GRADE Recommendation Rating and Definitions

GRADE: Grading of Recommendations, Assessment, Devlopment, and Evaluation

The GRADE method was developed by an international group of research methodologists and guideline developers. The goal of the GRADE method is to develop a common, sensible and transparent approach to evaluate the quality of evidence (or certainty) and strength of recommendations. The GRADE method is used to evaluate and present evidence and to provide a systematic approach for developing clinical practice recommendations. More than 100 organizations worldwide officially endorse the GRADE method.

Quality of Evidence Grades

 High (A)  We are very confident that the true effect lies close to that of the estimate of the effect
 Moderate (B)  We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect but there is a possibility that it is substantially different.
 Low (C)  Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect.
 Very Low (D)  We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect.
Source: GRADE handbook

Implications of Strong and Weak Recommendatins for Different Users of Guidelines


Strong Recommendation
(Level 1 = We Recommend)

Weak Recommendation
(Level 2 = We Suggest)
  Patients  Most individuals in this situation would want the recommended course of action and only a small proportion would not.   The majority of individuals in this situation would want the suggested course of action, but many would not.
 Clinicians  Most individuals should receive the recommended course of action. Adherence to this recommendation according to the guideline could be used as a quality criterion or performance indicator. Formal decision aids are not likely to be needed to help individuals make decisions consistent with their values and preferences.  Recognize that the different choices will be appropriate for different patients, and that you must help each patient arrive at a management decision consistent with her/his values and preferences. Decision aids may well be useful helping individuals making decisions consistent with their values and preferences. Clinicians should expect to spend more time with patients when working towards a decision.
 Policy Makers  The recommendation can be adapted as policy in most situations including for the use as performance indicators.  Policy making will require substantial debates and involvement of many stakeholders. Policies are also more likely to vary between regions. Performance indicators would have to focus on the fact that adequate deliberation about the management options has taken place.
 Source: GRADE handbook


GRADE Translation to the Academy of Nutrition and Dietetics EAL Recommendations Rating

Systematic Review Rating
Quality of Evidence
Guideline Recommendation
Strength Rating
 GRADE Method  EAL Method  GRADE Method  EAL Method
 A  I (Good)  Level 1 (recommend)  Strong [1(A), 1(B)]
 B  II (Fair)  Level 1

 Strong [1(B)]; Fair [1(C)], 1(D)], Weak

 C  III (Limited)  Level 2 (suggest)  Fair [2(A), 2(B)], Weak [2(C), 2(D)]
 D  III (Limited)  Level 2  Fair, Weak
   IV (Expert Opinion)    Consensus
   V (Grade not assignable)    Consensus


Example Recommendation Translation

GRADE Recommendation Rating EAL Recommendation Rating
 1(A)  Strong
 1(B)  Strong
 1(C)  Fair
 1(D)  Fair
 2(A)  Fair
 2(B)  Fair
 2(C)  Weak
 2(D)  Weak



  • Andrews JC, Schunemann HJ, Oxman AD, Pottie K, Meerpohl JJ, Coello PA, Rind D, Montori VM, Brito JP, Norris S, Elbarbary M, Post P, Nasser M, Shukla V, Jaeschke R, Brozek J, Djulbegovic B, Guyatt G. GRADE guidelines: 15. Going from evidence to recommendation-determinants of a recommendation's direction and strength. J Clin Epidemiol. 66: 726-35, 2013. 
  • Andrews J, Guyatt G, Oxman AD, Alderson P, Dahm P, Falck-Ytter Y, Nasser M, Meerpohl J, Post PN, Kunz R, Brozek J, Vist G, Rind D, Akl EA, Schunemann HJ. GRADE guidelines: 14. Going from evidence to recommendations: the significance and presentation of recommendations. J Clin Epidemiol. 66: 719-25, 2013.
  • Academy Recommendations Rating. Accessed June 12, 2019