Objectives
Evidence
Based Dietetic Practice: Moving
Our Profession Forward

List potential benefits and goals of evidence
based practice

Describe
D
ib th
the process ffor d
developing
l i ADA
evidence based nutrition practice guidelines

Utilize ADA EAL and NCP for application of
evidence based nutrition practice guidelines
Angela DiTucci RD,LDN
Veterans Health Administration
Boston Health Care System
Evidence - Based Dietetic Practice


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
Why Evidence-Based Practice ?






History of ADA’s Guidelines
1990’s
• Medical Nutrition Therapy Across the Continuum of
Care (MNTACC)
Promotes practices that support the best
outcomes
Decreases wide variations in practices
Reduces the gap between research and expert
opinion
Saves time
Empowers
Increases credibility
Movement in healthcare for evidencebased practice
ADA Evidence Analysis Process
2001/2002
• MNT Evidence-Based Guideline for Practice
(Hyperlipidemia, Diabetes, CKD, Gestational Diabetes)
ADA’s Nutrition Care Process as framework
Electronic medium
• Evidence Analysis Library
2004
2005-2008
More resources for application
• Evidence-Based Nutrition Practice Guidelines and
Toolkits
Oversight by Evidence-Based Practice Committee
(2005)
1
Charge of EBP Committee
Evidence analysis process
Evidence Analysis Library
Evidence-based Guidelines
Evidence-based Toolkits
Oversight
Dissemination
Functions
Promote the implementation of
evidence-based dietetic practice
Presentations/workshops/
marketing initiatives
Appoint workgroup members
Prioritize evidence analysis projects
Determine format and content of products
Evaluate EA process
Implement Evidence Analysis
Process
 Step1:

Spinal Cord Injury & Nutrition
Select a topic
Example: Spinal Cord Injury (SCI)
project
Why Evidence is Needed …..

Evidence Analysis
p
Process Steps
Inconsistencies
Clinical indicators
 Nutrition risk criteria
 Outcome criteria
Variations
 Role of the RD
 Provision of MNT
Cost factor when MNT is not provided or delayed
CARF standards-Role of MNT and RD is weak
Implement Evidence Analysis
Process




 Step
2: Appoint a expert work
group
2
ADA Spinal Cord Injury Evidence Analysis
Project
Expert Work Group
Angela DiTucci, RD, LDN
Chair
Erin DeDecker, BSc, HBSc, RD
Mary Ann Djonne, MEd
Vickeri Barton, RD, CD
Yvonne C. Portelli, RD, LD, CDE
Melissa M
M. Shock
Shock, PhD
PhD, RD
Evidence Analysts
Sharon Balters, PhD, RD, LMNT
Christopher Taylor, PhD, RD
Madelyn L. Wheeler, MS, RD, FADA, CD, CDE
Sharon Wojnaroski, MA, RD
Megan Wolfe, MS, RD, CDN
Jane Ziegler, MS, RD, LDN, CNSD
Implement Evidence Analysis
Process
 Step
ADA Spinal Cord Injury Evidence Analysis
Project
Lead Analysts
Kyle Thompson, MS, RD, CD, CNSD
Erica Gradwell, MS, RD
Staff
Kari Kren, MPH, RD
Joan Schwaba, MS, RD, LDN
Deborah Cummins, PhD
Esther Myers, PhD, RD
Financial Contributors
Dietitians in Physical Medicine and Rehabilitation: ADA DPG
Paralyzed Veterans of America (PVA) Education and Training Foundation
Herbert and Nylda Gemple Foundation
American Dietetic Association Foundation
SCI Project
3: Identify topics to define
the questions
q
PICO model
 Good questions provide key outcomes

Implement Evidence Analysis
Process
 Step


Phases of Spinal Cord Injury
4: Gather and Classify the
Articles
Medline, Cochrane Reviews,CINAHL,
EMBASE,DARE,TRIP,AHRQ
Define Inclusion and Exclusion criteria
3
Classes of Evidence Reports
Primary
A = RCT
B = cohort study
C = case control, nonrandomized trial with concurrent or hisotrical controls,
time series
D = case report, case series
Synthesized
M = meta-analysis, systematic review
R = narrative review, consensus report
X = medical opinion
Apstein MD, George BC. Serum lipids during the first
year following acute spinal cord injury.Metabolism.
1998;47:367 370
Implement Evidence Analysis
Process
 Step


5: Critically Appraise the
Articles
Completion
C
l ti off worksheets
k h t and
d quality
lit
criteria checklists
Quality of the Report
+ - 0
Implement Evidence Analysis
Process
 Step
Study Design: Cohort Study
 Class:
B
 Quality Rating: NEGATIVE



6: Develop an Evidence
Summary for each
Q
Question
ti
Summary of the collective evidence from
the critical appraisal of the articles
Coherent, easy to read summary
How does physical activity affect energy needs
in spinal cord-injured individuals?
How does physical activity affect energy needs
in spinal cord-injured individuals?
A total of five studies were evaluated: two randomized crossover trials, two nonrandomized trials and one time series study.
Differences in Energy Costs between Wheelchair Types
In a positive-quality randomized crossover trial by Beekman et al (1999) 74 subjects (44 with paraplegia, 30 with tetraplegia)
performed 2 trials of wheelchair propulsion, one in a standard wheelchair (SWC) and one in an ultralight wheelchair (UWC). Speed in
meters/minute, distance traveled in meters and oxygen cost per distance traveled (Vo 2 mL/kg/m) were measured in a randomized
order and data collected at four predetermined intervals. The use of UWC instead of SWC for people with paraplegia and tetraplegia
resulted in increased speed, increased distance traveled, and decreased oxygen cost achieved. In a positive-quality randomized
crossover trial by Cooper et al (2001) performed a three phase study
study. In Phase 1 the pushrim
pushrim-activated,
activated power
power-assisted
assisted wheelchair
(PAPAW) was tested for compliance to the American National Standards Institute-Rehabilitation Engineering and Assistive
Technology Society of North America (ANSI-RESNA). In Phase 2 metabolic energy consumption was measured in ten subjects at
two speeds and three resistance levels in the subject's manual wheelchair and the PAPAW. In Phase 3, ten subjects were evaluated
for their ability to perform activities of daily living (ADLs) and ergonomics of the PAPAW compared with their personal wheelchair. In
Phase 2, with the PAPAW the subjects had increased. Oxygen consumption increased with increase in speed however oxygen
consumption did not increase at the same rate as speed. In a positive time series study by Algood et al (2004) 15 manual wheelchair
users (12 men, 3 women) with cervical-level tetraplegia were studied for differences in stroke frequency, metabolic demands, and
upper-extremity joint range of motion during pushrim-activated, power-assisted wheelchair (PAPAW) and traditional manual
wheelchair propulsion at three different speeds. The use of PAPAW demonstrated significantly lower oxygen consumption and
ventilation from the manual wheelchair trial. Mean heart rate was significantly reduced when using the PAPAW during the high
resistance trial. Stroke frequency was significantly reduced for participants in the PAPAW for the slight and moderate resistances.
 Physical Activity for Weight Management in Spinal Cord Injury
In a positive-quality nonrandomized group trial, Chen et al (2006) studied 16 overweight/obese
participants (9 males, 7 females) in a weight management program for spinal cord injured
subjects. The weight management program incorporated nutrition and exercise classes, homebased exercise, and behavior change. The participants were measured at baseline and 12
weeks and then again at 24 weeks (13 participants returned for follow-up
follow up at 24 weeks).
weeks) Body
mass index (BMI), body composition, anthropometrics, blood pressure, lipid profile, safety
profile, diet behaviors and psychological and physical functioning were assessed. at each of
the intervals. Weight loss averaged 3.5 ± 3.1 kg at week 12 and 2.9 ± 3.7 kg at 24 weeks.
There was a significant reduction in BMI, anthropometric measurements, and fat mass and an
improvement in diet behaviors and psychosocial and physical functioning, while lean mass,
albumin and hemoglobin levels were maintained. A carefully planned weight management
program is effective for overweight/obese individuals with spinal cord injury.
4
Implement Evidence Analysis
Process
Transition to Evidence-Based
Nutrition Practice Guideline
 Step
7: Form Conclusion
Statements
 Determine
the “bottom line” written
for the practitioner
All of EAL®
Conclusion Statement Grades
17% (159)
38% (6)





Grade I: Good / Strong
Grade II: Fair
Grade III: Limited / Weak
Grade IV: Expert Opinion Only
Grade V: Grade Not Assignable
56% (9)





Example – Conclusion Statement

Do cranberry extract supplements have a positive
impact on urologic health in people with spinal cord
injuries ?
Three double-blind, randomized controlled
trials (one positive quality, two neutral
quality) found
f
d that
th t cranberry
b
extract
t t
supplements, ingested in tablet or capsule
form, are not effective in prolonging the
UTI-free period, or decreasing bacteriuria
or WBC count, in people with spinal cord
injuries. Further research is needed to
determine the role of cranberry extract
supplements in spinal cord injury patients.
Grade II Fair
Grade I:
Grade II:
Grade III:
Grade IV:
Grade V:
Good/Strong
Fair
Limited/Weak
Expert Opinion Only
Grade Not Assignable
Implement Evidence Analysis
Process
 Step
8: Formulate
Recommendations
 Based
on Conclusion Statement
 The Step in NCP is identified
5
Recommendation Rating Scale
Statement Rating
Definition
Strong
Benefits of the recommended approach clearly exceed the
harms
Fair
Benefits exceed the harms, but quality of evidence is not as
strong
Weak
Quality of evidence that exists is suspect
Consensus/Expert opinion
Supports the guideline recommendation though scientific
evidence did not present consistent results
Insufficient Evidence

Spinal Cord Injury (SCI) Nutrition Assessment for Prevention and
Treatment of Overweight and Obesity

The Registered Dietitian should assess the weight and body composition of
persons with spinal cord injury (SCI), and adjust energy level or implement weight
management strategies as appropriate. The SCI population is at a higher risk of
associated comorbidities such as diabetes, metabolic syndrome and cardiovascular
disease. Lower levels of spontaneous physical activity and a lower thermic effect of
food result in decreased energy expenditure and energy needs. See Nutrition
Assessment recommendations for methods to determine weight and energy needs,
and ADA Adult Weight Management Evidence-based Nutrition Practice Guideline
for methods to manage overweight and obesity.
Rating: Strong
Conditional
Conditions of Application


clearly define a specific situation contain
conditional text that would limit applicability to
specified circumstances or to a sub-population
sub population
group can be stated in if/then terminology
Imperative recommendations
broadly applicable to the target population stated
as “require” or “must” or “should achieve certain goals”
Lack of pertinent evidence and/or unclear balance between
benefits and harms
Recommendation Summary Page

Conditional statements
This recommendation applies to persons
with spinal cord injury with increased body
weight.
Aim for consistency in method and
equipment used in measuring weight.
Risk and Harms of Implementating the
Recommendation

No potential harm or risks are associated
with implementation of this
recommendation
Potential Costs Associated with
Application

There are staffing
g and equipment
q p
costs
associated with weight management for
persons with spinal cord injury.
6
Recommendation Narrative
One positive-quality case-control study found that 24-hour total and resting energy expenditure were significantly lower in
SCI than in control subjects, that this difference was independent of body composition and that the difference may have
been related to a lower thermic effect of food and lower levels of spontaneous physical activity (Monroe et al, 1998). One
positive-quality cross-sectional study found that patients with SCI in the early rehabilitation phase had measured caloric
needs that were 45% to 90% of caloric needs as predicted by equations, and the reduction in energy needs was
proportional to the amount of denervated muscle (Cox et al, 1985). A neutral-quality case-series study recommended that
ideal body weights for persons with SCI be below those recommended by the NY Metropolitan Life Insurance table:
I di id l with
Individuals
ith paraplegia,
l i 10 lb to
t 15 lb lower;
l
with
ith quadraplegia,
d l i 15 lb to
t 20 lb lower
l
(Peiffer
(P iff ett al,l 1981).
1981)
A neutral quality systematic review concluded that patients with SCI in the chronic phase should consume a low-calorie
diet, since atrophied muscle cells are eventually partially replaced with connective tissue and filled with lipid and water
(Claus-Walker et al, 1981). A neutral quality narrative review found that the metabolic rates of patients with spinal cord
injury tend to be below predicted levels due to decreased metabolic activity of denervated muscle; the higher the lesion, the
lower the energy expenditure (Chin and Kearns, 1991). One neutral quality descriptive study found that glucose intolerance
and dyslipidemias were common among paraplegic and tetraplegic individuals (Tharion et al, 1998). One neutral quality
narrative review found that risk for obesity, CVD, type 2 diabetes and osteoporosis is higher in persons with SCI than ablebodied persons (Kocina, 1997). One neutral quality cross-sectional study found that fat-free mass composition changes
following SCI include a bone mineral content decrease of 25% to 50%; total body protein reduction of 30% and total body
water relative to body weight decrease of 15%, with body fatness related to level of SCI (Olle et al, 1993).
Recommendation Strength Rationale



Minority Opinions









Supporting Evidence

What are the indications for nutrition care to
prevent or treat overweight and obesity in
the community living phase of persons with
S
Spinal
C
Cord Injury?
?

What are the caloric needs for patients
during the acute and rehabilitation phases
following spinal cord injury?
Consensus reached
References
Chin DE, Kearns P. Nutrition in the Spinal-Injured Patient. NCP. 1991; 6(6):213-222.
Claus-Walker J, Halstead LS. Metabolic and Endocrine Changes in Spinal Cord Injury: I. The Nervous
System Before and After Transection of the Spinal Cord. Arch Phys Med Rehabil. 1981;62:595-601.
Cox SAR, Weiss SM, Posuniak EA, Worthington P, Prioleau M, Heffley G. Energy Expenditure after
Spinal Cord Injury: Evaluation of Stable Rehabilitating Patients. J Trauma 1985; 25: 419-423.
Kocina P. Body Composition of Spinal Cord Injured Adults. Sports Med. 1997;23(1): 48-60.
Monroe MB, Tataranni PA, Pratley R, Manore MM, Skinner JS, Ravussin E. Lower Daily Energy
Expenditure as Measured by a Respiratory Chamber in Subjects with Spinal Cord Injury Compared with
Control Subjects. Am J Clin Nutr, 1998; 68: 1223-1227.
Olle MM, Pivarnik JM, Klish WJ, Morrow JR. Body Composition of Sedentary and Physically Active
Spinal Cord Injured Individuals Estimated from Total Body Electrical Conductivity. Arch Phys Med
Rehabil, 1993; 74: 706-710.
Peiffer SC, Blust P, Leyson JF. Nutritional Assessment of the Spinal Cord Injured Patient. J Am Diet
Assoc, 1981; 78: 501-505.
Tharion G, Prasad KR, Gopalan L, Bhattacharji S. Glucose Intolerance and Dyslipidaemias in Persons
with Paraplegia and Tetraplegia in South India. Spinal Cord, 1998; 36: 228-230.
Eight studies in substantial agreement
T
Two
studies
t di off strong
t
design
d i for
f answering
i
the question
Conclusion statements are Grade II and III.
Citations not used in Evidence
Analysis

None
7
The Nutrition Care Process
Links to:
Nutrition Screening
S
Recommendation
Step of NCP
Implement Evidence Analysis
Process
 Step 9:

Assessment

Internal and External Reviews
Step 10: Adjust Guideline with
Consensus – EBP Committee
 Step 11: EBP Committee Approval
View on the
Evidence Analysis Library
8
Implement Evidence Analysis
Process
Step 12: Update and Revise


Guidelines and supporting evidence will
be reviewed yearly
- Re-run search
- Determine if revision is needed
- Revise or post as “Reviewed”
ADA Evidence-Based Nutrition
Practice Guidelines



are statements of best practice available on
the latest available evidence at the time of
publishing
not intended to overrule professional
judgment
intended to summarize best available
research as a decision tool
Produce and Publish EvidenceBased Toolkit
Transition to Evidence-Based
Toolkit

Step 1: Develop companion documents for the
Toolkit for application of guidelines







Medical Nutrition Therapy



Individualized nutrition goals
Appropriate interventions and strategies to achieve
nutrition goals
The SCI person’s ability and motivation to
implement nutrition therapy recommendations
Documentation forms for medical record
Forms to monitor outcomes
Case studies
Client education resources
Step 2: Pilot test of toolkit
Step 3: Revise Toolkit by consensus
Step 4: Disseminate Toolkit
Medical Nutrition Therapy


Scientific evidence supports the importance of the Registered Dietitian (RD)
as a member of the interdisciplinary team caring for adults with spinal cord
injury.
The Registered Dietitian plays an integral role on the interdisciplinary care
team by determining the optimal nutrition prescription and developing the
nutrition care plan for spinal cord-injured patients in all phases of injury.
Based on the patient’s plan for treatment, potential for rehabilitation, and
concurrent comorbidities, the dietitian monitors and evaluates the
effectiveness of the nutrition care plan in promoting the patient’s nutritional
health and quality of life. Based on the results of his/her ongoing monitoring
and evaluation of the patient’s nutritional status, the dietitian adjusts the
nutrition care plan as necessary to achieve desired outcomes.
9
Case Study

Mr. J. is a 49-year old male with a T5 complete SCI 2nd to a MVA,
date of injury 7/9/2006. As part of the preventative SCI
medicine/annual physical, Mr. J. has been referred to the dietitian for
nutritional assessment of weight status and abnormal lipid values.




Height: 5’7”
Weight: 253 lb
Preinjury weight: 210 lb
Activity: manual wheelchair




Assessment
1.
Why should a nutrition assessment
be a part of the yearly SCI physical ?
Recommendation:
 SCI: Nutrition Assessment in the
Community Setting
Assessment
3. How should energy needs and body composition
be assessed?
Recommendations:
 SCI: Assessment of Body Composition:
Estimation of Ideal Body Weight
 SCI: Assessment: Energy Needs in the
Rehabilitation Phase
Cholesterol: 220
(high)
HDL: 30 (low)
LDL: 141 (high)
Triglyceride: 189
(high)
Assessment
2. Should weight management be a primary
goal for Mr. J? Why or why not?
Recommendations:
 SCI:
SCI Nutrition
N t iti Assessment
A
t for
f Prevention
P
ti
and
d
Treatment of Overweight and Obesity
 SCI: Nutrition Assessment of Lipid Abnormalities
 SCI: Assessment of Anthropometric, Nutrition
and Lifestyle Factors Associated with Prevention
of Pressure Ulcers
Assessment
4.
Should physical activity be a factor for
assessment? Why or why not?
Recommendation:
SCI: Physical Activity and Energy Needs

10
Intervention
Intervention
2. Should Coordination of Care be an intervention
focus? Why or why not?
1. What is the role for nutrition education?
Recommendations:
 SCI: Nutrition Education and Counseling
g for Lipid
p
Abnormalities
 SCI: Nutrition Education Regarding Physical
Activity
 SCI: Nutrition Education Regarding Physical
Activity in Overweight and Obese Persons with SCI
Monitoring and Evaluating
1.
Should a focus for continued follow-up nutrition
care be on monitoring weight based on activity
level?
Recommendation:
 SCI: Coordination of Care in Spinal Cord Injury
Implementing the Recommendations



Recommendation:
 SCI: Monitoring and Evaluation of Energy
Needs During the Rehabilitation Phase


Evaluate barriers that may hinder the
application of the recommendation
Review safety issues
R i the
Review
th SCI persons age, socioeconomic
i
i
status, cultural issues, health history, comorbid conditions
Assess the SCI persons home resources,
caregiver status, meal preparation resources
Life adjustments with SCI
Questions?
11