MiOA: Methods (2023)

MiOA: Methods (2023)

The National Academy of Science describes Clinical Practice Guidelines (CPGs) as “statements that include recommendations intended to optimize patient care that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options.”1 The development of CPGs is guided by systematic methodology in order to introduce as little bias as possible when interpreting evidence. However, recommendations must also consider client values as well as other crucial factors (such as financial cost, feasibility of implementation, or stakeholder buy-in) when recommending practice decisions. This section outlines and details the methodology used to develop the Malnutrition in Older Adults (2023) Evidence-Based Nutrition Practice Guideline (MiOA EBNPG).

The MiOA EBNPG was developed using Academy methods and the GRADE Evidence-to-Decision Framework (EtD). The methodologist drafted a sample action statement based on results from systematic reviews. Each expert panel member evaluated the draft action statement through completion of the EtD framework that guided consideration of the following factors: balance of benefits and harms, resources, equity, acceptability to stakeholders, and feasibility of implementation. After each expert panel member completed the EtD framework, the methodologist compiled the results. The expert panel reviewed the EtD results to draft recommendations and supporting information such as implementation considerations. Supporting information was based on MiOA panel member expertise and references from reputable sources.  

Overview of the Guideline Development Process

Evidence-based recommendations are the product of a rigorous and systematic, step-by-step process. These steps are listed and described in detail in the sections below. 

  1. Conduct a scoping review to determine literature availability;
  2. Recruit an expert panel;
  3. Determine priorities, gaps in research, and, consequently, Population-Intervention-Comparison-Outcome (PICO)-formatted systematic review research questions to support recommendations;
  4. Develop a priori eligibility criteria for the systematic review;
  5. Design a search plan and register on the PROSPERO database;
  6. Information Specialist conducts the search of databases;
  7. Titles and abstracts from database searches are screened and hand searched for relevant articles; review full-text articles for inclusion;
  8. Trained evidence analysts extract data using a standardized tool and assess quality (risk of bias) for each included article; 
  9. Study characteristics and results are summarized in tabular form and evidence for each outcome is synthesized qualitatively (evidence summary and conclusion statement), quantitatively (in meta-analyses when possible) and in tabular form (summary of findings table) for each outcome reported in the included studies. Conclusion statements are graded according to Academy and GRADE principles. 
  10. When evidence is available, expert panel members complete GRADE’s evidence-to-decision (EtD) framework to determine the best recommendations based on evidence, clinical expertise and client values.
  11. When no evidence is available from the systematic review, expert panel members used these same principles (supporting evidence outside of the systematic review, clinical expertise and patient values) to develop consensus recommendations; 
  12. Recommendations are rated according to Academy principles and voted on and approved by expert panel members;
  13. Evidence-based practice guideline is reviewed externally by thirteen individuals with content expertise using the AGREE II tool and key recommendations were posted for public comment;
  14. Authors responded to peer reviewer comments.


The GRADE-ADOLOPMENT process was used to adapt the Community Preventive Services Task Force (CPSTF) TFFRS – Nutrition: Home-delivered and Congregate Meal Services for Older Adults Recommendation. The CPSTF recommendation was identified by the MiOA expert panel. The MiOA Panel determined that the CPSTF recommendations were based on systematic reviews of the evidence which did not require updating, and the scope matched the MiOA EBNPG scope. CPSTF uses an EtD framework to create recommendations. However, the framework was not accessible. Therefore, MiOA expert panel members completed an EtD framework based on CPSTF systematic review results. The MiOA expert panel decided to adapt the CPSTF congregate and meal delivery recommendation based on EtD framework results and the scope of the MiOA EBNPG.

CPSTF Recommendation

The Community Preventive Services Task Force (CPSTF) recommends home-delivered and congregate meal services for older adults living independently (i.e., not residents of senior living or retirement community centers). Systematic review evidence shows reductions in malnutrition.

Adapted Academy Recommendation

Older adults living in the community, especially those considered malnourished or at risk for malnutrition, should be referred to home-delivered and congregate meal services to improve calorie and protein intake and to reduce the incidence and risk of malnutrition.

Stakeholder Involvement 

The MiOA systematic reviews were conducted and the MiOA EBNPG was developed by an expert panel of volunteer Academy of Nutrition and Dietetics (Academy) members that work in a variety of dietetic settings including academia, clinical, government, and the community. Two of the members also served as patient advocates to provide the perspective of caretakers of older adults. Recommendations were assessed for safety, social and financial concerns and to prevent any avoidable burdens on the recipients.

External Review

A peer review was conducted by twenty-two external reviewers that completed the AGREE II (Appraisal of Guidelines for Research Evaluation). The guideline was also reviewed by Academy staff to ensure the guideline is aligned with the Academy’s vision, mission, and principles. The MiOA expert panel revised the guideline based on reviewer feedback accordingly. The Academy’s Council on Research reviewed the feedback to ensure appropriate revisions were made, and approved the MiOA guideline for publication. Finally, a practitioner guide was developed and shared with practitioners who were encouraged to use the guide in practice and obtain input from patients, clients, and/or colleagues. Practitioners shared their feedback during a one-hour virtual focus group. Feedback was used to revise the practitioner guide.    

Guideline Update

Academy EBNPGs are considered for update every five years. At that point, a scoping review is conducted to determine whether substantial literature on the topic has been published since the past systematic review. The Academy’s Council on Research, informed by the research team, determines whether this EBNPG requires modification to all, some, or none of the recommendation statements.


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