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.
Food and Nutrition for Older Adults (FNOA): Weight Management in the Older Adult
FNOA: Considerations for Weight Management in the Older Adult
Regardless of age, the registered dietitian (RD) should consider the following when assessing the need for weight management through modifications in dietary intake and physical activity in older adults:
- Classification of overweight or obesity
- Presence of comorbidities
- Physical function
- Cognitive function
- Attitude toward longevity
- Personal choice
- Quality of life
While studies have demonstrated varying associations between assessment indicators of overweight or obesity and physical function and mortality in the older adult, the need for weight loss should be based on input from the physician or geriatrician, RD, qualified exercise specialist and other members of the health care team and will ultimately be the personal decision made by the older adult.
FNOA: Use Multiple Assessment Indicators for Classification of Overweight/Obesity
Regardless of age, the RD should use more than one of the following assessment indicators when classifying overweight or obesity:
- Weight change (and weight history)
- Current (and past) weight, height and body mass index (BMI)
- Waist circumference
- Body composition
More than one assessment indicator should be used, due to the potential limitations of each indicator in the older adult, such as gender and ethnic differences in their application. In addition, studies demonstrated that muscle mass generally decreases and fat mass generally increases over time, even when weight is stable.
Recommendation Strength Rationale
- Conclusion statements are Grades I and II.
FNOA: United States Department of Agriculture (USDA) and Older Americans Act (OAA) Nutrition Service Programs for Older Adults
FNOA: Screen for USDA and OAA Program Eligibility
The RD should screen all older adults for eligibility (or refer for screening) in USDA programs and the OAA Nutrition Service Program and identify potential barriers to participation, such as disability, functional impairment, attitude toward program utilization and income level. Research reported racial and ethnic differences in program participation, as well as in subjects with vision or hearing difficulties, special dietary needs, functional limitations or disabilities.
FNOA: Encourage Participation in USDA and OAA Programs
The RD should encourage eligible older adults to apply for and participate in the following USDA and OAA programs:
- Supplemental Nutrition Assistance Program (SNAP)
- Senior Farmer's Market Nutrition Program (SFMNP)
- Child and Adult Care Food Program (CACFP)
- Emergency Food Assistance Program
- Commodity Supplemental Food Program (CSFP)
- OAA Congregate Nutrition Program
- OAA Home Delivered Nutrition Program
Research reported that participation in USDA and OAA programs improved food and nutrient intake, increased fruit and vegetable consumption, stimulated interest in healthy foods, improved quality of life and improved nutritional status. However, some subjects felt that they did not need food assistance and some participants did not know that they were eligible or how to apply.
Recommendation Strength Rationale
- Conclusion statements are Grades II and III.
FNOA: Antioxidant Consumption and Age-Related Macular Degeneration and Cognitive Function in Older Adults
FNOA: Encourage Dietary Reference Intakes (DRI) for All Older Adults
For all older adults, the RD should encourage food intake meeting the Dietary Reference Intakes (or other recommended levels) for antioxidant vitamins and minerals and recommend a multi-vitamin if food intake is low. Studies regarding antioxidant intakes below recommended levels reported an association with cognitive decline, however, research regarding age-related macular degeneration was inconclusive.
FNOA: Collaborate with Others Regarding Treatment of Diagnosed Age-Related Macular Degeneration
- For older adults with diagnosed age-related macular degeneration, the RD should collaborate with others on the inter-professional team (such as physicians, ophthalmologists, pharmacists and other healthcare professionals) to determine whether an older adult would benefit from high-dose supplementation of antioxidants, as some formulations have side-effects and contraindications.
- Studies have found a beneficial effect of antioxidant (beta-carotene, vitamin C and vitamin E), lutein/zeaxanthin and zinc and copper from diet or supplementation on delaying progression of advanced age-related macular degeneration. However, other studies report inconclusive findings.
FNOA: Advise against Antioxidants for Treatment of Diagnosed Cognitive Impairment/Alzheimer's Disease
- For older adults with diagnosed cognitive impairment or Alzheimer's disease, the RD should advise against antioxidant supplementation, as it has not been shown to have an effect and some formulations have side effects and contraindications.
- Findings from studies of antioxidant intake above recommended dietary allowance (RDA) levels in subjects with diagnosed cognitive impairment or Alzheimer's disease demonstrated no difference in the delay of cognitive decline. These findings were substantiated by one systematic Cochrane review.
Recommendation Strength Rationale
- Conclusion statements are Grade II.
Conditional vs 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
Expert Opinion Only
Grade Not Assignable
- 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
Only studies of weaker study design for question
|Studies of weak design for answering the question
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
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
Consistency with minor exceptions across studies of weaker designs
|Unexplained inconsistency among results from different studies
Single study unconfirmed by other studies
|Conclusion supported solely by statements of informed nutrition or medical commentators
- 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
- 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
Size of effect is small or lacks statistical and/or clinical significance
|Objective data unavailable
||Indicates area for future research
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
This grading system was based on the grading system from Greer, Mosser, Logan, & Wagstrom Halaas. 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
||Implication for Practice
||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.
||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.
||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.
||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 as Consensus, although they may set boundaries on alternatives. Patient preference should have a substantial influencing role.
||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 Academy of Nutrition and Dietetics (AND) from the American Academy of Pediatrics, Classifying Recommendations for Clinical Practice Guideline, Pediatrics. 2004;114;874-877. Revised by the AND Evidence-Based Practice Committee, Feb 2006.