Evidence-Based Practice Committee 2007-2008

1. The Evidence Analysis Library: A Wealth of Handy Information Jo Ann S. Carson, PhD, RD, LDon behalf of the American Dietetic AssociationEvidence-Based Practice Committee

2. 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 Evidence-Based Practice Committee 2007-2008

3. Participants will be able to: Describe the basic processes used in development of the ADA Evidence-Based Practice Guidelines Incorporate American Dietetic Association Evidence-Based Practice Guidelines into dietetic practice. Objectives

4. 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?

5. 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

6. 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 Evidence-Based Dietetics Practice

7. 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?

8. 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. • StrongImperative

9. 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?

10. 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 meta-analysis 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.

11. 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?

12. Associated with increased adioposity in youth Excessive television viewing Intake of calorically-sweetened beverages (in children) Associated with less adioposity Intake of fruits and vegetables Participation in regular physical activity Examples of Grade II Conclusions under Childhood Overweight

13. 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.

14. A rigorous and systematic process for searching, analyzing and summarizing research on a specific nutrition topic. ADA’s Evidence Analysis Process

16. ADA Evidence Analysis Projects HOD BOD Active Work Group Project Update Inactive Work Group Evidence-Based Practice Committee Adult Weight Management 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 Aspartame Breastfeeding Sodium

17. Evidence-Analysis Process Steps 1. Select topic & appoint expert work group 3. Conduct literature review for each question 4. Analyze Articles/ Critical Appraisal 2. Define questions and determine inclusion/ exclusion criteria 5. Overview Table & Evidence summary • Develop conclusion • statement & assign grade 7. Publish to online EAL

18. 8. Formulate guideline recommendations 9. Develop algorithms based on NCP 10. Internal/external review and revise 11. Publish guideline on EAL Guideline Development

19. 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 Features of Evidence-Based Toolkits

20. 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 Published Evidence-Based Guidelines and Toolkits

21. 2008: Critical Illness Toolkit Heart Failure Guideline Upcoming guidelines and toolkits: Gestational Diabetes Spinal Cord Injury COPD Chronic Kidney Disease Unintended Weight Loss Upcoming Evidence-Based Guidelines and Toolkits

22. How you can use the EAL? * • 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

23. Now… Let’s look at the Evidence Analysis Library

24. Enter your ADA member number and password to access complete library ADA Evidence Analysis Librarywww.adaevidencelibrary.com

25. 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 • Currently available for 6 areas: • Adult and Pediatric Weight Management • Critical Illness • Disorders of Lipid Metabolism • Oncology • Hypertension Notice how clicking on Evidence Based Guidelines changes the 2nd row of the menu

26. “Evidence-Based Guideline”

27. Select “Guideline List” From Navigation Bar Select Oncology

29. 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.

30. How it can help you-- * 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.

31. Recommendation for Head/neck cancer, radiation and enteral nutrition -Risks/Harms -Conditions of Application -Potential Costs -Narrative -Rationale for Rating

32. 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 Recommendation Example:

34. Drill down to supporting evidence

35. 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

36. Conclusion Grades

37. Evidence Summary: narrative summary

38. Evidence Summary: overview table

39. Bibliography Listed at end of Evidence Summary and linked to evidence worksheets

40. 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

41. Example: Quality Criteria Checklist • Validity questions • Determines Quality rating of article • Based on AHRQ quality domains

42. Remember * • 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.

43. How do the Evidence Analysis Products Support the Nutrition Care Process?

44. Main Menu: AlgorithmsStep-by-step flowchart for treatment following NCP

45. Oncology Algorithms Assessment Diagnosis Intervention Monitor/Evaluation

46. Nutrition Intervention Algorithm: Breast Cancer Use of arginine Use of parenteral nutrition Use of vitamin E supplement

47. The Toolkits Model the NCP

48. AWM Toolkit Contents • 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

49. MNT Protocol provides • Summary of Recommendations • Length of encounters • Expected outcomes of MNT

50. Check off nutrition Dx • Write PES statement • Determine Nutrition Rx • Check off nutrition intervention • Document intervention details • Document goals and expected outcomes MNT Initial Progress Note