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Guideline Summary
Guideline Title
Unintended weight loss in older adults (UWL) evidence-based nutrition practice guideline.
Bibliographic Source(s)
American Dietetic Association (ADA). Unintended weight loss (UWL) in older adults evidence-based nutrition practice guideline. Chicago (IL): American Dietetic Association (ADA); 2009 Oct. Various p. [177 references]
Guideline Status

This is the current release of the guideline.

Scope

Disease/Condition(s)

Unintended weight loss (UWL)

Guideline Category
Assessment of Therapeutic Effectiveness
Counseling
Evaluation
Management
Rehabilitation
Treatment
Clinical Specialty
Cardiology
Colon and Rectal Surgery
Critical Care
Endocrinology
Family Practice
Gastroenterology
Geriatrics
Hematology
Internal Medicine
Nephrology
Neurological Surgery
Neurology
Nursing
Nutrition
Oncology
Orthopedic Surgery
Pharmacology
Physical Medicine and Rehabilitation
Psychiatry
Psychology
Surgery
Thoracic Surgery
Urology
Intended Users
Advanced Practice Nurses
Dietitians
Health Care Providers
Nurses
Pharmacists
Physician Assistants
Physicians
Psychologists/Non-physician Behavioral Health Clinicians
Students
Guideline Objective(s)

Overall Objectives

  • To help dietetic practitioners, patients and consumers make shared decisions about health care choices in specific clinical circumstances
  • To provide medical nutrition therapy (MNT) guidelines for older adults with unintended weight loss (UWL) to increase energy, protein and nutrient intakes, improve nutritional status, and improve quality of life

Specific Objectives

  • To define evidence-based UWL nutrition recommendations for registered dietitians (RDs) that are carried out in collaboration with other healthcare providers
  • To guide practice decisions that integrate medical, nutritional, and behavioral strategies
  • To reduce variations in practice among RDs
  • To provide the RD with data to make recommendations to adjust MNT or recommend other therapies to achieve desired outcomes
  • To develop guidelines for interventions that have measurable clinical outcomes
  • To define the highest quality of care within cost constraints of the current healthcare environment
Target Population

Older adults (65 years and older) with unintended weight loss

Interventions and Practices Considered
  1. Referral to registered dietitian for medical nutrition therapy (MNT)
  2. Nutrition screening using the Mini-Nutritional Assessment Short Form and the Nutrition Screening Initiative DETERMINE Your Nutritional Health (DETERMINE) instrument
  3. Nutrition assessment
    • Assessment of food, fluid, and nutrient intake
    • Methodologies for assessment of intake
    • Assessment of nutritional status (anthropometric measurements, biochemical data, client history, food/nutrition-related history)
    • Use of the Mini-Nutritional Assessment
  4. Nutrition diagnosis of involuntary weight loss
  5. Nutrition intervention (planning and implementation based on individualized prescription for MNT)
    • Estimating energy needs of healthy older adults
    • Estimating energy needs of underweight older adults
    • Collaboration for modified texture diets
    • Eating assistance
    • Encouraging dining with others
    • Improvement of dining ambiance
    • Creative dining programs 
    • Enteral nutrition
    • Medical food supplementation
    • Diet liberalization
    • Resident involvement in meal planning
    • Evaluation and treatment of depression
    • Use of appetite stimulants
  6. Nutrition monitoring and evaluation
    • Nutritional status
    • Food, fluid, and nutrient intake
    • Anthropometric measurements
Major Outcomes Considered
  • Nutritional status
  • Weight gain/change
  • Weight maintenance
  • Activities of daily living
  • Quality of life
  • Depression
  • Morbidity
  • Mortality
  • Cost

Methodology

Methods Used to Collect/Select the Evidence
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

General Methods for Collecting/Selecting the Evidence

The following list provides an overview of the steps which the American Dietetic Association (ADA) evidence analysis team goes through to identify research through database searches.

  1. Plan the search strategy to identify the "current best evidence" relevant to the question. The plan for identification and inclusion of articles and reports should be systematic and reproducible, not haphazard. Write out the original search strategy and document adjustments to the strategy if they occur. Allow for several iterations of searches.
  2. List inclusion and exclusion criteria. The work group will define the inclusion and exclusion criteria. These criteria will be used in defining the search strategy and for filtering the identified research reports. ADA uses only peer-reviewed research; that is, articles accepted for evidence analysis must be peer-reviewed and published in a juried publication. Additionally, ADA only uses human subjects in its research and does not include animal studies in its evidence analysis.
  3. Identify search words. During the process of considering outcomes, interventions, nutrition diagnoses, and assessments, the work group may have identified a number of specific terms or factors that were important, but were not included in the actual question. These terms can be used as additional search terms to help identify relevant pieces of research. Both text word search and keyword search using Medical Subject Headings (MeSH) definitions may be used.
  4. Identify databases to search. PubMed, Medline, CINAHL, EMBASE, Cochrane, Agricola, DARE, TRIP, AHRQ and ERIC are some common databases for clinical nutritional research. Note that search terms can vary depending on the database.
  5. Conduct the search. Depending on the number and type of sources found in the initial search, adjustments might have to be made in the search strategy and to inclusion/exclusion criteria, and additional searches run. Changes to the search plan should be recorded for future reference. Document the number of sources identified in each search.
  6. Review titles and abstracts. At this point, a filtering procedure is used to determine whether a research article matches the inclusion criteria and is relevant to the work group's questions. Typically, the lead analyst, along with a member of the expert workgroup, first reviews the citations and abstracts to filter out reports that are not applicable to the question. If a determination cannot be made based on the citation and abstract, then the full text of the article is obtained for review.
  7. Gather all remaining articles and reports. Obtain paper or electronic copies of research articles that remain on the list following the citation and abstract review. If there are less than six citations, it could mean that the search was too specific to identify relevant research or that research has not been done on this topic. A broadened search should be tried. When there is a long list of citations, ascertain whether it includes articles that are tangential to the question or address the question in only a general way. In this case a more focused search strategy may be necessary.

Specific Methods for This Guideline

The recommendations in the guideline were based on a systematic review of the literature. Searches of PubMed and CENTRAL databases were performed on the following topics:

  • Medical nutrition therapy (MNT)
  • Caloric needs
  • Diet liberalization
  • Modified texture diets
  • Medical food supplements
  • Enteral nutrition
  • Dining environment
  • Eating assistance

Each evidence analysis topic has a link to supporting evidence in the original guideline, where the Search Plan and Results can be found. Here the reader can view when the search plan was performed, specific inclusion and exclusion criteria, search terms, data bases that were searched, and the excluded articles.

Number of Source Documents

2,251 articles were considered for this guideline.

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

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.

Methods Used to Analyze the Evidence
Systematic Review with Evidence Tables
Description of the Methods Used to Analyze the Evidence

Step 1: Formulate Evidence Analysis Question

Specify a question in a defined area of practice; or state a tentative conclusion or recommendation that is being considered. Include the patient type and special needs of the target population involved, the alternatives under consideration, and the outcomes of interest (PICO format).

Step 2: Gather and Classify Evidence

Conduct a systematic search of the literature to find evidence related to the question, gather studies and reports, and classify them by type of evidence. Classes differentiate primary reports of new data according to study design, and distinguish them from secondary reports that include systematic and/or narrative review.

Step 3: Critically Appraise Each Article

Review each article for relevance to the question and use the checklist of questions to evaluate the research design and implementation. Abstract key information from the report.

Step 4: Summarize Evidence

Synthesize the reports into an overview table and summarize the research relevant to the question.

Step 5: Write and Grade the Conclusion Statement

Develop a concise conclusion statement (the answer to the question). Assign a grade to indicate the overall strength or weakness of evidence informing the conclusion statement (see "Rating Scheme for the Strength of the Evidence").

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

Moving From Analysis to the Evidence-Based Nutrition Practice Guideline

The expert workgroup, which includes practitioners and researchers with a depth of experience in the specific field of interest, develops the disease-specific guideline. The guideline development involves the following steps.

Review the Conclusion Statements

The workgroup meets to review the materials resulting from the evidence analysis, which may include review of the conclusion statements, evidence summaries, and evidence worksheets.

Formulate Recommendations for the Guideline Integrating Conclusions from Evidence Analysis

The workgroup uses an expert consensus method to formulate the guideline recommendations and complete the various sections on the recommendation page. These include:

  • Recommendation(s): This is a course of action for the practitioner. The recommendation is written using two brief and separate statements. The first statement is "what" the dietitian should do or not do? The second statement describes the "why" of the recommendation. More than one recommendation may be formulated depending on a particular topic and the supporting conclusion statements.
  • Rating: The rating for the recommendation is based on the strength of the supporting evidence. The grade of the supporting conclusion statement(s) will be help determining this rating (see "Rating Scheme for the Strength of the Recommendation").
  • Label of Conditional or Imperative: Each recommendation will have a label of "conditional" or "imperative". Conditional statements clearly define a specific situation, while imperative statements are broadly applicable to the target population without restraints on their pertinence.
  • Risks and Harms of Implementing the Recommendation: Includes any potential risks, anticipated harms or adverse consequences associated with applying the recommendation(s) to the target population.
  • Conditions of Application: Includes any organizational barriers or changes that would need to be made within an organization to apply the recommendation in daily practice. Also includes any conditions which may limit the application of the recommendation(s). For instance, application may be limited to only people in an inpatient setting, or not applicable for pregnant women. Conditional recommendations will always have conditions specified. Imperative recommendations may have some general conditions for application.
  • Potential Costs Associated with Application: Includes any costs that may be associated with the application of this recommendation such as specialized staff, new equipment or treatments.
  • Recommendation Narrative: Provides a brief description of the evidence that supports this recommendation.
  • Recommendation Strength Rationale: Provides a brief list of the evidence strength and methodological issues that determined the recommendation strength.
  • Minority Opinions: If the expert workgroup cannot reach consensus on the recommendation, the minority opinions may be listed here.
  • Supporting Evidence: Provides links to the conclusions statements, evidence summaries and worksheets related to the formulation of this recommendation(s).
  • References Not Graded in the American Dietetic Association's (ADA) Evidence Analysis Process: Recommendations will be based on the summarized evidence from the analysis. Sources that were not analyzed during the evidence analysis process may be used to support and formulate the recommendation or to support information under other categories on the recommendation page, if the workgroup deems necessary. References must be credible resources (e.g., consensus reports, other guidelines, position papers, standards of practice, articles from peer-reviewed journals, nationally recognized documents or websites). If recommendations are based solely on these types of references, they will be rated as "consensus."

    Occasionally recommendations will include references that were not reviewed during the evidence analysis process but are relevant to the recommendation, risks and harms of implementing the recommendation, conditions of application, or potential costs associated with application. These references will be listed on the recommendation page under "References Not Graded in ADA's Evidence Analysis Process."

Develop a Clinical Algorithm for the Guideline

The workgroup develops a clinical algorithm based on ADA's Nutrition Care Process, to display how each recommendation can be used within the treatment process and how they relate to the Nutrition Assessment, Diagnosis, Intervention and Monitoring and Evaluation.

Complete the Writing of the Guideline

Each disease-specific guideline has a similar format which incorporates the Introduction (includes: Scope of the Guideline, Statement of Intent, Guideline Methods, Specific Methods, Implementation, Benefits and Risks/Harms of Implementation), Background Information, and any necessary Appendices. The workgroup develops these features.

Criteria Used in Guideline Development

The criteria used in determining the format and process for development of ADA's guidelines is based on the following tools and criteria for evidence-based guidelines:

  • Guideline Elements Model (GEM), which has been incorporated by the American Society for Testing and Materials (ASTM) as a Standard Specification for clinical practice guidelines.
  • AGREE (Appraisal for Guidelines Research and Evaluation) Instrument
  • National Guideline Clearinghouse (www.guideline.gov External Web Site Policy)
Rating Scheme for the Strength of the Recommendations

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.

Cost Analysis

Guideline developers reviewed published cost analyses.

Method of Guideline Validation
External Peer Review
Internal Peer Review
Description of Method of Guideline Validation

Each guideline is reviewed internally and externally using the AGREE (Appraisal of Guidelines for Research and Evaluation) instrument as the evaluation tool. The external reviewers consist of a multidisciplinary group of individuals (may include dietitians, doctors, psychologists, pharmacists, nurses, etc.). The review is done electronically. The guideline is adjusted by consensus of the expert panel and approved by American Dietetic Association's Evidence-Based Practice Committee prior to publication on the Evidence Analysis Library (EAL).

Recommendations

Major Recommendations

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.

Clinical Algorithm(s)

Algorithms are provided in the original guideline document for:

  • Unintended weight loss in older adults
  • Unintended weight loss in older adults nutrition assessment
  • Unintended weight loss in older adults nutrition diagnosis
  • Unintended weight loss in older adults nutrition intervention
  • Unintended weight loss in older adults nutrition monitoring and evaluation

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

The guideline contains conclusion statements that are supported by evidence summaries and evidence worksheets. These resources summarize the important studies (randomized controlled trials [RCTs], clinical trials, observational studies, cohort and case-control studies) pertaining to the conclusion statement and provide the study details.

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

A primary goal of implementing these recommendations is improving an older adult's ability to increase energy, protein, and nutrient intakes, improve nutritional status, and improve quality of life.

Following these guidelines will increase the likelihood of meeting regulatory requirements.

Potential Harms

Risks/Harms Considerations

  • To prevent potential adverse outcomes due to overconsumption of a particular nutrient, use clinical judgment.
  • Patient denial or misclassification of the necessary dysphagia diet may result in aspiration pneumonia due to poor swallowing function.
  • Use clinical judgment in applying the guidelines when evaluating older adults with unintended weight loss (UWL).
  • Failure to make a nutrition diagnosis of involuntary weight loss may lead to lack of treatment and increased risk of mortality.
  • Continued involuntary weight loss may lead to potential for litigation.
  • Standard weighing procedures must be followed or weights may be inaccurate.
  • In some individuals, resting metabolic rate (RMR) estimation may be inadequate or excessive and clinical judgment should be used.
  • Sufficient feeding assistance may not be available.
  • Appetite stimulants may result in side effects.
  • Inadvertent misplacement of the enteral feeding tube may occur. 
  • Overfeeding, underfeeding, and social isolation may contribute to greater risks of complications over time.

Contraindications

Contraindications
  • Clinical judgment is crucial in the application of these guidelines. Careful consideration should be given to the application of these guidelines for older adults with significant medical comorbidities.
  • 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.

Qualifying Statements

Qualifying Statements
  • This nutrition practice guideline is meant to serve as a general framework for handling clients with particular health problems. It may not always be appropriate to use these nutrition practice guidelines to manage clients because individual circumstances may vary. For example, different treatments may be appropriate for clients who are severely ill or who have co-morbid, socioeconomic, or other complicating conditions. The independent skill and judgment of the health care provider must always dictate treatment decisions. These nutrition practice guidelines are provided with the express understanding that they do not establish or specify particular standards of care, whether legal, medical, or other.
  • While the evidence-based nutrition practice guideline represents a statement of promising practice based on the latest available evidence at the time of publication, the guideline is not intended to overrule professional judgment. Rather, it may be viewed as a relative constraint on individual clinician discretion in a particular clinical circumstance.
  • This guideline recognizes the role of patient and family preferences for possible outcomes of care, when the appropriateness of a clinical intervention involves a substantial element of personal choice or values.

Implementation of the Guideline

Description of Implementation Strategy

The publication of this guideline is an integral part of the plans for getting the American Dietetic Association (ADA) Medical Nutrition Therapy (MNT) evidence-based recommendations on unintended weight loss to all dietetics practitioners engaged in, teaching about or researching the topic. National implementation workshops at various sites around the country and during the ADA Food Nutrition Conference Exposition (FNCE) are planned. Additionally, there are recommended dissemination and adoption strategies for local use of the ADA Unintended Weight Loss in Older Adults Evidence-Based Nutrition Practice Guideline.

The guideline development team recommended multi-faceted strategies to disseminate the guideline and encourage its implementation. Management support and learning through social influence are likely to be effective in implementing guidelines in dietetic practice. However, additional interventions may be needed to achieve real change in practice routines.

Implementation of the guideline will be achieved by announcement at professional events, presentations and training. Some strategies include:

  • National and local events: State dietetic association meetings and media coverage will help launch the guideline
  • Local feedback adaptation: Presentation by members of the work group at peer review meetings and opportunities for continuing professional education units (CPEUs) for courses completed
  • Education initiatives: The guideline and supplementary resources will be freely available for use in the education and training of dietetic interns and students in approved Commission on Accreditation of Dietetics Education (CADE) programs
  • Champions: Local champions will be identified and expert members of the guideline team will prepare articles for publications. Resources will be provided that include PowerPoint presentations, full guidelines and pre-prepared case studies
  • Practical tools: Some of the tools that will be developed to help implement the guideline include specially-designed resources such as clinical algorithms, slide presentations, training and toolkits.

Specific distribution strategies include:

Publication in full: The guideline is available electronically at the ADA Evidence Analysis Library Web site (www.adaevidencelibrary.com External Web Site Policy) and announced to all ADA Dietetic Practice Groups. The ADA Evidence Analysis Library will also provide downloadable supporting information and links to relevant position papers.

Implementation Tools
Clinical Algorithm
Quick Reference Guides/Physician Guides
Resources
Slide Presentation
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
End of Life Care
Getting Better
Living with Illness
Staying Healthy
IOM Domain
Effectiveness
Patient-centeredness
Safety

Identifying Information and Availability

Bibliographic Source(s)
American Dietetic Association (ADA). Unintended weight loss (UWL) in older adults evidence-based nutrition practice guideline. Chicago (IL): American Dietetic Association (ADA); 2009 Oct. Various p. [177 references]
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2009 Oct
Guideline Developer(s)
Academy of Nutrition and Dietetics - Professional Association
Source(s) of Funding

American Dietetic Association

Guideline Committee

American Dietetic Association (ADA) Unintended Weight Loss Expert Workgroup

Composition of Group That Authored the Guideline

Workgroup Members: Mary Ellen Posthauer, RD, CD, LD, Chair; Ronni Chernoff, PhD, RD; Krista Clark, RD, LD, CNSD; Becky Dorner, RD, LD; Charlette Gallagher-Allred, PhD, RD; Gretchen Robinson, MS, RD, LD, FADA

Financial Disclosures/Conflicts of Interest

In the interest of full disclosure, American Dietetic Association (ADA) has adopted the policy of revealing relationships workgroup members have with companies that sell products or services that are relevant to this topic. Workgroup members are required to disclose potential conflicts of interest by completing the ADA Conflict of Interest Form. It should not be assumed that these financial interests will have an adverse impact on the content, but they are noted here to fully inform readers. Users of the evidence analysis library may assume that only work group members listed below have potential conflicts of interest to disclose.

Charlette Gallagher-Allred: Employed by Ross Products, Division of Abbott laboratories, Inc., shareholder of Abbott Laboratories, Inc. stock

Becky Dorner: Employed by Becky Dorner & Associates, Inc. Company has received program sponsorship from Abbott Laboratories, Nestle/Novartis, and US Foods.

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available from the American Dietetic Association Web site External Web Site Policy.

Availability of Companion Documents

The following are available:

  • American Dietetic Association (ADA) unintended weight loss (UWL) in older adults evidence-based nutrition practice guideline. Executive summary of recommendations. Chicago (IL): American Dietetic Association. 2009. Electronic copies: Available from the ADA Web site External Web Site Policy.
  • ADA unintended weight loss (UWL) in older adults evidence-based nutrition practice guideline presentation. Slide set. Chicago (IL): American Dietetic Association. 56 p. Electronic copies: Available for purchase from the ADA Web site External Web Site Policy.
  • Guideline brief: ADA unintended weight loss (UWL) in older adults evidence-based nutrition practice guideline. Audio/video tutorial. Available for download from the ADA Web site External Web Site Policy.
Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on August 18, 2010. The information was verified by the guideline developer on September 22, 2010.

Copyright Statement

The American Dietetic Association encourages the free exchange of evidence in nutrition practice guidelines and promotes the adaptation of the guidelines for local conditions. However, please note that guidelines are subject to copyright provisions. To replicate or reproduce this guideline, in part or in full, please obtain agreement from the American Dietetic Association. Contact Kari Kren, Manager, Research and Strategic Business Development at kkren@eatright.org for copyright permission.

When modifying the guidelines for local circumstances, significant departures from these comprehensive guidelines should be fully documented and the reasons for the differences explicitly detailed.

Disclaimer

NGC Disclaimer

The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

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