Clinical Nutrition Management: A Reference Guide

CLINICAL NUTRITION MANAGEMENT
A REFERENCE GUIDE

INTRODUCTION

The material in this section:

provides the dietitian with relevant evidence-based information to consider in the development of the nutrition care plan
forms the basis for the development of disease- or condition-specific nutrition interventions and protocols as required by the organization

As part of Morrison Management Specialists’ strategic plan to support and assimilate evidence-based research into clinical practice, the Manual of Clinical Nutrition Management integrates the American Dietetic Association’s (ADA’s) recommendations and conclusion-grading statements established as part of the ADA’s Evidence Analysis Library and evidence-based analysis process. The ADA’s Evidence Analysis Library (www.adaevidencelibrary.com) is an online library that includes a synthesis of the best, most relevant research on important dietetic practice questions. The library’s resources include conclusion statements that provide a concise summary of the research on a given question. The ADA has assigned grades, ranging from Grade I (good/strong) to Grade V (insufficient evidence), to evidence and conclusion statements. These grades, which are based on the quality and extent of the research, are a tool for practitioners to use when determining the certainty of information.

The ADA’s grades are integrated throughout the Manual to assist the dietitian in interpreting the strength and relevance of evidence on a particular topic. The criteria and characteristics of the five grades are described in Table III-1.

Table III-1: Conclusion Grading Characteristicsa

Grade I Good/strong	Quality of studies is strong and free from design flaws, bias, and execution problems. Uses large number of subjects; outcomes directly related to question; statistical difference is large and meaningful; can be generalized to population of interest.
Grade II Fair	Quality of studies is strong, however, with minor methodological concerns; inconsistency among results of studies, or studies evaluated have weaker design; doubts about adequate sample size; doubts about statistical significance; minor doubts about generalizability to population of interest.
Grade III Limited/weak	Studies of weak design; inconclusive findings due to design flaws, bias, or execution problems; inconsistency among results that cannot be explained; inadequate sample size; serious doubts about generalizability to population of interest.
Grade IV Expert opinion only	No studies available; conclusion based on usual practice, expert consensus, clinical experience, opinion, or extrapolation from the research.
Grade V Insufficient evidence	No evidence pertains to the question being addressed.

aThe grading system is based on the grading system from: Greer N, Mosser G, Logan G, Halaas GW. A practical approach to evidence grading. Jt Comm J Qual Improv. 2000;26:700-712. In September 2004, the ADA Research Committee modified the grading system to this current version.

When necessary, the practitioner can use grading information to assist in clinical decision-making as described in Table III-2.

Table III-2: Grading Implications for Practicea

Grade I Good/strong	Practitioners should follow recommendation unless a clear and compelling rationale for an alternative approach is present.
Grade II Fair	Practitioners should generally follow recommendation but remain alert to new information and be sensitive to patient preferences.
Grade III Limited/weak	Practitioners should be cautious in deciding whether to follow recommendation, and should exercise judgment and be alert to emerging publications that report evidence. Patient preference should have substantial influencing role.
Grade IV Expert opinion only	Practitioners should be flexible in deciding whether to follow recommendation, although the recommendation may set boundaries on alternatives. Patient preference should have a substantial influencing role.
Grade V Insufficient evidence	Practitioner should exercise judgment and be alert to emerging publications that report evidence that clarifies the balance of benefit vs. harm. Patient preference should have a substantial influencing role.

aAdapted by the ADA from: American Academy of Pediatrics Steering Committee on Quality Improvement and Management. Classifying recommendations for clinical practice guidelines. Pediatrics. 2004;114:874-877.

Grading information in the Manual appears in parentheses, as seen in the following example:

Evidence shows that physical activity at any level, light, moderate, or vigorous, as well as food patterns emphasizing a diet high in fruits, vegetables, and whole grains is associated with reduced incidence of metabolic syndrome (Grade II) (1).

Disorders of Lipid Metabolism Evidence-Based Nutrition Practice Guideline. American Dietetic Association Evidence Analysis Library. American Dietetic Association; 2005. Available at: http://www.adaevidencelibrary.com. Accessed June 1, 2006.

Because the ADA’s Evidence Analysis Library is an evolving project, not all sections and recommendations in the Manual contain grading information. Also, the recommendations that are graded may be frequently updated as evidence emerges. The practitioner is encouraged to refer to the ADA’s online library for updates on emerging topics. The grading information is provided to assist practitioners in making decisions about clinical care and interventions. Grading informationshould complement clinical decision-making, not replace sound clinical judgment or expertise.

This section also contains information (eg, medical diagnostic tests or laboratory indexes) that may not necessarily be mentioned in the nutrition assessment care plan. The evidence that supports the nutrition-specific information is included to strengthen the dietitian’s role as a participating member of the health care team. In developing the individual patient care plan, the dietitian selectively discusses the assessment parameters and interventions that are pertinent to improving the patient’s nutrition care.

In conclusion, the approaches mentioned for each condition are suggestions that should not be interpreted as definitive nutrition therapy for the given condition. The evidence grades are provided to guide clinical decision-making and the selection of optimal nutrition approaches. Medical approaches are listed with medical nutrition therapy approaches to create an awareness of coordinated therapies. Diets approved by the organization’s medical staff are included in Section I. Condition-specific protocols, if developed by the organization from the following material, should be approved by the appropriate committee and placed in the organization’s practice guidelines manual.

Additional information can be obtained at www.adadevidencelibrary.com
The material in this section is intended:

To provide the dietitian with relevant information that may be considered in the development of the nutrition care plan.
To form the basis for the development of disease- or condition-specific protocols and nutrition prescriptions as required by the organization.

For many of the diseases and conditions, information is included that would not necessarily be mentioned in the nutrition assessment care plan (eg, diagnostic laboratory indexes). This information is included to provide a more complete picture of the multidisciplinary management in order to strengthen the dietitian’s role as a participating member of the health care team. In developing the individual patient care plan, the dietitian selectively discusses only those assessment parameters that are pertinent to the specific nutrition care approach.

The approaches mentioned for each condition are suggestions and are not to be interpreted as definitive nutrition therapy for the given condition. Medical approaches are listed with medical nutrition therapy approaches, so as to create an awareness of coordinated therapies. Diets approved for the organization’s implementation are included in Section I. Condition-specific protocols, if developed by the organization from the following material, should be approved by the appropriate committee and placed in the organization’s practice guidelines manual.