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EAL Guideline Development Process

Evidence-Based Nutrition Practice Guidelines

Evidence-Based Nutrition Practice Guidelines are a series of guiding statements developed from a systematic review. They are designed to assist practitioner and patient decisions about appropriate nutrition care for specific disease states or conditions in typical settings. Key elements include scope, intent, major recommendations, methods, rating of the evidence and harms and potential benefits of implementing the guideline. 

Development of Evidence-Based Nutrition Practice Guidelines

The multidisciplinary expert workgroup, which includes practitioners and researchers with a depth of experience in the specific field of interest, develops the nutrition practice guideline. The guideline development involves the following steps.
 

1. Review the conclusion statements - The workgroup meets to review the materials resulting from the evidence analysis (sysematic review), which may include review of the conclusion statements, evidence summary narratives and tables, and evidence worksheets.
    
2. Formulate recommendations for the guideline integrating conclusions from evidence analysis - The workgroup uses an expert consensus method to formulate the guideline recommendations and complete the various sections on the recommendation page. These include:

• Recommendation(s): This is a course of action for the practitioner. The recommendation is written using two brief and separate statements. The first statement is "what" the dietitian should do or not do. The second statement describes the “why” of the recommendation. More than one recommendation may be formulated depending on a particular topic and the supporting conclusion statements.
  • Rating: The rating for the recommendation is based on the strength of the supporting evidence. The grade of the supporting conclusion statement(s) will be help determining this rating. Recommendation Rating Scale.
  • Label of Conditional or Imperative: Each recommendation will have a label of “conditional” or “imperative”. Conditional statements clearly define a specific situation, while imperative statements are broadly applicable to the target population without restraints on their pertinence.
  • Risks and Harms of Implementing the Recommendation: Includes any potential risks, anticipated harms or adverse consequences associated with applying the recommendation(s) to the target population.
  • Conditions of Application: Includes any organizational barriers or changes that would need to be made within an organization to apply the recommendation in daily practice. Also includes any conditions which may limit the application of the recommendation(s). For instance, application may be limited to only people in an inpatient setting, or not applicable for pregnant women. Facilitators for the application of the guideline may also be listed here. Conditional recommendations will always have conditions specified. Imperative recommendations may have some general conditions for application.
  • Potential Costs Associated with Application: Includes any costs that may be associated with the application of this recommendation such as specialized staff, new equipment or treatments.
  • Recommendation Narrative: Provides a brief description of the evidence that supports this recommendation.
  • Recommendation Strength Rationale: Provides a brief list of the evidence strength and methodological issues that determined the recommendation strength.
  • Minority Opinions: If the expert workgroup cannot reach consensus on the recommendation, the minority opinions may be listed here.
  • Supporting Evidence: Provides links to the conclusions statements, evidence summaries and worksheets related to the formulation of this recommendation(s).
     

3. References Not Graded in the Academy's Evidence Analysis Process -Recommendations will be based on the summarized evidence from the analysis. Sources that were not analyzed during the evidence analysis process may be used to support and formulate the recommendation or to support information under other categories on the recommendation page, if the workgroup deems necessary. References must be credible resources (e.g. consensus reports, other guidelines, position papers, standards of practice, articles from peer-reviewed journals, nationally recognized documents or websites). If recommendations are based solely on these types of references, they will be rated as “consensus”. These references will be listed on the recommendation page under "References Not Graded in the Academy's Evidence Analysis Process."
    
4. Nutrition Care Process - The workgroup assigns a category based on the Academy's Nutrition Care Process to display how each recommendation can be used within the treatment process and how they relate to Nutrition Assessment, Diagnosis, Intervention and Monitoring and Evaluation.
    
5. Complete the writing of the guideline  - Each disease-specific guideline has a similar format which incorporates the Introduction (includes: Scope of the Guideline, Statement of Intent, Guideline Methods, Implementation, Benefits and Risks/Harms of Implementation), Background Information and any necessary Appendices. The workgroup develops these features.
    
6. Criteria used in guideline development - The criteria used in determining the format and process for development of ADA's guidelines is based on the following tools and criteria for evidence-based guidelines:

• Guideline Elements Model (GEM) which has been Incorporated by the American Society for Testing and Materials (ASTM) as a Standard Specification for clinical practice guidelines.
• AGREE II (Appraisal for Guidelines Research and Evaluation) Instrument

7. Internal and External Review - Each guideline is reviewed internally and externally using the AGREE II (Appraisal of Guidelines for Research and Evaluation) Instrument as the evaluation tool. The external reviewers consists of a interdisciplinary group of individuals (may include dietitians, doctors, psychologists, nurses, etc.). The guideline is adjusted by consensus of the expert panel prior to publication on the EAL.
    
8. Revision - Academy guidelines are revisited every five years. A scoping review will be conducted to examine the need for new and revised recommenations based on the available science.  The process includes:   
   
   
   • Literature searches and evidence mapping to identify new research published since the previous searches were completed. Updated inclusion/exclusion criteria and search terms may be warranted.
   • Review to determine if the update will include modification to all, some or no recommendations compared to the earlier version(s) of the guideline, or development of new recommendations.
   • Creation of a table comparing the new guideline and the older version of the guideline. The document will indicate which recommendations remained unchanged; updated; new; or not reviewed.

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