Evidence Analysis Library and Evidence-Based Nutrition Practice Guidelines and Toolkits

1. Evidence Analysis Library andEvidence-BasedNutrition Practice Guidelines and Toolkits

2. “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.” Approved by ADA HOD February 2006 ADA Definition/Description

3. To improve patient outcomes To improve safety, quality, efficiency To take advantage of “exploding” biomedical knowledge (thousands of new research studies appear every month) Why Evidence-based Practice?

4. Online Resource with the best available research on important dietetics topics in a practitioner-friendly format ADA Evidence Analysis Librarywww.adaevidencelibrary.com

5. Select Topic & Appoint Expert Working Group Define Questions & Analytical Framework/ Determine Inclusion/Exclusion Criteria Conduct Literature Review for each question Analyze articles Complete Evidence Summaries & Tables Draft proposed Conclusion Statements Reach Consensus on Conclusion Statements/Grades PUBLISH to ONLINE LIBRARY (EAL) What are the steps in ADA’s Evidence Analysis Process?

6. 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 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 Nutrition Care Process Estimating EnergyExpenditure/Indirect Calorimetry Nutrition Counseling Foods Fiber Non-nutritive Sweetener Vegetarian Nutrition Current List of ADA EAL Projects

7. Navigate through the library by selecting from tabs:

8. 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 EAL

9. Select from list of Diseases & Conditions Choose a Topic Disorders of Lipid Metabolism Macronutrients Trans-fatty acids Then, choose a sub-topic

10. Example: View EA Question What is the relationship between diets high in trans fatty acids and serum cholesterol levels? Bibliography for Topic

11. Example: Conclusion Statement (answer to question) and Grade “Mouse over” Question to see Conclusion & Grade or click on question to continue drilling down.

12. 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

13. Explanation of Grades

14. Narrative Summary Of the research available to answer question Example: Evidence Summary All articles used to answer question are summarized here.

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

16. 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

17. Example: Quality Criteria Checklist • Primary Research • or • Narrative Review • Determine Quality Rating of Article

18. Evidence Summaries/Conclusion Statements = whatthe evidence says Guideline = course of actionfor the practitioner based on the evidence Transition from Evidence to Evidence-Based Guideline

19. 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 ADA’s Evidence-Based Guidelines

20. Criteria used to develop: Guideline Elements Model (GEM) AGREE Instrument National Guidelines Clearinghouse standards Classification: Recommendation ratings adapted from American Academy of Pediatrics Criteria and Classification for Guideline Development

21. 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 Transition from evidence to Guideline

22. 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 Introduction

23. 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 Features of Guideline Recommendations

24. Evidence-Based Guidelines Homepage

25. Select Guidelines from Guideline List

26. Example: Select Disorders of Lipid Metabolism

27. Disorders of Lipid MetabolismEvidence-Based Nutrition Practice GuidelineMain Menu Choose a Category

28. Disorders of Lipid MetabolismEvidence-Based Nutrition Practice Guideline • Introduction • Guideline Overview • Scope of Guideline • Statement of Intent • Guideline Methods • Implementation • Benefits and Risks/harms

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

30. Disorders of Lipid MetabolismEvidence-Based Nutrition Practice Guideline Scope of Guideline • Disease/Condition • Guideline Category • Intended Users • Objectives • Target Population

31. Disorders of Lipid MetabolismEvidence-Based Nutrition Practice Guideline Introduction: Guideline Methods • Method for Creating Guidelines • Inclusion and Exclusion Criteria

32. Disorders of Lipid MetabolismEvidence-Based Nutrition Practice Guideline Main Menu: Major Recommendations

33. Disorders of Lipid MetabolismEvidence-Based Nutrition Practice Guideline Select a Recommendation (listed by topic) Macronutrients: Fat Sub-topic: Trans-fatty Acid Intake

34. Disorders of Lipid MetabolismEvidence-Based Nutrition Practice Guideline Recommendationdomains: • Recommendation & Rating • Risks/Harms • Conditions of Application • Potential Costs • Narrative • Rationale for Rating

35. Disorders of Lipid MetabolismEvidence-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.

37. Disorders of Lipid MetabolismEvidence-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?

38. Disorders of Lipid MetabolismEAL Trans fatty acids question View Conclusion Statement and Grade Drill down to the Evidence Summary

39. Disorders of Lipid MetabolismEAL Trans fatty acids question Evidence Summary Scroll down for worksheets

40. Disorders of Lipid MetabolismEAL Trans fatty acids question Drill down to Quality rating And worksheets

41. Disorders of Lipid MetabolismEvidence-Based Nutrition Practice Guideline Main Menu: Algorithms

42. Main Algorithm for Disorders of Lipid Metabolism View recommendations organized within a treatment plan Nutrition Care Process Assessment Diagnosis Intervention Monitoring & Evaluation

43. 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

44. View second level algorithm • Link to Recommendation Recommend Intake of as Few Trans Fatty Acids as Possible Select

45. View Recommendation • Drill down as needed

46. 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 Evidence-Based Toolkits

47. Disorders of Lipid Metabolism Toolkit

48. STORE • Choose Quantity • Add to Cart

49. 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 Disorders of Lipid Metabolism Toolkit Contents

50. 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