research: foundation of the dietetics profession evidence analysis library and evidence-based...

Research: Foundation of the Dietetics Profession

Evidence Analysis Library Evidence Analysis Library andand

Evidence-BasedEvidence-BasedNutrition Practice Guidelines Nutrition Practice Guidelines

and Toolkitsand Toolkits

ADA Definition/Description

“Evidence-Based Dietetics Practice is the use of systematically reviewed scientific evidence in making food and nutrition practice decisions by integrating best available evidence with professional expertise and client values to improve outcomes.”

Approved by ADA HOD February 2006

Why Evidence-based Practice?

• To improve patient outcomes

• To improve safety, quality, efficiency

• To take advantage of “exploding” biomedical knowledge (thousands of new research studies appear every month)

OnlineResourcewith the bestavailable researchon importantdietetics topics in

apractitioner-

friendlyformat

ADA Evidence Analysis Library

www.adaevidencelibrary.com

What are the steps in ADA’s Evidence Analysis Process?

1) Select Topic & Appoint Expert Working Group 2) Define Questions & Analytical Framework/

Determine Inclusion/Exclusion Criteria3) Conduct Literature Review for each question 4) Analyze articles5) Complete Evidence Summaries & Tables6) Draft proposed Conclusion Statements7) Reach Consensus on Conclusion

Statements/Grades8) PUBLISH to ONLINE LIBRARY (EAL)

Current List of ADA EAL ProjectsDiseases & Conditions

Adult Diabetes 1 & 2 (revision)Adult Weight Management

Childhood OverweightChronic Kidney Disease

(revision)Chronic Obstructive Pulmonary

Disease (COPD)Critical Illness

Disorders of Lipid Metabolism (Hyperlipidemia revision)

Gestational Diabetes (revision)Gluten Intolerance/ Celiac

Heart FailureHIV/AIDS

Diseases & Conditions (continued)

HydrationHypertension

Nutrition in Athletic PerformanceNutrition Care in Bariatric Surgery

OncologyPediatric Weight ManagementSpinal Cord Injury & Nutrition

Unintended Weight Loss

Nutrition Care ProcessEstimating Energy

Expenditure/Indirect CalorimetryNutrition Counseling

FoodsFiber

Non-nutritive SweetenerVegetarian Nutrition

Navigate through the library by selecting from tabs:

EALDrill down to the amount of information you desire on EAL

• Question• Conclusion Statement/Grade of

the strength and quality of the evidence

• Evidence Summary• Bibliography/Worksheets on

each article• Quality Checklists

Select from list of Diseases & Conditions

Trans-fatty acids

Disorders of

Lipid Metabolism

Macronutrients

Choose a Topic

Then, choose a sub-topic

Example: View EA Question

Bibliography for Topic

What is the relationship between diets high in trans fatty acids and

serum cholesterol levels?

Example: Conclusion Statement (answer to question) and Grade

“Mouse over” Question to see Conclusion & Grade or

click on question to continue drilling down.

Conclusion Statement

Trans-fatty acids raise total cholesterol and LDL-C. Unlike saturated fatty

acids, trans-fatty acids do not increase and may decrease HDL-C. Trans-fatty acids increase the TC/HDL-C ratio in a

dose dependent manner. GRADE I

Explanation of Grades

Example: Evidence Summary

Narrative Summary

Of the researchavailable to answerquestion

All articles used to answer question are summarized here.

Example: BibliographyBibliography for Question listed at end of Evidence Summary (and linked to

worksheets)

Example: Worksheet for each article•Citation / PubMed ID

•Date•Study Design•Class•Rating (+/0/-)•Research Purpose•Inclusion Criteria•Exclusion Criteria•Description of Study Protocol •Data Collection Summary•Description of Actual Data Sample •Summary of Results •Author Conclusion•Reviewer Comments

Example: Quality Criteria Checklist

•Primary Research or•Narrative Review

Determine Quality Rating of Article

Transition from Evidence to Evidence-Based Guideline

Evidence Summaries/Conclusion Statements = what the evidence says

Guideline = course of action for the practitioner based on the evidence

ADA’s Evidence-Based Guidelines

• Use best available evidence in making clinical decisions

• Use a systematic process for identifying, assessing, analyzing and synthesizing evidence as a basis for development

• Promote use of professional expertise where evidence is weak or lacking

Criteria and Classification for Guideline Development

• Criteria used to develop:• Guideline Elements Model (GEM)• AGREE Instrument • National Guidelines Clearinghouse

standards

• Classification:• Recommendation ratings adapted from

American Academy of Pediatrics

Transition from evidence to Guideline

• Formulation of:• Recommendations: a series of guiding

statements that propose a course of action for practitioners

• Clinical Algorithms: step-by-step flowchart for treatment of the specific disease/condition

• Introduction: scope, intent, methods, benefits/harms

• Appendices: food tables, etc.• Glossary

• External review• Publish on EAL

Features of Guideline Introduction

• Scope: disease/condition, objective, intended users, target population

• Statement of Intent• Guideline Methods: process of

guideline development, inclusion/exclusion criteria

• Implementation of Guideline• Benefits and Potential

Risks/Harms of Implementing

Features of Guideline Recommendations

• Written for the practitioner, as a course of action

• Describe “what” the practitioner should do and “why” it should be done

• Display rating using ADA scale Strong, Fair, Weak, Consensus, Insufficient Evidence

• List potential risks/harms for implementing • Provide a brief narrative illustrating the

supporting evidence• Provide rationale for the recommendation rating• List any minority opinions• Link to supporting evidence

Evidence-Based Guidelines Homepage

Select Guidelines from Guideline List

Example: Select Disorders of Lipid Metabolism

Disorders of Lipid MetabolismEvidence-Based Nutrition Practice Guideline

Main Menu

Choose a

Category

Introduction•Guideline Overview•Scope of Guideline•Statement of Intent•Guideline Methods•Implementation•Benefits and Risks/harms

Disorders of Lipid MetabolismEvidence-Based Nutrition Practice Guideline

Select a Category within Introduction

Disorders of Lipid MetabolismEvidence-Based Nutrition Practice Guideline

Scope ofGuideline

Scope of Guideline Disease/Condition Guideline Category Intended Users Objectives Target Population

Disorders of Lipid MetabolismEvidence-Based Nutrition Practice Guideline

Introduction: Guideline MethodsMethod for Creating GuidelinesInclusion and ExclusionCriteria

Disorders of Lipid MetabolismEvidence-Based Nutrition Practice Guideline

Main Menu: Major Recommendations

Disorders of Lipid MetabolismEvidence-Based Nutrition Practice Guideline

Macronutrients: FatSub-topic:Trans-fatty Acid Intake

Disorders of Lipid MetabolismEvidence-Based Nutrition Practice Guideline

Select a Recommendation(listed by topic)

Recommendationdomains:Recommendation & Rating

Risks/Harms

Conditions of Application

Potential Costs

Narrative

Rationale for Rating

Disorders of Lipid MetabolismEvidence-Based Nutrition Practice Guideline

E.g.Recommendation: Trans-fatty acids consumption should be as low as possible. A cardioprotective dietary pattern should contain less than 7% of calories from saturated fat and trans-fatty acids. Trans-fatty acids raise total cholesterol and LDL-C and may decrease HDL-C, thereby increasing the TC/HDL-C and LDL-C/HDL-C ratios. Increasing trans-fatty acid intake increases risk of CHD events.

Disorders of Lipid MetabolismEvidence-Based Nutrition Practice Guideline

Statement Rating

Definition Implication for Practice

Strong A Strong recommendation means that the workgroup believes that the benefits of the recommended approach clearly exceed the harms (or that the harms clearly exceed the benefits in the case of a strong negative recommendation), and that the quality of the supporting evidence is excellent/good (grade I or II). In some clearly identified circumstances, strong recommendations may be made based on lesser evidence when high-quality evidence is impossible to obtain and the anticipated benefits strongly outweigh the harms.

Practitioners should follow a Strong recommendation unless a clear and compelling rationale for an alternative approach is present.

Fair A Fair recommendation means that the workgroup believes that the benefits exceed the harms (or that the harms clearly exceed the benefits in the case of a negative recommendation), but the quality of evidence is not as strong (grade II or III). In some clearly identified circumstances, recommendations may be made based on lesser evidence when high-quality evidence is impossible to obtain and the anticipated benefits outweigh the harms.

Practitioners should generally follow a Fair recommendation but remain alert to new information and be sensitive to patient preferences.

Weak A Weak recommendation means that the quality of evidence that exists is suspect or that well-done studies (grade I, II, or III) show little clear advantage to one approach versus another.

Practitioners should be cautious in deciding whether to follow a recommendation classified as Weak, and should exercise judgment and be alert to emerging publications that report evidence. Patient preference should have a substantial influencing role.

Consensus A Consensus recommendation means that Expert opinion (grade IV) supports the guideline recommendation even though the available scientific evidence did not present consistent results, or controlled trials were lacking.

Practitioners should be flexible in deciding whether to follow a recommendation classified as Consensus, although they may set boundaries on alternatives. Patient preference should have a substantial influencing role.

Insufficient Evidence

An Insufficient Evidence recommendation means that there is both a lack of pertinent evidence (grade V) and/or an unclear balance between benefits and harms.

Practitioners should feel little constraint in deciding whether to follow a recommendation labeled as Insufficient Evidence and should exercise judgment and be alert to emerging publications that report evidence that clarifies the balance of benefit versus harm. Patient preference should have a substantial influencing role.

Scroll down recommendation page for links to the supporting evidence and worksheets

Disorders of Lipid MetabolismEvidence-Based Nutrition Practice Guideline

What is the relationship between diets high in trans fatty acids and risk for CHD?

View Conclusion Statement and Grade

Drill down to the Evidence Summary

Disorders of Lipid MetabolismEAL Trans fatty acids question

Evidence Summary

Disorders of Lipid MetabolismEAL Trans fatty acids question

Scroll down for worksheets

Drill down toQuality ratingAndworksheets

Disorders of Lipid MetabolismEAL Trans fatty acids question

Main Menu: Algorithms

Disorders of Lipid MetabolismEvidence-Based Nutrition Practice Guideline

Main Algorithm for Disorders of Lipid MetabolismView recommendations organized within a treatment plan

Nutrition Care Process

Assessment

Diagnosis

Intervention

Monitoring & Evaluation

Link to another level within the Algorithm

Red = link to different level in algorithm

Blue = link to recommendation

Select: Determine Meal Plan and Nutrition Recommendations

•View second level algorithm•Link to Recommendation

Recommend Intake of as Few Trans Fatty Acids as Possible

Select

•View Recommendation• Drill down as needed

Evidence-Based Toolkits • Set of companion documents for

application of the practice guideline• Disease or condition specific • Include:

• documentation forms• outcomes monitoring sheets• client education resources• case studies • MNT protocol for treatment of

disease/condition • Incorporate Nutrition Care Process and

Standardized Language• Electronic download purchase item

Disorders of Lipid Metabolism Toolkit

• Choose Quantity• Add to Cart

STORE

Disorders of Lipid Metabolism Toolkit Contents

MNT Protocol• Summary Page for DLM and DLM with Metabolic Syndrome  • MNT Flowchart of Encounters• MNT Encounter Process

Documentation Forms• Instructions for Sample Referral Form• MNT Sample Referral Form • Initial and Follow-up Nutrition Progress Note• Sample Case Study #1• Sample Case Study #2

Summary Page for DLM: based on evidence

Outcomes Assessment Factors• e.g. soluble fiber intakeExpected Outcomes• increased intakeIdeal Goals of MNT• >25g dietary fiber of which 7-13g soluble fiber per day

©2006 American Dietetic AssociationDisorders of lipid Metabolism Toolkit

Encounter Process for Disorders of Lipid Metabolism

ENCOUNTER: Initial Encounter 45 to 90 minutes

AssessmentObtain the following from client, medical record/information system or clinical referral form within 30 days of encounter. Client History consists of four areas: medication and supplement history, social history, medical/health history, and personal history.

•Medication and Supplement History includes, for instance, prescription lipid-lowering, antihypertensive, diabetes, and thyroid medications, over the counter (OTC) drugs, herbal and dietary supplements (for example folate, B-complex vitamins, Co-enzyme Q10, those with potential for food/drug interaction), and illegal drugs.• Social History may include such items as smoking history, alcohol intake (frequency and amount), socioeconomic status, social and medical support, cultural and religious beliefs, housing situation, and social isolation/connection.•Medical/Health History includes chief nutrition complaint, present/past illness particularly of cardiovascular disease, diabetes, thyroid disease, evaluate risk factors for cardiovascular disease, metabolic syndrome, family medical history, especially of premature cardiovascular disease, mental/emotional health and cognitive abilities.•Personal History consists of factors including age, occupation, role in family, and education level.

Biochemical Data includes laboratory data, for example, lipid profile, glucose, hemoglobin A1C, liver function tests, thyroid, Lp(a), homocysteine, and high-sensitivity C reactive protein.Anthropometric Measurements include height, weight, weight history, body mass index (BMI), waist circumference (WC), waist to hip ratio (WHR) Physical Exam Findings includes blood pressure, general physical appearance (abdominal girth and presence of xanthomas) muscle and subcutaneous fat wasting, and affectFood and Nutrition History consists of four areas: Food consumption, nutrition and health awareness and management, physical activity and exercise, and food availability

Encounter Process: detailed process for assessment, diagnosis, intervention and monitoring and evaluation ofpatients with DLM

Case Studies: • Initial and Follow-up Encounters• Illustrates the Nutrition Care Process• Uses new SL for Nutrition Diagnosis and Intervention

DLM Toolkit Contents

Client Education Resources• Executive Summary and List of ADA Client Education

Resources • Client Agreement for Care                        • Other Client Education Resources

             Alcohol             Soluble Fiber Tips            The Low-down on Trans Fats            Health Benefits of Nuts             Omega-3 Fatty Acids             Sample Menu #1 and #2

• Appendices          

Client Education Materials: 6-7th grade reading level

DLM Toolkit Contents

Outcomes Monitoring Forms• Individual Outcomes Monitoring Form• Aggregate Input Form• Aggregate Outcomes Monitoring Form

 • Sample Individual Outcomes Form• Sample Aggregate Input Form• Sample Aggregate Outcomes Form

Monitoring Outcomes: use for individuals or a population –monitor change (e.g. kcal, lipid values)• document over several encounters• programmed formulas for % change and averages

Published and Upcoming Evidence-Based Guidelines and Toolkits

Published:•Disorders of Lipid Metabolism Guideline and Toolkit•Adult Weight Management Guideline•Critical Illness Guideline

Coming Soon:•Adult Weight Management Toolkit •Pediatric Weight Management Guideline•Critical Illness Toolkit

Upcoming guidelines and toolkits:•Diabetes Type 1 and 2 •Oncology•Hypertension•Heart Failure •Gestational Diabetes•Spinal Cord Injury•COPD•Chronic Kidney Disease•Unintended Weight Loss

These resources can assist you in:

• Implementing evidence-based practice

• Implementing Nutrition Care Process

• Using recommendations based on a collective body of evidence

• Training new staff, students and interns

• Understand treatment for an unfamiliar topic

• Meeting regulations based on current standards of practice –best practice

Other EAL Features

Robust Search

Help and FAQs

Contributors (lists workgroup

members, analysts, and sponsors for each

project)

Evidence Analysis Process

(describes methods in detail)

ADA’s Evidence Analysis Library ADA’s Evidence Analysis Library can be found at can be found at

www.adaevidencelibrary.com

For questions:For questions:• See HELP and FAQs See HELP and FAQs • Email at Email at

eal@adaevidencelibrary.com