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, 19 (1), 178

Hierarchies of Evidence Applied to Lifestyle Medicine (HEALM): Introduction of a Strength-Of-Evidence Approach Based on a Methodological Systematic Review


Hierarchies of Evidence Applied to Lifestyle Medicine (HEALM): Introduction of a Strength-Of-Evidence Approach Based on a Methodological Systematic Review

D L Katz et al. BMC Med Res Methodol.


Background: Current methods for assessing strength of evidence prioritize the contributions of randomized controlled trials (RCTs). The objective of this study was to characterize strength of evidence (SOE) tools in recent use, identify their application to lifestyle interventions for improved longevity, vitality, or successful aging, and to assess implications of the findings.

Methods: The search strategy was created in PubMed and modified as needed for four additional databases: Embase, AnthropologyPlus, PsycINFO, and Ageline, supplemented by manual searching. Systematic reviews and meta-analyses of intervention trials or observational studies relevant to lifestyle intervention were included if they used a specified SOE tool. Data was collected for each SOE tool. Conditions necessary for assigning the highest SOE grading and treatment of prospective cohort studies within each SOE rating framework were summarized. The expert panel convened to discuss the implications of findings for assessing evidence in the domain of lifestyle medicine.

Results and conclusions: A total of 15 unique tools were identified. Ten were tools developed and used by governmental agencies or other equivalent professional bodies and were applicable in a variety of settings. Of these 10, four require consistent results from RCTs of high quality to award the highest rating of evidence. Most SOE tools include prospective cohort studies only to note their secondary contribution to overall SOE as compared to RCTs. We developed a new construct, Hierarchies of Evidence Applied to Lifestyle Medicine (HEALM), to illustrate the feasibility of a tool based on the specific contributions of diverse research methods to understanding lifetime effects of health behaviors. Assessment of evidence relevant to lifestyle medicine requires a potential adaptation of SOE approaches when outcomes and/or exposures obviate exclusive or preferential reliance on RCTs. This systematic review was registered with the International Prospective Register of Systematic Reviews, PROSPERO [CRD42018082148].

Keywords: HEALM; Lifestyle medicine; Lifetime effects; SOE; Strength of evidence; Systematic review.

Conflict of interest statement

MC was a consultant to the National Academy of Sciences, Engineering, and Medicine’s Dietary Reference Intakes panel on sodium and potassium and also has received funding from Agency for Healthcare Research and Quality to conduct systematic reviews but declares no competing interests. All other authors declare that no competing interests exist.


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PRISMA flow diagram

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