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.
Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS) Screening and Referral for Medical Nutrition Therapy (MNT)
HIV/AIDS: Screening for People with HIV Infection
The registered dietitian (RD) should collaborate with other health care professionals, administrators and public policy decision-makers to ensure that all people with HIV infection are screened for nutrition-related problems, based on referral criteria regardless of setting, at every visit. People with HIV infection are at nutritional risk at any time-point during the course of their illness.
Consensus, Imperative
HIV/AIDS: Referral for MNT
The RD should collaborate with other health care professionals, administrators and public policy decision-makers to ensure that all people with HIV infection are referred for MNT based on nutritional risk. The timeline for referral of patients categorized by nutritional risk is as follows: High risk, to be seen by an RD within one week; moderate risk, to be seen by an RD within one month; low risk, to be seen by an RD at least annually.
Consensus, Conditional
Recommendation Strength Rationale
- The American Dietetic Association (ADA) HIV/AIDS Work Group concurs with the references cited.
HIV/AIDS Medical Nutrition Therapy (MNT)
HIV/AIDS: MNT
MNT provided by an RD is recommended for individuals with HIV infection. Four studies regarding MNT (with or without oral nutritional supplementation) report improved outcomes related to energy intake, symptoms and cardiovascular risk indices. Two studies regarding nutritional counseling (non-MNT) also report improved outcomes related to weight gain, CD4 count and quality of life.
Strong, Imperative
HIV/AIDS: Frequency of MNT
The RD should provide at least one to two MNT encounters per year for people with HIV infection (asymptomatic) and at least two to six (or more) MNT encounters per year for people with HIV infection (symptomatic but stable, acute or palliative), based on the following:
- Appropriate disease classifications
- Nutritional status
- Comorbidities
- Opportunistic infections
- Physical changes
- Weight or growth concerns
- Oral or gastrointestinal symptoms
- Metabolic complications
- Barriers to nutrition
- Living environment
- Functional status
- Behavioral concerns or unusual eating behaviors
Studies regarding MNT (with or without oral nutritional supplementation) report improved outcomes related to energy intake, symptoms, and cardiovascular risk indices, especially with increased frequency of visits.
Consensus, Imperative
Recommendation Strength Rationale
- Conclusion Statement was Grade I
HIV/AIDS Nutrition Assessment
HIV/AIDS: Nutrition Assessment
The RD should assess the following for people with HIV infection:
- Food/nutrition-related history, such as knowledge, beliefs and attitudes and factors affecting access to food and food/nutrition-related supplies (see also the Assess Food/Nutrition-Related History recommendation)
- Anthropometrics (see also the Anthropometric Assessment recommendation)
- Biochemical data, medical tests and procedures such as lipid profile, fasting blood glucose, electrolytes, complete blood count and bone density measurements
- Nutrition-focused physical findings
- Client history
- Patient, client and family medical/health history
- Social history
- Comparative standards
Assessment of nutritional and medical status is crucial to quality nutrition care for every person living with HIV infection.
Consensus, Imperative
Recommendation Strength Rationale
- The ADA HIV/AIDS Work Group concurs with the references cited.
HIV/AIDS Assess Food/Nutrition-Related History
HIV/AIDS: Assess Food/Nutrition-Related History
The RD should assess the food and nutrition-related history of people with HIV infection, including but not limited to:
- Food and nutrient intake, focusing on energy, protein, fat, fiber, sodium, calcium and vitamin D
- Medications, herbal supplements and their potential negative interactions
- Knowledge, beliefs and attitudes
- Behavior
- Factors affecting access to food and food and nutrition-related supplies
- Physical activity and function
- Nutrition-related patient and client-centered measures
Several studies report variations in energy and nutrient intake in people with HIV infection, some were under- and over-estimated requirements. A clear understanding of food and nutrient intake will form the basis for the nutrition diagnosis, prescription and intervention.
Strong, Imperative
Recommendation Strength Rationale
- Conclusion statement was Grade II
HIV/AIDS Anthropometric Assessment
HIV/AIDS: Anthropometric Assessment
The RD should include the following anthropometric measurements in the initial assessment: Weight, height and body mass index; for children, growth pattern indices. In addition, measurements of body compartment estimates should also be included, such as circumference measurements (mid-arm muscle, waist, hip and waist-to-hip ratio) or measurements of body cell mass and body fat (measured with dual energy x-ray absorptiometry [DXA], bioelectrical impedance analysis [BIA], bioimpedance spectroscopy or skinfold thickness measurements). Baseline anthropometric measurements provide information for the nutrition assessment and the majority of research in men, women, children and adolescents reports that fat-free mass and fat mass are altered in people with HIV infection.
Strong, Imperative
Recommendation Strength Rationale
- Conclusion statements were Grades I and II.
HIV/AIDS Energy Needs
HIV/AIDS: Determining Energy Needs
The RD should use clinical judgment and consider several factors when determining the energy needs of adults and children with HIV infection to maintain a healthy body weight. Factors related to energy needs in people with HIV infection include age, gender, stage of disease, nutritional status, opportunistic infections and comorbidities, inflammation and effects of medications. Although research reports increased resting energy expenditure (as much as 5% to 17%) in people with HIV infection, total energy expenditure may be similar to that of healthy control subjects.
Fair, Imperative
Recommendation Strength Rationale
- Conclusion statement was Grade II.
Refer to the original guideline document for information about resting metabolic rate and adult and pediatric weight management (PWM).
HIV/AIDS Macronutrient Composition
HIV/AIDS: Macronutrient Composition
- The RD should prescribe an individualized diet with a macronutrient composition based on the Dietary Reference Intakes (DRI) (20% to 35% of calories from fat, 45% to 65% of calories from carbohydrate, 14g fiber per 1,000 kcal and 10% to 35% of calories from protein)
- In people with HIV infection, protein needs are highly individualized. Low-fiber/high-fat diets are associated with fat deposition, insulin resistance and obesity. Studies indicate that diets low in saturated and total fat resulted in reduced triglyceride levels, increased HDL-cholesterol levels and a lower risk of lipohypertrophy.
Fair, Imperative
HIV/AIDS: Macronutrient Composition for Hyperlipidemia
- For people with HIV infection who have hyperlipidemia, the RD should encourage consumption of a cardioprotective dietary pattern tailored to the individual's needs to provide a fat intake of 25% to 35% of calories, less than 7% of calories from saturated fat, less than 1% of calories from trans-fatty acids and under 200 mg of cholesterol per day
- Research on several lifestyle modification interventions for the treatment of hyperlipidemia in people with HIV infection reports improvements in serum lipid profile. Studies indicate that diets low in saturated and total fat and including omega-3 fatty acids resulted in reduced triglyceride levels, increased HDL-cholesterol levels and a lower risk of lipohypertrophy.
Strong, Conditional
Recommendation Strength Rationale
- For the recommendation HIV/AIDS: Micronutrient Composition, conclusion statements were Grades II and III
- For the recommendation HIV/AIDS: Macronutrient Composition for Hyperlipidemia, conclusion statements were Grades I and II.
HIV/AIDS Vitamin and Mineral Supplementation
HIV/AIDS: Vitamin and Mineral Supplementation
If people with HIV infection cannot meet their Recommended Dietary Allowance (RDA) levels for micronutrients through diet, the RD should recommend vitamin and mineral supplements, especially for calcium and vitamin D. Micronutrient deficiencies are common in HIV-infected individuals and studies report increased morbidity and mortality in those not taking vitamin supplementation.
Strong, Conditional
HIV/AIDS Treatment of Diarrhea/Malabsorption
HIV/AIDS: Treatment of Diarrhea/Malabsorption
For people with HIV infection who have diarrhea/malabsorption, the RD should encourage the consumption of soluble fiber, electrolyte-repleting beverages and medium-chain triglycerides (MCT) and decrease the consumption of foods that may exacerbate diarrhea. Studies of fat malabsorption reported that consumption of MCT resulted in fewer stools, decreased stool fat and weight and increased fat absorption.
Fair, Conditional
Recommendation Strength Rationale
- Conclusion statement was Grade II.
HIV/AIDS Encourage Physical Activity
HIV/AIDS: Encourage Physical Activity
If not contraindicated, the RD should encourage physical activity for people with HIV infection. Studies report that performing constant or interval aerobic exercise, progressive resistance exercise or a combination of both, for at least 20 minutes per session at a frequency of three times per week is generally safe in adults with HIV infection and may lead to significant improvements in strength, endurance, cardiopulmonary fitness and reductions in depressive symptoms.
Strong, Conditional
Recommendation Strength Rationale
- Conclusion statement was Grade I.
HIV/AIDS Educate on Food and Water Safety
HIV/AIDS: Educate on Food and Water Safety
The RD should educate people with HIV infection, especially those who are severely immunocompromised (having CD4 levels less than 200 cells per mm3) and others involved in their care, about food and water safety. Studies report that people with HIV infection are more susceptible to foodborne illness and also lack knowledge regarding food safety.
Strong, Imperative
Recommendation Strength Rationale
- Conclusion statement was Grade I.
HIV/AIDS Coordination of Care
HIV/AIDS: Coordination of Care
For people with HIV infection, the RD should implement MNT and coordinate care with an interdisciplinary team and community resources. The interdisciplinary team is composed of health professionals including, but not limited to: RDs, physicians, physician assistants, nurse practitioners, nurses, pharmacists, case managers, substance use disorders treatment providers, respiratory care practitioners, occupational therapists, physical therapists, speech therapists, exercise physiologists, dentists and mental health professionals. Community resources may include, but are not limited to, food assistance programs, support systems and recreational facilities. This approach is necessary to effectively integrate MNT into overall management for people with HIV infection.
Consensus, Imperative
Recommendation Strength Rationale
- The ADA HIV/AIDS Work Group concurs with the references cited.
HIV/AIDS Educate on Breastfeeding Avoidance
HIV/AIDS: Educate on Breastfeeding Avoidance
The RD should educate women with HIV infection who are pregnant or lactating about the presence of HIV in breast milk. To reduce perinatal HIV transmission, breastfeeding is NOT recommended for HIV-infected women where safe, affordable and feasible alternatives are available and culturally acceptable.
Consensus, Conditional
Recommendation Strength Rationale
- The ADA HIV/AIDS Work Group concurs with the references cited.
- Evidence in support of the recommendation was level "A-II evidence"; however, the evidence analysis was not reviewed by the ADA HIV/AIDS Work Group using the ADA evidence analysis methodology, resulting in a strength of Consensus.
HIV/AIDS Educate on Medications
HIV/AIDS: Educate on Medications
For people with HIV infection who are prescribed medications, the RD should provide education regarding food and drug interactions, nutrition-related adverse effects and risk of teratogenicity. Adverse effects of medications, including metabolic complications, gastrointestinal disturbances, and compromised nutrition intake, may lead to non-adherence and/or resistance to the prescribed medication regimen and poor nutrition status.
Consensus, Conditional
Recommendation Strength Rationale
- The ADA HIV/AIDS Work Group concurs with the references cited.
- Evidence in support of the recommendation was level A-I, A-II and A-III evidence.
HIV/AIDS Monitor and Evaluate Food- and Nutrition-Related History
HIV/AIDS: Monitor and Evaluate Food- and Nutrition-Related History
The RD should monitor and evaluate the food- and nutrition-related history of people with HIV infection, including but not limited to:
- Food and nutrient intake, focusing on energy, protein, fat, fiber, sodium, calcium and vitamin D
- Medications, herbal supplements and their potential negative interactions
- Knowledge, beliefs and attitudes
- Behavior
- Factors affecting access to food and food- and nutrition-related supplies
- Physical activity and function
- Nutrition-related patient and client-centered measures
Several studies report variations in energy and nutrient intake in people with HIV infection. Some were under- and over-estimated requirements. A clear understanding of food and nutrient intake will form the basis for the nutrition diagnosis, prescription and intervention.
Strong, Imperative
Recommendation Strength Rationale
- Conclusion statement was Grade II.
HIV/AIDS Monitor and Evaluate Anthropometric Measurements
HIV/AIDS: Monitor and Evaluate Anthropometric Measurements
Using the same methodology as in the assessment of anthropometric measurements, the RD should monitor and evaluate body weight and height, body mass index, body compartment estimates and for children, growth pattern indices. The majority of research in men, women, children and adolescents reports that fat-free mass and fat mass are altered in people with HIV infection.
Strong, Imperative
Recommendation Strength Rationale
- Conclusion statements were Grades I and 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 1g 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 studied
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.