***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: The number of published systematic review s of studies of healthcare interventions has increased rapidly and these are used extensively for clinical and policy decisions . Systematic review s are subject to a range of biases and increasingly include non-r and omised studies of interventions . It is important that users can distinguish high quality review s. Many instruments have been design ed to evaluate different aspects of review s , but there are few comprehensive critical appraisal instruments . AMSTAR was developed to evaluate systematic review s of r and omised trials . In this paper , we report on the updating of AMSTAR and its adaptation to enable more detailed assessment of systematic review s that include r and omised or non-r and omised studies of healthcare interventions , or both . With moves to base more decisions on real world observational evidence we believe that AMSTAR 2 will assist decision makers in the identification of high quality systematic review s , including those based on non-r and omised studies of healthcare interventions Objectives Assisting patients in lifestyle change using collaborative e-health tools can be an efficient treatment for non-communicable diseases like diabetes , cardiovascular disease and chronic obstructive lung disease that are caused or aggravated by unhealthy living in the form of unhealthy diet , physical inactivity or tobacco smoking . In a prospect i ve pilot study , we tested an online collaborative e-health tool in general practice . The aim of this study was to identify drivers of importance for long-term personal lifestyle changes from a patient perspective when using a collaborative e-health tool , including the support of peers and healthcare professionals . Setting General practice clinics in the Region of Southern Denmark . Participants 10 overweight patients who had previously successfully used a hybrid online collaborative e-health tool with both face-to-face and online consultations  to lose weight . Results The main themes identified were facilitators , barriers and support from family and peers . Establishment of a trustworthy relationship with the healthcare professionals was of paramount importance . It was important for the patients to monitor the measurable outcomes with realistic goals and feedback from a trusted person . Often , significant life events were identified as catalysts for successful long-term lifestyle changes . Dominant barriers to change were perception of insurmountable obstacles , experience of lack of self-efficacy and excess eating of high-calorie food . Finally , experiencing of trustworthy person-to-person forums , need for acknowledgement from referent others and support from family and peers were important drivers for long-term lifestyle change . Conclusion The most important driver in long-term weight loss was a strong relationship with a healthcare professional . Collaborative e-health tools can support the relationship and behavioural changes through monitoring and providing relevant feedback . The support from family and peers also matters , and long-term success depends on the ability to establish strong , positive support on a day-to-day basis to test early  nutritional interventions  and prospect i ve observational cohorts . RCTs are generally accepted as method ologically the best approach for informing health policy . They can equalise unknown as well as known confounding factors and so can demonstrate causation ; they permit estimation of effect size and so can be used to assess likely Flaws in the design , conduct , analysis , and reporting of r and omised trials can cause the effect of an intervention to be underestimated or overestimated . The Cochrane Collaboration ’s tool for assessing risk of bias aims to make the process clearer and more CONTEXT Given the obesity epidemic , effective but re source -efficient weight loss treatments are needed . Stepped-treatment approaches customize interventions based on milestone completion and can be more effective while costing less to administer than conventional treatment approaches . OBJECTIVE To determine whether a stepped-care weight loss intervention ( STEP ) compared with a st and ard behavioral weight loss intervention ( SBWI ) would result in greater weight loss . DESIGN , SETTING , AND PARTICIPANTS A r and omized clinical trial of 363 overweight and obese adults ( body mass index : 25-<40 ; age : 18 - 55 years , 33 % nonwhite , and 83 % female ) who were r and omized to SBWI ( n = 165 ) or STEP ( n = 198 ) at 2 universities affiliated with academic medical centers in the United States ( Step-Up Study ) . Participants were enrolled between May 2008 and February 2010 and data collection was completed by September 2011 . INTERVENTIONS All participants were placed on a low-calorie diet , prescribed increases in physical activity , and attended group counseling sessions ranging from weekly to monthly during an 18-month period . The SBWI  group was assigned to a fixed program . Counseling frequency , type , and weight loss strategies could be modified every 3 months for the STEP group in response to observed weight loss as it related to weight loss goals . MAIN OUTCOME MEASURE Mean change in weight over 18 months . Additional outcomes included resting heart rate and blood pressure , waist circumference , body composition , fitness , physical activity , dietary intake , and cost of the program . RESULTS Of the 363 participants r and omized , 260 ( 71.6 % ) provided a measure of mean change in weight over 18 months . The 18-month intervention result ed in weight decreasing from 93.1 kg ( 95 % CI , 91.0 to 95.2 kg ) to 85.6 kg ( 95 % CI , 83.4 to 87.7 kg ) ( P < .001 ) in the SBWI group and from 92.7 kg ( 95 % CI , 90.8 to 94.6 kg ) to 86.4 kg ( 95 % CI , 84.5 to 88.4 kg ) in the STEP group ( P < .001 ) . The percentage change in weight from baseline to 18 months was -8.1 % ( 95 % CI , -9.4 % to -6.9 % ) in the SBWI group ( P < .001 ) compared with -6.9 % ( 95 % CI , -8.0 % to -5.8 % ) in the STEP group ( P < .001 ) . Although the between-group difference in 18-month weight loss was not statistically different ( -1.3 kg [ 95 % CI , -2.8 to 0.2 kg ] ; P = .09 ) , there was a significant group × time interaction effect ( P = .03 ) . The cost per participant was $ 1357 ( 95 % CI , $ 1272 to $ 1442 ) for the SBWI group vs $ 785 ( 95 % CI , $ 739 to $ 830 ) for the STEP group ( P < .001 ) . Both groups had significant and comparable improvements in resting heart rate , blood pressure level , and fitness . CONCLUSIONS Among overweight and obese adults , the use of SBWI result ed in a greater mean weight loss than STEP over 18 months . Compared with SBWI , STEP result ed in clinical ly meaningful weight loss that cost less to implement . TRIAL REGISTRATION clinical trials.gov Identifier : NCT00714168 Non-r and omised studies of the effects of interventions are critical to many areas of healthcare evaluation , but their results may be biased . It is therefore important to underst and and appraise their strengths and weaknesses . We developed ROBINS-I ( “ Risk Of Bias In Non-r and omised Studies - of Interventions ” ) , a new tool for evaluating risk of bias in estimates of the comparative effectiveness ( harm or benefit ) of interventions from studies that did not use r and omisation  to allocate units ( individuals or clusters of individuals ) to comparison groups . The tool will be particularly useful to those undertaking systematic review s that include non-r and omised studies Background It is unclear whether the common physical activity ( PA ) intensity descriptors used in PA guidelines worldwide align with the associated percent heart rate maximum method used for prescribing relative PA intensities consistently between sexes , ethnicities , age categories and across body mass index ( BMI ) classifications . Objectives The objectives of this study were to determine whether individuals properly select light , moderate and vigorous intensity PA using the intensity descriptions in PA guidelines and determine if there are differences in estimation across sex , ethnicity , age and BMI classifications . Methods 129 adults were instructed to walk/jog at a “ light , ” “ moderate ” and “ vigorous effort ” in a r and omized order . The PA intensities were categorized as being below , at or above the following % HRmax ranges of : 50–63 % for light , 64–76 % for moderate and 77–93 % for vigorous effort . Results On average , people correctly estimated light effort as 51.5±8.3%HRmax but underestimated moderate effort as 58.7±10.7%HRmax and vigorous effort as 69.9±11.9%HRmax . Participants walked at a light intensity ( 57.4±10.5%HRmax ) when asked to walk at a pace that provided health benefits , wherein 52 % of participants walked at a light effort pace , 19 % walked at a moderate effort and 5 % walked at a vigorous effort pace . These results did not differ by sex , ethnicity or BMI class . However , younger adults  underestimated moderate and vigorous intensity more so than middle-aged adults ( P<0.05 ) . Conclusion When the common PA guideline descriptors were aligned with the associated % HRmax ranges , the majority of participants underestimated the intensity of PA that is needed to obtain health benefits . Thus , new subjective descriptions for moderate and vigorous intensity may be warranted to aid individuals in correctly interpreting PA intensities BACKGROUND : Previous studies suggest that few individuals achieve long-term weight loss maintenance . Because most of these studies were based on clinical sample s and focused on only one episode of weight loss , these results may not reflect the actual prevalence of weight loss maintenance in the general population . DESIGN : A r and om digit dial telephone survey was conducted to determine the point prevalence of  weight loss maintenance in a nationally representative sample of adults in the United States . Weight loss maintainers were defined as individuals who , at the time of the survey , had maintained a weight loss of ≥10 % from their maximum weight for at least 1 y. The prevalence of weight loss maintenance was first determined for the total group ( n=500 ) , and then for the subgroup of individuals who were overweight ( body mass index BMI ≥27kg/m2 at their maximum ( n=228 ) . RESULTS : Weight loss was quite common in this sample : 54 % of the total sample and 62 % of those who were ever overweight reported that they had lost ≥10 % of their maximum weight at least once in their lifetime , with approximately one-half to two-thirds of these cases being intentional weight loss . Among those who had achieved an intentional weight loss of ≥10 % , 47–49 % had maintained this weight loss for at least 1 y at the time of the survey ; 25–27 % had maintained it for 5 y or more . Fourteen percent of all subjects surveyed and 21 % of those with a history of obesity were currently 10 % below their highest weight , had reduced intentionally , and had maintained this 10 % weight loss for at least 1 y. CONCLUSIONS : A large proportion of the American population has lost ≥10 % of their maximum weight and has maintained this weight loss for at least 1 y. These findings are in sharp contrast to the belief that few people succeed in long-term weight loss maintenance Importance Effective long-term treatments are needed to address the obesity epidemic . Numerous wearable technologies specific to physical activity and diet are available , but it is unclear if these are effective at improving weight loss . Objective To test the hypothesis that , compared with a st and ard behavioral weight loss intervention ( st and ard intervention ) , a technology-enhanced weight loss intervention ( enhanced intervention ) would result in greater weight loss . Design , Setting , Participants R and omized clinical trial conducted at the University of Pittsburgh and enrolling 471 adult participants between October 2010 and October 2012 , with data collection completed by December 2014 . Interventions Participants were placed on a low-calorie diet , prescribed increases in physical activity , and had group counseling sessions . At 6 months , the interventions added telephone counseling sessions , text message prompts , and access to study material s on a website . At 6 months , participants r and omized to the st and ard intervention group initiated self-monitoring of diet and physical activity using a website , and those r and omized to the enhanced intervention group were provided with a wearable device and accompanying web interface to monitor diet and physical activity . Main Outcomes and Measures The primary outcome of weight was measured over 24 months at 6-month intervals , and the primary hypothesis tested the change in weight between 2 groups at 24 months . Secondary outcomes included body composition , fitness , physical activity , and dietary intake . Results Among the 471 participants r and omized ( body mass index [ BMI ] , 25 to < 40 ; age range , 18 - 35 years ; 28.9 % nonwhite , 77.2 % women ) , 470 ( 233 in the st and ard intervention group , 237 in the enhanced intervention group ) initiated the interventions as r and omized , and 74.5 % completed the study . For the enhanced intervention group , mean base line weight was 96.3 kg ( 95 % CI , 94.2 - 98.5 ) and 24-month weight 92.8 kg ( 95 % CI , 90.6- 95.0 ) [ corrected ] . For the st and ard intervention group , mean baseline weight was 95.2 kg ( 95%CI,93.0 - 97.3 ) and 24-month weight was 89.3 kg ( 95%CI , 87.1 - 91.5 ) [ corrected ] . Weight change at 24 months differed significantly by intervention group ( estimated 
    Output:
    
The interventions delivered by wearable devices did not show a benefit over comparator interventions , but overweight and obese participants still lost weight over time .
This review showed some evidence that wearable devices can improve long-term physical activity and weight loss outcomes , but there was not enough evidence to show a benefit over the comparator methods .