NPA-GP: Guideline Strenghts and Limitations
Strengths of this EBNPG include that it was based on a systematic review examining the efficacy of combined nutrition and physical activity interventions provided by qualified nutrition and/or exercise practitioners. This focus allowed for recommendations that provide specific means of effectively delivering lifestyle behavior interventions in real-world settings. The supporting systematic review was based on high-quality methods from the Academy and the Cochrane Collaboration and adhered to PRISMA guidelines. A multi-disciplinary team of nutrition and exercise practitioners and researchers conducted the systematic review and translated the evidence for application to practice. The EBNPG was developed based on best available evidence and content expertise and consideration for client values, elucidated using an evidence-to-decision framework. This guideline provides information about components of successful lifestyle behavior interventions and provides guidance on implementing interventions for adults who are healthy or have cardiometabolic disease (CMD) risk factors. Importantly, this guideline discusses when and how to provide guidance in a field other than one practitioner’s expertise (e.g., a dietitian discussing physical activity), and when someone should refer to an allied health practitioner with necessary specializations.
This EBNPG has some limitations. It provides nutrition and exercise practitioners working with adults who are healthy or have cardiometabolic risk factors with information to guide improvement of nutrition and physical activity behaviors and CMD risk reduction. However, nutrition and exercise practitioners require resources beyond this EBNPG to fully screen and assess clients and create specific, individualized care plans.
The systematic review supporting this guideline included 31 contemporary RCTs examining lifestyle behavioral interventions provided by qualified nutrition and exercise practitioners for the target population. However, insufficient interventions focused on adults with increased risk of CMDs according to social determinants of health (SDoH), such as members of racial, ethnic or gender minority groups. Also, relatively few studies reported important outcomes of interest, such as quality of life, mental health outcomes, and adverse events. The recommendations and supporting information in this guideline are applicable for adults who are healthy (no diagnosed disease or disease risk factors) or who have CMD risk factors such as overweight/obesity or diabetes risk. However, this guideline is not meant to be an exclusive course of treatment for individuals with CMD risk factors, and nutrition and exercise practitioners may need to consult complementary evidence-based practice guidelines for more information on individualizing interventions for adults with these risk factors/conditions.
Though the guideline panel consisted of interdisciplinary practitioners, the development team was not able to secure a consumer advocate to participate in the guideline development process. However, the consumer perspective will be sought and incorporated during the stakeholder review period.
Future Research
This EBNPG provides a framework to deliver effective nutrition and physical activity interventions to adults who are healthy or have risk factors for CMD. However, additional research is warranted to establish guidelines for providing effective and individualized care for under-resourced populations such as those with low socioeconomic status or those from under-represented racial, ethnic or gender groups. A major barrier to care for adults without a diagnosed disease includes overall cost, as well as the “cost” of not improving health behaviors. Future research determining which policies and what level of support is needed could facilitate behavior change among clients who lack the means or desire to pay out-of-pocket for services would benefit nutrition and exercise practitioners. Future research should also examine how intervention duration, frequency, intensity, and methodology, particularly delivering education alone versus counseling/coaching for behavior change, differentially affect outcomes. In future studies, investigators should embrace the precision medicine and precision performance concepts which analyze individual treatment responses rather than report mean responses, leading to distinct client care.
Conclusion
This EBNPG provides nutrition and exercise practitioners with best-available evidence, translated to guidance for delivering interventions within professional scopes of practice. Population-based nutrition and physical activity evidence-based guidelines serve as a standard from which practitioners can individualize care for a wide range of adults. This EBNPG provides a means for effective delivery of individualized nutrition and physical activity interventions to healthy clients and those with CMD risk factors, with the intent of preventing disease. Guidelines do not, however, function as strict directives and nutrition and exercise practitioners should always use critical thinking and clinical judgement and observe client values to determine if and how to implement a recommendation. Practitioners may increase their ability to tailor interventions through precision nutrition and precision performance, as applicable, which includes the use of resources, knowledge, and therapies to select specific and optimal interventions. Research often summarizes and reports an intervention’s mean, rather than individual responses; thus translating evidence to practice can be a complex process. Therefore, the authors encourage practitioners to view every client as a unique individual who likely diverges from means according to genetics, sex/gender, SDoH, lifestyle behaviors, activity demands and/or other factors. Nutrition and exercise practitioners can consistently provide individualized, practical, and evidence-based interventions by seeking to understand their clients’ needs, circumstances and values and co-creating interventions with the client and their allied health team. Individualized, collaborative care that respects IDEA provided within their scope of practice is a crucial component to preventing CMDs at a population level.
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