OBJECTIVE:To systematically summarise people's health-related values and preferences related to fat intake. DESIGN:We searched five databases for studies reporting people's perspectives on fats. Screening, data extraction and risk of bias assessment were performed by two independent reviewers. Data was analysed using a convergent integrated approach and the certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation methodology. SETTING:Qualitative and quantitative studies from any country or language. PARTICIPANTS:Primary studies of adults, with or without cardiometabolic conditions. RESULTS:From 52 166 records, we included eleven quantitative and two qualitative studies; studies were primarily conducted in high-income countries. Five main themes were identified: (i) negative perception of fat in food, (ii) positive perception of vegetable oil as being beneficial to health, (iii) willingness to lower fat consumption, (iv) willingness to pay for healthier fat content and (v) barriers towards unsaturated fat consumption. The most frequently reported themes were negative perception of fat and willingness to consume low-fat products, while prioritising vegetable oil as a healthy fat. The evidence certainty for these themes was very low to moderate, rated down for risk of bias and indirectness issues. CONCLUSIONS:People's perception of fats and oils in diets is complex and often contradictory; most viewed high-fat products as unhealthy and associated with weight gain, while vegetable oils were generally perceived as beneficial. However, views varied significantly depending on sex, age and dietary patterns. Overall, the evidence supporting these perceptions is of moderate to very low certainty and to inform guideline recommendations more research is needed.

BACKGROUND AND OBJECTIVE:This commentary provides contextual information to support interpretation of new guidance for the use of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) evidence-to-decision (EtD) framework for environmental and occupational health (EOH) METHODS: Based on a systematic review and narrative synthesis of EOH decision frameworks, and input from subject matter experts in environmental health and GRADE, we developed and pilot-tested an EOH framework through a series of virtual workshops. The resulting guidance was approved by the GRADE Working Group in May 2023. RESULTS:The new EtD framework for EOH follows the same structure as the existing EtD frameworks, including a scoping and contextualization process and 12 assessment criteria. CONCLUSION:Modifications to the framework to improve applicability for the EOH context include changes to terminology, tailoring of the framework detailed judgments (eg, broadening the scope of the equity decision criterion to include nonhealth equity issues), and guidance for users (eg, emphasis on the scoping phase of the guideline development process).

Summary The journey of guidelines being informed by evidence is less than 50 years old, but it has seen notable advances documented in various publication series and led by key organizations. Although Evidence‐to‐Decision (EtD) frameworks were officially born in 2016, since the early 2000s, groups like GRADE had begun to formulate key determinants of the recommendation‐formulation process. The EtD frameworks started with criteria such as the balance between desirable and undesirable outcomes, values and preferences, and resource use. Nowadays, they are extended to cover criteria like planetary health, human rights, and socio‐cultural acceptability. Experiences with the use of EtD frameworks are generally positive; they are flexible, facilitate multidisciplinary discussions, and bring rigor and transparency to the guidelines. More guidance is required on how to use EtD frameworks, as well as more research to understand how they can lead to better guidelines, and more recently, how artificial intelligence can responsibly help navigate this path.

Human health and natural systems are intrinsically linked-stable natural systems enable healthy human life. Health systems aim to promote, restore, and maintain health. Health systems may promote human health while having detrimental effects on natural systems, contributing to the transgression of planetary boundaries, such as biosphere integrity, climate change, and the introduction of new entities like microplastics. To date, the health guideline field lacks methods to assess the impacts of health interventions on planetary boundaries. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) Working Group established the Planetary Health Project Group in 2023 to develop formal GRADE guidance for integrating planetary health into guideline recommendations to address this gap. Guided by the concepts of planetary health and planetary boundaries and following established methods for GRADE guidance development, the project group conducted iterative case study analyses, expert workshops, and a 2-round global Delphi consensus process. Four case studies were selected for application of this guidance before recommendations were finalized. The GRADE Working Group approved the official guidance. The Planetary Health Project Group presents 7 domains of guidance for incorporating planetary health aspects into the guideline development process, including highly desirable items and optional items. Highly desirable items include formally addressing planetary health in public health and health system guidelines and explicitly justifying its exclusion where it is not addressed. Judgments within the evidence-to-decision (EtD) framework should systematically integrate included evidence across the prioritized planetary boundaries and equity. This guidance aims to support guideline developers and policymakers in making evidence-based, trustworthy recommendations to protect individual and planetary health, while maintaining thoroughness and feasibility for guideline developers within the GRADE approach.

Background The adaptation of clinical practice guidelines (CPGs) is increasingly used to efficiently develop contextualised recommendations for local, regional and national settings. However, adaptation approaches lack standardisation, and their application remains unclear.Objective To identify existing literature on CPG adaptation approaches, synthesise and analyse the definitions, rationales, key steps and their applications.Methods We conducted a scoping review and identified studies through (1) database searches in MEDLINE and EMBASE (October 2024); (2) forward citation searches (January 2024); (3) manual searches; and (4) expert recommendations. We included documents describing adaptation approaches that allow reproducibility or adapted guidelines reflecting their application, without language restriction. We analysed data using descriptive and content analysis, with visualisations using Tableau.Results We identified 49 adaptation approaches (2000-2024) and 151 applications (2007-2024). 28 approaches originated from high-income countries (57.1%), primarily aimed at improving guideline development efficiency. We categorised these approaches into methodological frameworks (n=16, 32.7%), medical association frameworks (n=7, 14.3%), organisational handbooks (n=12, 24.5%), national or regional approaches (n=13, 26.5%) and one topic-specific methodology. From the key adaptation steps of the identified approaches, we found that 'judging quality of evidence' and 'establishing guideline group processes' were the least addressed. Approximately 20% of applications modified the original approaches during the adaptation process. ADAPTE (n=50, 33.1%) and the Grading of Recommendations, Assessment, Development and Evaluations (GRADE)-ADOLOPMENT (n=41, 27.2%) are the most commonly used adaptation approaches. Also, over half of the identified applications were adapted at the evidence level (n=88, 58.3%) and completed the process within 12 months (range: 2-36 months).Conclusions 49 adaptation approaches were identified, with a recent surge in interest and utilisation. Although adaptation can save time and resources, substantial variations among existing approaches and their applications remain. These findings highlight the need for comprehensive guidance to support standardisation and optimise the quality of the adaptation process.

BACKGROUND:Immunonutrition examines how diet influences immune development. Complementary feeding represents a critical window for long-term health. We aimed to map evidence linking complementary feeding to immune outcomes, allergy, infection, and growth in infants and toddlers (≤ 3 years). We conducted a scoping review and evidence-gap mapping, following PRISMA-ScR. MEDLINE and Epistemonikos were searched from inception to November 2024. Concepts included diet diversity/patterns, feeding practices/models, and timing of allergen introduction, timing of complementary feeding, macronutrients, micronutrients, foods, supplementation, and ultra-processed foods. We included systematic reviews and recent primary studies meeting criteria. RESULTS:From 13,512 records screened, 108 systematic reviews were included, comprising 99 randomized controlled trials, 41 cohorts, 22 case-control, and 14 cross-sectional studies. Most reviews addressed nutrient intake, supplementation, or timing of allergen introduction, while fewer reviews explored diet diversity, foods, or ultra-processed food intake. Responsive complementary feeding was consistently associated with healthier growth and lower obesity risk, whereas restrictive practices showed adverse effects. Greater diet diversity was linked to reduced asthma and food allergy risk, though eczema findings were inconsistent. Western-style diets high in processed foods, fat, sugar, and meat correlated with higher allergy risk, while home-prepared diets were protective. Micronutrient supplementation (iron, zinc, vitamin D) reduced infection and anemia risk but had mixed effects on allergy. Early allergen introduction reduced food allergy incidence. CONCLUSIONS:Complementary feeding research now extends beyond calorie counting, macronutrients, and early allergen introduction to dietary patterns and early life nutrition that supports the microbiome. Evidence supports dietary diversity, timely food allergen introduction, and responsive feeding, while discouraging restrictive practices and ultra-processed foods. Future work should harmonize definitions and investigate plant-based diets, advanced glycation end products, and processed food exposures.

INTRODUCTION:Patients are increasingly recognized as key interest holders in health care decision‑making. Integrating patient perspective is crucial to patient‑centered, evidence‑based nutrition guideline recommendations. OBJECTIVES:Our aim was to examine individual willingness to decrease consumption of foods high in saturated fatty acids (SFAs) after being informed about the estimated absolute risk reduction (ARR) of myocardial infarction (MI), together with the certainty of the supporting evidence based on a Cochrane systematic review. PATIENTS AND METHODS:Respondents from 7 countries were presented with a conversation aid with the ARR of MI, together with the certainty of evidence, and asked about their willingness to reduce their intake of SFA‑rich foods. Using a multivariable logistic regression model, we explored 12 variables to identify factors underlying respondent willingness to introduce dietary fat changes. RESULTS:We analyzed 3663 respondents from Brazil, Canada, China, Croatia, Poland, Spain, and the United States. Overall, 50.2% were willing to reduce their SFA intake. Women (odds ratio [OR], 1.51; 95% CI, 1.29-1.77), nonomnivores (OR, 1.73; 95% CI, 1.37-2.19), and respondents from Spain, China, and Brazil (OR, 2.45; 95% CI, 1.83-3.27; OR, 4.36; 95% CI, 3.49-5.45; and OR, 1.31; 95% CI, 1.08-1.58, respectively) showed greater willingness, whereas those from Croatia or holding a university degree showed lower willingness (OR, 0.7; 95% CI, 0.51-0.95; OR, 0.73; 95% CI, 0.61-0.87, respectively). CONCLUSIONS:The significant variation in people willingness (depending, eg, on sex, education levels, or dietary pattern) to reduce their intake of SFA‑rich foods underscores potential importance of incorporating patient preference when developing dietary guideline recommendations, and of promoting individualized evidence‑based care using absolute effects and certainty of evidence.

Evidence-based decision making in health often requires comparison of multiple options for a given condition. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) evidence-to-decision (EtD) framework provides a structured approach for moving from evidence to decisions but was originally designed for pairwise comparisons. Hence, there is a need to accommodate decision making based on multiple comparisons, especially with the increasing use of systematic reviews and network meta-analyses in guideline development. Furthermore, since the original EtD framework was developed, further relevant GRADE guidance has been developed. The aim of this work was to develop a new EtD framework to accommodate multiple comparisons and reflect current GRADE guidance. The new EtD framework was revised and developed through iterative discussion, feedback, and refinement by the GRADE EtD Project Group and the GRADE Working Group. Experiences and examples from guideline developers, methodological experts, and other stakeholders informed improvements in its structure and usability for multiple comparisons and were subsequently approved by the GRADE Working Group. This article describes the new EtD framework, which now includes 2 corresponding parts for reviews of pairwise and multiple comparisons. The authors describe application to a review with multiple comparisons for the different parts of the EtD framework: the question definition, which now includes the presentation of values of health outcomes and decision thresholds; the assessment section, where the new "net effect" criterion has been included; and the conclusion section, which includes an adaptation for multiple comparisons. The article provides examples and suggestions for presentation of findings. The framework does have limitations, in that its usability has not been tested across a broad spectrum of guideline development contexts.

OBJECTIVES:Many clinical practice guidelines (CPGs) claim to follow the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach, yet their actual adherence remains uncertain. We aimed to identify and evaluate existing criteria for evaluating adherence to GRADE in CPGs and describe the extent of adherence revealed by their application. STUDY DESIGN AND SETTING:We systematically searched PubMed, Embase, Web of Science, and the Cochrane Library from January 2004 to November 2024, supplemented by manual reviews of the GRADE handbook and related websites. Eligible documents were those that either proposed or applied criteria for evaluating GRADE adherence. We summarized the criteria offered, evaluated the extent to which they meet standards for a structured instrument, and analyzed adherence findings. RESULTS:We identified 11 eligible documents: eight proposed evaluation criteria (four applying their own to evaluate CPGs) and three applied existing criteria. From these criteria, we derived 10 clearly discrete items that can be used to define good adherence to GRADE. The most common items addressed the criteria for assessing certainty of evidence (CoE) and criteria for making recommendations (seven of eight documents), while question framing and outcome selection and importance rating were less frequent (3/8). Among the eight documents proposing criteria, four failed to report their development methods and response options; furthermore, none conducted user testing or provided guidance manuals. The number of CPGs assessed in the included studies ranged from 4 to 86. Reported adherence to GRADE varied considerably across these studies; nevertheless, the median adherence rates were suboptimal for five of the 10 items. CONCLUSION:Existing criteria for assessing GRADE adherence are varied and suboptimal in usability. Evaluations based on these criteria reveal significant application gaps in key areas among CPGs that claim to use GRADE. These findings highlight the need to develop a structured, user-tested evaluation instrument and improve the implementation of GRADE in CPGs. PLAIN LANGUAGE SUMMARY:Many medical guidelines say that they use a trusted scientific method called GRADE to make their advice reliable. But we neither know if they actually follow it correctly nor were there good tools to check. We wanted to find out: 1) what checklists exist to audit GRADE use? and 2) what do those checklists tell us about how well guidelines really apply GRADE? We searched scientific databases and official GRADE sources for studies that either created or used checklists to evaluate GRADE in guidelines. We reviewed these checklists, checked their quality, and summarized what they found when applied. We found 11 relevant studies. The checklists they proposed were inconsistent and poorly designed; none were tested with real users or came with instructions. When used, they showed that many guidelines fail to properly apply key steps of the GRADE method, even though they claim to use it. For half of the important steps, less than 50% of guidelines followed them correctly. This means that current tools for checking GRADE use are unreliable, and many guidelines may not be as trustworthy as they claim. To protect patients and improve medical advice, we urgently need a better, user-friendly audit tool and more support to help guideline developers apply the GRADE method correctly.

ABSTRACT Introduction Artificial intelligence (AI) may support several processes of the health guideline enterprise. This article describes the development of an extension of the Guidelines International Journal (GIN)‐McMaster Guideline Development Checklist (GDC) for integrating AI in the guideline enterprise. This development has been led by the GIN‐AI Working Group. Methods We started by prompting a large language model (LLM) for items related to the use of AI in each of the steps of the original GDC. Subsequently, the members of the working group engaged in a set of iterative discussions, resulting in item refinement and in a consensus first version of the extension. We retrospectively applied this first version to a case use of guidelines incorporating AI in their development (Allergic Rhinitis and its Impact on Asthma [ARIA] 2024‐2025 guidelines), leading to further refinement and to the approval of the final extension tool. Results Prompting LLMs resulted in the generation of 149 items. Of those, 117 were removed and 19 were modified by members of the working group. On the other hand, 17 new items were added during the iterative discussion process. The retrospective application of the extension led to changes in the wording of four items. The final version of the checklist extension has been approved with 49 items modifying or adding to the original GDC. Discussion We have developed an extension of the GIN‐McMaster GDC that encompasses a set of conduct standards that are intended to facilitate the comprehensive and transparent integration of AI in the health guideline enterprise. Clinical Trial Registration Not applicable. This study is not a clinical trial.

Objective To inform the development of an evidence synthesis taxonomy, we aimed to identify and examine all classification systems, typologies or taxonomies that have been proposed for evidence synthesis methods.Design Scoping review.Methods This review followed JBI (previously Joanna Briggs Institute) scoping review methodology and was reported according to PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews). Resources that investigated typologies, taxonomies, classification systems and compendia for evidence synthesis within any field were eligible for inclusion. A comprehensive search across MEDLINE (Ovid), Embase (OVID), CINAHL with Full-Text (EBSCO), ERIC (EBSCO), Scopus, Compendex (Elsevier) and JSTOR was performed on 28 April 2022. This was supplemented by citation searching of key articles, contact with experts, targeted searching of organisational websites and additional grey literature searching. Documents were extracted by one reviewer and extractions verified by another reviewer. Data were analysed using frequency counts and a basic qualitative content analysis approach. Results are presented using bar charts, word clouds and narrative summary.Results There were 15 634 titles and abstracts screened, and 703 full texts assessed for eligibility. Ultimately, 446 documents were included, and 49 formal classification systems identified, with the remaining documents presenting structured lists, simple listings or general discussions. Included documents were mostly not field-specific (n=242) or aligned to clinical sciences (n=83); however, public health, education, information technology, law and engineering were also represented. Documents (n=148) mostly included two to three evidence synthesis types, while 22 documents mentioned over 20 types of evidence synthesis. We identified 1010 unique terms to describe a type of evidence synthesis; of these, 742 terms were only mentioned once. Facets that could usefully distinguish (ie, similarities and differences or characteristics) between evidence synthesis approaches were categorised based on similarity into 15 overarching dimensions. These dimensions include review question and foci of interest, discipline/field, perspective, coverage, eligibility criteria, review purpose, methodological principles, theoretical underpinnings/philosophical perspective, resource considerations, compatibility with heterogeneity, sequence planning, analytical synthesis techniques, intended product/output, intended audience and intended impact or influence.Conclusion This scoping review identified numerous unique terms to describe evidence synthesis approaches and many diverse ways to distinguish or categorise review types. These results suggest a need for the evidence synthesis community to organise, categorise and harmonise evidence synthesis approaches and terminolog

Background and Objectives Health guidelines play a central role in informing clinical practice, public health measures and health policy. But their trustworthiness may be undermined by factors such as insufficient methodological rigor, lack of transparency, conflicts of interest, and inconsistent application of established standards. Existing appraisal tools address selected aspects of guideline quality but do not comprehensively assess the trustworthiness of individual recommendations, nor do they adequately reflect recent advances in guideline methodology, including living guidelines, Grading of Recommendations, Assessment, Development, and Evaluation, adaptation, and the use of artificial intelligence (AI). This study aims to develop and validate Transparent, Rigorous, Useable, Standardized, and Trustworthy Guide (TRUSTGUIDES), a globally applicable, flexible set of tools to assess the trustworthiness of health guideline recommendations. We define trustworthiness as distinct from methodological quality: it encompasses not only rigorous methods but also transparency, independence, and applicability, which together determine whether a recommendation merits user confidence. Methods TRUSTGUIDES will be developed through a multistep, mixed-methods process. First, a scoping review and expert consultation will identify existing guideline appraisal tools and inform domains and items generation. Using deductive and inductive approaches, domains and items will be generated and may be refined through focus groups and selected through iterative Delphi surveys involving an international, multidisciplinary working group. TRUSTGUIDES will be validated by assessing internal consistency, inter-rater reliability, content validity, and construct validity, including comparisons with established instruments such as the Grading of Recommendations, Assessment, Development, and Evaluation certainty domains, AGREE II, and PANELVIEW. Psychometric properties will be examined using factor analysis and, as necessary, item response theory models. AI will be integrated both as an object of assessment and as methodological support for tool application, with large language models evaluated against a human reference standard. Conclusion TRUSTGUIDES will be designed to evaluate the trustworthiness of individual guideline recommendations across key factors, including transparency and credibility, and to address relevant domains such as the certainty of evidence, strength of recommendations, conflicts of interest, applicability, adaptability, currency, certification, and the appropriate use of AI. TRUSTGUIDES addresses critical gaps in current guideline appraisal by offering a comprehensive, recommendation-level assessment of trustworthiness aligned with the World Health Organization guideline standard methodology. By integrating AI, our tools will support efficient, transparent, and future-ready guideline evaluation within an evolving health evidence ecosystem.

Introduction: Guideline development is both time-consuming and resource-intensive, and duplication of efforts contribute to research waste. Although adopting existing guidelines is an efficient alternative, it often fails to account for contextual factors. Adapting trustworthy, previously developed relevant guidelines offers a promising alternative. Thus, we aimed to identify, describe and evaluate formal frameworks for the adaptation of health-related guidelines.Methods: We updated a previously published systematic survey of guideline adaptation frameworks by searching MEDLINE (Ovid) and Embase (Ovid) from January 1st, 2015, to October 31st, 2025. Eligible studies described an adaptation framework for health guidelines in sufficient detail to allow reproducibility. We excluded reviews, guideline adaptations, and implementation reports. We extracted in duplicate and independently data on framework characteristics and presented results in both narrative and tabular formats.Results: Our search identified 20 guideline adaptation frameworks, up from eight identified in the previous survey. These frameworks included five to 24 steps (median: 13). Each framework followed one of four primary approaches: ADAPTE-based (6/20); GRADE-ADOLOPMENT-based (3/20); hybrid approaches (2/20); and non-systematic approaches (9/20). ADAPTE-based frameworks follow a comprehensive three-phase, 24-step process to assess and modify entire source guidelines. In contrast, GRADE-ADOLOPMENT-based frameworks focus on recommendation-level contextualization using evidence-to-decision frameworks. The remaining frameworks primarily utilize non-systematic methods. The most frequently reported challenges were high resource and expertise requirements, dependence on the quality and availability of source guidelines, contextual and implementation barriers, and limited capacity for new evidence synthesis.Discussion: Guideline adaptation frameworks vary substantially in scope and methods, reflecting a balance between methodological rigor and feasibility. ADAPTE- and GRADE- ADOLOPMENT-based approaches provide structured methods, while more recent frameworks prioritize flexibility. This synthesis will help guideline developers select approaches that best fit their context and resources.

Objectives:In patients living with advanced dementia, the intensity of care during life-threatening infections remains controversial and marked by wide variation in practice. This international survey investigated physicians' and physicians-in-training's management choices for individuals with advanced dementia and the factors associated with those choices. Design:Vignette-based survey. Setting:Twelve countries across five continents. Methods:We administered our vignette-based survey to medical students, residents and physicians. The survey elicited participants' views on whether antibiotics should be administered to an elderly patient with advanced dementia and very poor quality of life, presenting with bacterial pneumonia. We explored factors associated with treatment choices using univariable analysis and multiple logistic regression models. Results:Of the 785 participants (age, mean (SD): 31.1 (11.5) years), one-third (31.2%) resided in the Region of the Americas, 21.9% in Europe, 16.2% in the Eastern Mediterranean region and 17.1% in China. In the univariable analysis, choice to treat was associated with younger age, country/WHO region (African region highest overall, European region lowest overall), stage of medical training (medical student most inclined to treat) and absence of medical assistance in dying (MAiD) legislation. Multivariable analyses provided evidence that country was the variable most strongly associated with the choice to treat with antibiotics (Cameroon, China, Saudi Arabia highest; Norway, Switzerland, Spain lowest), with the presence of MAiD legislation also strongly associated (OR 0.35, 95% CI 0.23 to 0.51). Age (OR 0.82, 95% CI 0.66 to 1.00) and religiosity level (OR 0.93, 95% CI 0.87 to 0.99) showed weaker associations with treatment decisions. Conclusion:Inclination to treat individuals with advanced dementia who develop pneumonia varies greatly between and within jurisdictions. Social factors (in particular country but also presence of MAiD legislation) proved the most prominent associations, with individual characteristics much less influential. These findings underscore the importance of contextual and cultural factors in value-sensitive clinical decisions. Registration:We registered the protocol at Open Science Framework (osf.io/6kfbt).

Objectives The aims of this study were (1) to develop and validate the interactive CLAIM Test (iCLAIM Test) to measure children’s ability to assess claims about treatment effects and make informed health choices and (2) to measure this ability in Spanish primary school children using the developed test.Design We followed a multistep process including (1) definition of the test scope, (2) selection of the questions, (3) translation process, (4) design and development of the online test, (5) external review with experts, (6) user-test with children and (7) cross-sectional validation study with Rasch analysis.Setting Spanish primary schools.Participants Twelve experts (75% women) participated in the review, 11 children (45% girls) participated in the user-test and 480 Spanish primary school children (46.5% girls) from fourth to sixth grades (9–12 years old) participated in the cross-sectional validation study.Results The iCLAIM Test is an online, interactive and user-friendly test in Spanish that measures children’s ability to understand and apply key concepts of the informed health choices (IHC) Project when assessing claims about treatment effects and making IHCs. The test includes 30 questions: six demographic questions and 24 questions from the Claim Evaluation Tools item bank. Less than 40% of the students who participated in the cross-sectional validation study showed basic knowledge of the IHC Key Concepts and how to apply them, and less than 4% showed a clear knowledge. The test showed a good fit to the Rasch model and was acceptable to the target audience.Conclusions The iCLAIM Test is the first instrument validated for measuring children’s ability to assess treatment claims in Spain. In the future, we can tailor IHC education interventions and improve critical thinking skills about the health of Spanish children.

Despite published guidance by the GRADE (Grading of Recommendations Assessment, Development and Evaluation) Working Group on the use of good practice statements (GPSs), their appropriate development remains challenging. This article provides updated guidance with nuanced operationalization. The updated guidance was developed on the basis of examples and iterative discussions. The lead authors refined the approach according to the feedback from GRADE Working Group meetings and presented the summary of the results to all attendees of the GRADE Working Group meeting for feedback in September 2023 and for final approval in September 2024. The 5 signaling questions from the original guidance were leveraged, and the authors recommend that guideline developers select relevant Evidence to Decision criteria to assess the potential downstream consequences of implementing the statement. They have updated the definition of a GPS, classifying GPSs into the following 3 categories: those grounded in ethics and human rights; those grounded in essential principles, practices, and protocols; and those grounded in established scientific evidence. Practical examples accompany the steps as they relate to each type of GPS. In addition, the authors introduce a tool to streamline GPS development and enhance the reporting process. This GRADE guidance article provides an update on when and how to develop a GPS. Adherence to the guidance will add to the trustworthiness of guidelines and may facilitate reducing the inappropriate use or overuse of the GPS.

Objective To provide guidance for the use of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Evidence-to-Decision (EtD) framework for environmental and occupational health (EOH). Study design and setting We conducted a systematic review and narrative synthesis of published and public EOH decision frameworks, followed by a modified Delphi process leading to development of a draft GRADE EtD framework for EOH. We pilot tested the provisional framework through a virtual workshop series, which further informed guidance for the framework’s application. We presented a summary of the results to all attendees of the GRADE Working Group meeting for feedback in July 2022 and November 2022, and for approval in May 2023. Results Consistent with existing GRADE EtD frameworks, the EtD framework for EOH includes a scoping and contextualization process and twelve assessment criteria. Modifications to the existing EtD frameworks include: consideration of the socio-political context when making judgments about the priority of the problem and feasibility of different alternatives; the addition of timing when making judgments about benefits and harms, the balance of effects, and feasibility; broadening of the equity criterion to include considerations beyond health equity; and more explicit accommodation of variable or conflicting stakeholder views when considering values and acceptability. The new EtD framework is also accompanied by a user guide intended to support its implementation in the EOH context. Conclusion Policymakers, regulators, and other stakeholders may use this GRADE EtD framework to approach decision-making about environmental and occupational exposures and interventions.

This systematic review evaluated the association between lower respiratory tract infections (LRTI) in infancy with respiratory syncytial virus (RSV), rhinovirus (RV) or infestation with helminths and the risk of developing asthma and allergic diseases. The risk of bias was assessed with ROBINS-E, and the certainty of evidence (CoE) with GRADE. Meta-analysis applied a random-effects model. RSV LRTI is likely associated with an increased risk of developing asthma by age 7 (OR 3.02, 95% CI 2.23-4.09; I2 = 98%; moderate CoE). The impact on wheezing, atopic dermatitis (AD), and allergic rhinitis is uncertain. RV LRTI may be associated with increased risk of developing asthma (OR 8.40, 95% CI 2.56-27.55; I2 = 43%; low CoE). The impact on wheezing and AD is uncertain. Trichuris trichiura infestation might be associated with reduced risk of new-onset wheezing (OR 0.57, 95% CI 0.35-0.94; very low CoE) or AD (HR: 0.35, 95% CI 0.18-0.67; very low CoE). The association between Ascaris lumbricoides and hookworm infestation and the risk of developing asthma or AD is uncertain. Infestation with any helminths might be associated with reduced risk of new-onset asthma by age 5 (OR: 0.60, 95% CI 0.38-0.95; very low CoE) and wheezing (OR 0.70, 95% CI 0.51-0.95; very low CoE). More high-quality studies are needed to confirm these findings.