American Dietetic
Association
Navigating the Evidence
Analysis Library
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.”
Revised and approved by EBP Committee January 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)
ADA Evidence Analysis
Library
www.adaevidencelibrary.com
Online
Resource
with the best
available research
on important
dietetics topics in a
practitioner-friendly
format
What are the steps in ADA’s
Evidence Analysis Process?
1)
2)
3)
4)
5)
6)
7)
8)
Select Topic & Appoint Expert Working Group
Define Questions & Analytical Framework/
Determine Inclusion/Exclusion Criteria
Conduct Literature Review for each question
Analyze articles
Complete Evidence Summaries & Tables
Draft proposed Conclusion Statements
Reach Consensus on Conclusion
Statements/Grades
PUBLISH to ONLINE LIBRARY (EAL)
Current List of ADA EAL Projects
Diseases & Conditions
Adult Diabetes 1 & 2 (revision)
Adult weight management
Determinants of Pediatric
Overweight (FNPA)
Chronic Kidney Disease
(revision)
Chronic Obstructive Pulmonary
Disease (COPD)
Critical Illness
Disorders of Lipid Metabolism
(Hyperlipidemia revision)
Gestational Diabetes (revision)
Gluten Intolerance/ Celiac
Heart Failure
HIV/AIDS
Diseases & Conditions
(continued)
Hydration
Hypertension
Nutrition in Athletic Performance
Nutrition Care in Bariatric Surgery
Oncology
Pediatric Weight Management
Spinal Cord Injury & Nutrition
Unintended weight loss
Assessment
Estimating Energy
Expenditure/Indirect Calorimetry
Foods
Non-nutritive sweetener
Navigate through the library by
selecting from tabs:
EAL
Drill 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
Choose a Topic
Disorders of
Lipid Metabolism
Macronutrients
Trans-fatty acids
Then, choose a sub-topic
Example: View EA Question
What is the relationship between
diets high in trans fatty acids and
serum cholesterol levels?
Bibliography
for Topic
Example:
EA Conclusion Statement/Grade
“Mouse over” Question to
see Conclusion & Grade
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
Evidence Summary
Of the
research
available
to answer
question
Example: Bibliography
Bibliography 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
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:
• Guideline Elements Model (GEM)
• AGREE Instrument
• National Guidelines Clearinghouse standards
• Classification:
• American Academy of Pediatrics
Transition from evidence to
Guideline
• Review of conclusion statements, evidence
summaries and supporting evidence.
• 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: how
• 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
Guideline
List
Guideline List:
Select Disorders of Lipid
Metabolism
Disorders of Lipid Metabolism
Evidence-Based Nutrition Practice Guideline
Main Menu
Choose
a
Category
Disorders of Lipid Metabolism
Evidence-Based Nutrition Practice Guideline
Introduction
Guideline Overview
•Scope of Guideline
•Statement of Intent
•Guideline Methods
•Implementation
•Benefits and Risks/harms
Select a
Category
within
Introduction
Scope of
guideline
Disorders of Lipid Metabolism
Evidence-Based Nutrition Practice Guideline
•Introduction
Scope
 Disease/Condition
 Guideline Category
 Intended Users
 Objectives
 Target Population
Disorders of Lipid Metabolism
Evidence-Based Nutrition Practice Guideline
Disorders of Lipid Metabolism
Evidence-Based Nutrition Practice Guideline
•Introduction
Guideline Methods
Method for Creating
Guidelines
Inclusion and Exclusion
Criteria
Main Menu:
Major Recommendations
Disorders of Lipid Metabolism
Evidence-Based Nutrition Practice Guideline
Introduction
Select
Guideline
Methods
Disorders of Lipid Metabolism
Evidence-Based Nutrition Practice Guideline
•Introduction
Guideline Methods
Method for Creating
Guidelines
Inclusion and Exclusion
Criteria
Disorders of Lipid Metabolism
Evidence-Based Nutrition Practice Guideline
Choose a
different
category
Select
• Major
Recommendations
Return to Main Menu
Disorders of Lipid Metabolism
Evidence-Based Nutrition Practice Guideline
• Major
Recommendations
(listed by topics)
• Macronutrients:
Fat (Topic)
Select a
Recommendation
Trans-fatty Acid Intake
and Disorders of
Lipid Metabolism
• Major
Recommendations
Trans-fatty Acid
Intake and DLM
Recommendation
Features:
 Recommendation
 Rating
 Risks/Harms
 Strength
 Rationale
 Narrative
Disorders of Lipid Metabolism
Evidence-Based Nutrition Practice Guideline
Disorders of Lipid Metabolism
Evidence-Based Nutrition Practice Guideline
• Major
Recommendations
Trans-fatty Acid Intake
and DLM
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.
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.
Disorders of Lipid Metabolism
Evidence-Based Nutrition Practice Guideline
Link to the
supporting
evidence on
the EAL
What is the relationship between diets
high in trans fatty acids and risk for CHD?
Disorders of Lipid Metabolism
EAL Trans fatty acids question
View Conclusion Statement and Grade
Drill down to the Evidence Summary
Evidence Summary
Disorders of Lipid Metabolism
EAL Trans fatty acids question
Scroll down for worksheets
Disorders of Lipid Metabolism
EAL Trans fatty acids question
Drill down to
Quality rating
And
worksheets
Disorders of Lipid Metabolism
Evidence-Based Nutrition Practice Guideline
Main Menu:
Algorithms
•View Main Algorithm for Disorders of Lipid Metabolism
•See recommendations organized within a treatment plan
Nutrition Care Process
Assessment
Diagnosis
Intervention
Monitoring &
Evaluation
Link to another level within the Algorithm
Red = different
level in algorithm
Blue =
recommendation
Select
Determine Meal Plan
and Nutrition
Recommendation
•View second level algorithm
•Link to Recommendation
Select
Recommend
Intake of as Few
Trans Fatty Acids
as Possible
•View Recommendation
• Drill down as needed
Evidence-Based Guideline
Projects
Current [Published Online]
• Disorders of Lipid Metabolism
2006
• Adult Weight Management (May)
• Critical Illness
2007
• Pediatric Weight Management
• Oncology
• Hypertension
• Heart Failure
• Spinal Cord Injury
Next Steps
• Develop companion documents for
the Toolkit for application of
guidelines
•
•
•
•
Documentation forms for medical record
Forms to monitor outcomes
Case studies
Client education resources
• Pilot test Toolkits
Other EAL Features
Robust Search
Help and FAQs
Evidence Analysis Process
(describes methods in detail)
Contributors
(lists workgroup members,
analysts, and sponsors for
each project)
Summary
• ADA’s Evidence Analysis Library can
be found at
www.adaevidencelibrary.com
• For questions contact:
eal@adaevidencelibrary.com