Methods for Evaluating Natural Experiments in Obesity: A Systematic Review

Ann Intern Med. 2018 Jun 5;168(11):791-800. doi: 10.7326/M18-0309. Epub 2018 May 1.


Background: Given the obesity pandemic, rigorous methodological approaches, including natural experiments, are needed.

Purpose: To identify studies that report effects of programs, policies, or built environment changes on obesity prevention and control and to describe their methods.

Data sources: PubMed, CINAHL, PsycINFO, and EconLit (January 2000 to August 2017).

Study selection: Natural experiments and experimental studies evaluating a program, policy, or built environment change in U.S. or non-U.S. populations by using measures of obesity or obesity-related health behaviors.

Data extraction: 2 reviewers serially extracted data on study design, population characteristics, data sources and linkages, measures, and analytic methods and independently evaluated risk of bias.

Data synthesis: 294 studies (188 U.S., 106 non-U.S.) were identified, including 156 natural experiments (53%), 118 experimental studies (40%), and 20 (7%) with unclear study design. Studies used 106 (71 U.S., 35 non-U.S.) data systems; 37% of the U.S. data systems were linked to another data source. For outcomes, 112 studies reported childhood weight and 32 adult weight; 152 had physical activity and 148 had dietary measures. For analysis, natural experiments most commonly used cross-sectional comparisons of exposed and unexposed groups (n = 55 [35%]). Most natural experiments had a high risk of bias, and 63% had weak handling of withdrawals and dropouts.

Limitation: Outcomes restricted to obesity measures and health behaviors; inconsistent or unclear descriptions of natural experiment designs; and imperfect methods for assessing risk of bias in natural experiments.

Conclusion: Many methodologically diverse natural experiments and experimental studies were identified that reported effects of U.S. and non-U.S. programs, policies, or built environment changes on obesity prevention and control. The findings reinforce the need for methodological and analytic advances that would strengthen evaluations of obesity prevention and control initiatives.

Primary funding source: National Institutes of Health, Office of Disease Prevention, and Agency for Healthcare Research and Quality. (PROSPERO: CRD42017055750).

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, U.S. Gov't, P.H.S.
  • Systematic Review

MeSH terms

  • Adult
  • Bias
  • Built Environment
  • Child
  • Diet, Reducing
  • Exercise
  • Health Behavior
  • Health Policy
  • Humans
  • Obesity / prevention & control*
  • Program Evaluation
  • Research Design
  • United States