ADAs EvidenceBased Nutrition Practice Guidelines and Toolkits Kari

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 l 1990’s: Medical Nutrition Therapy Across the Continuum of Care (MNTACC) (research-based) l 2001 & 2002: MNT Evidence-Based Guides for Practice n Hyperlipidemia, Diabetes Type 1 and 2, Gestational Diabetes, Chronic Kidney Disease l 2005 & 2006: Evidence-Based Nutrition Practice Guidelines & Toolkits

What’s New? l Movement in healthcare towards evidence-based practice l More systematic, rigorous process of evidence analysis l Use of ADA’s Nutrition Care Process n n Assessment Diagnosis Intervention Monitoring & Evaluation l Guidelines are a free member benefit on the Evidence Analysis Library l Toolkits consist of more resources for application of the Guidelines l 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 n n 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: n n n 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 l Implementing Nutrition Care Process l Using recommendations based on a collective body of evidence Training new staff, students and interns l 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 l Describe “what” and “why” l Display rating using AAP adapted scale n Strong, Fair, Weak, Consensus, Insufficient Evidence l List potential risks/harms for implementing l Narrative illustrating the supporting evidence l 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 n Equipment n Patient Condition n Environment n 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 n n n Summary Page for DLM and DLM with Metabolic Syndrome MNT Flowchart of Encounters MNT Encounter Process Documentation Forms n n n 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. . . >40 mg/d. L (males), >50 mg/d. L (females) soluble fiber intake ………. increased intake………. >25 g dietary fiber of which 7 -13 g 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 Q 10, 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 A 1 C, liver function tests, thyroid, Lp(a), homocysteine, and high-sensitivity C reactive protein. Anthropometric Measurements include height, 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 n n 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 -7 th grade reading level

DLM Toolkit Contents Outcomes Monitoring Forms n n n 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?