ADA’s Evidence-Based ADA’s Evidence-Based Nutrition Practice Guidelines Nutrition Practice Guidelines

and Toolkitsand Toolkits

Kari Kren, MPH, RD, LDKari Kren, MPH, RD, LDManager, GovernanceManager, Governance

American Dietetic AssociationAmerican Dietetic AssociationNovember 1, 2006November 1, 2006

History of ADA’s MNT GuidesHistory of ADA’s MNT Guides

1990’s: Medical Nutrition Therapy Across the 1990’s: Medical Nutrition Therapy Across the Continuum of Care (MNTACC) (research-based)Continuum of Care (MNTACC) (research-based)

2001 & 2002: MNT Evidence-Based Guides for 2001 & 2002: MNT Evidence-Based Guides for Practice Practice Hyperlipidemia, Diabetes Type 1 and 2, Gestational Hyperlipidemia, Diabetes Type 1 and 2, Gestational

Diabetes, Chronic Kidney DiseaseDiabetes, Chronic Kidney Disease

2005 & 2006: Evidence-Based Nutrition Practice 2005 & 2006: Evidence-Based Nutrition Practice Guidelines & ToolkitsGuidelines & Toolkits

What’s New?What’s New?

Movement in healthcare towards evidence-based practiceMovement in healthcare towards evidence-based practice

More systematic, rigorous process of evidence analysisMore systematic, rigorous process of evidence analysis

Use of ADA’s Nutrition Care Process Use of ADA’s Nutrition Care Process AssessmentAssessment DiagnosisDiagnosis InterventionIntervention Monitoring & EvaluationMonitoring & Evaluation

Guidelines are a Guidelines are a freefree member benefit on the Evidence Analysis Library member benefit on the Evidence Analysis Library

Toolkits consist of more resources for application of the GuidelinesToolkits consist of more resources for application of the Guidelines

Oversight by Evidence-Based Practice Committee Oversight by Evidence-Based Practice Committee

What are Evidence-Based Nutrition What are Evidence-Based Nutrition PracticePractice Guidelines? Guidelines?

Evidence Summaries & Evidence Summaries & Conclusion Statements = Conclusion Statements = whatwhat the evidence saysthe evidence says

Guideline = Guideline = course of course of actionaction for the practitioner for the practitioner based on the evidencebased on the evidence

What are Evidence-Based What are Evidence-Based Nutrition Practice Nutrition Practice

Guidelines?Guidelines?Definition:Definition:

A series of guiding statements and treatment A series of guiding statements and treatment algorithms which are developed using a algorithms which are developed using a systematic process for identifying, analyzing and systematic process for identifying, analyzing and synthesizing scientific evidence. They are synthesizing scientific evidence. They are designed to assist practitioner and patient designed to assist practitioner and patient decisions about appropriate nutrition care for decisions about appropriate nutrition care for specific disease states or conditions in typical specific disease states or conditions in typical settings. settings.

Approved by Evidence-Based Practice Committee, 2006Approved by Evidence-Based Practice Committee, 2006

Features of GuidelinesFeatures of Guidelines

IntroductionIntroduction: scope, intent, : scope, intent, methods, benefits/harmsmethods, benefits/harms

RecommendationsRecommendations: a series of : a series of guiding statements that propose a guiding statements that propose a course of actioncourse of action for practitioners for practitioners

AlgorithmsAlgorithms: step-by-step flowchart : step-by-step flowchart for treatment of the specific for treatment of the specific disease/conditiondisease/condition

AppendicesAppendices: food tables, etc.: food tables, etc.

What are Evidence-Based What are Evidence-Based ToolkitsToolkits

Set of companion documents for Set of companion documents for application of the practice guidelineapplication of the practice guidelineDisease or condition specific Disease or condition specific Include:Include:

documentation formsdocumentation forms outcomes monitoring sheetsoutcomes monitoring sheets client education resourcesclient education resources case studies case studies MNT protocol for treatment of MNT protocol for treatment of

disease/condition disease/condition

Incorporate Nutrition Care Process Incorporate Nutrition Care Process as the standard process careas the standard process care

Why use these resourcesWhy use these resources??

Assist you in:Assist you in:ImplementingImplementing evidence-based practice evidence-based practice

Implementing Nutrition Care ProcessImplementing Nutrition Care Process

Using recommendations based on Using recommendations based on a a collectivecollective body of evidence body of evidence

Training new staff, students and internsTraining new staff, students and interns

Understand treatment for an unfamiliar topicUnderstand treatment for an unfamiliar topic

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

CuCurrentrrent Evidence-Based Evidence-Based Guidelines and ToolkitsGuidelines and Toolkits

Published on EAL:Published on EAL:

Disorders of Lipid Metabolism Disorders of Lipid Metabolism Guideline Guideline and Toolkitand Toolkit

Adult Weight Management Adult Weight Management GuidelineGuideline

Critical IllnessCritical Illness Guideline Guideline

Select “Guideline List” From

Navigation Bar

Select Critical Illness

Features of each Features of each Recommendation PageRecommendation Page

Describe “what” and “why”Describe “what” and “why”

Display rating using AAP adapted scale Display rating using AAP adapted scale Strong, Fair, Weak, Consensus, Insufficient EvidenceStrong, Fair, Weak, Consensus, Insufficient Evidence

List potential risks/harms for implementing List potential risks/harms for implementing

Narrative illustrating the supporting evidenceNarrative illustrating the supporting evidence

Provide rationale for the recommendation ratingProvide rationale for the recommendation rating

Link to supporting evidenceLink to supporting evidence

Recommendation forImmune-enhancing formula

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

Definition

Recommendation ExampleRecommendation Example

• R.5. Blue dye should not be added to EN for detection R.5. Blue dye should not be added to EN for detection of aspiration. The risk of using blue dye outweighs any of aspiration. The risk of using blue dye outweighs any perceived benefit. The presence of blue dye in tracheal perceived benefit. The presence of blue dye in tracheal secretions is not a sensitive indicator for aspiration. secretions is not a sensitive indicator for aspiration.

• StrongStrongImperativeImperative

•

Recommendation RatingRecommendation Rating• StrongStrong = = Practitioners should follow a Practitioners should follow a Strong Strong

recommendation unless a clear and compelling recommendation unless a clear and compelling rationale for an alternative approach is present.rationale for an alternative approach is present.

• Imperative = Imperative = imperative recommendations imperative recommendations “require,” or “must,” or “should achieve certain “require,” or “must,” or “should achieve certain goals,” but do not contain conditional text that goals,” but do not contain conditional text that would limit their applicability to specified would limit their applicability to specified circumstances. circumstances.

Statement RatingStatement Rating DefinitionDefinition Implication for PracticeImplication for Practice

Strong 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 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.

WeakWeak 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.

ConsensusConsensus 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 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.

Drill down as needed

Evidence Summary

Critical Illness RecommendationsCritical Illness RecommendationsEnteral vs. Parenteral Nutrition Enteral vs. Parenteral Nutrition

Timing of FeedingTiming of Feeding

Immune-Enhancing Enteral FormulaImmune-Enhancing Enteral Formula

Feeding Tube SiteFeeding Tube Site

Blue Dye UseBlue Dye Use

Monitoring Criteria in Critical CareMonitoring Criteria in Critical Care

Monitoring Delivery of Energy Monitoring Delivery of Energy

Blood Glucose Control Blood Glucose Control

Energy ExpenditureEnergy Expenditure EquipmentEquipment Patient ConditionPatient Condition EnvironmentEnvironment Test InterpretationTest Interpretation

Energy AssessmentEnergy Assessment

Main Menu: Algorithms

Adult Weight Management Adult Weight Management AlgorithmsAlgorithms

Weight Management TreatmentWeight Management TreatmentEnergy ExpenditureEnergy ExpenditureAssess Nutritional StatusAssess Nutritional StatusDietary InterventionsDietary Interventions

Weight Management Treatment Algorithm

AssessmentDiagnosisIntervention Monitor/Evaluation

Select: Determine Diet Intervention

Dietary Intervention Algorithm

Eating Frequency

Meal Replaceme

nts

Portion Control

Nutrition Education

Meal Replacements Recommendation

Disorders of Lipid Metabolism Disorders of Lipid Metabolism ToolkitToolkit

   

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STORE

Click here to see sample forms

Disorders of Lipid Metabolism Disorders of Lipid Metabolism Toolkit ContentsToolkit Contents

Summary Page for DLM and DLM with Metabolic Summary Page for DLM and DLM with Metabolic Syndrome  Syndrome 

MNT Flowchart of EncountersMNT Flowchart of Encounters MNT Encounter Process MNT Encounter Process

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

Summary Page for DLM: based on evidence

e.g. HDL-C……........…...increase or no change.....>40mg/dL (males), >50mg/dL (females)

soluble fiber intake ……….increased intake………. >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 ContentsDLM Toolkit Contents

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

Resources Resources Client Agreement for Care                        Client Agreement for Care                        Other Client Education ResourcesOther Client Education Resources

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

Appendices Appendices                 

Client Education Materials: 6-7th grade reading level

DLM Toolkit ContentsDLM Toolkit Contents

Outcomes Monitoring FormsOutcomes Monitoring Forms Individual Outcomes Monitoring FormIndividual Outcomes Monitoring Form Aggregate Input FormAggregate Input Form Aggregate Outcomes Monitoring FormAggregate Outcomes Monitoring Form

   

Sample Individual Outcomes FormSample Individual Outcomes Form Sample Aggregate Input FormSample Aggregate Input Form Sample Aggregate Outcomes FormSample 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

Upcoming Evidence-Based Upcoming Evidence-Based Guidelines and ToolkitsGuidelines and Toolkits

2006-2007 pro2006-2007 program gram year:year:Adult Weight Management Adult Weight Management ToolkitToolkit

Critical Illness Critical Illness ToolkitToolkit

Pediatric Weight ManagementPediatric Weight Management GuidelineGuideline

Upcoming guidelines and Upcoming guidelines and toolkits:toolkits:

Diabetes Type 1 and 2 Diabetes Type 1 and 2

OncologyOncology

HypertensionHypertension

Heart Failure Heart Failure

Gestational DiabetesGestational Diabetes

Spinal Cord InjurySpinal Cord Injury

COPDCOPD

Chronic Kidney DiseaseChronic Kidney Disease

Unintended Weight LossUnintended Weight Loss

For Further Information:For Further Information:

See “Help” tab and FAQs on EALSee “Help” tab and FAQs on EAL

Or Or Contact:Contact:

Kari Kren Kari Kren kkren@eatright.orgkkren@eatright.orgEAL Help EAL Help eal@adaevidencelibrary.comeal@adaevidencelibrary.com  

Website: Website: www.adaevidencelibrary.comwww.adaevidencelibrary.com

Questions?Questions?

Thank you for your attention!Thank you for your attention!