Lifestyle interventions for the treatment of urinary incontinence in adults

Mari Imamura; Kate Williams; Mandy Wells; Catherine McGrother

doi:10.1002/14651858.CD003505.pub5

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Figure 1

PRISMA study flow diagram

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Figure 2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies

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Figure 3

Risk of bias summary: review authors' judgements about each risk of bias item for each included study

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Analysis 1.1

Comparison 1 Weight loss versus no active intervention, Outcome 1 Improvement rates based on women's perception (all types UI).

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Study	Outcome	Weight loss ( number improved)	Weight loss (t otal N)	Weight loss (%)	Control ( number improved)	Control (t otal N)	Control (%)	Reported P value
Subak 2009	At 12 months (N = 298)	Not reported	Not reported	75	Not reported	Not reported	68	0.2
Subak 2009	At 18 months (N = 291)	Not reported	Not reported	75	Not reported	Not reported	62	0.02

Analysis 1.2

Comparison 1 Weight loss versus no active intervention, Outcome 2 Improvement rates based on women's perception (all types UI).

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Study	Outcome	Weight loss (total N)	Weight loss, median (IQR)	Control (total N)	Control, median (IQR)	Reported P value
Subak 2005	3 months
Subak 2005	Incontinence Impact Questionnaire (score range 0‐400 with lower score indicating better quality of life)	19	37 (11 to 86)	21	89 (56 to 136)	0.01
Subak 2005	Urogenital Distress Inventory (score range 0‐300 with lower scores indicating less distress)	19	104 (67 to 122)	21	195 (156 to 228)	<0.0001
Subak 2005	SF‐36 physical component (higher scores indicate better quality of life)	19	55 (49 to 58)	21	47 (41 to 50)	0.003
Subak 2005	SF‐36 mental component (higher scores indicate better quality of life)	19	48 (46 to 49)	21	51 (48 to 54)	0.09

Analysis 1.3

Comparison 1 Weight loss versus no active intervention, Outcome 3 Quality of life and symptom scores.

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Analysis 1.4

Comparison 1 Weight loss versus no active intervention, Outcome 4 Cure rates based on quantification of symptoms (all types UI).

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Study	Outcome	Weight loss (number cured)	Weight loss (total N)	Weight loss (%)	Control (number cured)	Control (total N)	Control (%)	Reported P value
Subak 2009	Stress UI at 6 months	Not reported	Not reported	27	Not reported	Not reported	15	0.004
Subak 2009	Urgency UI at 6 months	Not reported	Not reported	19	Not reported	Not reported	11	0.02

Analysis 1.5

Comparison 1 Weight loss versus no active intervention, Outcome 5 Cure rates based on quantification of symptoms (by type of UI).

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Analysis 1.6

Comparison 1 Weight loss versus no active intervention, Outcome 6 Improvement rates based on quantification of symptoms (all types UI).

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Study	Outcome	Weight loss (number cured)	Weight loss (total)	Weight loss (%)	Control (number cured)	Control (total)	Control (%)	Reported P value
Subak 2009	Stress UI at 6 months	Not reported	Not reported	51	Not reported	Not reported	34	0.01
Subak 2009	Urgency UI at 6 months	Not reported	Not reported	41	Not reported	Not reported	29	0.04
Subak 2009	Stress UI at 6 months	Not reported	Not reported	51	Not reported	Not reported	34	0.01
Subak 2009	Urgency UI at 6 months	Not reported	Not reported	41	Not reported	Not reported	29	0.04
Subak 2009	Stress UI at 18 months	Not reported	Not reported	61	Not reported	Not reported	62	0.92
Subak 2009	Urgency UI at 18 months	Not reported	Not reported	47	Not reported	Not reported	34	0.03

Analysis 1.7

Comparison 1 Weight loss versus no active intervention, Outcome 7 Improvement rates based on quantification of symptoms (by type of UI).

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Analysis 1.8

Comparison 1 Weight loss versus no active intervention, Outcome 8 Prevalence of weekly urinary incontinence after intervention (all types UI).

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Study	Outcome	Weight loss (number with UI)	Weight loss (total N)	Weight loss (%)	Control (number with UI)	Control (total N)	Control (%)	Reported P value	Reported adjusted odds ratio (95% CI)
Brown 2006b	SUI at 2.8 years	206	659	31	242	660	37	0.04	0.80 (0.64 to 1.01)
Brown 2006b	UUI at 2.8 years	156	659	24	169	660	26	0.41	Not reported
Phelan 2012	SUI at 1 year	145	1385	11	173	1354	13	0.07	0.73 (0.55 to 0.96)
Phelan 2012	UUI at 1 year	Not reported	Not reported	Not reported	Not reported	Not reported	Not reported	Not reported	0.93 (0.70 to 1.23)

Analysis 1.9

Comparison 1 Weight loss versus no active intervention, Outcome 9 Prevalence of weekly urinary incontinence after intervention (by type of UI).

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Analysis 1.10

Comparison 1 Weight loss versus no active intervention, Outcome 10 Incontinent episodes per week (% change from baseline; all UI types).

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Study	Outcome	Weight loss (total N)	Weight loss (% change from baseline)	Control (total N)	Control (% change from baseline)	Reported P value
Subak 2005	All UI at 3 months, median (IQR)	19	‐60 (‐89 to ‐30)	21	‐15 (‐25 to 9)	0.0005
Subak 2005	Stress UI at 3 months, median (IQR)	19	‐92 (‐100 to ‐66)	21	5 (‐63 to 33)	0.003
Subak 2005	Urgency UI at 3 months, median (IQR)	19	‐70 (‐100 to ‐16)	21	‐11 (‐67 to 69)	0.03
Subak 2005
Subak 2005
Subak 2005
Subak 2005
Subak 2005
Subak 2005
Subak 2009	All UI at 6 months, mean (95% CI)	214	‐47 (‐54 to ‐40)	90	‐28 (‐41 to ‐13)	0.01
Subak 2009	Stress UI at 6 months, mean (95% CI)	214	‐58 (‐67 to ‐46)	90	‐33 (‐50 to ‐9)	0.02
Subak 2009	Urgency UI at 6 months, mean (95% CI)	214	‐42 (‐51 to ‐32)	90	‐26 (‐44 to ‐3)	0.14
Subak 2009	All UI at 12 months, mean (95% CI)	207	‐57 (‐63 to ‐50)	87	‐45 (‐56 to ‐32)	0.08
Subak 2009	Stress UI at 12 months, mean (95% CI)	207	‐66 (‐71 to ‐59)	87	‐45 (‐59 to ‐27)	<0.001
Subak 2009	Urgency UI at 12 months, mean (95% CI)	207	‐50 (‐59 to ‐39)	87	‐48 (‐63 to ‐29)	0.87
Subak 2009	All UI at 18 months, mean (95% CI)	197	‐62 (‐67 to ‐55)	90	‐55 (‐65 to ‐43)	0.3
Subak 2009	Stress UI at 18 months, mean (95% CI)	197	‐69 (‐76 to ‐61)	90	‐62 (‐73 to ‐48)	0.32
Subak 2009	Urgency UI at 18 months, mean (95% CI)	197	‐56 (‐64 to ‐46)	90	‐49 (‐64 to ‐28)	0.46

Analysis 1.11

Comparison 1 Weight loss versus no active intervention, Outcome 11 Incontinence episodes per week (% change from baseline; by type of UI).

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Study	Outcome	Soy‐rich diet (n/N)	Soy‐rich diet (%)	Control diet (n/N)	Control diet (%)
Manonai 2006	SUI episodes: before (baseline)	22/36	61	23/36	63
Manonai 2006	SUI episodes: after	22/36	61	18/36	51
Manonai 2006	UUI episodes: before (baseline)	7/36	19	4/36	11
Manonai 2006	UUI episodes: after	6/36	17	8/36	22

Analysis 2.1

Comparison 2 Soy‐rich diet versus control, Outcome 1 Number of women with UI episodes: soy‐rich diet versus control.

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Study	Outcome	Soy‐rich diet (n = 36)	Soy‐rich diet (n = 36)
Manonai 2006	SUI episodes: before (baseline)	0.67 (0.68)	0.75 (0.65)
Manonai 2006	SUI episodes: after	0.72 (0.66)	0.72 (0.74)
Manonai 2006	Reported P value	> 0.05	> 0.05
Manonai 2006	UUI episodes: before (baseline)	0.17 (0.38)	0.14 (0.35)
Manonai 2006	UUI episodes: after	0.19 (0.47)	0.25 (0.50)
Manonai 2006	Reported P value	> 0.05	< 0.05

Analysis 2.2

Comparison 2 Soy‐rich diet versus control, Outcome 2 Mean UI symptom scores (SD; 0 = none, 1 = mild, 2 = moderate, 3 = severe): soy‐rich diet versus control.

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Study	Type of UI	Baseline	Caffeine‐free baseline	Caffeine‐free and increasing fluids	Caffeine‐free and decreasing fluids
Swithinbank 2005	Urodynamic stress incontinence (SUI), n = 39	1.6 (0.6 to 2.8)	0.8 (0.1 to 1.9)	0.7 (0.3 to 3)	0.5 (0.2 to 2.1)
Swithinbank 2005	Idiopathic detrusor overactivity (IDO), n = 30	0.9 (0.4 to 2)	0.6 (0.2 to 1.8)	1.1 (0.2 to 3)	0.5 (0.2 to 1.2)

Analysis 3.1

Comparison 3 Increase in fluid intake versus decrease in fluid intake, Outcome 1 Median number of daily UI episodes (IQR).

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Study	Randomised group	N	Median (range)	Reported P value compared with baseline
Hashim 2008	Baseline	24	0 (0, 4.8)
Hashim 2008	25% less fluid	24	0 (0, 5.5)	1.0
Hashim 2008	50% less fluid	12	0 (0, 4.5)	0.69
Hashim 2008	25% more fluid	21	0 (0, 10.3)	1.00
Hashim 2008	50% more fluid	14	0 (0, 12.8)	0.69

Analysis 3.2

Comparison 3 Increase in fluid intake versus decrease in fluid intake, Outcome 2 Median number of daily UI episodes (range).

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Study	Time period	Maintain fluid (N = 14)	Increase fluid (N = 10)	Decrease fluid (N = 8)
Dowd 1996	Week 1 (baseline)	0.48	0.6	0.54
Dowd 1996	Week 2	0.71	0.61	0.26
Dowd 1996	Week 3	0.81	0.67	0.17
Dowd 1996	Week 4	0.57	0.5	0.14
Dowd 1996	Week 5	0.48	0.55	0.07

Analysis 3.3

Comparison 3 Increase in fluid intake versus decrease in fluid intake, Outcome 3 Mean number of daily UI episodes (any UI).

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Study	Outcome	Caffeine substitution	Caffeine exposure	Reported P value
Wells 2011	ICIQ Overactive Bladder (ICIQ‐OAB) total score (N = 11); 0‐16 overall score with greater values indicating increased symptom severity	4.64	6.55	< 0.01
Wells 2011	ICIQ Overactive Bladder Symptoms Quality of Life (ICIQ‐OABqol) score (N = 11); 25‐160 overall score with greater values indicating increased impact on quality of life
Wells 2011	1) How regularly bladder symptoms interfered with the ability to get a good night's rest	2.64	4.09	< 0.01
Wells 2011	2) How often bladder symptoms caused anxiety or worry	1.73	2.64	< 0.05
Wells 2011	3) How much bladder symptoms interfered with everyday life overall	3.73	5.64	< 0.01
Wells 2011	4) Total scores for the ICIQ‐OABqol	53.91	68.36	0.065

Analysis 4.1

Comparison 4 Caffeine reduction versus control, Outcome 1 Mean quality of life scores.

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Analysis 4.2

Comparison 4 Caffeine reduction versus control, Outcome 2 Mean number of UI episodes per 24 hours (SD).

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Analysis 5.1

Comparison 5 Lifestyle weight loss versus metformin, Outcome 1 Prevalence of weekly UI after intervention.

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Summary of findings for the main comparison. Weight loss compared to control for the treatment of urinary incontinence in adults

Weight loss compared to control for the treatment of urinary incontinence in adults
Patient or population: adults with urinary incontinence Settings: Intervention: weight loss Comparison: control
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	Control	Weight loss
Cure rates by patient observation (all UI types) ‐ not reported			Not estimable	‐
Improvement rates by patient observation (all UI types) Follow‐up: 6 months	544 per 1000	762 per 1000 (621 to 931)	RR 1.4 (1.14 to 1.71)	304 (1 study)	⊕⊕⊝⊝ low^1,2
Condition‐specific quality of life Incontinence Impact Questionnaire. Scale from: 0 to 400. Better quality of life indicated by lower values. Follow‐up: 3 months	The median condition‐specific quality of life in the control groups was 89 points	The median condition‐specific quality of life in the intervention groups was 52 lower (95% CI not estimable)		40 (1 study)	⊕⊕⊝⊝ low^1,2
Adverse effects Follow‐up: 3 months			Not estimable	48 (1 study)		The study reported that the intervention had 'few side effects'.
Cure rates by symptom quantification (all UI types) Follow‐up: 12 months	315 per 1000	350 per 1000 (287 to 431)	RR 1.11 (0.91 to 1.37)	738 (1 study)	⊕⊕⊝⊝ low^1,3,4
Improvement rates by symptom quantification (all UI type) Follow‐up: 12 months	325 per 1000	393 per 1000 (332 to 468)	RR 1.21 (1.02 to 1.44)	1032 (2 studies)	⊕⊕⊝⊝ low^1,3,4
Prevalence of weekly UI (all UI type) Follow‐up: 12 months	286 per 1000	252 per 1000 (223 to 286)	RR 0.88 (0.78 to 1)	2739 (1 study)	⊕⊝⊝⊝ very low^1,3,4,5
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; RR: risk ratio; UI: urinary incontinence
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
¹ Risk of bias: We downgraded the evidence by one level because blinding of participants and personnel was unlikely. ² Indirectness: We downgraded the evidence by one level because of short follow‐up < 12 months ³ Risk of bias: We downgraded the evidence by one level because the authors did not report or provide a description of an allocation concealment method in one study (Phelan 2012). ⁴ Missing outcome data in 7%‐10% of the participants in one study (Phelan 2012). ^‐ Indirectness: We downgraded the evidence by one level because data include a sub‐study of a trial (Phelan 2012) for diabetes that included continent as well as incontinent patients; only 27% had weekly urinary incontinence at baseline.

Summary of findings for the main comparison. Weight loss compared to control for the treatment of urinary incontinence in adults

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Summary of findings 2. Soy‐rich diet compared to control for the treatment of urinary incontinence in adults

Soy‐rich diet compared to control for the treatment of urinary incontinence in adults
Patient or population: adults with urinary incontinence Settings: Intervention: soy‐rich diet Comparison: control
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	Control	Soy rich diet
Cure rates by patient observation (all UI types) ‐ not reported			Not estimable	‐
Improvement rates by patient observation (all UI types) ‐ not reported			Not estimable	‐
Condition‐specific quality of life ‐ not reported			Not estimable	‐
Adverse effects ‐ not reported			Not estimable	‐
Cure rates by symptom quantification (all UI types) ‐ not reported			Not estimable	‐
Improvement rates by symptom quantification (all UI types) ‐ not reported			Not estimable	‐
Incontinent episodes per week (all UI types) ‐ not reported			Not estimable	‐
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; RR: risk ratio; UI: urinary incontinence
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.

Summary of findings 2. Soy‐rich diet compared to control for the treatment of urinary incontinence in adults

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Summary of findings 3. Decreasing fluids compared to increasing fluids for the treatment of urinary incontinence in adults

Decreasing fluids compared to increasing fluids for the treatment of urinary incontinence in adults
Patient or population: adults with urinary incontinence Settings: Intervention: decreasing fluids Comparison: increasing fluids
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	Increasing fluids	Decreasing fluids
Cure rates by patient observation (all UI types) ‐ not reported			Not estimable	‐
Improvement rates by patient observation (all UI types) ‐ not reported			Not estimable	‐
Condition‐specific quality of life Follow‐up: 1 weeks	See comment	See comment	Not estimable	69 (1 study¹)	⊕⊝⊝⊝ very low^2,3,4,5,6	Quality of life improved when fluid intake was decreased but the impact of incontinence on daily life did not differ significantly before or after the treatment
Adverse effects Follow‐up: 1 weeks	See comment	See comment	Not estimable	93 (2 studies¹)	⊕⊝⊝⊝ very low^2,3,5,6,7,8	Reported adverse effects include constipation, thirst, headache and concentrated urine with decreasing fluids
Cure rates by symptom quantification (all UI types) ‐ not reported			Not estimable	‐
Improvement rates by symptom quantification (all UI types) ‐ not reported			Not estimable	‐
Incontinent episodes per week (all UI types) Follow‐up: 1‐4 weeks	See comment	See comment	Not estimable	125 (3 studies⁹)	⊕⊝⊝⊝ very low^{2,3,5,6,8,10,11}	Decreasing fluid intake significantly reduced incontinent episodes in one study, no difference was found in another study and the results were inconclusive in the other study
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; UI: urinary incontinence
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
¹ Randomised cross‐over trial ² Risk of bias: We downgraded the evidence by one level because blinding of participants, personnel and outcome assessors was probably not done and could introduce bias. ³ Risk of bias: We downgraded the evidence by one level because the authors did not report or provide a description of an allocation concealment method. ⁴ Missing outcome data in 18% of participants. ⁵ Indirectness: We downgraded the evidence by two levels because of short follow‐up < 12 months in all studies and because study participants included both continent and incontinent patients in one study (Hashim 2008) ⁶ Imprecision: We downgraded the evidence by one level because confidence intervals for relative effect were not estimable. ⁷ Missing outcome data in 18% of participants in one study (Swithinbank 2005), whereas the other study had no missing outcome data (Hashim 2008). ⁸ Inconsistency: We downgraded the evidence by one level because becuse of heterogenous interventions. ⁹ One RCT compared increasing versus decreasing versus maintaining fluid intake (Dowd 1996) and two randomized cross‐over trials comparing increasing versus decreasing fluid intake (Hashim 2008; Swithinbank 2005). ¹⁰ Missing outcome data in 45% of participants in the RCT (Dowd 1996), 18% of participants in a cross‐over trial (Swithinbank 2005), whereas the other cross‐over trial had no missing outcome data (Hashim 2008). ¹¹ Low adherence to the protocol was reported in two studies (Dowd 1996;Hashim 2008).

Summary of findings 3. Decreasing fluids compared to increasing fluids for the treatment of urinary incontinence in adults

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Summary of findings 4. Caffeine reduction compared to control for the treatment of urinary incontinence in adults

Caffeine reduction compared to control for the treatment of urinary incontinence in adults
Patient or population: adults with urinary incontinence Settings: Intervention: caffeine reduction Comparison: control
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	Control	Caffeine reduction
Cure rates by patient observation (all UI types) ‐ not reported			Not estimable	‐
Improvement rates by patient observation (all UI types) ‐ not reported			Not estimable	‐
Condition‐specific quality of life ICIQ Overactive Bladder Symptoms Quality of Life. Scale from: 25 to 160. Better quality of life indicated by lower values. Follow‐up: 2 weeks	The mean condition‐specific quality of life in the control groups was 68.36 points	The mean condition‐specific quality of life in the intervention groups was 14.45 lower (95% CI not estimable)	Not estimable	11 (1 study¹)	⊕⊝⊝⊝ very low^2,3,4,5,6
Adverse effects ‐ not reported			Not estimable	‐
Cure rates by symptom quantification (all UI types) ‐ not reported			Not estimable	‐
Improvement rates by symptom quantification (all UI types) ‐ not reported			Not estimable	‐
Incontinent episodes per day (all UI types) Follow‐up: 4 weeks	The mean number of incontinent episodes per day (all UI types) in the control groups was 1.4	The mean number of incontinent episodes per day (all UI types) in the intervention groups was 0.2 lower (1.02 lower to 0.62 higher)	Not estimable	74 (1 study⁷)	⊕⊝⊝⊝ very low^2,4,5,6,8
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
¹ Randomised cross‐over trial; feasibility study. ² Risk of bias: We downgraded the evidence by one level because blinding of participants, personnel and outcome assessors was probably not done. ³ Risk of bias: We downgraded the evidence by one level because the authors did not report or provide a description of an allocation concealment method. ⁴ Missing outcome data in > 20% of participants. ⁵ Indirectness: We downgraded the evidence by two levels because of short follow‐up < 12 months and because study participants included both continent and incontinent patients. ⁶ Imprecision: We downgraded the evidence by one level because confidence intervals for relative effect were not estimable. ⁷ A quasi‐randomised controlled trial based on health record numbers. ⁸ Risk of bias: We downgraded the evidence by one level because allocation concealment was inadequate (quasi‐randomisation based on health record numbers).

Summary of findings 4. Caffeine reduction compared to control for the treatment of urinary incontinence in adults

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Summary of findings 5. Lifestyle weight loss compared to metformin weight loss for the treatment of urinary incontinence in adults

Lifestyle weight loss compared to metformin weight loss for the treatment of urinary incontinence in adults
Patient or population: adults with urinary incontinence Settings: Intervention: lifestyle weight loss Comparison: metformin weight loss
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	Metformin weight loss	Lifestyle weight loss
Cure rates by patient observation (all UI types) ‐ not reported			Not estimable	‐
Improvement rates by patient observation (all UI types) ‐ not reported			Not estimable	‐
Condition‐specific quality of life ‐ not reported			Not estimable	‐
Adverse effects ‐ not reported			Not estimable	‐
Cure rates by symptom quantification (all UI types) ‐ not reported			Not estimable	‐
Improvement rates by symptom quantification (all UI types) ‐ not reported			Not estimable	‐
Prevalence of weekly UI (all UI types) Follow‐up: mean 2.8 years	482 per 1000	381 per 1000 (337 to 434)	RR 0.79 (0.7 to 0.9)	1294 (1 study)	⊕⊝⊝⊝ very low^1,2,3,4
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; RR: risk ratio
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
¹ Risk of bias: We downgraded the evidence by one level because blinding of participants, personnel and outcome assessors was not mentioned and may introduce bias. ² Risk of bias: We downgraded the evidence by one level because the authors did not report or provide a description of an allocation concealment method. ³ Missing outcome data in 11% of participants. ⁴ Indirectness: We downgraded the evidence by one level because data come from a sub‐study of a trial (Brown 2006) for diabetes that included continent as well as incontinent patients.

Summary of findings 5. Lifestyle weight loss compared to metformin weight loss for the treatment of urinary incontinence in adults

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Comparison 1. Weight loss versus no active intervention

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Improvement rates based on women's perception (all types UI) Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

1.1 At 6 months	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
2 Improvement rates based on women's perception (all types UI) Show forest plot			Other data	No numeric data

3 Quality of life and symptom scores Show forest plot			Other data	No numeric data

4 Cure rates based on quantification of symptoms (all types UI) Show forest plot	3		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

4.1 At 3 months	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
4.2 At 6 months	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
4.3 At 12 months	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
5 Cure rates based on quantification of symptoms (by type of UI) Show forest plot			Other data	No numeric data

6 Improvement rates based on quantification of symptoms (all types UI) Show forest plot	3		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

6.1 At 3 months	1	40	Risk Ratio (M‐H, Fixed, 95% CI)	16.5 [1.01, 270.78]
6.2 At 6 months	1	304	Risk Ratio (M‐H, Fixed, 95% CI)	1.85 [1.22, 2.81]
6.3 At 12 months	2	1032	Risk Ratio (M‐H, Fixed, 95% CI)	1.21 [1.02, 1.44]
6.4 At 18 months	1	287	Risk Ratio (M‐H, Fixed, 95% CI)	1.15 [0.86, 1.55]
7 Improvement rates based on quantification of symptoms (by type of UI) Show forest plot			Other data	No numeric data

8 Prevalence of weekly urinary incontinence after intervention (all types UI) Show forest plot	2		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

8.1 At 12 months	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
8.2 At 2.8 years	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
9 Prevalence of weekly urinary incontinence after intervention (by type of UI) Show forest plot			Other data	No numeric data

10 Incontinent episodes per week (% change from baseline; all UI types) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

10.1 At 6 months	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
10.2 At 12 months	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
10.3 At 18 months	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
11 Incontinence episodes per week (% change from baseline; by type of UI) Show forest plot			Other data	No numeric data

Comparison 1. Weight loss versus no active intervention

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Comparison 2. Soy‐rich diet versus control

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Number of women with UI episodes: soy‐rich diet versus control Show forest plot			Other data	No numeric data

2 Mean UI symptom scores (SD; 0 = none, 1 = mild, 2 = moderate, 3 = severe): soy‐rich diet versus control Show forest plot			Other data	No numeric data

Comparison 2. Soy‐rich diet versus control

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Comparison 3. Increase in fluid intake versus decrease in fluid intake

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Median number of daily UI episodes (IQR) Show forest plot			Other data	No numeric data

2 Median number of daily UI episodes (range) Show forest plot			Other data	No numeric data

3 Mean number of daily UI episodes (any UI) Show forest plot			Other data	No numeric data

Comparison 3. Increase in fluid intake versus decrease in fluid intake

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Comparison 4. Caffeine reduction versus control

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Mean quality of life scores Show forest plot			Other data	No numeric data

2 Mean number of UI episodes per 24 hours (SD) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

Comparison 4. Caffeine reduction versus control

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Comparison 5. Lifestyle weight loss versus metformin

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Prevalence of weekly UI after intervention Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

1.1 All UI types at 2.8 years	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
1.2 Stress UI at 2.8 years	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
1.3 Urgency UI at 2.8 years	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

Comparison 5. Lifestyle weight loss versus metformin

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