American Dietetic Association Navigating the Evidence Analysis Library

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American Dietetic AssociationNavigating the
Evidence Analysis Library
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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

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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)

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ADA Evidence Analysis Librarywww.adaevidencelibra
ry.com

• Online
• Resource
• with the best
• available research
• on important
• dietetics topics in a
• practitioner-friendly
• format

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What are the steps in ADAs Evidence Analysis
Process?

1. Select Topic Appoint Expert Working Group
2. Define Questions Analytical Framework/
   Determine Inclusion/Exclusion Criteria
3. Conduct Literature Review for each question
4. Analyze articles
5. Complete Evidence Summaries Tables
6. Draft proposed Conclusion Statements
7. Reach Consensus on Conclusion Statements/Grades
8. PUBLISH to ONLINE LIBRARY (EAL)

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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

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• Navigate through the library by selecting from
  tabs

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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

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Select from list of Diseases Conditions
Choose a Topic
Disorders of Lipid Metabolism
Macronutrients
Trans-fatty acids
Then, choose a sub-topic
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Example View EA Question
What is the relationship between diets high in
trans fatty acids and serum cholesterol levels?
Bibliography for Topic
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ExampleEA Conclusion Statement/Grade
Mouse over Question to see Conclusion Grade
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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
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Explanation of Grades
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Example Evidence Summary

• Narrative
• Summary
• Of the
• research
• available
• to answer
• question

Evidence Summary
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Example Bibliography
Bibliography for Question listed at end of
Evidence Summary (and linked to worksheets)
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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

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Example Quality Criteria Checklist

• Primary Research
• or
• Narrative Review
• Determine Quality Rating of Article

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ADAs 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

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Criteria and Classification for Guideline
Development

• Criteria
• Guideline Elements Model (GEM)
• AGREE Instrument
• National Guidelines Clearinghouse standards
• Classification
• American Academy of Pediatrics

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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

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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

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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

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Evidence-Based Guidelines Homepage
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Guideline List
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Guideline List Select Disorders of Lipid
Metabolism
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Disorders of Lipid MetabolismEvidence-Based
Nutrition Practice GuidelineMain Menu
Choose a Category
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Disorders of Lipid MetabolismEvidence-Based
Nutrition Practice Guideline
Introduction

• Guideline Overview
• Scope of Guideline
• Statement of Intent
• Guideline Methods
• Implementation
• Benefits and Risks/harms

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Disorders of Lipid MetabolismEvidence-Based
Nutrition Practice Guideline
Select a Category within Introduction
Scope of guideline
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Disorders of Lipid MetabolismEvidence-Based
Nutrition Practice Guideline

• Introduction
• Scope

• Disease/Condition
• Guideline Category
• Intended Users
• Objectives
• Target Population

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Disorders of Lipid MetabolismEvidence-Based
Nutrition Practice Guideline

• Introduction
• Guideline Methods

• Method for Creating Guidelines
• Inclusion and Exclusion
• Criteria

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Main Menu Major Recommendations
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Disorders of Lipid MetabolismEvidence-Based
Nutrition Practice Guideline
Introduction

• Select
• Guideline
• Methods

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Disorders of Lipid MetabolismEvidence-Based
Nutrition Practice Guideline

• Introduction
• Guideline Methods

• Method for Creating Guidelines
• Inclusion and Exclusion
• Criteria

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Disorders of Lipid MetabolismEvidence-Based
Nutrition Practice Guideline
Choose a different category
Return to Main Menu

• Select
• Major
• Recommendations

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Disorders of Lipid MetabolismEvidence-Based
Nutrition Practice Guideline

• Major
• Recommendations
• (listed by topics)
• Macronutrients Fat (Topic)

• Trans-fatty Acid Intake
• and Disorders of
• Lipid Metabolism

Select a Recommendation
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Disorders of Lipid MetabolismEvidence-Based
Nutrition Practice Guideline

• Major
• Recommendations
• Trans-fatty Acid Intake and DLM

RecommendationFeatures

• Recommendation
• Rating
• Risks/Harms
• Strength
• Rationale
• Narrative

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Disorders of Lipid MetabolismEvidence-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.
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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.
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Disorders of Lipid MetabolismEvidence-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?
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Disorders of Lipid MetabolismEAL Trans fatty
acids question
View Conclusion Statement and Grade
Drill down to the Evidence Summary
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Disorders of Lipid MetabolismEAL Trans fatty
acids question
Evidence Summary
Scroll down for worksheets
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Disorders of Lipid MetabolismEAL Trans fatty
acids question
Drill down to Quality rating And worksheets
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Disorders of Lipid MetabolismEvidence-Based
Nutrition Practice Guideline
Main Menu Algorithms
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• View Main Algorithm for Disorders of Lipid
  Metabolism
• See recommendations organized within a treatment
  plan

Nutrition Care Process Assessment Diagnosis
Intervention Monitoring
Evaluation
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Link to another level within the Algorithm
Red different level in algorithm Blue
recommendation
Determine Meal Plan and Nutrition Recommendation
Select
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• View second level algorithm
• Link to Recommendation

Select
Recommend Intake of as Few Trans Fatty Acids as
Possible
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• View Recommendation
• Drill down as needed

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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

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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

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Other EAL Features
Robust Search
Help and FAQs
Contributors (lists workgroup members, analysts,
and sponsors for each project)
Evidence Analysis Process (describes methods in
detail)
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Summary

• ADAs Evidence Analysis Library can be found at
  www.adaevidencelibrary.com
• For questions contact
• eal_at_adaevidencelibrary.com