Ratings for the strength of the recommendations (Strong, Fair, Weak, Consensus, Insufficient Evidence), conclusion grades (I-V), and statement labels (Conditional versus Imperative) are defined at the end of the "Major Recommendations" field.
Unintended Weight Loss (UWL) in Older Adults: Nutrition Screening
UWL: Nutrition Screening
The registered dietitian (RD) should collaborate with other health care professionals, administrators and public policy decision makers to ensure that all older adults are screened for unintended weight loss, regardless of setting. Weight change is included in virtually all validated and unvalidated instruments for nutrition risk screening in older adults. Studies support an association between unintended weight loss and increased morbidity and mortality.
Strong, Imperative
Recommendation Strength Rationale
Conclusion statements were Grades I and II.
UWL: Instruments for Nutrition Screening
The RD should collaborate with other health care team members and policy makers to ensure that nutrition screening tools have been validated in the older population. The Mini Nutritional Assessment Short Form and the Nutrition Screening Initiative DETERMINE Your Nutritional Health (DETERMINE) instruments are the most widely studied and validated in this population; several other nutrition screening instruments have been developed but not validated in older adults.
Strong, Imperative
Recommendation Strength Rationale
Conclusion statement was Grade I.
UWL in Older Adults: Medical Nutrition Therapy
UWL: Medical Nutrition Therapy
Medical nutrition therapy (MNT) is strongly recommended for older adults with unintended weight loss. Individualized nutrition care, directed by an RD, as part of the healthcare team, results in improved outcomes related to increased energy, protein and nutrient intakes, improved nutritional status, improved quality of life or weight gain.
Strong, Imperative
Recommendation Strength Rationale
Conclusion statement was Grade I.
UWL in Older Adults: Assessment of Nutritional Status
UWL: Assessment of Nutritional Status
The RD should ensure that the nutrition assessment of older adults with unintended weight loss includes (but is not limited to) the following:
- Anthropometric measurements (e.g., height, weight, weight change)
- Biochemical data, medical tests and procedures
- Client history (e.g., cognitive decline, depression, neurological disease, hydration status, presence of infection and pressure ulcers, recent hospitalization, admission to healthcare communities and female gender)
- Food/nutrition-related history (e.g., loss of appetite, swallowing problems, eating dependency, low physical activity level, decreased activities of daily living)
Assessment of the above factors is needed to effectively determine nutrition diagnoses and plan the nutrition interventions; all of these are associated with adverse health effects in older adults.
Strong, Imperative
Recommendation Strength Rationale
Conclusion statements were Grades I and II.
UWL: Instruments for Assessment of Nutritional Status
The RD should collaborate with other health care team members and policy makers to ensure that nutrition assessment tools have been validated in the older population. The Mini-Nutritional Assessment is the most widely studied and validated in this population; several other nutrition assessment instruments have also been developed but not validated.
Strong, Imperative
Recommendation Strength Rationale
Conclusion statement was Grade I.
UWL in Older Adults: Assessment of Food, Fluid and Nutrient Intake
UWL: Assessment of Food, Fluid and Nutrient Intake
The RD and/or Dietetic Technician Registered (DTR) should assess and evaluate food, fluid and nutrient intake in older adults with unintended weight loss. Research reports decreased intake of energy and nutrients in older adults who are acutely/chronically ill and/or underweight and those with cognitive impairment and dysphagia.
Strong, Imperative
Recommendation Strength Rationale
Conclusion statement was Grade I.
UWL: Methodologies for Assessment of Food, Fluid and Nutrient Intake
To assess food, fluid and nutrient intake in older adults with unintended weight loss, the RD and/or DTR should use quantitative methods (such as calorie counts, percentage of food eaten, individual plate waste studies, etc.) rather than qualitative methods (such as interviews) over a period of several days. Research supports multiple days of assessment of food and nutrient intake, and studies report that quantitative methods are necessary to provide estimations of energy intake.
Fair, Imperative
Recommendation Strength Rationale
Conclusion statement was Grade II.
UWL in Older Adults: Assess Anthropometric Measurements
UWL: Assess Anthropometric Measurements
The RD should ensure that older adults are weighed upon initial visit, admission or readmission to obtain a baseline weight, and then weekly thereafter, using standard procedures. Studies support an association between unintended weight loss and increased mortality.
Strong, Imperative
Recommendation Strength Rationale
Conclusion statement was Grade II.
UWL in Older Adults: Nutrition Diagnosis of Involuntary Weight Loss
UWL: Nutrition Diagnosis of Involuntary Weight Loss
The RD will use clinical judgment in interpreting nutrition assessment data to diagnose unintended weight loss and/or underweight in the older adult. Studies support an association between increased mortality and underweight (body mass index [BMI] < 20 kg/m2 or current weight compared with usual or desired body weight) and/or unintended weight loss (5% in 30 days, or any further weight loss after meeting these criteria).
Strong, Imperative
Recommendation Strength Rationale
Conclusion statement was Grade II.
UWL in Older Adults: Resident Involvement in Meal Planning
UWL: Resident Involvement in Meal Planning
The RD should collaborate with other health care professionals and administrators to encourage older adults' involvement in planning menus and meal patterns, since studies show that this may result in improved food and fluid intake.
Strong, Imperative
Recommendation Strength Rationale
Conclusion statement was Grade I.
UWL in Older Adults: Diet Liberalization
UWL: Diet Liberalization
For older adults the RD should recommend liberalization of diets with the exception of texture modification. Increased food and beverage intake is associated with liberalized diets. Research has not demonstrated benefits of restricting sodium, cholesterol, fat and carbohydrate in older adults.
Strong, Imperative
Recommendation Strength Rationale
Conclusion statement was Grade I.
UWL in Older Adults: Medical Food Supplements
UWL: Indications for Medical Food Supplements
The RD should recommend medical food supplements for older adults who are undernourished or at risk of undernutrition (i.e., those who are frail, those who have infection, impaired wound healing, pressure ulcers, depression, early to moderate dementia and/or after hip fracture and orthopedic surgery). Studies support medical food supplementation as a method to provide energy and nutrient intake, promote weight gain and maintain or improve nutritional status or prevent undernutrition.
Strong, Imperative
Recommendation Strength Rationale
Conclusion statement was Grade I.
UWL in Older Adults: Enteral Nutrition
UWL: Indications for Enteral Nutrition
The RD should recommend consideration of enteral nutrition for older adults who are undernourished or at risk of undernutrition; it is clearly indicated in patients with severe dysphagia. Studies support enteral nutrition as a method to provide energy and nutrient intake, promote weight gain and maintain or improve nutritional status or prevent undernutrition.
Strong, Imperative
UWL: Contraindications for Enteral Nutrition
Enteral nutrition may not be appropriate for terminally ill older adults with advanced disease states, such as terminal dementia, and should be in accordance with advance directives. The development of clinical and ethical criteria for the nutrition and hydration of persons through the life span should be established by members of the health care team, including the RD.
Consensus, Conditional
UWL: Initiation of Enteral Nutrition
To improve energy and nutrient intake in older adults at nutritional risk, enteral nutrition should be initiated as early as possible after confirming tube placement. Studies support that enteral nutrition can be initiated 3 hours after a percutaneous endoscopic gastrostomy (PEG) tube is placed, and placement is confirmed.
Strong, Imperative
UWL: Route of Enteral Nutrition
For older adults with neurological dysphagia and/or if enteral nutrition is anticipated for longer than 4 weeks, the use of a PEG tube is preferable to nasogastric tubes. Studies report that PEG tube use is associated with fewer treatment failures and improved nutritional status.
Strong, Conditional
UWL in Older Adults: Energy Needs
UWL: Estimating Energy Needs of Healthy Older Adults
When estimating energy needs for weight maintenance of healthy older adults, the RD should prescribe an energy intake of 25 to 35 kcal/kg/day in females and 30 to 40 kcal/kg/day in males. Research reports that applying physical activity levels ranging from 1.25 to 1.75 with measured resting metabolic rate (RMR) (via indirect calorimetry) in healthy older adults results in these mean total daily energy estimates.
Fair, Conditional
Recommendation Strength Rationale
Conclusion statement was Grade II.
UWL: Estimating Energy Needs of Underweight Older Adults
When estimating energy needs for weight maintenance of underweight older adults, the RD should prescribe an energy intake of 25 to 30 kcal/kg/day, or higher energy levels for weight gain. Research reports that applying physical activity levels ranging from 1.25 to 1.5 with measured RMR (via indirect calorimetry) in older adults who are chronically or acutely ill and/or underweight results in these mean total daily energy estimates.
Weak, Conditional
Recommendation Strength Rationale
Conclusion statements were Grades II and III.
UWL in Older Adults: Eating Assistance
UWL: Eating Assistance
The RD should collaborate with other health care professionals and administrators to ensure that all older adults who need assistance to eat receive it. Research indicates a positive association between eating dependency and poor nutritional status, especially in older adults with dysphagia who receive modified texture diets. In addition, research reports an association between poor nutritional status, frailty, underweight and/or weight loss with cognitive impairment and a decrease in the activities of daily living, including decreased ability to eat independently.
Strong, Conditional
Recommendation Strength Rationale
Conclusion statements were Grades I and II.
UWL in Older Adults: Dining Environment
UWL: Dining with Others
The RD should collaborate with other health care professionals and administrators to encourage all older adults to dine with others rather than dining alone. Research reports improved food intake and nutritional status in older adults eating in a socially stimulating common dining area.
Strong, Imperative
UWL: Improvement of Dining Ambience
The RD should collaborate with other health care professionals and administrators to promote improvement of dining ambience. Research indicates that improvements in physical environment and atmosphere of the dining room, food service and meals, and organization of the nursing staff assistance may result in weight gain in older adults.
Strong, Imperative
UWL: Creative Dining Programs
The RD should encourage creative dining programs for older adults. Research indicates that dining programs, such as buffet-style dining and decentralization of food service, demonstrate improvements in food intake and/or quality of life.
Strong, Imperative
Recommendation Strength Rationale
Conclusion statement for the three Dining Environment recommendations was Grade II.
UWL in Older Adults: Collaboration for Modified Texture Diets
UWL: Collaboration for Modified Texture Diets
The RD should collaborate with the speech-language pathologist and other healthcare professionals to ensure that older adults with dysphagia receive appropriate and individualized modified texture diets. Older adults consuming modified texture diets report an increased need for assistance with eating, dissatisfaction with foods, and decreased enjoyment of eating, resulting in reduced food intake and weight loss.
Strong, Conditional
Recommendation Strength Rationale
Conclusion statement was Grade I.
UWL in Older Adults: Evaluation and Treatment of Depression
UWL: Evaluation and Treatment of Depression
The RD should collaborate with other healthcare professionals to consider evaluation and treatment of depression for patients who are undernourished or at risk of undernutrition when medical nutrition therapy (MNT) interventions have not resulted in improved nutrient intake or stabilization of weight. Research reports an association between depression and weight loss or poor nutritional status.
Strong, Conditional
Recommendation Strength Rationale
Conclusion statement was Grade II.
UWL in Older Adults: Appetite Stimulants
UWL: Appetite Stimulants
When MNT interventions for older adults have not resulted in improved nutrient intake and/or stabilization of weight, the RD should collaborate with other healthcare professionals to consider appetite stimulants. There is no research on the effectiveness of appetite stimulants for older adults that meets the American Dietetic Association criteria for evidence analysis.
Consensus, Conditional
Recommendation Strength Rationale
Conclusion statement was Grade V.
UWL in Older Adults: Monitor and Evaluate Nutritional Status
UWL: Monitor and Evaluate Nutritional Status
The RD should monitor and evaluate the nutritional status of older adults with unintended weight loss, based on the methodology initially used during assessment, including (but not limited to) the following:
- Anthropometric measurements (e.g., weight, weight change)
- Biochemical data, medical tests and procedures
- Client history (e.g., cognitive decline, depression, neurological disease, hydration status, presence of infection and pressure ulcers, recent hospitalization)
- Food/nutrition-related history (e.g., loss of appetite, swallowing problems, eating dependency, low physical activity level, decreased activities of daily living)
Monitoring and evaluation of the above factors is needed to determine the effectiveness of medical nutrition therapy (MNT); all of these are associated with adverse health effects in older adults.
Strong, Imperative
Recommendation Strength Rationale
Conclusion statements were Grades I and II.
UWL in Older Adults: Monitor and Evaluate Food, Fluid and Nutrient Intake
UWL: Monitor and Evaluate Food, Fluid and Nutrient Intake
The RD and/or DTR should monitor and evaluate food, fluid and nutrient intake in older adults with unintended weight loss, based on the methodology initially used during assessment. Research reports decreased intake of energy and nutrients in older adults who are acutely/chronically ill and/or underweight and those with cognitive impairment and dysphagia. In addition, research supports multiple days of assessment of food and nutrient intake, and studies report that quantitative methods are necessary to provide estimations of energy intake.
Strong, Imperative
Recommendation Strength Rationale
Conclusion statements were Grades I and II.
UWL in Older Adults: Monitor and Evaluate Anthropometric Measurements
UWL: Monitor and Evaluate Anthropometric Measurements
The RD should monitor and evaluate weekly body weights of older adults with unintended weight loss, until body weight has stabilized, to determine effectiveness of medical nutrition therapy (MNT). Studies support an association between unintended weight loss and increased mortality.
Strong, Imperative
Recommendation Strength Rationale
Conclusion statement was Grade II.
Definitions:
Conditional versus Imperative Recommendations
Recommendations can be worded as conditional or imperative statements. Conditional statements clearly define a specific situation, while imperative statements are broadly applicable to the target population without restraints on their pertinence. More specifically, a conditional recommendation can be stated in if/then terminology (e.g., If an individual does not eat food sources of omega-3 fatty acids, then 1 g of EPA and DHA omega-3 fatty acid supplements may be recommended for secondary prevention).
In contrast, imperative recommendations "require," or "must," or "should achieve certain goals," but do not contain conditional text that would limit their applicability to specified circumstances (e.g., Portion control should be included as part of a comprehensive weight management program. Portion control at meals and snacks results in reduced energy intake and weight loss).
Conclusion Grading Table
Strength of Evidence Elements |
Grade I
Good/Strong |
Grade II
Fair |
Grade III
Limited/Weak |
Grade IV
Expert Opinion Only |
Grade V
Grade Not Assignable |
Quality
- Scientific rigor/validity
- Considers design and execution
|
Studies of strong design for question
Free from design flaws, bias and execution problems |
Studies of strong design for question with minor methodological concerns
OR
Only studies of weaker study design for question |
Studies of weak design for answering the question
OR
Inconclusive findings due to design flaws, bias or execution problems |
No studies available
Conclusion based on usual practice, expert consensus, clinical experience, opinion, or extrapolation from basic research |
No evidence that pertains to question being addressed |
Consistency
Of findings across studies |
Findings generally consistent in direction and size of effect or degree of association, and statistical significance with minor exceptions at most |
Inconsistency among results of studies with strong design
OR
Consistency with minor exceptions across studies of weaker designs |
Unexplained inconsistency among results from different studies
OR
Single study unconfirmed by other studies |
Conclusion supported solely by statements of informed nutrition or medical commentators |
NA |
Quantity
- Number of studies
- Number of subjects in studies
|
One to several good quality studies
Large number of subjects studies
Studies with negative results having sufficiently large sample size for adequate statistical power |
Several studies by independent investigators
Doubts about adequacy of sample size to avoid Type I and Type II error |
Limited number of studies
Low number of subjects studied and/or inadequate sample size within studies |
Unsubstantiated by published studies |
Relevant studies have not been done |
Clinical Impact
- Importance of studied outcomes
- Magnitude of effect
|
Studied outcome relates directly to the question
Size of effect is clinically meaningful
Significant (statistical) difference is large |
Some doubt about the statistical or clinical significance of effect |
Studied outcome is an intermediate outcome or surrogate for the true outcome of interest
OR
Size of effect is small or lacks statistical and/or clinical significance |
Objective data unavailable |
Indicates area for future research |
Generalizability
To population of interest |
Studied population, intervention and outcomes are free from serious doubts about generalizability |
Minor doubts about generalizability |
Serious doubts about generalizability due to narrow or different study population, intervention or outcomes studied |
Generalizability limited to scope of experience |
NA |
This grading system was based on the grading system from: Greer N, Mosser G, Logan G, Wagstrom Halaas G. A practical approach to evidence grading. Jt Comm. J Qual Improv. 2000; 26:700-712. In September 2004, The ADA Research Committee modified the grading system to this current version.
Criteria for Recommendation Rating
Statement Rating |
Definition |
Implication for Practice |
Strong |
A Strong recommendation means that the workgroup believes that the benefits of the recommended approach clearly exceed the harms (or that the harms clearly exceed the benefits in the case of a strong negative recommendation), and that the quality of the supporting evidence is excellent/good (grade I or II)*. In some clearly identified circumstances, strong recommendations may be made based on lesser evidence when high-quality evidence is impossible to obtain and the anticipated benefits strongly outweigh the harms. |
Practitioners should follow a Strong recommendation unless a clear and compelling rationale for an alternative approach is present. |
Fair |
A Fair recommendation means that the workgroup believes that the benefits exceed the harms (or that the harms clearly exceed the benefits in the case of a negative recommendation), but the quality of evidence is not as strong (grade II or III)*. In some clearly identified circumstances, recommendations may be made based on lesser evidence when high-quality evidence is impossible to obtain and the anticipated benefits outweigh the harms. |
Practitioners should generally follow a Fair recommendation but remain alert to new information and be sensitive to patient preferences. |
Weak |
A Weak recommendation means that the quality of evidence that exists is suspect or that well-done studies (grade I, II, or III)* show little clear advantage to one approach versus another. |
Practitioners should be cautious in deciding whether to follow a recommendation classified as Weak, and should exercise judgment and be alert to emerging publications that report evidence. Patient preference should have a substantial influencing role. |
Consensus |
A Consensus recommendation means that Expert opinion (grade IV)* supports the guideline recommendation even though the available scientific evidence did not present consistent results, or controlled trials were lacking. |
Practitioners should be flexible in deciding whether to follow a recommendation classified Consensus, although they may set boundaries on alternatives. Patient preference should have a substantial influencing role. |
Insufficient Evidence |
An Insufficient Evidence recommendation means that there is both a lack of pertinent evidence (grade V)* and/or an unclear balance between benefits and harms. |
Practitioners should feel little constraint in deciding whether to follow a recommendation labeled as Insufficient Evidence and should exercise judgment and be alert to emerging publications that report evidence that clarifies the balance of benefit versus harm. Patient preference should have a substantial influencing role. |
*Conclusion statements are assigned a grade based on the strength of the evidence. Grade I is good; grade II, fair; grade III, limited; grade IV signifies expert opinion only and grade V indicates that a grade is not assignable because there is no evidence to support or refute the conclusion. The evidence and these grades are considered when assigning a rating (Strong, Fair, Weak, Consensus, Insufficient Evidence - see chart above) to a recommendation.
Adapted by the American Dietetic Association from the American Academy of Pediatrics, Classifying Recommendations for Clinical Practice Guideline, Pediatrics. 2004;114;874-877.