ADA’s Evidence-Based Nutrition Practice Guidelines and Toolkits Kari Kren, MPH, RD, LD Manager,...
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Transcript of ADA’s Evidence-Based Nutrition Practice Guidelines and Toolkits Kari Kren, MPH, RD, LD Manager,...
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
• Choose Quantity• Add to Cart
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 [email protected]@eatright.orgEAL Help EAL Help [email protected]@adaevidencelibrary.com
Website: Website: www.adaevidencelibrary.comwww.adaevidencelibrary.com
Questions?Questions?
Thank you for your attention!Thank you for your attention!