The Evidence Analysis Library:
A Wealth of Handy Information
Jo Ann S. Carson, PhD, RD, LD
on behalf of the
American Dietetic Association
Evidence-Based Practice Committee
Evidence-Based Practice
Committee 2007-2008
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Kathleen Niedert, MBA, RD, CSG, LD, FADA (Chair)
Nancy McQuillan-Copperman, MS, RD (Vice Chair)
Ethan Bergman, PhD, RD, CD, FADA
JoAnn Carson, PhD, RD, LD
David Frankenfield, MS, RD
Trisha Fuhrman, MS, RD, LD, FADA
Wahida Karmally, DrPH, CDE
Sue Kent, MS, RD, LD
Jessie Pavlinac, MS, RD, CSR, LD
Objectives
Participants will be able to:
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Describe the basic processes used in development of the
ADA Evidence-Based Practice Guidelines
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Incorporate American Dietetic Association Evidence-Based
Practice Guidelines into dietetic practice.
• What do you know about
the EAL?
• How many of you have
been to the EAL?
• How many have an
example of how it was
helpful to you?
• Are there any analysts
here?
• What do you want to
learn about the EAL?
What another RD says:
• It is evident much work went into the
development of the guidelines - speaking
for myself this effort is much appreciated!
Allowing us this evidence at our fingertips
only works to strengthen our practice and
validity as a profession.
…. From Testimonial section of EAL
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.
Source: ADA Scope of Dietetics Practice Framework Definition of Terms, 2007
How the EAL has been helped me
• In the Preventive Cardiology clinic, do
we need to just do BMI, or should we
also do waist circumference or waist to
hip ratio?
Practice Guideline:
Disorders of Lipid Metabolism:
BMI, WC & WHR
• In addition to BMI, use waist circumference or
waist to hip ratio (WHR) to assess obesity and
CVD risk. BMI alone is not a good predictor of
CVD risk in persons over 65 years old.
Increases in waist circumference, WHR, and
BMI are associated with CHD events and CVD
mortality.
• Strong
Imperative
How the EAL has been helped me
• Did the student who did a seminar on
omega-3 fat and heart disease include
the important research on the topic?
•
Albert CM, Campos H, Stampfer MJ, Ridker PM, Manson JE, Willett WC, Ma J. Blood levels of long-chain n-3 fatty
acids and the risk of sudden death. N Engl J Med 2002; 346(15):1113-1118.
Albert CM, Hennekens CH, O’Donnell CJ, Ajani UA, Carey FJ, Willett WC, Riskin JN, Manson JE. Fish
consumption and risk of sudden cardiac death. JAMA. 1998;279:23-28.
Baylin A, Kabagambe EK, Ascherio A, Spiegelman D, and Campos H. Adipose tissue a-linolenic acid and nonfatal
acute myocardial infarction in Costa Rica. Circulation 2003 Apr; 107(12):1586-1591.
Bucher HC, Hengstler P, Schindler C, Meier G. N-3 polyunsaturated fatty acids in coronary heart disease: a metaanalysis of randomized controlled trials. Am J Med. 2002 Mar;112(4):298-304.
Burr ML, Ashfield-Watt PA, Dunstan FD, Fehily AM, Breay P, Ashton T, Zotos PC, Haboubi NA, Elwood PC.Lack of
benefit of dietary advice to men with angina: results of a controlled trial. Eur J Clin Nutr. 2003 Feb;57(2):193-200.
Daviglus ML, Samler J, Orencia AJ, Dyer AR, Liu P, et.al. Fish consumption and the 30-year risk of fatal
myocardial infarction. N Engl J Med. 1997;336:1046-1053.
De Lorgeril M, Salen P, Martin JL, Monjaud I, Delaye J, Mamelle N. Mediterranean Diet, traditional risk factors, and
the rate of cardiovascular complications after myocardial infarction, final report of the Lyon Diet Heart Study.
Circulation. 1999;99:779-785.
Erkkila AT, Lehto S, Pyorala K, and Uusitupa MIJ. N-3 fatty acids
and 5-y risks of death and cardiovascular disease events in patients
with coronary artery disease. Am J Clin Nutr 2003 July; 78(1):65-71.
Hu FB, Stampfer MJ, Manson JE, et al. Frequent nut consumption and risk of coronary heart disease in women:
Prospective cohort study. Nurses Health Study. BMJ 1998;317:1341-1345.
Kris-Etherton PM, Harris WS, Appel LJ for the Nutrition Committee.
AHA Scientific Statement: Fish Consumption, Fish Oil, Omega-3
Fatty Acids, and Cardiovascular Disease. Arterioscler Thromb Vasc
Biol 2003 Feb; 23(2):e20-30.
How the EAL has been helped me
• The community obesity coalition wants
to know which interventions would be
most beneficial in trying to reduce
obesity in Dallas children. What do we
currently know about this?
Examples of Grade II Conclusions
under Childhood Overweight
• Associated with
increased adioposity
in youth
– Excessive television
viewing
– Intake of caloricallysweetened beverages
(in children)
• Associated with less
adioposity
– Intake of fruits and
vegetables
– Participation in regular
physical activity
Examples of Grade III Conclusions
under Childhood Overweight
• Limiting media influences as part of a
school-based intervention may be
associated with changes in weight
status/adiposity
• Sports participation may be associated
with lower adiposity.
ADA’s Evidence Analysis
Process
A rigorous and systematic process
for searching, analyzing and
summarizing research on a specific
nutrition topic.
Toolkit
Evidence-based
Guideline
Summary of Evidence
ADA Evidence Analysis Projects
HOD
Active Work Group
BOD
Inactive Work Group
Project Update
Evidence-Based Practice Committee
Childhood
Overweight
Chronic Kidney
Disease
Chronic Obstructive
Pulmonary
Disease (COPD)
Critical Illness
Diabetes
1&2
Disorders
Of Lipid
Metabolism
Fiber
Gestational
Diabetes
Gluten
Intolerance /
Celiac Disease
Heart
Failure
HIV – AIDS
Nutrition
Hydration
Hypertension
Measuring
Energy
Expenditure
Non-nutritive
sweeteners
Nutrition
Counseling
Nutrition
In Athletic
Performance
Nutrition in
Bariatric
Surgery
Oncology
Nutrition
Pediatric
Weight
Management
Spinal Cord
Injury Nutrition
Unintended
Weight Loss
Vegetarian
Nutrition
Nutrition
Screening
MNT
Effectiveness
Fortifications &
Supplements
Breastfeeding
Adult Weight
Management
Aspartame
Sodium
Evidence-Analysis Process Steps
1. Select topic & appoint
expert work group
2. Define questions
and determine inclusion/
exclusion criteria
3. Conduct literature
review for each question
4. Analyze Articles/
Critical Appraisal
5. Overview Table
& Evidence summary
6. Develop conclusion
statement & assign grade
7. Publish to online EAL
Guideline Development
8. Formulate guideline recommendations
9. Develop algorithms based on NCP
10. Internal/external review and revise
11. Publish guideline on EAL
Features of Evidence-Based
Toolkits
Set of companion documents for application
of the practice guideline
• Disease/condition specific
• Include:
– documentation forms
– outcomes monitoring sheets
– client education resources
– case studies
– MNT protocol for treatment of
disease/condition
• Incorporate Nutrition Care Process/SL as
the standard for care
• Electronic downloadable purchase item
Published Evidence-Based
Guidelines and Toolkits
• Disorders of Lipid Metabolism Guideline
and Toolkit
• Adult Weight Management Guideline
and Toolkit
• Critical Illness Guideline
• Pediatric Weight Management Guideline
• Oncology Guideline
• Diabetes Type 1 and 2 Guideline
• Hypertension Guideline
Upcoming Evidence-Based
Guidelines and Toolkits
2008:
• Critical Illness Toolkit
• Heart Failure Guideline
Upcoming guidelines and
toolkits:
• Gestational Diabetes
• Spinal Cord Injury
• COPD
• Chronic Kidney Disease
• Unintended Weight Loss
How you can use the EAL?
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To support your patient care practices to the MD
To up-date your knowledge in an unfamiliar area
To answer a question from a patient
To develop a class for patients or professionals
To double-check the accuracy of a statement
To provide a reference list on a topic
To strengthen your ability to critically analyze a
research study
• To find ideas for a research project
Now…
Let’s look at the Evidence Analysis Library
ADA Evidence Analysis Library
www.adaevidencelibrary.com
Enter your ADA
member number
and password to
access complete
library
Navigating the Library
Two critical sections!
– Diseases and Condition
• Provides conclusion statements that indicate the
strength of research or evidence on many topics
– Evidence Based Guidelines
• Translates the evidence into a guideline advising
what an RD should do
Notice how
• Currently available for 6 areas:
clicking on
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Adult and Pediatric Weight Management
Critical Illness
Disorders of Lipid Metabolism
Oncology
Hypertension
Evidence
Based
Guidelines
changes the 2nd
row of the menu
“Evidence-Based
Guideline”
Select “Guideline List” From
Navigation Bar
Select
Oncology
Features of Guidelines
– 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.
How it can help you--
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Your “gut” tells you that some of the cancer
patients on your floors should be receiving
enteral nutrition. When you approached
one of the oncologist he quoted a review
from the 1980’s that said nutrition support
did not make a difference in the survival of
cancer patients. You would like to see
what the latest research says and perhaps
use it to support your recommendations
for tube feedings for some of the patients.
Recommendation for
Head/neck cancer,
radiation and enteral
nutrition
-Risks/Harms
-Conditions of Application
-Potential Costs
-Narrative
-Rationale for Rating
Recommendation Example:
Use enteral nutrition (EN) to increase
calorie and protein intake for outpatients
with stage III or IV head and neck
cancer undergoing intensive radiation
treatment. Maintenance of nutritional
status by EN during radiation therapy
may improve tolerance of therapy to
promote better outcomes.
Strong, Imperative
Rating
Strong
Definition
• benefits clearly exceed the harms (or harms clearly exceed
the benefits for a negative recommendation)
• the quality of the supporting evidence is excellent/good
(grade I or II)
Fair
Weak
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benefits exceed the harms (or harms clearly exceed the
benefits for a negative recommendation)
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quality of evidence is not as strong (grade II or III)
• 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
Consensus
Insufficient
Evidence
• Expert opinion (grade IV) supports the guideline
recommendation
• both a lack of pertinent evidence (grade V)* and/or an
unclear balance between benefits and harms
Drill down to supporting evidence
Conclusion Statement
Two positive quality RCTs found that head and neck
cancer patients receiving radiation therapy may
benefit from EN. Energy and protein goals for
patients in the RCTs were 40 kcals/kg and 1.0 - 1.5
g/kg body weight, respectively........
GRADE II
Conclusion Grades
Grade I
Good/Strong
Grade II
Fair
Grade III
Limited
Grade V
Expert Opinion
Only
Not Assignable (no
Grade V
evidence)
Evidence Summary:
narrative summary
Evidence Summary:
overview table
Bibliography
Listed at end of Evidence
Summary and linked to
evidence 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
•Validity questions
•Determines Quality
rating of article
•Based on AHRQ quality
domains
Remember
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• The guidelines and conclusions can offer
you what current research says.
• As a clinician you use your professional
judgment in how it applies to your patient
• There is not always a good research base
for decisions we must make in patient
care.
How do the Evidence
Analysis Products Support
the Nutrition Care
Process?
Main Menu: Algorithms
Step-by-step flowchart for treatment
following NCP
Oncology Algorithms
Assessment
Diagnosis
Intervention
Monitor/Evaluation
Nutrition
Intervention
Algorithm: Breast
Cancer
Use of arginine
Use of parenteral
nutrition
Use of vitamin E
supplement
The Toolkits Model the NCP
AWM Toolkit Contents
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Overview
MNT Protocol Forms
• Summary Recommendations for AWM
• Flowchart of Encounters
• Encounter Process
Documentation Forms
• Sample Referral Form for MNT
• Initial & follow-up MNT Progress Note
• Sample Case Study
Outcomes Management Forms in Excel
Client Education Resources
• Executive Summary
• Client Agreement for Care & Encounter Contract
• Can Dairy Help Control Weight?
• Low-Carbohydrate Diets: Hype or Hope?
• Meals on the Go
• Portion Distortion
• Weight Control Meal Patterns
MNT Protocol provides
•Summary of Recommendations
•Length of encounters
•Expected outcomes of MNT
MNT Initial Progress Note
•Check off nutrition Dx
• Write PES statement
•Determine Nutrition Rx
•Check off nutrition
intervention
• Document intervention
details
• Document goals and
expected outcomes
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Case Studies:
• Initial and Follow-up
Encounters
• Illustrates the Nutrition
Care Process
• Uses new SL for
Nutrition Diagnosis,
Intervention, Monitoring
And Evaluation
Client Education Materials:
5-6th grade reading level
Within Electronic Health
Record, can store on-line;
Print as needed; even
customize for a patient
In Summary
Evidence-based Guidelines and Toolkits
can help you:
• Implement evidence-based practice
• Implement NCP/SL
• Promote consistency
• Achieve expected outcomes
• Assure quality care
Your patient is a 45 year old female admitted
to rule out an MI. She is a nursing
professor and has several questions about
nutrition and heart disease. Specifically,
she wants to know whether eating nuts is
really good for her, and if so, which ones
to eat.
DLM: Disorders of Lipid Metabolism,
Nuts and CHD
• If consistent with patient preference and not
contraindicated by risks or harms, then nuts (walnuts,
almonds, peanuts, macadamia, pistachios, and pecans)
may be isocalorically incorporated into a cardioprotective
dietary pattern. Consuming five ounces of nuts per week
is associated with a reduced risk of CHD. Because of
their beneficial fatty acid profile as well as other
nutritional components, nuts may be incorporated into a
cardioprotective dietary pattern low in saturated fat and
cholesterol to reduce TC by 4-21% and LDL-C by 629%.
• Fair
Conditional
Risks/Harms of Implementing This
Recommendation
• Nuts contain a high level of calories and
should only be included in a
cardioprotective diet if weight can be
maintained.
• Brazil nuts are higher in saturated fat and
should not be consumed regularly as part
of a cardioprotective diet.
You are new to a geriatric unit. In a multidisciplinary meeting concerns regarding
whether many of the patients are
dehydrated. You are asked to develop a
policy and procedure for the health care
team to use in detecting dehydration in
patients. What information can you find in
the EAL that will help you?
• There is no evidence, which identifies a clinical, and/or
biochemical parameter, which is best for assessing hydration
status in the older adult. One positive quality study suggested
ranges of Psg (plasma specific gravity) which may be useful for
assessing volume depletion in elderly adults. A neutral quality
study found Ucol reflected hydration status (narrow range) as
measured by Usg and Uosm in euhydrated, elderly patients.
• Based upon a positive quality study, researchers identified the
following physical exam data as useful in detecting severe
dehydration: dry tongue, longitudinal tongue furrows, dry
mucous membranes of nose and mouth, eyes that appear
recessed in their sockets, upper body muscle weakness,
speech difficulty, and confusion. A positive quality study found
multi-frequency BIA useful in detecting change in hydration
status, but a single measurement was a poor indicator of
hydration status. Additional well-controlled studies are needed
to validate these findings.
• Grade III
You would like to establish an organized
ambulatory nutrition clinic at your hospital.
You are looking for evidence that nutrition
therapy provided in multiple sessions can
reduce cardiovascular risk. What
information from the EAL can help you?
• Seven studies describe individualized MNT that
results in improved cardioprotective dietary pattern
changes and/or subsequent plasma lipid changes,
thereby decreasing cardiac heart disease risks.
Reductions in total fat and saturated fat intake were
seen in three studies (two high- and one neutralquality). Decreases in TC and LDL-C were reported
in five studies. Three of these studies found
reductions in body weight. Four studies looked at
the impact on TG and HDL-C and found varying
results.
• Two studies found that decreases in total
cholesterol correlated with time spent with a
dietitian. A third high-quality RCT found that
individuals who went to three or four MNT sessions
had lower LDL-C compared to those that attended
fewer than three sessions.
Thank you for your attention!
Questions?