ADA’s Evidence-Based
Nutrition Practice Guidelines
and Toolkits
Kari Kren, MPH, RD, LD
Manager, Governance
American Dietetic Association
November 1, 2006
History of ADA’s MNT Guides
1990’s: Medical Nutrition Therapy Across the
Continuum of Care (MNTACC) (research-based)
2001 & 2002: MNT Evidence-Based Guides for
Practice
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Hyperlipidemia, Diabetes Type 1 and 2, Gestational
Diabetes, Chronic Kidney Disease
2005 & 2006: Evidence-Based Nutrition Practice
Guidelines & Toolkits
What’s New?
Movement in healthcare towards evidence-based practice
More systematic, rigorous process of evidence analysis
Use of ADA’s Nutrition Care Process
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Assessment
Diagnosis
Intervention
Monitoring & Evaluation
Guidelines are a free member benefit on the Evidence
Analysis Library
Toolkits consist of more resources for application of the
Guidelines
Oversight by Evidence-Based Practice Committee
What are Evidence-Based Nutrition
Practice Guidelines?
Evidence Summaries &
Conclusion Statements =
what the evidence says
Guideline = course of
action for the practitioner
based on the evidence
What are Evidence-Based
Nutrition Practice
Guidelines?
Definition:
A series of guiding statements and treatment
algorithms which are developed using a
systematic process for identifying, analyzing and
synthesizing scientific evidence. They are
designed to assist practitioner and patient
decisions about appropriate nutrition care for
specific disease states or conditions in typical
settings.
Approved by Evidence-Based Practice Committee, 2006
Features of Guidelines
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Introduction: scope, intent,
methods, benefits/harms
Recommendations: a series of
guiding statements that propose a
course of action for practitioners
Algorithms: step-by-step flowchart
for treatment of the specific
disease/condition
Appendices: food tables, etc.
What are Evidence-Based
Toolkits
Set of companion documents for
application of the practice guideline
Disease or condition specific
Include:
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documentation forms
outcomes monitoring sheets
client education resources
case studies
MNT protocol for treatment of
disease/condition
Incorporate Nutrition Care Process
as the standard process care
Why use these resources?
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
Current Evidence-Based
Guidelines and Toolkits
Published on EAL:
Disorders of Lipid Metabolism Guideline
and Toolkit
Adult Weight Management Guideline
Critical Illness Guideline
Select “Guideline List” From
Navigation Bar
Select
Critical
Illness
Features of each
Recommendation Page
Describe “what” and “why”
Display rating using AAP adapted scale
 Strong, Fair, Weak, Consensus, Insufficient Evidence
List potential risks/harms for implementing
Narrative illustrating the supporting evidence
Provide rationale for the recommendation rating
Link to supporting evidence
Recommendation for
Immune-enhancing
formula
Definition
-Risks/Harms
-Conditions of Application
-Potential Costs
-Narrative
-Rationale for Rating
Recommendation Example
• R.5. Blue dye should not be added to EN for
detection of aspiration. The risk of using blue
dye outweighs any perceived benefit. The
presence of blue dye in tracheal secretions is
not a sensitive indicator for aspiration.
• Strong
Imperative
•
Recommendation Rating
• Strong = Practitioners should follow a Strong
recommendation unless a clear and compelling
rationale for an alternative approach is present.
• Imperative = imperative recommendations
“require,” or “must,” or “should achieve certain
goals,” but do not contain conditional text that
would limit their applicability to specified
circumstances.
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.
Drill down as needed
Evidence Summary
Critical Illness Recommendations
Enteral vs. Parenteral Nutrition
Timing of Feeding
Immune-Enhancing Enteral Formula
Feeding Tube Site
Blue Dye Use
Monitoring Criteria in Critical Care
Monitoring Delivery of Energy
Blood Glucose Control
Energy Expenditure
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Equipment
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Patient Condition
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Environment
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Test Interpretation
Energy Assessment
Main Menu: Algorithms
Adult Weight Management
Algorithms
Weight Management Treatment
Energy Expenditure
Assess Nutritional Status
Dietary Interventions
Weight Management
Treatment Algorithm
Assessment
Diagnosis
Intervention
Monitor/Evaluation
Select: Determine
Diet Intervention
Dietary Intervention Algorithm
Eating Frequency
Portion Control
Meal
Replacements
Nutrition
Education
Meal Replacements
Recommendation
Disorders of Lipid Metabolism
Toolkit
STORE
Click here to see
sample forms
• Choose Quantity
• Add to Cart
Disorders of Lipid Metabolism
Toolkit Contents
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Summary Page for DLM and DLM with Metabolic
Syndrome
MNT Flowchart of Encounters
MNT Encounter Process
Documentation Forms
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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
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 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
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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
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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
Upcoming Evidence-Based
Guidelines and Toolkits
2006-2007 program year:
Adult Weight Management Toolkit
Critical Illness Toolkit
Pediatric Weight Management
Guideline
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
For Further Information:
See “Help” tab and FAQs on EAL
Or Contact:
Kari Kren kkren@eatright.org
EAL Help eal@adaevidencelibrary.com
Website: www.adaevidencelibrary.com
Thank you for your attention!
Questions?