Perspective: USDA Nutrition Evidence Systematic Review Methodology: Grading the Strength of Evidence in Nutrition- and Public Health-Related Systematic Reviews.

The USDA's Nutrition Evidence Systematic Review (NESR) team conducts food- and nutrition-related systematic reviews used to inform US Federal guidelines and programs, including the Dietary Guidelines for Americans. NESR's systematic review methodology includes a step to grade the strength of the evidence underlying conclusion statements, which is critical for ensuring that end users understand the level of certainty in conclusions when using them to make decisions. Over time, NESR has ensured its grading process not only remains state of the art but is also designed specifically for systematic reviews that inform Federal guidelines and programs on nutrition and public health. The NESR grading process used by the 2020 Dietary Guidelines Advisory Committee included 5 grading elements: risk of bias, consistency, directness, precision, and generalizability. Evidence was grouped by study design and assessed against these elements, and the grade assigned to the entire body of evidence took into consideration the strengths and limitations of each design. Based on this assessment, 1 of 4 grades was assigned: strong, moderate, limited, or grade not assignable. The grade was clearly communicated by integrating specific language into each conclusion statement (e.g., "strong evidence demonstrates" or "limited evidence suggests"), and supported by rationale documented in the review. NESR's grading process aligns with approaches used by other organizations that conduct systematic reviews, while retaining aspects unique to NESR's role in informing Federal nutrition and public health guidelines and programs. It provides a framework that promotes consistency in grading across food- and nutrition-related reviews, while offering flexibility that allows for thorough consideration of the body of evidence underlying an individual conclusion statement. NESR's rigorous and transparent methods for grading the strength of evidence in food- and nutrition-related systematic reviews ensure that decisions related to nutrition and public health are based on the strongest available evidence.