The Evidence Analysis Library: A Wealth of Handy Information

Jo Ann S. Carson, PhD, RD, LDon behalf of the

American Dietetic AssociationEvidence-Based Practice Committee

Evidence-Based Practice Committee 2007-2008

• Kathleen Niedert, MBA, RD, CSG, LD, FADA (Chair)• Nancy McQuillan-Copperman, MS, RD (Vice Chair)• Ethan Bergman, PhD, RD, CD, FADA• JoAnn Carson, PhD, RD, LD • David Frankenfield, MS, RD • Trisha Fuhrman, MS, RD, LD, FADA• Wahida Karmally, DrPH, CDE • Sue Kent, MS, RD, LD• Jessie Pavlinac, MS, RD, CSR, LD

Objectives

Participants will be able to:

• Describe the basic processes used in development of the ADA Evidence-Based Practice Guidelines

• Incorporate American Dietetic Association Evidence-Based Practice Guidelines into dietetic practice.

• What do you know about the EAL?

• How many of you have been to the EAL?

• How many have an example of how it was helpful to you?

• Are there any analysts here?

• What do you want to learn about the EAL?

What another RD says:

• It is evident much work went into the development of the guidelines - speaking for myself this effort is much appreciated! Allowing us this evidence at our fingertips only works to strengthen our practice and validity as a profession.

…. From Testimonial section of EAL

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.

Source: ADA Scope of Dietetics Practice Framework Definition of Terms, 2007

How the EAL has been helped me

• In the Preventive Cardiology clinic, do we need to just do BMI, or should we also do waist circumference or waist to hip ratio?

Practice Guideline:Disorders of Lipid Metabolism:

BMI, WC & WHR

• In addition to BMI, use waist circumference or waist to hip ratio (WHR) to assess obesity and CVD risk. BMI alone is not a good predictor of CVD risk in persons over 65 years old. Increases in waist circumference, WHR, and BMI are associated with CHD events and CVD mortality.

• StrongImperative

How the EAL has been helped me

• Did the student who did a seminar on omega-3 fat and heart disease include the important research on the topic?

• Albert CM, Campos H, Stampfer MJ, Ridker PM, Manson JE, Willett WC, Ma J. Blood levels of long-chain n-3 fatty acids and the risk of sudden death. N Engl J Med 2002; 346(15):1113-1118.

Albert CM, Hennekens CH, O’Donnell CJ, Ajani UA, Carey FJ, Willett WC, Riskin JN, Manson JE. Fish consumption and risk of sudden cardiac death. JAMA. 1998;279:23-28.

Baylin A, Kabagambe EK, Ascherio A, Spiegelman D, and Campos H. Adipose tissue a-linolenic acid and nonfatal acute myocardial infarction in Costa Rica. Circulation 2003 Apr; 107(12):1586-1591.

Bucher HC, Hengstler P, Schindler C, Meier G. N-3 polyunsaturated fatty acids in coronary heart disease: a meta-analysis of randomized controlled trials. Am J Med. 2002 Mar;112(4):298-304.

Burr ML, Ashfield-Watt PA, Dunstan FD, Fehily AM, Breay P, Ashton T, Zotos PC, Haboubi NA, Elwood PC.Lack of benefit of dietary advice to men with angina: results of a controlled trial. Eur J Clin Nutr. 2003 Feb;57(2):193-200.

Daviglus ML, Samler J, Orencia AJ, Dyer AR, Liu P, et.al. Fish consumption and the 30-year risk of fatal myocardial infarction. N Engl J Med. 1997;336:1046-1053.

De Lorgeril M, Salen P, Martin JL, Monjaud I, Delaye J, Mamelle N. Mediterranean Diet, traditional risk factors, and the rate of cardiovascular complications after myocardial infarction, final report of the Lyon Diet Heart Study. Circulation. 1999;99:779-785.

Erkkila AT, Lehto S, Pyorala K, and Uusitupa MIJ. N-3 fatty acids and 5-y risks of death and cardiovascular disease events in patients with coronary artery disease. Am J Clin Nutr 2003 July; 78(1):65-71.Hu FB, Stampfer MJ, Manson JE, et al. Frequent nut consumption and risk of coronary heart disease in women: Prospective cohort study. Nurses Health Study. BMJ 1998;317:1341-1345.

Kris-Etherton PM, Harris WS, Appel LJ for the Nutrition Committee. AHA Scientific Statement: Fish Consumption, Fish Oil, Omega-3 Fatty Acids, and Cardiovascular Disease. Arterioscler Thromb Vasc Biol 2003 Feb; 23(2):e20-30.

How the EAL has been helped me

• The community obesity coalition wants to know which interventions would be most beneficial in trying to reduce obesity in Dallas children. What do we currently know about this?

Examples of Grade II Conclusions under Childhood Overweight

• Associated with increased adioposity in youth– Excessive television

viewing– Intake of calorically-

sweetened beverages (in children)

• Associated with less adioposity– Intake of fruits and

vegetables– Participation in regular

physical activity

Examples of Grade III Conclusions under Childhood Overweight

• Limiting media influences as part of a school-based intervention may be associated with changes in weight status/adiposity

• Sports participation may be associated with lower adiposity.

ADA’s Evidence Analysis Process

A rigorous and systematic process for searching, analyzing and summarizing research on a specific nutrition topic.

ToolkitToolkit

Evidence-based Evidence-based

GuidelineGuideline

Summary of EvidenceSummary of Evidence

HOD BOD

UnintendedWeight Loss

OncologyNutrition

Spinal CordInjury Nutrition

VegetarianNutrition

Nutrition in Bariatric Surgery

ADA Evidence Analysis Projects

Adult WeightManagement

Diabetes 1 & 2

Evidence-Based Practice Committee

Chronic KidneyDisease

Chronic ObstructivePulmonary

Disease (COPD)

HIV – AIDS Nutrition

HeartFailure

GlutenIntolerance /

Celiac Disease

GestationalDiabetes

FiberDisordersOf Lipid

Metabolism

Hydration HypertensionNutrition

Counseling

Nutrition Screening

MNTEffectiveness

Fortifications &Supplements

BreastfeedingAspartame

ChildhoodOverweight

Critical Illness

MeasuringEnergy

Expenditure

Non-nutritivesweeteners

Nutrition In Athletic

Performance

PediatricWeight

Management

Active Work Group

Inactive Work Group Project Update

Sodium

Evidence-Analysis Process Steps

1. Select topic & appoint expert work group

2. Define questions and determine inclusion/

exclusion criteria

3. Conduct literature review for each question

4. Analyze Articles/Critical Appraisal

5. Overview Table& Evidence summary

6. Develop conclusionstatement & assign grade

7. Publish to online EAL

Guideline Development

8. Formulate guideline recommendations

9. Develop algorithms based on NCP

10. Internal/external review and revise eview and revise

11. Publish guideline on EAL11. Publish guideline on EAL

Features of Evidence-Based Toolkits

Set of companion documents for application of the practice guideline

• Disease/condition specific • Include:

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

disease/condition • Incorporate Nutrition Care Process/SL as

the standard for care• Electronic downloadable purchase item

Published Evidence-Based Guidelines and Toolkits

• Disorders of Lipid Metabolism Guideline and Toolkit

• Adult Weight Management Guideline and Toolkit

• Critical Illness Guideline• Pediatric Weight Management Guideline• Oncology Guideline• Diabetes Type 1 and 2 Guideline• Hypertension Guideline

Upcoming Evidence-Based Guidelines and Toolkits

2008:• Critical Illness Toolkit• Heart Failure Guideline

Upcoming guidelines and toolkits:

• Gestational Diabetes• Spinal Cord Injury• COPD• Chronic Kidney Disease• Unintended Weight Loss

How you can use the EAL?• To support your patient care practices to the MD• To up-date your knowledge in an unfamiliar area • To answer a question from a patient• To develop a class for patients or professionals• To double-check the accuracy of a statement• To provide a reference list on a topic• To strengthen your ability to critically analyze a

research study• To find ideas for a research project

*

Now…

Let’s look at the Evidence Analysis Library

ADA Evidence Analysis Librarywww.adaevidencelibrary.com

Enter your ADA member number and password to access complete library

Navigating the Library

Two critical sections!– Diseases and Condition

• Provides conclusion statements that indicate the strength of research or evidence on many topics

– Evidence Based Guidelines• Translates the evidence into a guideline advising

what an RD should do• Currently available for 6 areas:

– Adult and Pediatric Weight Management– Critical Illness– Disorders of Lipid Metabolism– Oncology– Hypertension

Notice how clicking on Evidence

Based Guidelines

changes the 2nd row of the menu

“Evidence-Based Guideline”

Select “Guideline List” From

Navigation Bar

Select Oncology

Features of Guidelines

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

– Recommendations: a series of guiding statements that propose a course of action for practitioners

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

– Appendices: food tables, etc.

How it can help you--Your “gut” tells you that some of the cancer

patients on your floors should be receiving enteral nutrition. When you approached one of the oncologist he quoted a review from the 1980’s that said nutrition support did not make a difference in the survival of cancer patients. You would like to see what the latest research says and perhaps use it to support your recommendations for tube feedings for some of the patients.

*

Recommendation forHead/neck cancer, radiation and enteral nutrition

-Risks/Harms-Conditions of Application-Potential Costs-Narrative-Rationale for Rating

Recommendation Example:

Use enteral nutrition (EN) to increase calorie and protein intake for outpatients with stage III or IV head and neck cancer undergoing intensive radiation treatment. Maintenance of nutritional status by EN during radiation therapy may improve tolerance of therapy to promote better outcomes.

Strong, Imperative

Rating Definition

Strong • benefits clearly exceed the harms (or harms clearly exceed the benefits for a negative recommendation)

• the quality of the supporting evidence is excellent/good (grade I or II)

Fair benefits exceed the harms (or harms clearly exceed the benefits for a negative recommendation)

quality of evidence is not as strong (grade II or III)

Weak• 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

Consensus • Expert opinion (grade IV) supports the guideline recommendation

Insufficient Evidence • both a lack of pertinent evidence (grade V)* and/or an

unclear balance between benefits and harms

Drill down to supporting evidence

Conclusion Statement

Two positive quality RCTs found that head and neck cancer patients receiving radiation therapy may benefit from EN. Energy and protein goals for patients in the RCTs were 40 kcals/kg and 1.0 - 1.5 g/kg body weight, respectively........

GRADE II

Conclusion Grades

Grade I Good/Strong

Grade II Fair

Grade III Limited

Grade V Expert Opinion Only

Grade V Not Assignable (no evidence)

Evidence Summary: narrative summary

Evidence Summary: overview table

BibliographyListed at end of Evidence Summary and linked to evidence 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

•Validity questions•Determines Quality rating of article •Based on AHRQ quality domains

Remember

• The guidelines and conclusions can offer you what current research says.

• As a clinician you use your professional judgment in how it applies to your patient

• There is not always a good research base for decisions we must make in patient care.

*

How do the Evidence Analysis Products Support

the Nutrition Care Process?

Main Menu: AlgorithmsStep-by-step flowchart for treatment Step-by-step flowchart for treatment following NCPfollowing NCP

Oncology Algorithms

AssessmentDiagnosisIntervention Monitor/Evaluation

Nutrition Intervention

Algorithm: Breast Cancer

Use of arginine

Use of parenteral nutrition

Use of vitamin E supplement

The Toolkits Model the NCP

 

AWM Toolkit Contents– Overview – MNT Protocol Forms

• Summary Recommendations for AWM• Flowchart of Encounters• Encounter Process

– Documentation Forms• Sample Referral Form for MNT• Initial & follow-up MNT Progress Note • Sample Case Study

– Outcomes Management Forms in Excel– Client Education Resources

• Executive Summary • Client Agreement for Care & Encounter Contract• Can Dairy Help Control Weight?• Low-Carbohydrate Diets: Hype or Hope?• Meals on the Go• Portion Distortion• Weight Control Meal Patterns

MNT Protocol provides•Summary of Recommendations•Length of encounters•Expected outcomes of MNT

MNT Initial Progress Note •Check off nutrition Dx• Write PES statement•Determine Nutrition Rx •Check off nutrition intervention• Document intervention details• Document goals and expected outcomes

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

Client Education Materials: 5-6th grade reading level

Within Electronic HealthRecord, can store on-line;Print as needed; even customize for a patient

In Summary

Evidence-based Guidelines and Toolkits

can help you:

• Implement evidence-based practice

• Implement NCP/SL

• Promote consistency

• Achieve expected outcomes

• Assure quality care

Your patient is a 45 year old female admitted to rule out an MI. She is a nursing professor and has several questions about nutrition and heart disease. Specifically, she wants to know whether eating nuts is really good for her, and if so, which ones to eat.

DLM: Disorders of Lipid Metabolism, Nuts and CHD

• If consistent with patient preference and not contraindicated by risks or harms, then nuts (walnuts, almonds, peanuts, macadamia, pistachios, and pecans) may be isocalorically incorporated into a cardioprotective dietary pattern. Consuming five ounces of nuts per week is associated with a reduced risk of CHD. Because of their beneficial fatty acid profile as well as other nutritional components, nuts may be incorporated into a cardioprotective dietary pattern low in saturated fat and cholesterol to reduce TC by 4-21% and LDL-C by 6-29%.

• FairConditional

Risks/Harms of Implementing This Recommendation

• Nuts contain a high level of calories and should only be included in a cardioprotective diet if weight can be maintained.

• Brazil nuts are higher in saturated fat and should not be consumed regularly as part of a cardioprotective diet.

You are new to a geriatric unit. In a multi-disciplinary meeting concerns regarding whether many of the patients are dehydrated. You are asked to develop a policy and procedure for the health care team to use in detecting dehydration in patients. What information can you find in the EAL that will help you?

• There is no evidence, which identifies a clinical, and/or biochemical parameter, which is best for assessing hydration status in the older adult. One positive quality study suggested ranges of Psg (plasma specific gravity) which may be useful for assessing volume depletion in elderly adults. A neutral quality study found Ucol reflected hydration status (narrow range) as measured by Usg and Uosm in euhydrated, elderly patients.

• Based upon a positive quality study, researchers identified the following physical exam data as useful in detecting severe dehydration: dry tongue, longitudinal tongue furrows, dry mucous membranes of nose and mouth, eyes that appear recessed in their sockets, upper body muscle weakness, speech difficulty, and confusion. A positive quality study found multi-frequency BIA useful in detecting change in hydration status, but a single measurement was a poor indicator of hydration status. Additional well-controlled studies are needed to validate these findings.

• Grade III

You would like to establish an organized ambulatory nutrition clinic at your hospital. You are looking for evidence that nutrition therapy provided in multiple sessions can reduce cardiovascular risk. What information from the EAL can help you?

• Seven studies describe individualized MNT that results in improved cardioprotective dietary pattern changes and/or subsequent plasma lipid changes, thereby decreasing cardiac heart disease risks. Reductions in total fat and saturated fat intake were seen in three studies (two high- and one neutral-quality). Decreases in TC and LDL-C were reported in five studies. Three of these studies found reductions in body weight. Four studies looked at the impact on TG and HDL-C and found varying results.

• Two studies found that decreases in total cholesterol correlated with time spent with a dietitian. A third high-quality RCT found that individuals who went to three or four MNT sessions had lower LDL-C compared to those that attended fewer than three sessions.

Thank you for your attention!Questions?