Nature of the evidence base and approaches to guide nutrition interventions for individuals: a position paper from the Academy of Nutrition Sciences.

This Position Paper from the Academy of Nutrition Sciences is the third in a series which describe the nature of the scientific evidence and frameworks that underpin nutrition recommendations for health. This paper focuses on evidence which guides the application of dietary recommendations for individuals. In some situations, modified nutrient intake becomes essential to prevent deficiency, optimise development and health, or manage symptoms and disease progression. Disease and its treatment can also affect taste, appetite and ability to access and prepare foods, with associated financial impacts. Therefore, the practice of nutrition and dietetics must integrate and apply the sciences of food, nutrition, biology, physiology, behaviour, management, communication and society to achieve and maintain human health. Thus, there is huge complexity in delivering evidence-based nutrition interventions to individuals. This paper examines available frameworks for appraising the quality and certainty of nutrition research evidence, the development nutrition practice guidelines to support evidence implementation in practice and the influence of other sources of nutrition information and misinformation. The paper also considers major challenges in applying research evidence to an individual and suggests consensus recommendations to begin to address these challenges in the future. Our recommendations target three groups; those who deliver nutrition interventions to individuals, those funding, commissioning or undertaking research aimed at delivering evidence-based nutrition practice, and those disseminating nutritional information to individuals.

Academy of Nutrition and Dietetics Commentary on the Phosphorus Recommendation in the KDOQI Clinical Practice Guidelines for Nutrition in CKD: 2020 Update.

The Kidney Disease Outcomes Quality Initiative Clinical Practice Guidelines for Nutrition in Chronic Kidney Disease: 2020 Update recommends adjusting dietary phosphorus to maintain a serum phosphate goal for hemodialysis patients in the normal range (0.81 to 1.45 mmol/L [2.5 to 4.5 mg/dL]). This is lower than the serum phosphate goal used by many dialysis centers (0.97 to 1.78 mmol/L [3.0 and 5.5 mg/dL]). Although context and clinical judgment must always be considered when providing individualized care to patients, a guideline implementation study conducted from December 2020 to December 2022 found that, based on their documentation, registered dietitian nutritionists from two national dialysis chains are almost universally using dialysis center goals instead of the lower phosphate goal recommended by the guideline. This commentary discusses the possible barriers to implementing the Kidney Disease Outcomes Quality Initiative 2020 nutrition guideline's phosphorus recommendation and proposes a systems level approach to promote and support adoption of the recommendation. Calls to action for potential changes in clinician practices, organizational/institutional culture, and government regulations are put forth.

Harnessing the Benefits of the Nutrition Care Process Quality Evaluation and Standardization Tool: A National Auditing Initiative to Improve Quality of Documentation.

The Nutrition Care Process Quality Standardization and Evaluation Tool (NCP QUEST) is a validated audit instrument assessing the quality of NCP documentation by registered dietitian nutritionists. The present quality improvement project describes change in documentation quality as measured by NCP QUEST and word count of notes after a monthly national digital training provided to Veterans Affairs registered dietitian nutritionists. The training and adoption of NCP QUEST was voluntary. Facilities were recruited among those that had participated during the design and validation study of NCP QUEST. The NCP QUEST score was calculated and the word count was determined for 52 documentation notes (28 from NCP QUEST nonuser facilities and 24 from NCP QUEST user facilities) before and after training. The mean pretraining NCP QUEST score for notes from NCP QUEST nonuser facilities was 13.71 and 13.88 for NCP QUEST user facilities. The mean posttraining total NCP QUEST score for nonuser facilities was 14.00 and 17.65 for user facilities, with no improvement for the nonuser facilities (P = 0.69). A significant improvement was identified for the NCP QUEST user facilities (P ≤ 0.001). All facilities experienced a significant reduction in the word count of assessment notes (P = 0.04). Use of the electronic NCP Terminology website increased 123-fold and was sustained after the training. NCP QUEST users reported that the audit tool is useful. The NCP QUEST should be at the center of registered dietitian nutritionists' training and more strategic effort is needed to engage practitioners in the optimal application of the NCP.

The "Breastmilk Ecology: Genesis of Infant Nutrition (BEGIN)" Project - executive summary.

The public health community has come to appreciate that a deeper understanding of the biology of human milk is essential to address ongoing and emerging questions about infant feeding practices. The critical pieces of that understanding are that 1) human milk is a complex biological system, a matrix of many interacting parts that is more than the sum of those parts, and 2) human milk production needs to be studied as an ecology that consists of inputs from the lactating parent, their breastfed baby, and their respective environments. The "Breastmilk Ecology: Genesis of Infant Nutrition (BEGIN)" Project was designed to examine this ecology as well as its functional implications for both the parent and infant and to explore ways in which this emerging knowledge can be expanded via a targeted research agenda and translated to support the community's efforts to ensure safe, efficacious, and context-specific infant feeding practices in the United States and globally. The five working groups of the BEGIN Project addressed the following themes: 1) parental inputs to human milk production and composition; 2) the components of human milk and the interactions of those components within this complex biological system; 3) infant inputs to the matrix, emphasizing the bidirectional relationships associated with the breastfeeding dyad; 4) the application of existing and new technologies and methodologies to study human milk as a complex biological system; and 5) approaches to translation and implementation of new knowledge to support safe and efficacious infant feeding practices.

Documentation of the evidence-diagnosis link predicts nutrition diagnosis resolution in the Academy of Nutrition and Dietetics' diabetes mellitus registry study: A secondary analysis of Nutrition Care Process outcomes.

Objectives: To describe nutrition care documentation patterns and investigate predictors of nutrition diagnosis resolution. Methods: This is a secondary data analysis of a 2-year pragmatic, quasi-experimental study conducted in outpatient clinics where nutrition care was provided to adults with diabetes Type 1 or 2 from May 2017 to June 2019 (n = 564 patients). The main outcome measures were frequency of standardized Nutrition Care Process (NCP) terms, NCP links, nutrition diagnosis resolution and predictors of nutrition diagnosis resolution. Predictors of diagnosis resolution were identified using a multivariable logistic regression model. Results: The most prevalent resolved diagnoses were excessive carbohydrate intake (32%), undesirable food choices (21%) and excessive energy intake (13%). The top etiology was food and nutrition related knowledge deficit (57%) and interventions were drawn mainly from the Nutrition Education domain (64%). One hundred forty-six patient cases (26%) had at least one follow-up visit and 26% of those with a follow-up (n = 38) had a resolved diagnosis. The presence of the evidence-diagnosis NCP link in documentation predicted diagnosis resolution (OR = 2.80, 95% CI 1.30-6.02; p = 0.008). Conclusion: Most diagnoses were caused by patients' lack of knowledge and respective interventions focused on nutrition education. Odds of diagnosis resolution improved when the signs and symptoms of the diagnosis were documented during assessment (evidence-diagnosis NCP link). Training dietitians on NCP links may be important to resolve nutrition diagnoses. Presented findings are hypothesis generating.

A quasi-experimental study provides evidence that registered dietitian nutritionist care is aligned with the Academy of Nutrition and Dietetics evidence-based nutrition practice guidelines for type 1 and 2 diabetes.

Background: One previous study examined implementation of evidence-based nutrition practice guidelines (EBNPG). Objectives: To describe alignment of registered dietitian nutritionists' (RDNs) documented nutrition care with the Academy of Nutrition and Dietetics' EBNPG for Type 1 and Type 2 diabetes and examine impact of a midpoint training on care alignment with the guideline. Methods: In this 2-year, quasi-experimental study, 19 RDNs providing outpatient medical nutrition therapy to adults with diabetes (n = 562) documented 787 initial and follow-up encounters. At study midpoint, RDNs received a guideline content training. A validated, automated tool was used to match standardized nutrition care process terminology (NCPT) in the documentation to NCPT expected to represent guideline implementation. A congruence score ranging from 0 (recommendation not identified) to 4 (recommendation fully implemented) was generated based on matching. Multilevel linear regression was used to examine pre-to-post training changes in congruence scores. Results: Most patients (~75%) had only one documented RDN encounter. At least one guideline recommendation was fully implemented in 67% of encounters. The recommendations "individualize macronutrient composition" and "education on glucose monitoring" (partially or fully implemented in 85 and 79% of encounters, respectively) were most frequently implemented. The mean encounter congruence scores were not different from pre-to-post guideline training (n = 19 RDNs, 519 encounters pre-training; n = 14 RDNs, 204 encounters post-training; ß = -0.06, SE = 0.04; 95% CI: -0.14, 0.03). Conclusions: Most RDN encounters had documented evidence that at least one recommendation from the EBNPG was implemented. The most frequently implemented recommendations were related to improving glycemic control. A midpoint guideline training had no impact on alignment of care with the guideline.

Research at the Academy of Nutrition and Dietetics: What, How, and Why?

Research is essential to further advance our understanding of the role of nutrition and dietetics in maintenance and improvement of health. Research is also essential for nutrition and dietetics practitioners to create and provide evidence-based interventions, including medical nutrition therapy provided by registered dietitian nutritionists. Given this critical role of research, the Academy of Nutrition and Dietetics (Academy) has a variety of resources to assist its members in accessing, understanding, participating in, conducting, and disseminating nutrition research. These resources are comprehensive and include opportunities to participate in research (eg, Nutrition Research Network and Data Science Center), tools to aggregate practice data (Nutrition Care Process and Terminology and the Academy of Nutrition and Dietetics Informatics Infrastructure), funding opportunities to support primary research (eg, Academy Foundation), resources to understand the latest research informing evidence-based practice (eg, Evidence Analysis Center), and avenues for sharing research findings (eg, Food & Nutrition Conference & Expo™). The aim of this article is to encourage Academy members to get involved in research by describing Academy-based research resources and opportunities to contribute to nutrition and dietetics research, as well as describe specific examples of research conducted at the Academy. The information presented can serve as a framework to guide members in engaging in research through the Academy.

Academy of Nutrition and Dietetics Nutrition Research Network: Validation of a Novel Nutrition Informatics Tool to Assess Agreement Between Documented Nutrition Care and Evidence-Based Recommendations.

More evidence regarding registered dietitian nutritionist implementation of evidence-based nutrition practice guidelines (EBNPGs) is needed. We assessed the utility of an automated informatics tool to evaluate congruence of documented nutrition care with 13 individual recommendations in the diabetes mellitus (DM) EBNPG and with the guideline overall. A concurrent validation study was conducted using Nutrition Care Process Terminology documentation entered in the Academy of Nutrition and Dietetics Health Informatics Infrastructure by registered dietitian nutritionists caring for patients with DM. A 15% subset (n = 115) of the 790 patient encounters recorded were selected randomly, and the documented care was evaluated using the automated DM Expected Care Plan (ECP) Analyzer and expert audit. Recommendation-level congruence, as determined by each method, was compared using Cohen's κ analysis, and the accuracy, sensitivity, and specificity of the DM ECP Analyzer for assessing overall guideline-level congruence was calculated with expert audits as the "gold standard." For recommendation-level congruence, the DM ECP Analyzer identified more instances of recommendation implementation in the patient encounters, and classified more encounters as including partial or full recommendation implementation for 10 of the 13 recommendations, compared with the expert audit. There was slight to fair agreement between the DM ECP and the expert audit for most individual recommendations, with a mean ± standard deviation level of agreement of κ = .17 ± .19 across all eligible recommendations. At the guideline level, the DM Analyzer had high accuracy (98.3%) and sensitivity (99.1%) and low specificity (0%; no true negatives detected). The DM ECP Analyzer is acceptable for conducting automated audits of nutrition documentation to assess congruence of documented care with recommendations for evidence-based care. Future changes to the EBNPG, Nutrition Care Process Terminology, Academy of Nutrition and Dietetics Health Informatics Infrastructure, and the DM ECP Analyzer could potentially improve recommendation-level performance. The DM ECP Analyzer can be modified for other EBNPGs to facilitate automated assessment of guideline implementation.

Evaluating the Implementation of Evidence-based Kidney Nutrition Practice Guidelines: The AUGmeNt Study Protocol.

Evidence-based nutrition practice guidelines (EBNPGs) inform registered dietitian nutritionist (RDN) care for patients with chronic kidney disease grade 5 treated by dialysis; however, there has been little evaluation of best practices for implementing EBNPGs. In this effectiveness-implementation hybrid study with a quasi-experimental design, United States RDNs in hemodialysis clinics will document initial and follow-up nutrition care for patients with chronic kidney disease grade 5 treated by dialysis using the Academy of Nutrition and Dietetics Health Informatics Infrastructure before and after being randomly assigned to a training model: (1) EBNPG knowledge training or (2) EBNPG knowledge training plus an implementation toolkit. The aims of the study include examining congruence of RDN documentation of nutrition care with the EBNPG; describing common RDN-reported EBNPG acceptability, adoption, and adaptation issues; and determining the feasibility of estimating the impact of RDN care on nutrition-related patient outcomes. The AUGmeNt study can inform effective development and implementation of future EBNPGs. Keywords: Chronic kidney diseases; medical nutrition therapy; implementation science; clinical practice guideline; nutrition care process terminology; dietitian.

Nutrition Care Process Quality Evaluation and Standardization Tool: The Next Frontier in Quality Evaluation of Documentation.

Documentation is essential for communicating care between credentialed nutrition and dietetics practitioners and other health care providers. A validated tool that can evaluate quality documentation of the Nutrition Care Process (NCP) encounter, including progress on outcomes is lacking. The aim of the NCP Quality Evaluation and Standardization Tool (QUEST) validation study is to revise an existing NCP audit tool and evaluate it when used within US Veterans Affairs in all clinical care settings. Six registered dietitian nutritionists revised an existing NCP audit tool. The revised tool (NCP-QUEST) was analyzed for clarity, relevance, and reliability. Eighty-five documentation notes (44 initial, 41 reassessment) were received from eight volunteer Veterans Affairs sites. Five of six registered dietitian nutritionists participated in the interrater reliability testing blinded to each other's ratings; and two registered dietitian nutritionists participated in intrarater reliability reviewing the same notes 6 weeks later blinded to the original ratings. Results showed moderate levels of agreement in interrater reliability (Krippendorff's α = .62 for all items, .66 for total score, and .52 for quality category rating). Intrarater reliability was excellent for all items (α = .86 to .87 for all items; .91 to .94 for total score and.74 to .89 for quality category rating). The NCP-QUEST has high content validity (Content Validity Index = 0.78 for item level, and 0.9 for scale level) after two cycles of content validity review. The tool can facilitate critical thinking, improved linking of NCP chains, and is a necessary foundation for quality data collection and outcomes management. The NCP-QUEST tool can improve accuracy and confidence in charting.

Predictors of nutrition care process knowledge and use among dietitians internationally.

BACKGROUND: The nutrition care process (NCP) and its associated standardised terminology (NCPT, referred to collectively as NCP/T) forms a problem-solving framework fundamental to dietetic practice. Global implementation would assist in confirming outcomes from dietetic care, but implementation rates have varied between countries. We investigated which factors predict NCP/T knowledge and use among dietetic professionals in an international cohort, aiming to understand how implementation can be strengthened. METHODS: The validated International NCP Implementation Survey was disseminated to dietitians in 10 countries via professional networks. Implementation, attitudes and knowledge of the NCP/T along with workplace and educational data were assessed. Independent predictive factors associated with higher NCP/T knowledge and use were identified using backward stepwise logistic regression. RESULTS: Data from 6149 respondents was used for this analysis. Enablers that were independent predictors of both high knowledge and frequent use of NCP/T were peer support, recommendation from national dietetic association and workplace requirements (all p < 0.001). Country of residence and working in clinical settings (p < 0.001) were demographic characteristics that were independent predictors of high knowledge and frequent use of NCP/T. A high knowledge score was an independent predictor of frequent NCP/T use (p = 0.002). CONCLUSIONS: Important modifiable enablers for NCP knowledge and use rely on organisational management. National dietetic organisations and key stakeholders such as employers are encouraged to integrate active NCP/T support in their leadership initiatives. This could take the form of policies, formalised and structured training strategies, and informatics initiatives for the integration in electronic health records.

Applying Contemporary Machine Learning Approaches to Nutrition Care Real-World Evidence: Findings From the National Quality Improvement Data Set.

Using real-world data from the Academy of Nutrition and Dietetics Health Informatics Infrastructure, we use state-of-the-art clustering techniques to identify 2 phenotypes characterizing the episodes of nutrition care observed in the National Quality Improvement (NQI) registry data set. The 2 phenotypes identified from recorded Nutrition Care Process data in the NQI exhibit a strong correspondence with the clinical expertise of registered dietitian nutritionists. For one of these phenotypes, it was possible to implement state-of-the-art classification techniques to predict the nutrition problem-resolution status of an episode of care. Prediction results show that the assessment of nutrition history, number of recorded visits in the episode, and use of nutrition counseling interventions were significantly and positively correlated with problem resolution. Meanwhile, evaluations of nutrition history that were not within the desired ranges were significantly and negatively correlated with problem resolution. Finally, we assess the usefulness of the current NQI data set and data model for supporting the application of contemporary machine learning methods to the data set. We also suggest ways of enhancing the NQI since registered dietitian nutritionists are encouraged to continue to contribute patient cases in this and other registry nutrition studies.

Nutrition care practice patterns for patients with COVID-19-A preliminary report.

BACKGROUND: Severe acute respiratory syndrome coronavirus 2 is a respiratory virus that poses risks to the nutrition status and survival of infected patients, yet there is paucity of data to inform evidence-based quality care. METHODS: We collected data on the nutrition care provided to patients with coronavirus disease 2019 (COVID-19) by registered dietitian nutritionists (RDNs). RESULTS: Hospitalized COVID-19 patients (N = 101) in this cohort were older adults and had elevated body mass index. The most frequent nutrition problems were inadequate oral intake (46.7%), inadequate energy intake (18.9%), and malnutrition (18.4%). These problems were managed predominantly with enteral nutrition, food supplements, and multivitamin-multimineral supplement therapy. Over 90% of documented problems required a follow-up. CONCLUSION: This data set is the first of its kind to report on the types of nutrition diagnoses and interventions for COVID-19 cases used by RDNs and highlights the need for increased and continued nutrition care.

Etiology Intervention Link Predicts Resolution of Nutrition Diagnosis: A Nutrition Care Process Outcomes Study from a Veterans' Health Care Facility.

In this article, we evaluate relationships between Nutrition Care Process (NCP) chain links and improvement or resolution of the nutrition diagnosis. We conducted a retrospective record review for 12 months in a single Veterans Health Administration health care system using the Veterans Health Administration-specific monitoring and evaluation terms, NCP terminology, and its etiology categories to evaluate outcomes. Logistic regression analysis revealed that the strongest predictor for diagnosis improvement was the etiology-intervention link. The odds of improving the nutrition diagnosis were 51.43 times higher when the etiology-intervention link was present. The odds of improving the nutrition diagnosis were 19.74 times higher when the evidence-diagnosis link was present and 9.46 times higher when the intervention-goal link was present. For every added nutrition visit by the registered dietitian nutritionist, the odds of improving the nutrition diagnosis increased by 32.5%. For every increased point on the NCP audit score, the odds of resolving or improving the nutrition diagnosis increased by 37.7%. When applying the NCP, the presence of the etiology-intervention link significantly improves the odds of resolving the nutrition diagnosis in a Veterans Health Administration population. For the first time, we show evidence that the NCP works as designed. Also, we demonstrate that the quality of NCP documentation impacts resolution of the diagnosis, and we describe the methodology for how to evaluate NCP outcomes. Registered dietitian nutritionists are encouraged to critically evaluate links of the NCP chain, assess NCP documentation for quality, and pursue follow-up visits to improve resolution of nutrition problems.

Impact of Diabetes Prevention Guideline Adoption on Health Outcomes: A Pragmatic Implementation Trial.

Limited research exists to evaluate nutrition guideline impact on clinical practice and patient health outcomes. In this study we investigate (1) the impact of guideline training on the implementation of the diabetes prevention Evidence-Based Nutrition Practice Guideline (EBNPG), and (2) the relationship between EBNPG congruence and resulting health outcomes in patients with prediabetes. We conducted an implementation study in which registered dietitian nutritionists (RDNs) provided nutrition care with 3-month follow-up to 102 pre-diabetes patients before and after a professional training on the implementation of the Diabetes Prevention EBNPG. Using the RDNs' Nutrition Care Process (NCP) documentation, we measured percent guideline congruence and health outcomes (body weight, waist circumference, fasting glucose, glycosylated hemoglobin), and modeled health outcomes. Guideline congruence improved after training by 4.3% (P < 0.05). However, no significant associations were observed between guideline training, or guideline congruence and health outcomes. Our model showed a reduction in waist circumference (2.1 ± 0.92 cm; P = 0.023), and body weight (-1.78 ± 0.55 kg; P = 0.001) throughout the course of the study. Training of nutrition professionals improved congruence to EBNPG for Diabetes Prevention. Nevertheless, improved guideline congruence did not impact related health outcomes. Standard care including nutrition intervention resulted in body weight and waist circumference reductions. Future research needs to further address the impact of evidence-based guidelines on outcomes in all areas of practice.

Consensus Recommendations for Optimizing Electronic Health Records for Nutrition Care.

Provision of nutrition care is vital to the health and well-being of any patient who enters the health care system, whether in the ambulatory, inpatient, or long-term care setting. Interdisciplinary professionals-nurses, physicians, advanced practice providers, pharmacists, and dietitians-identify and treat nutrition problems or clinical conditions in each of these health care settings. The documentation of nutrition care in a structured format from screening and assessment to discharge allows communication of the nutrition treatment plans. The goal of this document is to provide recommendations to clinicians for working with an organization's Information Systems department to create tools for documentation of nutrition care in the electronic health record. These recommendations can also serve as guidance for health care organizations choosing and implementing health care software.