Authors: Ximena Ramos Salas, Brad Hussey, Susie Birney, Cathy Breen, Michael Crotty, Kajsa Järvholm, Vicki Mooney, Erla Sveinsdóttir, Jack Hussey, Euan Woodward, Volkan Yumuk
Categories: Research Article, Clinical practice guidelines, Obesity, Obesity care
Source: Obesity Facts
Doi: 10.1159/000549374
Authors: Ximena Ramos Salas, Brad Hussey, Susie Birney, Cathy Breen, Michael Crotty, Kajsa Järvholm, Vicki Mooney, Erla Sveinsdóttir, Jack Hussey, Euan Woodward, Volkan Yumuk
Obesity is a chronic, progressive, and recurring disease that contributes significantly to multi-morbidity across Europe. Despite the publication of numerous clinical practice guidelines (CPGs) for obesity, many chronic disease guidelines for obesity-related diseases such as diabetes, MASLD, heart disease, and obstructive sleep apnoea do not integrate contemporary understandings of obesity as an adiposity-based disease requiring direct management in its own right. The objective of this qualitative content analysis was to evaluate the extent to which recent chronic disease CPGs align with current evidence-based obesity guidance.
A working group convened by the European Association for the Study of Obesity reviewed 13 chronic disease CPGs published since 2019. Guidelines were assessed using nine predefined criteria based on leading obesity CPGs. Data were extracted, and content analysis was used to identify gaps and opportunities across the chronic disease CPGs.
Three key themes were (1) inconsistent scientific/medical conceptualization of obesity, (2) limited integration of evidence-based obesity management guidance, and (3) minimal inclusion of person-centred care principles. Most guidelines treated obesity as a risk factor, not a disease, and lacked reference to contemporary obesity frameworks or person-first language.
Greater alignment across CPGs is essential to improve obesity care within multi-morbidity management. Collaborative, cross-speciality approaches are recommended to harmonize clinical guidance and promote integrated, stigma-free care.
As a serious, progressive, and recurring chronic disease that contributes significantly to multi-morbidity and poor population health outcomes across the world, obesity requires comprehensive, long-term and patient-centred care [1, 2]. Despite substantial advances in understanding obesity as an adiposity-based chronic disease, many chronic disease clinical practice guidelines (CPGs) continue to frame obesity primarily as a risk factor rather than a disease requiring direct, long-term management. In 2019, an estimated 16.5% of adults in the European Union were living with obesity, while 36% were living with overweight [3].
Multi-morbidity (two or more chronic conditions) affects nearly 40% of adults in Europe and obesity is associated with over 200 health conditions as both a risk factor and disease modifier [4–8]. Yet, healthcare systems and CPGs often remain organized around single diseases, limiting integration across conditions and failing to account for the shared biological and behavioural mechanisms that link them.
CPGs are a tool guiding evidence-based care and improved patient outcomes [9]. However, variation in how chronic disease CPGs define, assess, and manage obesity can create inconsistencies in clinical recommendations and hinder effective treatment.
A 2024 publication in The Lancet Diabetes & Endocrinology highlights the evolving paradigm in obesity care, emphasizing that clinical diagnosis should be based on alterations in the function of tissues, organs, the entire individual, or a combination thereof due to excess adiposity rather than weight alone [10]. This perspective aligns with the shift seen in modern obesity CPGs, including the European Association for the Study of Obesity (EASO) obesity management framework, which view obesity as an adiposity-based chronic disease requiring comprehensive, long-term management aimed at improving health and wellbeing – not solely on reducing weight [2]. Despite the development of numerous obesity-specific CPGs across Europe, implementation remains limited [11, 12].
One strategy to improve uptake is integrating obesity guidance within chronic disease frameworks, thereby ensuring consistency and promoting comprehensive, stigma-free care [3, 11]. Our review extends this work by examining how chronic disease CPGs operationalize these principles – particularly how they frame obesity management in relation to health and functional improvements beyond weight reduction.
The objective of this qualitative content analysis was to evaluate the extent to which recent chronic disease CPGs align with current evidence-based obesity guidance. Specifically, we examined how these CPGs conceptualize obesity, integrate obesity management recommendations, and reflect person-centred care principles. By identifying gaps and areas for harmonization, this study aimed to inform future CPG development and promote a more integrated approach to obesity care within chronic disease management.
A working group composed of obesity clinicians, scientists, researchers and individuals with lived experience of obesity was established under the umbrella of EASO. The working group was responsible for the Determining inclusion and assessment criteria for this content analysis.Identifying and prioritizing key obesity-related chronic disease guidelines to be evaluated for congruence with obesity-specific guidelines.Interpreting findings and finalizing key themes (e.g., congruence, gaps, inconsistencies, and opportunities for future integration or updates).Developing recommendations for harmonizing or updating obesity-related chronic disease CPGs to ensure alignment with evidence-based obesity prevention and management practices.
To ensure scientific rigour and transparency, the working group followed a predefined protocol for selection, extraction, and coding of data. Each guideline was independently reviewed by two investigators using standardized data extraction forms. Findings were then verified through group consensus, ensuring reproducibility consistent with established qualitative health research methods.
The selection of CPGs for inclusion in this study was based on the following eligibility 1.Scope and obesity-related diseases of interest were selected based on their prevalence, impact on health outcomes, impact to individuals living with obesity, and alignment with EU policy priorities (e.g., multi-morbidity). A list of prioritized diseases was created to inform the search strategy. The list included cardio-metabolic-renal complications including type 2 diabetes mellitus, metabolic dysfunction-associated steatotic liver disease (MASLD), chronic kidney disease, hypertension, heart failure, coronary artery disease, and cerebrovascular disease and/or other complications such as obstructive sleep apnoea, osteoarthritis, lipoedema, reproductive health conditions, mental illness, and cancers known to be associated with obesity (e.g., endometrial cancer). Guidelines were selected based on a predefined hierarchy of sources. Priority was given to graded evidence-based CPGs, followed by consensus statements, and then position statements. This approach ensured the inclusion of the most authoritative materials for the analysis.2.Comprehensiveness: ideally, CPGs focussing on the entirety of discrete chronic diseases were of interest. However, some common chronic diseases represent a spectrum of conditions (e.g., cardiovascular diseases, mental illness) and are often broken down by issuing organizations into subtopics with individual CPGs. In these cases, the working group agreed on one CPG selection from a common sub-focus area.3.Population guidelines must be applicable to adult populations. Guidelines focussing exclusively on paediatric or adolescent populations were excluded, with the intention to address these groups in a separate study.4.Geographic and organizational guidelines developed or endorsed by European national bodies, EU policy stakeholders, or disease-specific professional societies within Europe were considered first. Guidelines must be considered a credible source of guidance in the relevant disease area. National CPGs produced in EU member states were second choices if no European guidance met the other inclusion criteria, followed by international CPGs as a third option.5.Publication only CPGs published or updated in 2020 or later were included. However, exceptions were made for older guidelines if they were deemed to be of high quality, broad and/or regional scope, particularly in disease areas identified as priorities by the working group where no more recent guidelines were available. Guidelines had to be published in English or have an official English translation.
The working group searched PubMed, Google Scholar, Google, and ChatGPT to identify reasonable chronic disease CPGs for inclusion and assessment. One guideline from each chronic disease area was selected based on the criteria above. Importantly, the obesity-related content of each guideline was not assessed prior to inclusion; here, the working group sought only to establish that each CPG would be a reasonable resource for healthcare professionals to consult in support of treating patients living with the relevant chronic disease. The working group achieved 100% consensus on the included guidelines, which cover 13 chronic diseases related to acute and chronic heart failure, chronic coronary syndromes, chronic kidney disease, depression, elevated blood pressure and hypertension, endometrial cancer, fertility, hip and knee osteoarthritis, lipoedema, MASLD, obstructive sleep apnoea (OSA), polycystic ovary syndrome (PCOS), and type 2 diabetes. The included guidelines are captured in Table 1. In total, 7 of the 13 included guidelines represent European-wide guidance; four national guidelines (two from the UK and one each from Germany and Ireland); and two international guidelines.
The working group agreed to use the 2020 Canadian [28] and 2022 Irish [29] obesity CPGs as well as the 2024 EASO framework for the diagnosis, staging, and management of obesity in adults [2] as reference standards for assessing the congruence between obesity-specific guidelines and guidelines for other obesity-related chronic diseases. The 2020 Canadian Adult Obesity Clinical Practice Guidelines and the 2022 Adapted Clinical Practice Guideline for Ireland represent two of the most well-recognized CPGs in the domain of obesity which could inform the treatment practice of obesity globally at the time of conducting this study. The Canadian guideline is in the top 5% of all research outputs ever tracked by Altmetric. It has been cited in more than 1,041 publications as of August 2025, and was endorsed by international professional and patient associations and cited in the EASO framework for the diagnosis, staging and management of obesity, as well as adapted by Ireland in 2022 and incorporated into Mexican (2024) [30], Chilean (2022) [31], Spanish (2023) [32], and Dutch (2022) [33] guidelines. The EASO framework for the diagnosis, staging and management of obesity in adults, published in Nature Medicine in 2024 [2], expands the understanding of obesity as an adiposity-based chronic disease outlined in the Canadian CPG and aligns with the comprehensive, personalized treatment approaches used for other chronic non-communicable diseases (NCDs) [34]. The working group reached consensus on key principles that reflect current global evidence-based practice in obesity care identified across the three reference obesity guidance documents and used these to develop nine guideline assessment criteria summarized in Table 2.
Content analysis [41] was used to assess the scope, context and congruence of the guidelines. Two investigators on the working group (B.H. and X.R.S.) independently read each guideline to gain an overall knowledge of the content and independently extracted data from the 13 included CPGs using a pre-designed data extraction form that outlined the 9 key areas of assessment criteria. Any discrepancies in the extracted information were resolved through consensus among the two investigators.
Data were coded according to the assessment criteria (Table 2) and reviewed by the entire working group through a virtual meeting. A research assistant (J.H.) independently reviewed all data extraction entries to ensure consistency and accuracy in coding. For each specific criterion, investigators extracted relevant excerpts from the CPGs to illustrate how each guideline addressed the criterion (online suppl. material; for all online suppl. material, see https://doi.org/10.1159/000549374).
Through iterative discussions, the working group reached consensus on a set of key themes that emerged inductively across the guidelines (content analysis). These themes represented the overarching trends, gaps, and strengths in the collected data. The findings were interpreted to identify opportunities for harmonizing or updating chronic disease CPGs related to obesity, to ensure alignment with evidence-based clinical practices for obesity prevention and management in the context of multi-morbidity.
Results of the working group’s assessments of the included guidelines are presented below. Up to two supporting statements (SS), where applicable, for each criterion’s assessment can be found in the supplementary material. These are numbered for each guideline in Table 1, followed by the criteria number, and A or B for each of the selected statements.
Through the assessment of the included guidelines, three dominant and interrelated themes were 1.Conceptualization of obesity (includes assessment criteria on obesity definition, framing of obesity as a disease versus risk factor, obesity classification/staging)2.Integration of obesity guidance in NCD treatment (e.g., includes assessment criteria on recommendations on obesity/weight management to improve outcomes or as a prerequisite for treatment, specific recommendations for obesity treatment and outcomes, acknowledgement of obesity CPGs)3.Patient-centred obesity care (includes assessment criteria on acknowledgement of weight bias and stigma and use of person-first language in the context of obesity)
Together, these themes reveal significant gaps and inconsistencies in how obesity is framed, managed, and discussed in chronic disease care, with implications for both clinical practice and health policy.
The first theme identified in this study was about the discordance in the conceptualization of obesity in the reviewed obesity-related guidelines. Only two guidelines explicitly stated that obesity is a distinct chronic
Most of the CPGs framed obesity and weight as risk factors for the specific disease areas under review, reflecting a general awareness of the association between obesity and various obesity-related chronic conditions, and/or acknowledged obesity’s impact on the course of the disease in question (see also SS 2-2A; 8-1A):
This framing suggests recognition of obesity’s role in disease development, though often without addressing obesity as a condition requiring direct management in its own right. Many guidelines still rely on traditional anthropometric measures like weight, body mass index (BMI) or waist circumference (WC) to define obesity instead of applying an adiposity-based chronic disease definition as the three reference obesity guidelines do. Obesity is often defined as BMI >30 kg/m^2^ (SS 5-3A; 7-3A; 9-3A; 12-4B), with one CPG noting different BMI ranges for Asians (SS 10-3A; 10-3B). Only one document expressly noted the limitations of using BMI (SS 1-3B). Four CPGs mention waist circumference (WC); only two of these define WC parameters (obesity ≥94 cm for men and ≥80 cm for women) (SS 5-3A; 10-3B), and only one noted differences in values for Europeans, South Asians/Chinese, and Japanese (SS 10-3B). One CPG cites parameters for BMI, waist-to-hip ratio and waist-to-height ratio for normal weight, overweight and obesity (SS 9-3B). Obesity was frequently framed as a behavioural risk factor, often grouped with other health-related behaviours such as physical inactivity, smoking, and alcohol consumption, suggesting that obesity could be prevented or managed through individual behaviour changes such as healthy eating and physical activity (see SS 1-2B; 3-5A; 10-5A):
Furthermore, weight and BMI were often positioned as actions or behaviours that individuals can control through personal choice (SS 3-3B; 8-4A), rather than as outcomes influenced by a variety of factors, many of which are beyond an individual’s control.
While some guidelines discussed obesity severity, none fully cited existing disease severity or staging systems (e.g., Edmonton Obesity Staging System) [28]. Often, vague language is used to describe or imply severity (e.g., “overweight or mildly/moderately obese patients have a better prognosis than leaner patients [13]”; see also SS 2-3A; 9-4A). One CPG mentioned and defined Class III obesity but did not provide any further description of the other classes (SS 3-3A).
The second theme identified in this study focused on how guidelines integrate evidence-based obesity CPG recommendations into their own chronic disease recommendations. Four CPGs included specific weight-loss or BMI targets as a means to improve treatment outcomes, as a prerequisite for receiving treatment for the condition, or for suggested interventions in specific BMI ranges (see SS 9-5A; 10-4A/10-4B):
Nine CPGs generally suggested the benefits of weight loss and/or maintaining a healthy weight as important for outcomes in the disease in question (see SS 1-5A; 3-5A; 5-4A; 7-4A; 8-4A):
One of the reviewed CPGs, an update of a previous guideline, stressed the importance of dietary weight reduction, the relevance of which was “beyond question and did not require re-evaluation” ([25], pg. 14) (SS 11-4A). For more information, it referred readers to the previous guidance, published in 2011 [25].
Several guidelines recommend certain evidence-based interventions for obesity management, such as psychological and behavioural therapy, pharmacotherapy, or bariatric surgery alone or as adjuncts to nutrition and physical activity interventions. However, the most common recommendations included “lifestyle” or “behavioural changes” only (see also SS 1-5A; 3-5A; 6-5A):
Only three of the CPGs (chronic coronary syndromes [15], MASLD [24], and PCOS [26]) discuss or make specific recommendations about all of the pillars of obesity treatment outlined in the reference obesity guidelines (i.e., including pharmacotherapy and bariatric surgery options along with nutrition/physical activity/behavioural interventions). An additional CPG (type 2 diabetes [27]) mentions all the pillars, but for bariatric surgery and lifestyle interventions, it only includes encouragement to consult other guidelines.
Seven CPGs overtly assessed and/or encouraged both lifestyle intervention(s) and select obesity treatments (see also SS 2-5B, 5-5A/5-5B, 8-5A; 9-5A/9-5B, 10-5A/10-5B).
Two made no recommendations at all about obesity or weight management, though one of these referred readers to lifestyle and bariatric surgery guidelines for support (SS 13-7A). Only one other CPG explicitly referred readers to existing obesity management CPGs; neither of the two were the reference obesity guidelines described above (SS 9-7A/9-7B, 13-7A).
There is a disconnect between how obesity treatment outcomes are conceptualized in obesity medicine (where the focus is on health-related improvements) and in many other chronic disease guidelines. Many guidelines continue to frame obesity or weight management interventions primarily in terms of weight loss or BMI targets rather than broader outcomes such as metabolic, functional, mechanical, psychological, or quality-of-life improvements. Three guidelines linked amounts of weight reduction or the achievement of certain weight/obesity categories to quantifiable outcomes in treating the specific disease covered by the CPG (see SS 5-4B; 11-4B):
Six CPGs noted positive outcomes attributed to weight stabilization or small/modest amounts of weight loss (e.g., SS 5-4B; 6-5A; 10-6B)
Only one implied that long-term weight loss can be difficult to
One CPG mentioned the possibility of patients perceiving attempts at weight loss as
The final theme identified in this study focused on person-centred obesity care across the guidelines. This theme reveals a critical gap in the integration of person-centred principles within current CPGs related to obesity and multi-morbidity. While the concept of person-centred care is increasingly recognized as essential in chronic disease management, most of the reviewed guidelines fall short in acknowledging the unique experiences and challenges faced by people living with obesity and multi-morbidity, particularly regarding weight bias, stigma, and non-inclusive language.
Out of the 13 reviewed guidelines, only two explicitly addressed the impact of weight stigma on healthcare experiences and outcomes (see SS 9-8B;12-8B):
These recognized the biopsychosocial consequences of stigma, internalized bias, and media-driven body ideals, and offered actionable recommendations for stigma-reduction strategies in clinical practice and policy. In contrast, the remaining guidelines were largely silent on these issues.
Most guidelines employed outdated and non-person-first language, framing individuals primarily by their weight status (e.g., “obese patients”) (e.g., SS 1-9A; 2-9A; 10-9A) which reinforces objectification and contradicts person-centred
This qualitative content analysis identified opportunities to more effectively integrate obesity care within broader chronic disease management. While developers of non-obesity CPGs are fully aware of recent advances in obesity science, there is clear value in greater collaboration between obesity guideline developers and authors of other chronic disease guidelines to align best practices and promote consistent, evidence-based, and person-centred care for all patients.
Across the reviewed CPGs, obesity was commonly characterized as a risk factor rather than as a chronic, adiposity-based disease requiring comprehensive and sustained management. Although many guidelines acknowledged associations between obesity and conditions such as cardiovascular disease, diabetes, or cancer, few addressed obesity as a disease in its own right or referenced current diagnostic and staging systems. Most guidelines continued to rely on BMI or weight-based metrics, reinforcing a narrow, weight-centric perspective that can obscure the biological, social, and environmental complexity of obesity.
This limited framing has practical implications. By equating obesity with individual lifestyle choices, CPGs risk oversimplifying care and overlooking determinants such as genetics, neurohormonal energy regulation, and socioeconomic context. In contrast, contemporary frameworks, including the 2024 Lancet Diabetes & Endocrinology definition and diagnostic criteria of clinical obesity [10] and EASO 2024 obesity management framework [2], emphasize improvements in metabolic health, body composition, and quality of life as meaningful treatment outcomes, even without large weight changes. Aligning chronic disease CPGs with this multidimensional approach would improve both clinical effectiveness and patient experience.
Integration of obesity management recommendations within other disease guidelines was inconsistent. While many acknowledged weight loss as beneficial, few incorporated evidence-based interventions beyond diet and exercise, such as psychological and behavioural therapy, pharmacotherapy, or bariatric surgery. Cross-referencing existing obesity CPGs could address this gap without overextending individual disease guidelines.
Person-centred care principles were also rarely incorporated. Most CPGs did not address the impact of weight bias and stigma on healthcare access and outcomes, and many used non-person-first language [39, 40]. These omissions contrast with growing evidence that stigma undermines treatment adherence and health equity [42, 43]. Embedding person-centred and stigma-free care principles – through inclusive language, empathy-based practice, and attention to social determinants – would strengthen the clinical and ethical quality of all chronic disease CPGs.
In summary, chronic disease guidelines should evolve to reflect the modern understanding of obesity as a chronic, adiposity-based disease, integrate evidence-based management recommendations, and explicitly promote person-centred, stigma-free care. Cross-speciality collaboration will be key to achieving greater coherence and improving outcomes for people living with obesity and multi-morbidity.
The findings from this review suggest several important 1.Reframing Obesity in Chronic Disease Guidelines: There is a need for chronic disease guidelines to reflect the current scientific understanding of obesity as a complex, chronic, adiposity-based disease. This includes moving beyond weight and BMI as the sole diagnostic or treatment target and embracing multidimensional models of obesity staging and progression.2.Promoting Integrated and Evidence-Based Care: Chronic disease guidelines can routinely reference existing obesity management CPGs or integrate current obesity management recommendations when applicable – while also recognizing that addressing obesity can improve outcomes not just through weight loss but through a broad range of clinical benefits.3.Adopt person-centred CPGs should adopt a person-centred care framework that acknowledges the lived experiences of individuals with obesity and related chronic diseases, addresses weight bias and stigma, and promotes respectful, inclusive, and individualized care. When referring to people living with obesity or any other chronic disease, guidelines should adopt person-first language (e.g., patients with diabetes rather than diabetic patients) and actively work to minimize weight bias in clinical recommendations. This includes acknowledging the psychological and social dimensions of obesity, training providers on bias reduction, and promoting inclusive and patient-centred clinical practices.4.Cross-Guideline Consistency and Collaboration: Greater collaboration is needed between disease-specific and obesity-specific guideline developers to ensure coherence and consistency in recommendations, especially where obesity is a common complication.
Although interpretive elements are inherent in qualitative analysis, all findings in this study are grounded in an explicit, systematic, and consensus-based coding process. Interpretation of the words used in the CPGs analysed may be susceptible to the researchers’ biases. Our interpretive framing served merely to contextualize objectively identified patterns rather than project subjective opinions [44]. This approach aligns with emerging scientific consensus, which calls for obesity management to prioritize overall health improvements, metabolic outcomes, and preservation of muscle mass rather than focussing exclusively on weight loss.
Although recognition of obesity’s role in chronic disease care is increasing, many CPGs still fail to fully reflect its complexity, offer comprehensive management strategies, or apply person-centred principles. Advancing equitable and effective care for people living with obesity and multi-morbidity will require coordinated, cross-disciplinary efforts, a shift beyond weight-centric models, and sustained commitment to integrated, patient-centred chronic disease management.
This study did not involve human participants, animals, or identifiable personal data. Therefore, ethical approval was not required, and no ethics committee reference number is available.
K.J. and V.Y. were members of the journal’s Editorial Board at the time of submission. X.R.S. reports consulting fees and/or honoria/travel support from the European Association for the Study of Obesity (EASO) directly related to this work, as well as Health Service Executive Ireland, Obesity Canada (OC), European Coalition for People Living with Obesity (ECPO), Eli Lilly (Sweden), the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO), The Obesity Society (TOS), and Obesity Medicine Association (OMA) unrelated to this work. B.H. reports consulting fees from the EASO directly related to this work, as well as from TOS and OMA, and OC unrelated to this work. S.B. reports engagement on advisory boards or received honoraria for educational events from Boehringer Ingelheim, Roche, Novo Nordisk, the National Prevention and Cardiovascular Health, Apollo Endo Surgery, Radcliff Medical Education, Novo Nordisk Ireland, and consultancy from the ECPO, all unrelated to this work. C.B. reports honoraria for educational events or conference attendance from AstraZeneca, Behaviour Change Training Ltd., Diabetes Ireland, EASO, Eli Lilly, International Medical Press, Medscape, MSD, Novo Nordisk, and Sanofi Aventis unrelated to this work. M.C. is the Irish College of General Practitioners’ (ICGP) Clinical Lead for Obesity and owner of My Best Weight Clinic and has received speaker honoraria from OC, National Institute for Prevention and Cardiovascular Health (NIPC), Royal College of Physicians of Ireland (RCGP), Med Learning Group, Medscape, MedCon, Consilient Health, The Nutrition Society, Eli Lilly, and Amgen unrelated to this work. M.C. also reports travel and conference registration support from EASO, ECPO, Novo Nordisk, and ICGP unrelated to this work. K.J. reports speaker honoraria from Novo Nordisk and Johnson & Johnson unrelated to this work, with reimbursement directed to her clinical institution. V.M. reports engagement on advisory boards and/or has received honoraria for educational events from Boehringer Ingelheim, Roche, Novo Nordisk, Eli Lilly, Boston Scientific, and consultancy from ECPO, all unrelated to this work. E.S. reports speaker honoraria from Novo Nordisk and Vivus unrelated to this work. J.H. is related to BH and reports no conflicts of interest related to this work. E.W. is an employee of the European Association for the Study of Obesity and has no conflicts to declare. V.Y. reports engagement on advisory boards and lectures with Novo Nordisk, Eli Lilly, Rhythm Pharmaceuticals, and Regeneron.
Funding for this content analysis was provided by the European Association for the Study of Obesity.
X.R.S. conceptualized, implemented the study, and wrote the initial draft of the article. B.H. conceptualized, implemented the study, and wrote the initial draft of the article. Working on behalf of EASO, S.B., C.B., K.J., V.M., E.S., E.W., and V.Y. contributed jointly to the study design, CPG content analysis and consensus-building on findings, and review and revision of the article. J.H. fact checked and confirmed accuracy of supporting statements included in both supplementary material and in the article.