Evidence Analysis Library,
Evidence Analysis Process
and Evidence-Based
Nutrition Practice
Guidelines and Toolkits
Updated Feb 2007
ADA Staff
©2007 American Dietetic Association
Research: Foundation of the Dietetics Profession
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.”
definition
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
Free to all ADA Members
Sign-in:
Use Your
ADA
Member
ID &
password
What are the steps in
ADA’s Evidence Analysis
Process?
1. Select topic & appoint
expert work group
3. Conduct literature
review for each question
2. Define questions
and determine inclusion/
exclusion criteria
4. Analyze Articles/
Critical Appraisal
5. Overview Table
& Evidence summary
6. Develop conclusion
statement & assign grade
7. Publish to online EAL
Evidence-Analysis Process Steps
8. Review, Revise, Update
Roles and Responsibilities of EBP Committee
Oversight
Evidence analysis process
Evidence analysis library
Evidence-based Guidelines
Evidence-based Toolkits
Promotion
Functions
Promote the implementation of
evidence-based dietetic practice
Appoint workgroup members
Prioritize evidence analysis projects
Determine format and content of products
Evaluate EA process
Structure
of
EvidenceBased
Practice
Committee
Nutrition
Care
Process
Ambulatory
Care
Dietetic
Practice-Based
Research
Network
Public
Health
Research
ADA EBP
Committee
Long-Term
Care
Practice
• Joint ADA
• House of Delegates -&Board of Directors
appointed committee
Quality
Management
Board
Of
Directors
Acute
Care
Practice
Trained as evidence analysts
ADA Evidence-based Practice Committee
Evidence-Based Practice
Committee Members 2006-2007
• Marion Franz, MS, RD,
CDE (Chair)
• Kathleen Niedert,
MBA, RD, LD, FADA
(Vice Chair)
• Elvira Johnson, MS,
RD, CDE, LDN
• Margie Tate, MS, RD
• David Frankenfield,
MS, RD
• Nancy Lewis, PhD,
RD, FADA
• Kim Robien, PhD, RD,
FADA, CNSD
• Rita Johnson, PhD,
RD, LDN, FADA
• Trisha Furman, MS,
RD, LD, FADA
EBP Committee reports jointly to ADA House of Delegates
and ADA Board of Directors
EBP Committee Members
Expert Work Group
(6-8 persons for each project)
Experts in the field/project topic
Appointed by EBP Committee
Work by
Functions
Teleconferences
• Develop questions & search
criteria
• Review materials (articles,
worksheets, summaries)
• Form conclusion statements
– Assign Grade to strength of the
evidence
• Develop Guidelines, if
appropriate
Evidence Analysis Work
Groups
Evidence Analysts
Experts in critically
analyzing articles
Must have at least Master’s
degree; many have PhD’s
Trained at ADA’s EA
workshop
Mentored by ADA Staff and
Lead Analysts
Read and analyze articles
Work Online
o
o
o
o
Complete worksheets
Complete quality checklists
Complete overview tables
Complete evidence summaries
Contributors
• All members of each
Evidence Analysis
team are listed in
the Contributors
section on the EAL,
including work group
members, evidence
analysts, lead
evidence analysts,
project managers,
and sponsors.
Current List of ADA EAL Projects
Diseases & Conditions
Adult Diabetes 1 & 2 (revision)
Adult Weight Management
Childhood Overweight
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
Hydration
Diseases & Conditions (continued)
Hypertension
Nutrition in Athletic Performance
Nutrition Care in Bariatric Surgery
Oncology
Pediatric Weight Management
Spinal Cord Injury & Nutrition
Unintended Weight Loss
Nutrition Care Process
Estimating Energy
Expenditure/Indirect Calorimetry
Nutrition Counseling
Foods
Non-nutritive Sweetener
Vegetarian Nutrition
Nutrients
Fiber
Navigate through the library by
selecting from tabs:
EAL
Drill down to the amount of information
you desire on EAL
• Question
• Search Plan & Results
• Conclusion Statement/Grade of the
strength and quality of the evidence
• Evidence Summary
• Bibliography/Worksheets on each article
• Quality Checklists
1. Select from list of Diseases & Conditions
2. Choose a Topic
Disorders of
Lipid Metabolism
Macronutrients
Trans-fatty acids
3. 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
Search Plan & Results
for each question
Reports
Inclusion
& Exclusion
Criteria
Date of Search
Inclusion Criteria:
•Age
•Setting (outpatient)
•Sample Size
•Acceptable dropout
rate
•Year Range
•English Language
Databases Searched
Search Terms
List of Articles
Example: Search Plan & Results
Included articles and
Excluded articles (with reason)
List Reason for
exclusion
for each article not
Included in the
Analysis;
e.g. Sample size
Too small
Example: Search Plan & Results2 Excluded Articles
Example: Conclusion Statement
(answer to question) and Grade
“Mouse over” Question to
see Conclusion & Grade or
click on question to
continue drilling down.
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
SummaryAll articles used to
Of theanswer question are
summarized here.
research
available
to answer
question
Narrative Evidence Summary
Example: Summary of evidence for Low Glycemic Diets question
Overview
Table
Low Glycemic Diets
Lists Citation, Study Design, Quality Rating, Sample Size, Interventions
and Outcomes in table format
– enables user to compare studies side by side
Example: Overview Table
Evidence Summary - bibliography
Each citation in
bibliography
LINKS to
Worksheet
Example: Evidence Summary2 bibliography
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
Transition from Evidence to
Evidence-Based Guideline
Evidence Summaries/Conclusion
Statements = what the evidence says
Guideline = course of action for the
practitioner based on the evidence
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 used to develop:
• Guideline Elements Model (GEM)
• AGREE Instrument
• National Guidelines Clearinghouse standards
• Classification:
• Recommendation ratings adapted from
American Academy of Pediatrics
Transition from evidence to
Guideline
• 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
• 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
Select Guidelines from Guideline List
Example: 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
Disorders of Lipid Metabolism
Evidence-Based Nutrition Practice Guideline
Scope of Guideline
Disease/Condition
 Guideline Category
 Intended Users
 Objectives
 Target Population
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
Main Menu:
Major Recommendations
Disorders of Lipid Metabolism
Evidence-Based Nutrition Practice Guideline
Select a
Recommendation
(listed by topic)
Macronutrients: Fat
Sub-topic:
Trans-fatty Acid Intake
Disorders of Lipid Metabolism
Evidence-Based Nutrition Practice Guideline
Recommendation
domains:
Recommendation & Rating
Risks/Harms
Conditions of Application
 Potential Costs
 Narrative
Rationale for Rating
Disorders of Lipid Metabolism
Evidence-Based Nutrition Practice Guideline
E.g.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
Scroll down
recommendation
page for links to
the supporting
evidence and
worksheets
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
Disorders of Lipid Metabolism
EAL Trans fatty acids question
Evidence Summary
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
Main Algorithm for Disorders of Lipid Metabolism
View recommendations organized within a treatment plan
Nutrition Care Process
Assessment
Diagnosis
Intervention
Monitoring &
Evaluation
Link to another level within the Algorithm
Select: Determine Meal Plan
and Nutrition Recommendations
Red = link to
different level in
algorithm
Blue = link to
recommendation
•View second level algorithm
•Link to Recommendation
Recommend
Intake of as Few
Trans Fatty Acids
as Possible
Select
•View Recommendation
• Drill down as needed
Evidence-Based Toolkits
• Set of companion documents for application
of the practice guideline
• Disease or condition specific
• Include:
• documentation forms
• outcomes monitoring sheets
• client education resources
• case studies
• MNT protocol for treatment of
disease/condition
• Incorporate Nutrition Care Process and
Standardized Language
• Electronic download purchase item
Disorders of Lipid Metabolism
Toolkit
STORE
• Choose Quantity
• Add to Cart
Disorders of Lipid Metabolism
Toolkit Contents
MNT Protocol
•
Summary Page for DLM and DLM with Metabolic Syndrome
•
MNT Flowchart of Encounters
•
MNT Encounter Process
Documentation Forms
•
Instructions for Sample Referral Form
•
MNT Sample Referral Form
•
Initial and Follow-up Nutrition Progress Note
•
Sample Case Study #1
•
Sample Case Study #2
Summary Page for DLM:
based on evidence
Outcomes Assessment Factors
• e.g. soluble fiber intake
Expected Outcomes
• increased intake
Ideal Goals of MNT
• >25g dietary fiber of which 7-13g
soluble fiber per day
©2006 American Dietetic Association
Disorders of lipid Metabolism Toolkit
Encounter Process for Disorders of Lipid Metabolism
ENCOUNTER: Initial Encounter 45 to 90 minutes
Encounter Process: detailed
process for assessment,
diagnosis, intervention and
monitoring and evaluation of
patients with DLM
Assessment
Obtain 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 affect
Food and Nutrition History consists of four areas: Food consumption, nutrition and health awareness and
management, physical activity and exercise, and food availability
Case Studies:
• Initial and Follow-up
Encounters
• Illustrates the Nutrition
Care Process
• Uses new SL for
Nutrition Diagnosis and
Intervention
DLM Toolkit Contents
Client Education Resources
• Executive Summary and List of ADA Client Education
Resources
• Client Agreement for Care
• Other Client Education Resources
Alcohol
Soluble Fiber Tips
The Low-down on Trans Fats
Health Benefits of Nuts
Omega-3 Fatty Acids
Sample Menu #1 and #2
• Appendices
Client Education Materials:
6-7th grade reading level
DLM Toolkit Contents
Outcomes Monitoring Forms
• Individual Outcomes Monitoring Form
• Aggregate Input Form
• Aggregate Outcomes Monitoring Form
• Sample Individual Outcomes Form
• Sample Aggregate Input Form
• Sample 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
Published and Upcoming Evidence-Based
Guidelines and Toolkits
Published:
•Disorders of Lipid Metabolism
Guideline and Toolkit
•Adult Weight Management Guideline
•Critical Illness Guideline
Coming Soon:
•Adult Weight Management Toolkit
•Pediatric Weight Management
Guideline
•Critical Illness Toolkit
Upcoming guidelines and
toolkits:
•Diabetes Type 1 and 2
•Oncology
•Hypertension
•Heart Failure
•Gestational Diabetes
•Spinal Cord Injury
•COPD
•Chronic Kidney Disease
•Unintended Weight Loss
These resources can assist you in:
• Implementing evidence-based practice
• Implementing Nutrition Care Process
• Using recommendations based on a collective body
of evidence
• Training new staff, students and interns
• Understand treatment for an unfamiliar topic
• Meeting regulations based on current standards of
practice –best practice
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)
Resources
• Check Resources on EAL for additional
PowerPoint presentations.
ADA’s Evidence Analysis Library can be found at
www.adaevidencelibrary.com
For questions: see HELP and Frequently Asked Questions,
or contact:
eal@adaevidencelibrary.com
©2007 American Dietetic Association