Childhood Obesity as a Predictor of Adult Physical/Functional Mobility; a Protocol for Systematic Review and Meta-Analysis.

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Systematic reviews have linked it to short-term complications 1 during childhood and various long-term health issues in adulthood, including cardiovascular disease, cancer, renal disorders, adult obesity, and type 2 diabetes 2–6 . While evidence suggests musculoskeletal impairment in childhood and adolescence, data on its association with adult joint problems, pain, arthritis, impaired mobility, and physical disability remain limited. To address this gap, a systematic review is needed to examine the relationship between paediatric/adolescent obesity and the risk of impaired physical or functional mobility in adulthood. Aim and objective The primary objective of this systematic review is to explore whether childhood overweight/obesity is an independent predicator of impaired musculoskeletal health, physical function or mobility in adulthood. Methods This protocol is reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) guidelines. This review will include peer-reviewed observational studies (longitudinal and cohort) published between January 1994 and October 2024. Multiple databases will be searched (MEDLINE, Pubmed, Embase, and CINAHL), using medical subject heading (MeSH) terms and relevant keywords. Study screening (title, abstract, full text) will be carried out independently by two researchers. The Risk of Bias in Non-Randomized Studies of Exposure (ROBINS-E) tool will be used to assess included studies, while the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework will evaluate evidence quality. Meta-analysis will be conducted. Statistical analyses will be performed using Stata 17. Results This systematic review will be completed by June 2025. Literature searches was conducted following registration of the review in PROSPERO (CRD42024627371). Conclusion Results will build understanding regarding childhood factors that should be addressed in order to minimise impaired musculoskeletal health, physical function or mobility in adulthood. " } { "@context": "http://schema.org", "@type": "BreadcrumbList", "itemListElement": [ { "@type": "ListItem", "position": "1", "item": { "@id": "https://hrbopenresearch.org/", "name": "Home" } }, { "@type": "ListItem", "position": "2", "item": { "@id": "https://hrbopenresearch.org/browse/articles", "name": "Browse" } }, { "@type": "ListItem", "position": "3", "item": { "@id": "https://hrbopenresearch.org/articles/8-65", "name": "Childhood Obesity as a Predictor of Adult Physical/Functional Mobility;..." } } ] } Home Browse Childhood Obesity as a Predictor of Adult Physical/Functional Mobility;... ALL Metrics - Views Downloads Get PDF Get XML Cite How to cite this article Abu Bakar M, Clarke N, McGowan C et al. Childhood Obesity as a Predictor of Adult Physical/Functional Mobility; a Protocol for Systematic Review and Meta-Analysis. [version 1; peer review: 1 approved with reservations] . HRB Open Res 2025, 8 :65 ( https://doi.org/10.12688/hrbopenres.14087.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Study Protocol Childhood Obesity as a Predictor of Adult Physical/Functional Mobility; a Protocol for Systematic Review and Meta-Analysis. [version 1; peer review: 1 approved with reservations] Muhammad Abu Bakar https://orcid.org/0000-0001-9387-6287 1 , Nicholas Clarke 1 , Cliodhna McGowan https://orcid.org/0000-0001-7023-3844 1 , Edward Gregg 1 , Killian Ross Walsh 2 , Grace O'Malley 3 Muhammad Abu Bakar https://orcid.org/0000-0001-9387-6287 1 , Nicholas Clarke 1 , [...] Cliodhna McGowan https://orcid.org/0000-0001-7023-3844 1 , Edward Gregg 1 , Killian Ross Walsh 2 , Grace O'Malley 3 PUBLISHED 09 Jun 2025 Author details Author details 1 School of Population Health, Royal College of Surgeons in Ireland, Dublin, Leinster, Ireland 2 Information Specialist Library, Royal College of Surgeons in Ireland, Dublin, Leinster, Ireland 3 School of Physiotherapy, Royal College of Surgeons in Ireland, Dublin, Leinster, Ireland Muhammad Abu Bakar Roles: Conceptualization, Data Curation, Investigation, Methodology, Project Administration, Software, Writing – Original Draft Preparation, Writing – Review & Editing Nicholas Clarke Roles: Funding Acquisition, Supervision, Writing – Original Draft Preparation, Writing – Review & Editing Cliodhna McGowan Roles: Data Curation, Methodology Edward Gregg Roles: Conceptualization, Funding Acquisition, Methodology, Project Administration, Supervision, Writing – Original Draft Preparation, Writing – Review & Editing Killian Ross Walsh Roles: Data Curation, Validation Grace O'Malley Roles: Supervision, Writing – Original Draft Preparation, Writing – Review & Editing OPEN PEER REVIEW DETAILS REVIEWER STATUS This article is included in the Maternal and Child Health collection. Abstract Background Childhood and adolescent obesity is a global public health concern. Systematic reviews have linked it to short-term complications 1 during childhood and various long-term health issues in adulthood, including cardiovascular disease, cancer, renal disorders, adult obesity, and type 2 diabetes 2–6 . While evidence suggests musculoskeletal impairment in childhood and adolescence, data on its association with adult joint problems, pain, arthritis, impaired mobility, and physical disability remain limited. To address this gap, a systematic review is needed to examine the relationship between paediatric/adolescent obesity and the risk of impaired physical or functional mobility in adulthood. Aim and objective The primary objective of this systematic review is to explore whether childhood overweight/obesity is an independent predicator of impaired musculoskeletal health, physical function or mobility in adulthood. Methods This protocol is reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) guidelines. This review will include peer-reviewed observational studies (longitudinal and cohort) published between January 1994 and October 2024. Multiple databases will be searched (MEDLINE, Pubmed, Embase, and CINAHL), using medical subject heading (MeSH) terms and relevant keywords. Study screening (title, abstract, full text) will be carried out independently by two researchers. The Risk of Bias in Non-Randomized Studies of Exposure (ROBINS-E) tool will be used to assess included studies, while the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework will evaluate evidence quality. Meta-analysis will be conducted. Statistical analyses will be performed using Stata 17. Results This systematic review will be completed by June 2025. Literature searches was conducted following registration of the review in PROSPERO (CRD42024627371). Conclusion Results will build understanding regarding childhood factors that should be addressed in order to minimise impaired musculoskeletal health, physical function or mobility in adulthood. READ ALL READ LESS Keywords paediatric/adolescent obesity, functional health, physical mobility, pain, musculoskeletal. Corresponding Author(s) Muhammad Abu Bakar ( [email protected] ) Close Corresponding author: Muhammad Abu Bakar Competing interests: No competing interests were disclosed. Grant information: Health Research Board [22303A01] The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Copyright: © 2025 Abu Bakar M et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Abu Bakar M, Clarke N, McGowan C et al. Childhood Obesity as a Predictor of Adult Physical/Functional Mobility; a Protocol for Systematic Review and Meta-Analysis. [version 1; peer review: 1 approved with reservations] . HRB Open Res 2025, 8 :65 ( https://doi.org/10.12688/hrbopenres.14087.1 ) First published: 09 Jun 2025, 8 :65 ( https://doi.org/10.12688/hrbopenres.14087.1 ) Latest published: 09 Jun 2025, 8 :65 ( https://doi.org/10.12688/hrbopenres.14087.1 ) Introduction Childhood and adolescent overweight and obesity represent a significant global health concern. Prevalence estimates are variable across different countries and regions, typically indicating an upward trend over the past four decades 7 – 10 . The global prevalence of childhood obesity was 5% in 2015, affecting almost 108 million children 11 . The Global Atlas on Childhood Obesity observed a 1.5-fold increase in obesity prevalence between 2012 and 2023 compared to the period from 2000 to 2011 12 . It has also been reported that the increasing trend in childhood and adolescent obesity has yet to stabilise 13 . Projections estimate that 158 million individuals aged 5 to 19 years of age would be affected by obesity in 2020, increasing to 254 million by 2030 12 . Furthermore, when examined by geographical region, the occurrence of obesity among children and adolescents was highest in Polynesia (19%), followed by the Caribbean (19%), North America (17%), Central America (16%), and Western Asia (10%). In Europe, the incidence of childhood and adolescent obesity was greatest in Southern Europe (8%), followed by Eastern Europe (5%), Northern Europe (5%), and Western Europe (4%) 14 . The literature indicates an inverse relationship between socioeconomic status and childhood obesity, with higher obesity prevalence (age range 5–19 years) among boys (8%) compared to girls (6%) in upper-middle and high-income countries 15 – 17 . The growing burden of childhood obesity has resulted in escalating costs for individuals, society and national exchequers 18 . Obesity arises from a complex interplay of biological, genetic, behavioural, and environmental factors, with sub-optimal nutrition and sedentary lifestyle as key contributors 19 – 21 . Evidence suggests that low parental education levels, lower household income, limited participation in the labour market, and poor family conditions contribute to sub-optimal nutrition and fewer opportunities for play and physical activity among children and adolescents, which can influence the development of obesity 22 – 24 . Childhood obesity can lead to both short and long-term health complications such as hypertension, cavities and periodontal disease, reduced physical function, asthma, sleep apnoea, impaired glucose tolerance, metabolic dysfunction and constipation 1 . Furthermore, it has been demonstrated that childhood overweight/obesity frequently persist into adulthood 25 , Obesity, being a disease in its own right, presents significant management challenges, particularly when it coexists with other conditions, such as psychological disorders, neurological disability, or inflammatory disease 26 . Observed adverse outcomes in adulthood as a result of childhood overweight/obesity include an elevated risk and earlier onset of chronic diseases such as CVD, obesity in adults, Type 2 diabetes, anxiety, depression, physical or functional impairments, renal disorders, and certain cancers 3 – 6 , 25 , 27 – 31 . A systematic review on obesity tracking across the lifespan reported that approximately 55% of children with obesity have obesity in adolescence. In addition, 80% of adolescents with obesity continue to live with obesity into adulthood, and nearly 70% live with obesity beyond age 30 5 . Several systematic reviews indicated that childhood obesity is an independent risk factor for hypertension, dyslipidaemia, carotid artery atherosclerosis, insulin resistance, metabolic syndrome, premature mortality, and cardiovascular disease (CVD) in adulthood 6 , 32 – 35 . In addition, a systematic review published in 2017 reported a significant positive association between childhood obesity and adult systolic blood pressure, diastolic blood pressure, and triglyceride levels, along with a significant inverse association with adult high-density lipoprotein (HDL) cholesterol. Furthermore, these associations were reversed in studies that adjusted for adult body mass index (BMI), suggesting that adult BMI may act as a mediator of CVD 2 . Gallagher et al. , 28 reported that increasing adiposity from childhood to adulthood is linked to a heightened risk of depression, particularly among women. Another recent review found that children with an average increase in BMI (OR = 2.24) and those with persistently elevated BMI (OR = 2.64) had higher odds of experiencing depression in middle-age compared to individuals with a consistently average BMI trajectory 29 . In essence, those with a persistently high BMI from childhood through mid-adulthood, as well as those whose BMI rose from average levels in childhood to higher levels in adulthood, were at greater risk of depression in middle-age. Encouragingly, improving childhood adiposity profile by adulthood was linked to a reduction in anxiety symptoms 29 . Additionally, a 2023 systematic review and meta-analysis 3 found that childhood obesity raised the risk of cancer incidence and mortality in adulthood by 33% and 28%, respectively. Subgroup analysis by sex revealed higher hazard ratios in males compared to females (HRs) for cancer incidence (20% vs. 39%) and mortality (20% vs. 40%) 3 . Moreover, a systematic review by Pourghazi, Farzad, and colleagues identified a significant positive association between elevated BMI in early life and an increased risk of renal disease later in life 4 . In summary, there is strong evidence that childhood obesity is associated with increased risk of chronic disease and mental health difficulties later in life. However, there is a dearth of data regarding the relationship between childhood obesity and musculoskeletal health and physical function in adulthood. Functional movement refers to body movements characterised by proper joint and muscle function and efficient movement patterns, which reduce injury risk 36 , 37 , and is considered a foundation for more complex forms of movement 38 . Assessments of functional movement typically measure postural control, stability, flexibility, neuromuscular coordination, and balance 36 , 37 , 39 . These components not only support complex efficient movement but are also linked to key health indicators and activities of daily living (e.g. falls, sitting and standing, functional independence etc.) 40 – 43 . To reduce disability, enhance quality of life, and mitigate social and economic consequences, it is essential that musculoskeletal health is prioritised and addressed 44 . Children with obesity were found to have a higher incidence of fractures, lower extremity malalignment and musculoskeletal pain compared to their normal-weight peers 45 . Additionally, Thivel, et al. 46 report that children and adolescents with obesity exhibit reduced muscular fitness and strength compared to their healthy weight peers, primarily due to extreme body weight and bodily inertia. Additionally, a 2022 systematic review by O’Brien, Wesley, et al. , 47 identified a negative association between childhood obesity and functional mobility in children and adolescents. Regarding the risk of adult mobility impairment, a review by Yuan, and colleagues 48 revealed that obesity in adulthood is linked to an elevated risk of frailty (functional mobility impairment) in community-dwelling older adults. A 2012 study by Wills, et al. , 49 reported a strong positive association between obesity and musculoskeletal conditions, particularly osteoarthritis (OA) and in 2015, Antony et al. , 30 reported a significant positive association between childhood overweight and adult knee joint pain, stiffness and dysfunction in adult males (even when no longer living with overweight). This suggests that childhood overweight/obesity may contribute to knee abnormalities later in life and is supported by work exploring the impact of obesity on lower limb biomechanics and development 50 . Additionally, in 2018, Meng et al. , found that childhood adiposity results in ongoing patellar stress and structural anomalies in adults, indicating lasting consequences of excess weight during early life on knee development and health 31 . Given that the musculoskeletal system and biomechanic alignment of the lower limbs develops and matures during childhood and adolescence it is important to consider and address factors that might influence sub-optimal musculoskeletal development impacting adult musculoskeletal health, fitness and function. Therefore, following clinical guidelines by monitoring obesity development and providing access to early intervention during childhood is essential for longer-term health outcomes 51 , 52 . The literature indicates that childhood and adolescent obesity contribute to various health complications in children, adolescents, young adults, and older adults. While reviews have explored the link between childhood obesity and adult cardio-metabolic complications, a significant gap remains in understanding the impact of childhood overweight/obesity on adult musculoskeletal health, physical function or mobility. Specifically, it is unclear whether childhood obesity directly affects musculoskeletal health and/or physical mobility in adulthood, whether there is an association between the two, and if so, whether factors like age at obesity onset, stage of obesity, type of obesity, access to treatment, type of treatment received or sociodemographics are important factors to consider. To enhance the evidence base, we will undertake a systematic review and meta-analysis to determine whether childhood overweight/obesity is associated with musculoskeletal health, physical function or mobility in adulthood. This review will focus on determining whether childhood overweight/obesity constitutes an independent predicator of impaired musculoskeletal health, physical function or mobility in adulthood. Objectives PECO criteria Population: The population will include male and female children aged 2–9 years, adolescents aged 10–18 years, and adults over 18 years, where BMI has been measured in childhood or adolescence (<18 years). Studies reporting age ranges with maturity subgroups (e.g., Tanner stage) will also be included. Children under 2 years of age, those in state care, and those with chronic physical disabilities will be excluded. Exposure: The exposure to be examined will be childhood obesity. Obesity will be defined using standard measures such as body mass index (BMI,) BMI centile, BMI standardised deviation score and studies must report a cut-off for obesity based on local growth charts or those of WHO 53 , IOTF 54 , or CDC 55 . Studies of obesity treatment will also be included. Comparator: A comparison group of children without obesity or with a healthy or low BMI will serve as the comparators in the primary studies. Outcomes: Health outcomes will focus on the presence of musculoskeletal complications and functional mobility in adulthood, and studies should use validated outcome measures to assess these domains. Examples of musculoskeletal complications include pain, balance impairment or joint stiffness. Functional mobility is defined by the ICF (International Classification of Functioning, Disability and Health) of the WHO as the ability to move from one position or location to another 56 . Examples of functional mobility include independent walking ability, sit-to-stand ability, using stairs and getting up from the floor. Primary objective The primary objective of this systematic review is to examine whether there is an association between childhood overweight/obesity and musculoskeletal health, physical function or mobility in adulthood. Methods A systematic review and meta-analysis of the current literature will be conducted. This protocol follows the PRISMA-P guidelines 57 (see supplemental file 1). Eligibility criteria The review will encompass studies published from January 1994 to October 2024, and will include English language full-text articles published in peer-reviewed journals. Eligible study designs will include longitudinal and cohort studies, including case-cohort studies. Studies reporting on children's overweight and obesity status, as well as registry studies (retrospective in nature), will also be considered. While studies in languages other than English (LOE) will be excluded, we will document and report the number of studies published in LOE’s. Studies of adults over the age of 18 years who developed musculoskeletal health or functional mobility difficulties will be included. Search methods Information sources Multiple databases will be searched (MEDLINE, Embase, PubMed, and CINAHL), utilising medical subject headings and keywords. Additionally, the reference lists of included studies and any pertinent reviews will be manually searched. Literature searches was conducted following registration of the review in PROSPERO (CRD42024627371). Search strategy A comprehensive search strategy will be developed with a research librarian with expertise in systematic reviews (supplemental file 2). The search strategy will encompass literature published from January 1994 to October 2024. Examples of keywords used in the strategy include Pediatrics, Pediatric Obesity, Child, children, Childhood, Obesity, Body Mass Index, BMI, body mass index, adipose, adiposity, Balance, Functional Independence Measure, Falls Efficacy Scale Activity-Specific Balance Confidence, Sit-to-Stand Test, Functional Gait Assessment, Dynamic Gait Index, Functional impairment, timed up and go test, short physical performance battery test as shown in Table 1 . Forward searches will also be conducted on included studies. Searches will be rerun prior to the final analysis of the review to identify and include relevant newly published studies. Table 1. Draft search strategy (Database: PubMed, January 1994 to October 2024). #1 "Pediatric Obesity"[Mesh] OR "Child"[Title/Abstract] OR "children"[Title/Abstract] OR "youth"[Title/Abstract] OR "teen"[Title/Abstract] OR "teenager"[Title/Abstract] OR "adolescent"[Title/Abstract] OR "adolescence"[Title/Abstract] OR "Pediatric"[Title/Abstract] OR "childhood"[Title/Abstract] OR "childhood obesity"[Title/Abstract] OR "adolescent obesity"[Title/Abstract] OR "pediatric obesity"[Title/Abstract] #2 "BMI"[Title/Abstract] OR "body mass index"[Title/Abstract] OR "adipose"[Title/Abstract] OR "adiposity"[Title/Abstract] OR "obesity"[Title/Abstract] OR "obese"[Title/Abstract] OR "overweight"[Title/Abstract] OR "skin fold"[Title/Abstract] OR "waist girth"[Title/Abstract] OR "waist circumference"[Title/Abstract] OR "weight status"[Title/Abstract] OR "body mass"[Title/Abstract] OR "body weight"[Title/Abstract] OR "skinfold thickness"[Title/Abstract] OR "body composition"[Title/Abstract] #3 #1 AND #2 #4 "Balance"[Title/Abstract] OR "functional impairment"[Title/Abstract] OR "Musculoskeletal"[Title/Abstract] OR "dysfunction"[Title/Abstract] OR "pain"[Title/Abstract] OR "Quality of Life"[Title/Abstract] OR "Muscle Strength"[Title/Abstract] OR "Physical Fitness"[Title/Abstract] OR "Locomotion"[Title/Abstract] OR "Walking"[Title/Abstract] OR "Gait"[Title/Abstract] OR "function"[Title/Abstract] OR "Exercise Tolerance"[Title/Abstract] OR "Physical Fitness"[Title/Abstract] OR "Activities of Daily Living"[Title/Abstract] #5 "physical function"[Title/Abstract] OR "daily activities"[Title/Abstract] OR "activity limitation"[Title/Abstract] OR "disability"[Title/Abstract] OR "activities of daily living"[Title/Abstract] OR "functional capacity"[Title/Abstract] OR "physical comorbidity"[Title/Abstract] OR "ambulation"[Title/Abstract] OR "coordination"[Title/Abstract] OR "motor skill"[Title/Abstract] OR "motor activity"[Title/Abstract] OR "falls"[Title/Abstract] OR "discomfort"[Title/Abstract] OR "injury"[Title/Abstract] OR "knee pain"[Title/Abstract] OR "low back pain"[Title/Abstract] OR "back pain"[Title/Abstract] OR "Musculoskeletal"[Title/Abstract] OR "Musculoskeletal Pain"[Title/Abstract] OR "dysfunction"[Title/Abstract] OR "stiffness"[Title/Abstract] OR "leg pain"[Title/Abstract] OR "knee pain"[Title/Abstract] OR "Physical activity"[Title/Abstract] OR "Back pain"[Title/Abstract] OR "rehabilitation"[Title/Abstract] OR "difficulty in walking"[Title/Abstract] OR "Musculoskeletal Pain/etiology"[Title/Abstract] OR "osteoarthritis"[Title/Abstract] OR "rheumatoid arthritis"[Title/Abstract] OR "knee cartilage"[Title/Abstract] #6 "Functional Independence Measure"[Title/Abstract] OR "Modified Barthel Index"[Title/Abstract] OR "Falls Efficacy Scale"[Title/Abstract] OR "Activity-Specific Balance Confidence"[Title/Abstract] OR "Sit-to-Stand Test"[Title/Abstract] OR "Functional Gait Assessment"[Title/Abstract] OR "Dynamic Gait Index"[Title/Abstract] OR "timed up and go test"[Title/Abstract] OR "short physical performance battery test"[Title/Abstract] OR "Barthel index"[Title/Abstract] OR "6-minute walking test (6MWT)"[Title/Abstract] #7 #4 OR #5 OR #6 #8 #3 AND #7 #9 "Aged"[Mesh] OR "aged"[Title/Abstract] OR "elderly"[Title/Abstract] OR "mature"[Title/Abstract] OR "old"[Title/Abstract] OR "older"[Title/Abstract] OR "senior"[Title/Abstract] OR "venerable"[Title/Abstract] OR "geriatric*"[Title/Abstract] OR "Ageing"[Title/Abstract] OR "Aging"[Title/Abstract] OR "Above 18"[Title/Abstract] #10 #8 AND #9 #11 "Longitudinal Studies"[Mesh] OR "Cohort Studies"[Mesh] OR "Longitudinal Stud*"[Title/Abstract] OR "Cohort Stud*"[Title/Abstract] #12 #10 AND #11 #13 (#12) AND (("1994/01/01"[Date - Create] : "2024/10/31"[Date - Create])) #14 (#13) AND (("1994/01/01"[Date - Create] : "2024/10/31"[Date - Create])) AND (english[Filter]) #15 (#13) AND (("1994/01/01"[Date - Create] : "2024/10/31"[Date - Create])) AND (english[Filter]) Filters: Full text #16 (("Pediatric Obesity"[MeSH Terms] OR "Child"[Title/Abstract] OR "children"[Title/Abstract] OR "youth"[Title/Abstract] OR "teen"[Title/Abstract] OR "teenager"[Title/Abstract] OR "adolescent"[Title/Abstract] OR "adolescence"[Title/Abstract] OR "Pediatric"[Title/Abstract] OR "childhood"[Title/Abstract] OR "childhood obesity"[Title/Abstract] OR "adolescent obesity"[Title/Abstract] OR "Pediatric Obesity"[Title/Abstract]) AND ("BMI"[Title/Abstract] OR "body mass index"[Title/Abstract] OR "adipose"[Title/Abstract] OR "adiposity"[Title/Abstract] OR "obesity"[Title/Abstract] OR "obese"[Title/Abstract] OR "overweight"[Title/Abstract] OR "skin fold"[Title/Abstract] OR "waist girth"[Title/Abstract] OR "waist circumference"[Title/Abstract] OR "weight status"[Title/Abstract] OR "body mass"[Title/Abstract] OR "body weight"[Title/Abstract] OR "skinfold thickness"[Title/Abstract] OR "body composition"[Title/Abstract]) AND ("Balance"[Title/Abstract] OR "functional impairment"[Title/Abstract] OR "Musculoskeletal"[Title/Abstract] OR "dysfunction"[Title/Abstract] OR "pain"[Title/Abstract] OR "Quality of Life"[Title/Abstract] OR "Muscle Strength"[Title/Abstract] OR "Physical Fitness"[Title/Abstract] OR "Locomotion"[Title/Abstract] OR "Walking"[Title/Abstract] OR "Gait"[Title/Abstract] OR "function"[Title/Abstract] OR "Exercise Tolerance"[Title/Abstract] OR "Physical Fitness"[Title/Abstract] OR "Activities of Daily Living"[Title/Abstract] OR ("physical function"[Title/Abstract] OR "daily activities"[Title/Abstract] OR "activity limitation"[Title/Abstract] OR "disability"[Title/Abstract] OR "Activities of Daily Living"[Title/Abstract] OR "functional capacity"[Title/Abstract] OR "physical comorbidity"[Title/Abstract] OR "ambulation"[Title/Abstract] OR "coordination"[Title/Abstract] OR "motor skill"[Title/Abstract] OR "motor activity"[Title/Abstract] OR "falls"[Title/Abstract] OR "discomfort"[Title/Abstract] OR "injury"[Title/Abstract] OR "knee pain"[Title/Abstract] OR "low back pain"[Title/Abstract] OR "Back pain"[Title/Abstract] OR "Musculoskeletal"[Title/Abstract] OR "Musculoskeletal Pain"[Title/Abstract] OR "dysfunction"[Title/Abstract] OR "stiffness"[Title/Abstract] OR "leg pain"[Title/Abstract] OR "knee pain"[Title/Abstract] OR "Physical activity"[Title/Abstract] OR "Back pain"[Title/Abstract] OR "rehabilitation"[Title/Abstract] OR "difficulty in walking"[Title/Abstract] OR "osteoarthritis"[Title/Abstract] OR "rheumatoid arthritis"[Title/Abstract] OR "knee cartilage"[Title/Abstract]) OR ("Functional Independence Measure"[Title/Abstract] OR "Modified Barthel Index"[Title/Abstract] OR "Falls Efficacy Scale"[Title/Abstract] OR "Activity-Specific Balance Confidence"[Title/Abstract] OR "Sit-to-Stand Test"[Title/Abstract] OR "Functional Gait Assessment"[Title/Abstract] OR "Dynamic Gait Index"[Title/Abstract] OR "timed up and go test"[Title/Abstract] OR "short physical performance battery test"[Title/Abstract] OR "Barthel index"[Title/Abstract] OR "6 minute walking test 6mwt"[Title/Abstract])) AND ("Aged"[MeSH Terms] OR "Aged"[Title/Abstract] OR "elderly"[Title/Abstract] OR "mature"[Title/Abstract] OR "old"[Title/Abstract] OR "older"[Title/Abstract] OR "senior"[Title/Abstract] OR "venerable"[Title/Abstract] OR "geriatric*"[Title/Abstract] OR "Ageing"[Title/Abstract] OR "Aging"[Title/Abstract] OR "Above 18"[Title/Abstract]) AND ("Longitudinal Studies"[MeSH Terms] OR "Cohort Studies"[MeSH Terms] OR "longitudinal stud*"[Title/Abstract] OR "cohort stud*"[Title/Abstract]) AND 1994/01/01:2024/10/31[Date - Create] AND 1994/01/01:2024/10/31[Date - Create] AND "english"[Language]) AND (fft[Filter]) Data extraction and management Study selection One reviewer will conduct searches. To determine the eligibility of studies, two reviewers will independently screen the titles, abstracts, and full texts. Reviewers will apply the inclusion and exclusion criteria to identified studies, and any disagreements will be discussed and resolved through consensus. If consensus cannot be reached, a third reviewer will deliberate. In instances where clarity is needed or the full-text publication lacks sufficient information, the study authors will be contacted for the required information. A PRISMA flow chart will be used to document the number of studies included and excluded, and reasons for their exclusion. Data extraction Two reviewers will extract data on the predetermined outcomes from the final included studies. A standardised data extraction template will be designed to extract relevant data. The web-based software platform Covidence (covidence.org) will be used to streamline the management of the systematic review (i.e. screening, full text review, data extraction and quality assessment). The data abstraction template will be structured to capture key study data. Study information will include the year of publication, author’s names, sources of funding, citation and any conflicts of interest. Additionally, demographic data will be extracted, including characteristics of the sample such as age, sex, target population, ethnicity, parent’s characteristics, employment, education, or relevant life-style factors (such as smoking alcohol consumption and physical exercise). Study characteristics will include geographic location, study design, study dates, inclusion and exclusion criteria, as well as the statistical analysis used. Exposure data will focus on childhood overweight/obesity, including the criteria or tools used to define obesity in children as well as the use of validated outcome measures used to assess participant’s health outcomes. The outcome section will detail the criteria or tools used to measure participant health outcomes. Furthermore, information on data collection methods and adjustment of co-variates in the final analysis will be included. Data management Identified studies will be imported into Covidence software 58 , where duplicates will be removed before screening. An Open Science Framework (OSF) repository will be created to make the protocol, search strategy and review data publicly available. Assessment of risk of bias The ROBINS-E tool will be employed to assess observational studies, which are anticipated to comprise the majority of the evidence 59 . This tool evaluates seven bias domains: confounding, exposure measurement, participant selection, post-exposure interventions, missing data, outcome measurement, and selection of reported results. Each domain will be assessed using signalling questions rated as ‘yes’, ‘probably yes’, ‘probably no’, ‘no’, and ‘no information’, with the overall risk of bias classified as low, some concerns, high, or very high. The findings will be presented for each included study and summarised across domains to facilitate interpretation. Quality assessment The quality of evidence will be evaluated using the GRADE framework 60 . This approach assesses across five domains: imprecision, inconsistency, risk of bias, publication bias and indirectness. It also allows for increased certainty based on significant effect sizes, dose-response relationships, and potential residual confounding. Evidence quality will be classified as high, moderate, low, or very low, and summarised in a table, with assessments carried out independently by two reviewers. Furthermore, the Credibility of Effect Modification Analyses tool will be utilised to assess the reliability of subgroup analysis results 61 ; if credible, a distinct GRADE evaluation will be performed for each subgroup 62 . Data synthesis For each included article, individual details, methodologies, and outcomes will be summarised in descriptive tables to report study characteristics. A standardised coding system will be used to capture essential elements. A separate meta-analysis will be conducted for each outcome, contingent on having at least two studies with comparable exposure and outcome variables; otherwise, a narrative summary will be provided. A random effects model, following DerSimonian and Laird method, will be utilised to manage anticipated heterogeneity 63 . Sensitivity analyses will adopt the Hartung method and Knapp, treating each study as a random effect to address variation 64 , 65 . Heterogeneity will be evaluated using I² statistic and Cochran’s Q test 66 , 67 , categorised as low (0-percnet–40-percent), moderate (30-percent–60-percent), substantial (50-percent–90-percent), or considerable (75-percent–100-percent) 61 . Publication bias will be assessed via Egger's test and funnel plots 68 ; if asymmetry is detected, potential biases will be examined, and sensitivity analyses performed. Meta-analysis results will be illustrated using forest plots. All statistical analyses will be conducted with Stata®17 (Copyright 1985–2017, StataCorp LP). Results This systematic review is expected to be finalised by the end of June 2025. The results of this review will be organised into several subsections: Study selection (reported with PRISMA flowchart) and characteristics (synthesized and reported with tabular data), 2) study results and outcomes (including correlations between childhood obesity and functional and physical mobility in adulthood, and unadjusted and adjusted risk associated with childhood overweight/obesity and with impaired musculoskeletal health, physical function or mobility in adulthood. Discussion This systematic review will investigate the link between childhood overweight/obesity and musculoskeletal health, physical function health in adults, identifying factors contributing to their impact on adult mobility. This will guide targeted interventions and preventive measures, focusing on childhood factors and treatments to support long-term adult mobility and musculoskeletal health. This will provide an evidence base upon which early interventions can be developed to Maximise adult physical health and function. Ethics and consent Ethical approval and consent were not required for this protocol. Data availability Underlying data No data are associated with this article. Reporting guidelines Open Science Framework: PRISMA P checklist is upload for this project (Childhood obesity as a predicator of adult physical/functional mobility: A protocol for systematic review and meta-analysis). DOI 10.17605/OSF.IO/CKXT4 69 . Data are available under the terms of the Creative Commons Zero "No rights reserved" data waiver (CC0 1.0 Public domain dedication)( http://creativecommons.org/publicdomain/zero/1.0/ ). Faculty Opinions recommended References 1. Jebeile H, Kelly AS, O’Malley G, et al. : Obesity in children and adolescents: epidemiology, causes, assessment, and management. Lancet Diabetes Endocrinol. 2022; 10 (5): 351–365. 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March 23, 2025. https://osf.io/ckxt4/ Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 09 Jun 2025 ADD YOUR COMMENT Comment Author details Author details 1 School of Population Health, Royal College of Surgeons in Ireland, Dublin, Leinster, Ireland 2 Information Specialist Library, Royal College of Surgeons in Ireland, Dublin, Leinster, Ireland 3 School of Physiotherapy, Royal College of Surgeons in Ireland, Dublin, Leinster, Ireland Muhammad Abu Bakar Roles: Conceptualization, Data Curation, Investigation, Methodology, Project Administration, Software, Writing – Original Draft Preparation, Writing – Review & Editing Nicholas Clarke Roles: Funding Acquisition, Supervision, Writing – Original Draft Preparation, Writing – Review & Editing Cliodhna McGowan Roles: Data Curation, Methodology Edward Gregg Roles: Conceptualization, Funding Acquisition, Methodology, Project Administration, Supervision, Writing – Original Draft Preparation, Writing – Review & Editing Killian Ross Walsh Roles: Data Curation, Validation Grace O'Malley Roles: Supervision, Writing – Original Draft Preparation, Writing – Review & Editing Competing interests No competing interests were disclosed. Grant information Health Research Board [22303A01] The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Article Versions (1) version 1 Published: 09 Jun 2025, 8:65 https://doi.org/10.12688/hrbopenres.14087.1 Copyright © 2025 Abu Bakar M et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics VIEWS $counts.viewCount downloads Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article Abu Bakar M, Clarke N, McGowan C et al. Childhood Obesity as a Predictor of Adult Physical/Functional Mobility; a Protocol for Systematic Review and Meta-Analysis. [version 1; peer review: 1 approved with reservations] . HRB Open Res 2025, 8 :65 ( https://doi.org/10.12688/hrbopenres.14087.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS track receive updates on this article Track an article to receive email alerts on any updates to this article. TRACK THIS ARTICLE Share Open Peer Review Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Version 1 VERSION 1 PUBLISHED 09 Jun 2025 Views 0 Cite How to cite this report: Aragón-Martín R. Reviewer Report For: Childhood Obesity as a Predictor of Adult Physical/Functional Mobility; a Protocol for Systematic Review and Meta-Analysis. [version 1; peer review: 1 approved with reservations] . HRB Open Res 2025, 8 :65 ( https://doi.org/10.21956/hrbopenres.15474.r49944 ) The direct URL for this report is: https://hrbopenresearch.org/articles/8-65/v1#referee-response-49944 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 11 Dec 2025 Rubén Aragón-Martín , University of Cádiz, Cádiz, Spain Approved with Reservations VIEWS 0 https://doi.org/10.21956/hrbopenres.15474.r49944 Reviewer Report Summary of the article This manuscript presents a protocol for a systematic review and meta-analysis that aims to examine whether childhood overweight and obesity are associated with impaired musculoskeletal health, physical function, or mobility ... Continue reading READ ALL Reviewer Report Summary of the article This manuscript presents a protocol for a systematic review and meta-analysis that aims to examine whether childhood overweight and obesity are associated with impaired musculoskeletal health, physical function, or mobility in adulthood. The authors propose to synthesise evidence from longitudinal and cohort studies published between 1994 and October 2024, following PRISMA-P guidelines and with prior registration in PROSPERO. The protocol outlines a comprehensive search strategy across multiple databases, clearly defined eligibility criteria based on a PECO framework, and detailed plans for study selection, data extraction, risk of bias assessment (ROBINS-E), and certainty of evidence appraisal (GRADE). Meta-analyses are planned where appropriate, with strategies to account for heterogeneity and publication bias. Overall, the protocol addresses an important gap in the literature, as most existing reviews on childhood obesity have focused on cardiometabolic outcomes rather than long-term musculoskeletal and functional consequences. General assessment The topic is timely and of high public health relevance. The study design is appropriate for the research question, and the methodological framework is robust. However, several conceptual and methodological clarifications are needed to ensure internal consistency between the stated objectives, the PECO criteria, and the planned analyses, and to improve reproducibility and interpretability of the forthcoming review. Specific comments related to the review questions 1. Rationale and objectives (answered: Partly) The rationale for the review is clearly articulated and well supported by existing literature. The authors convincingly demonstrate that a gap exists regarding the long-term impact of childhood obesity on adult musculoskeletal health and functional mobility. However, the objectives would benefit from greater conceptual precision , particularly regarding the repeated use of the term “independent predictor” . While the introduction acknowledges that adult BMI may act as a mediator, it is not sufficiently clear how independence will be defined analytically. Must be addressed: Clarify whether the primary objective is to: assess total associations between childhood obesity and adult outcomes, assess effects independent of adult adiposity, or examine both, using stratified or adjusted analyses. Explicitly state how studies adjusting for adult BMI or other key mediators/confounders will be handled and prioritised. 2. Study design (answered: Yes) The proposed study design—a systematic review and meta-analysis of longitudinal and cohort studies—is appropriate and well aligned with the research question. The focus on studies with temporal separation between exposure and outcome is a key strength, as is the planned use of ROBINS-E and GRADE. No critical changes are required in this section. 3. Methods and replicability (answered: Partly) The protocol provides a substantial level of methodological detail, including databases searched, eligibility criteria, screening procedures, tools for risk of bias and evidence certainty, and statistical approaches. The availability of a detailed search strategy and OSF registration further supports transparency. Nevertheless, some procedural decisions remain insufficiently specified , which may limit full replication. Must be addressed: Specify how multiple outcomes within a single study will be handled (e.g., prioritisation rules or inclusion of correlated outcomes). Clarify the criteria for grouping outcomes into meta-analyses versus narrative synthesis (e.g., predefined outcome domains). Provide additional detail on how heterogeneity in covariate adjustment (particularly adult BMI and physical activity) will be managed. Should be considered: Further clarify how studies involving obesity treatment will be handled, particularly whether treatment modifies exposure status or is treated as a separate subgroup. 4. Data availability (answered: Not applicable) This article is a protocol and does not present datasets. The statement that no data are associated with the article is appropriate, and the use of OSF for protocol materials is commendable. No action is required. Additional minor comments The term “predicator” appears multiple times and should be corrected to “predictor” throughout the manuscript. Minor typographical and formatting issues should be corrected (e.g., spelling errors such as “percnet”). Age definition of adulthood outcomes: Adults are defined as individuals >18 years, but several cited outcomes (e.g., frailty, osteoarthritis, disability) are strongly age-dependent. The authors may consider specifying a minimum follow-up duration or minimum age at outcome assessment (e.g., ≥30 or ≥40 years), or planning age-based subgroup analyses, to avoid pooling early adulthood outcomes with those typical of older age. Overall recommendation This is a methodologically sound and well-conceived protocol addressing an important and underexplored research question. Addressing the highlighted points—particularly those concerning conceptual clarity of the objectives and greater specification of analytic decisions—will strengthen the protocol and enhance the robustness and reproducibility of the planned systematic review. Is the rationale for, and objectives of, the study clearly described? Partly Is the study design appropriate for the research question? Yes Are sufficient details of the methods provided to allow replication by others? Partly Are the datasets clearly presented in a useable and accessible format? Not applicable Competing Interests: No competing interests were disclosed. Reviewer Expertise: Childhood and adolescent obesity, physical activity and health, lifestyle-related health outcomes, musculoskeletal and functional health, and experience in longitudinal studies and systematic review methodology. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Aragón-Martín R. Reviewer Report For: Childhood Obesity as a Predictor of Adult Physical/Functional Mobility; a Protocol for Systematic Review and Meta-Analysis. [version 1; peer review: 1 approved with reservations] . HRB Open Res 2025, 8 :65 ( https://doi.org/10.21956/hrbopenres.15474.r49944 ) The direct URL for this report is: https://hrbopenresearch.org/articles/8-65/v1#referee-response-49944 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 09 Jun 2025 ADD YOUR COMMENT Comment keyboard_arrow_left keyboard_arrow_right Open Peer Review Reviewer Status info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Reviewer Reports Invited Reviewers 1 Version 1 09 Jun 25 read Rubén Aragón-Martín , University of Cádiz, Cádiz, Spain Comments on this article All Comments (0) Add a comment Sign up for content alerts Sign Up You are now signed up to receive this alert keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Aragón-Martín R. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 11 Dec 2025 | for Version 1 Rubén Aragón-Martín , University of Cádiz, Cádiz, Spain 0 Views copyright © 2025 Aragón-Martín R. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Reviewer Report Summary of the article This manuscript presents a protocol for a systematic review and meta-analysis that aims to examine whether childhood overweight and obesity are associated with impaired musculoskeletal health, physical function, or mobility in adulthood. The authors propose to synthesise evidence from longitudinal and cohort studies published between 1994 and October 2024, following PRISMA-P guidelines and with prior registration in PROSPERO. The protocol outlines a comprehensive search strategy across multiple databases, clearly defined eligibility criteria based on a PECO framework, and detailed plans for study selection, data extraction, risk of bias assessment (ROBINS-E), and certainty of evidence appraisal (GRADE). Meta-analyses are planned where appropriate, with strategies to account for heterogeneity and publication bias. Overall, the protocol addresses an important gap in the literature, as most existing reviews on childhood obesity have focused on cardiometabolic outcomes rather than long-term musculoskeletal and functional consequences. General assessment The topic is timely and of high public health relevance. The study design is appropriate for the research question, and the methodological framework is robust. However, several conceptual and methodological clarifications are needed to ensure internal consistency between the stated objectives, the PECO criteria, and the planned analyses, and to improve reproducibility and interpretability of the forthcoming review. Specific comments related to the review questions 1. Rationale and objectives (answered: Partly) The rationale for the review is clearly articulated and well supported by existing literature. The authors convincingly demonstrate that a gap exists regarding the long-term impact of childhood obesity on adult musculoskeletal health and functional mobility. However, the objectives would benefit from greater conceptual precision , particularly regarding the repeated use of the term “independent predictor” . While the introduction acknowledges that adult BMI may act as a mediator, it is not sufficiently clear how independence will be defined analytically. Must be addressed: Clarify whether the primary objective is to: assess total associations between childhood obesity and adult outcomes, assess effects independent of adult adiposity, or examine both, using stratified or adjusted analyses. Explicitly state how studies adjusting for adult BMI or other key mediators/confounders will be handled and prioritised. 2. Study design (answered: Yes) The proposed study design—a systematic review and meta-analysis of longitudinal and cohort studies—is appropriate and well aligned with the research question. The focus on studies with temporal separation between exposure and outcome is a key strength, as is the planned use of ROBINS-E and GRADE. No critical changes are required in this section. 3. Methods and replicability (answered: Partly) The protocol provides a substantial level of methodological detail, including databases searched, eligibility criteria, screening procedures, tools for risk of bias and evidence certainty, and statistical approaches. The availability of a detailed search strategy and OSF registration further supports transparency. Nevertheless, some procedural decisions remain insufficiently specified , which may limit full replication. Must be addressed: Specify how multiple outcomes within a single study will be handled (e.g., prioritisation rules or inclusion of correlated outcomes). Clarify the criteria for grouping outcomes into meta-analyses versus narrative synthesis (e.g., predefined outcome domains). Provide additional detail on how heterogeneity in covariate adjustment (particularly adult BMI and physical activity) will be managed. Should be considered: Further clarify how studies involving obesity treatment will be handled, particularly whether treatment modifies exposure status or is treated as a separate subgroup. 4. Data availability (answered: Not applicable) This article is a protocol and does not present datasets. The statement that no data are associated with the article is appropriate, and the use of OSF for protocol materials is commendable. No action is required. Additional minor comments The term “predicator” appears multiple times and should be corrected to “predictor” throughout the manuscript. Minor typographical and formatting issues should be corrected (e.g., spelling errors such as “percnet”). Age definition of adulthood outcomes: Adults are defined as individuals >18 years, but several cited outcomes (e.g., frailty, osteoarthritis, disability) are strongly age-dependent. The authors may consider specifying a minimum follow-up duration or minimum age at outcome assessment (e.g., ≥30 or ≥40 years), or planning age-based subgroup analyses, to avoid pooling early adulthood outcomes with those typical of older age. Overall recommendation This is a methodologically sound and well-conceived protocol addressing an important and underexplored research question. Addressing the highlighted points—particularly those concerning conceptual clarity of the objectives and greater specification of analytic decisions—will strengthen the protocol and enhance the robustness and reproducibility of the planned systematic review. Is the rationale for, and objectives of, the study clearly described? Partly Is the study design appropriate for the research question? Yes Are sufficient details of the methods provided to allow replication by others? Partly Are the datasets clearly presented in a useable and accessible format? Not applicable Competing Interests No competing interests were disclosed. Reviewer Expertise Childhood and adolescent obesity, physical activity and health, lifestyle-related health outcomes, musculoskeletal and functional health, and experience in longitudinal studies and systematic review methodology. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (0) Aragón-Martín R. Peer Review Report For: Childhood Obesity as a Predictor of Adult Physical/Functional Mobility; a Protocol for Systematic Review and Meta-Analysis. [version 1; peer review: 1 approved with reservations] . HRB Open Res 2025, 8 :65 ( https://doi.org/10.21956/hrbopenres.15474.r49944) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://hrbopenresearch.org/articles/8-65/v1#referee-response-49944 Alongside their report, reviewers assign a status to the article: Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions Adjust parameters to alter display View on desktop for interactive features Includes Interactive Elements View on desktop for interactive features Competing Interests Policy Provide sufficient details of any financial or non-financial competing interests to enable users to assess whether your comments might lead a reasonable person to question your impartiality. 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