG) (www.ecog-obesity.eu/)
l Centers for Disease Control and Prevention (CDC) Division of Nutrition, Physical Activity, and Obesity
(USA) (www.cdc.gov/nccdphp/dnpao/index.html)
l Weight-control Information Network (USA) (http://win.niddk.nih.gov/)
l The Obesity Society (USA) (www.obesity.org/)
l myhealthywaist.org (International Chair on Cardiometabolic Risk of Université Laval– QC, Canada)
(www.myhealthywaist.org/).
Citation searches were conducted in SCI and Google Scholar. All sources proposed in the protocol are listed above.
Inclusion criteria
As systematic reviews had already been conducted for questions 1 and 2, good-quality systematic reviews that could be used as a basis for the current review were sought for these questions. Given the nature of the data required for meta-analysis, many studies included for these questions may be of cohorts recruited when influences in childhood were most likely different to those experienced by the present-day child population. However, reviews where such older cohorts are included were not excluded from the review. Review of prediction of adult morbidities
l Outcomes The study had to report RRs, odds ratios (ORs), hazard ratios (HRs) or summary estimates of
predictive accuracy, or sufficient data from which these could be derived, for the association between childhood obesity and adult CVD, type 2 diabetes or cancer. For the purposes of this review, CVD incorporated major cardiovascular events such as cardiovascular death, myocardial infarction, stroke, heart failure, hypertension, hypercholesterolaemia and metabolic syndrome.
l Interventions Data for the following simple measures were included: BMI, NC, WC, WHR, WHtR, BAI,
Rohrer’s Ponderal Index, Benn’s Index, FMI, SFT, BIA and NIR. Studies were included for each of these
measures, regardless of how the measurement was conducted (i.e. any level at which WC was measured was eligible).
l Study design Prospective, longitudinal studies that were sufficiently powered (1000 participants) and
that evaluated any one of the interventions of interest used in childhood for the prediction of a
morbidity of interest in adolescence or adulthood were eligible; case–control studies and retrospective
There are many other types of morbidity where evidence of an association with obesity exists, including mental health problems, respiratory conditions and musculoskeletal conditions, among others. This review considered only cardiovascular conditions, diabetes, cancer and metabolic syndrome, in order to focus on those conditions most likely to lead to mortality, where the evidence of association with obesity was strongest, and where there was most likely to be long-term evidence in cohort studies of their association with childhood obesity.
Tracking of childhood obesity into adolescence/adulthood or adolescent obesity into adulthood
l Population Studies recruiting children and/or adolescents (up to the age of 18 years) were eligible for
inclusion. Studies recruiting a mixture of adults and children/adolescents were included if the results for children/adolescents were reported separately. Studies had to recruit either population-based samples of children or overweight/obese children; studies conducted only in children who were not overweight or obese were excluded. We accepted the definition of obesity/adiposity used in the study.
l Interventions Data for the following simple measures were sought: BMI, NC, WC, WHR, WHtR, BAI,
Ponderal Index, Benn’s Index, FMI, SFT, BIA and NIR. Studies were included for each of these measures,
regardless of how the measurement was conducted (i.e. any level at which WC was measured was eligible).
l Outcomes The study had to report estimates of test accuracy, or sufficient data from which these
could be derived, for the association between the weight status in childhood and/or adolescence and the incidence of obesity/overweight in adulthood. This was a change from the protocol, required as data on the association between weight status in childhood and adulthood would be insufficient to assess the predictive accuracy of childhood obesity/overweight. Studies that reported only correlations between the childhood and adult measures were also excluded.
l Study design Prospective, longitudinal studies that evaluate any one of the interventions of interest
were eligible; case–control studies and retrospective studies were excluded. Inclusion was initially
restricted to studies that recruited at least 100 children; this was increased to 1000 children in studies of BMI given the volume of evidence available and so as to include only well-powered studies. As inclusion was restricted to those studies where predictive accuracy of the anthropometric measure could be established, only studies that used an acceptable reference standard in adulthood
[i.e. a multicomponent model, D2O, underwater (hydrostatic) weighting, ADP or DEXA] were included.
BMI was added to the list of reference standards as it is generally accepted as a suitable estimate in adults and we expected it to be the most commonly used adult measure (see Appendix 2). The diagnostic accuracy of childhood measures of obesity
l Population Studies recruiting children and/or adolescents (up to the age of 18 years as defined in the
NICE CG43 obesity guidelines) were eligible for inclusion. Studies recruiting a mixture of adults and children/adolescents were included if the results for children/adolescents were reported separately. Studies had to recruit either a population-based sample of children or overweight/obese children; studies conducted only in children who were not overweight or obese were excluded.
l Interventions The following simple measures were evaluated: BMI, NC, WC, WHR, WHtR, BAI,
Ponderal Index, Benn’s Index, FMI, SFT, BIA and NIR.
l Reference standard A multicomponent model that measures four or five components was considered
the gold standard for assessing the accuracy of simple anthropometric measures of adiposity in children, because the precision of such a model is considered to be higher than other complex
measures. The other complex measures, such as DEXA, D2O and densitometry [underwater (hydrostatic)
weighting or ADP], were accepted as reference standards as they are more commonly used in research studies; these were considered imperfect reference standards.
l Outcomes The study had to report either summary estimates of diagnostic accuracy or sufficient data
l Study design Prospective single-gate (diagnostic cohort) studies that evaluated any one of the interventions of interest in comparison with any one of the reference standards were eligible for inclusion. For measures for which these are not available, prospective two-gate (diagnostic
case–control) studies were included; these had to match cases and controls on at least age and sex, or
provide estimates of sensitivity and specificity that had been adjusted for these variables. The acceptability and ease of use of childhood measures of obesity
The original intention was to identify primary studies that undertook a robust evaluation (such as the use of questionnaires or interviews) of the acceptability and ease of the most promising measure(s) in terms of diagnostic and predictive accuracy. Given that the majority of the data identified were for BMI, this was amended to a search for studies of acceptability and ease of use for the four measures most commonly used in clinical practice: BMI, SFT, WHR and WHtR. Studies could be from the perspective of the child, parent or health professional. Studies that discussed acceptability or ease of implementation with no direct measurement were not included. Given the recent changes in distribution across the population, the emphasis placed on education and intervention for obesity and general attitudes towards obesity, the inclusion of primary studies was initially restricted to those conducted within the previous 5 years (search start date 2008). It was expected that the number of studies addressing this issue would be small. Only one study was identified that met the inclusion criteria.73Two further studies were identified from the searches for questions 1, 2 and 3 that were
published in 200674and 2007;75given the paucity of evidence, the results of these are also presented.
To supplement the systematic review, a simple elicitation exercise (survey) was performed to obtain some indication of the attitudes of children, school nurses and parents to the measures being evaluated. Ethical approval from the Carnegie Faculty Committee, Leeds Metropolitan University, UK, was obtained. Overweight and obese children attending a weight management summer camp, parents of the children attending the weight management camp and school nurses were asked to complete a structured questionnaire developed specifically for the project that was suitable for the age group concerned. Opinions were elicited for the same four measures being evaluated in the systematic review of acceptability and ease of use: BMI, SFT, WHR and WHtR.