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 panel, which includes practitioners and researchers with a depth of experience in the specific field of interest, develops the nutrition practice guidelines. The guideline development involves the following steps.
- Review the conclusion statements - The workgroup meets to review the materials resulting from the evidence analysis (systematic review), which may include review of the conclusion statements, evidence summary narratives and tables, and evidence worksheets.
- Develop recommendation statements - The expert panel uses GRADE’s Evidence to Decision (EtD) Framework to ensure that the expert panel considers important factors such as balance of benefit and harm, evidence certainty, acceptability, feasibility, resources required, cost-effectiveness, and equity, along with evidence to formulate guideline recommendations. Recommendation statements including supporting information:
- Recommendation(s) Statement: This is a course of action for the practitioner. More than one recommendation may be formulated depending on a particular topic and the supporting evidence.
- Rating: The recommendation statement is rated with a number (1 or 2) and a letter (A-D). The A-D letters indicate the strength of the evidence (table) and the number in the recommendation refers to the strength of the recommendation (table). GRADE rating table.
- 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. Recommendation rating table.
- Risks and Harms of Implementing the Recommendation: This 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, it 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 panel 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).
- 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."
- Nutrition Care Process - The expert panel 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 it relates to Nutrition Assessment, Diagnosis, Intervention and Monitoring and Evaluation.
- 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 consist of an interdisciplinary group of individuals (may include dietitians, physicians, psychologists, nurses, etc.). Comments from external reviewers are reviewed, discussed, and addressed as appropriate by consensus of the expert panel prior to the publication on the EAL.
- Revision - Academy guidelines are revisited every five years. A scoping review will be conducted to examine the need for new and revised recommendations 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 modifications 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 remain unchanged; updated; new; or not reviewed.
Using the Academy's EAL process, an unbiased and transparent systematic review will be completed and the updated guidelines published on the EAL.
To learn more about the Academy's guideline development process, download Academy of Nutrition and Dietetics Methodology for Developing Evidence-Based Nutrition Practice Guidelines JAND May 2017 117(5):794-804
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