Direct observation of the use of evidence-based nutrition

practice guidelines for unintended weight loss

J. Einwechter, BS; P. Igo, RD; A. Charny, MSEd, RDN, CDE, CDN
ARAMARK Distance Learning Dietetic Internship Program, Philadelphia, PA

Introduction
In todays busy field of dietetics, the growing need for effective
nutrition therapy is putting greater responsibility on Registered
Dietitian Nutritionists (RDNs).
The Academy of Nutrition and Dietetics (AND) has recently created
a multitude of Evidence-Based Nutrition Practice Guidelines
(EBNPGs) related to various medical conditions and nutrition
problems to be used as a guide for RDNs implementing nutrition
therapy.
The newness of the EBNPGs creates a lack of research and
literature on the subject. The few articles that do research the
effectiveness of EBNPGs have concluded that not all guidelines
are being implemented in practice as expected. The AND has
great need to research why this is. This information will help the
AND make EBNPGs more useful to clinicians in the future.
By researching the frequency of implementation of guidelines, the
AND and all dietetic professionals involved would benefit.
By observing RDNs in real practice and analyzing data collected,
this study was able to assist in determining the extent of utilization
and implementation of the EBNPGs for Unintended Weight Loss
(UWL) in the clinical setting.

Purpose
The purpose of this study was to determine the extent of Registered
Dietitians utilization and implementation of the Evidence-Based
Nutrition Practice Guidelines for Unintended Weight Loss in a clinical
setting.
Based on the lack in research, and considering the newness of the
guidelines, it was theorized that the average frequency of
implementation would be 0-25%
TEMPLATE DESIGN 2008

www.PosterPresentations.com

Research Design
9-week study conducted from January to March 2015
All data was collected at XYZ Hospital located in XYZ.
Author observed various RDN-patient encounters that applied
to Unintended Weight Loss
An RDN-patient encounter is defined as any interaction with a
patient, family member, or member of the healthcare team;
data collection; and data recording related to an individuals
care.
This study was deemed exempt by Institutional Review Board
(IRB) under federal regulation 45 CFR 46.101(b).
Method of Data Collection
Each guideline observed being implemented was recorded on
a data collection sheet.
The author then conducted a post-encounter interview of the
RDN
All data collected was sent to the AND via Survey Monkey
Statistics
The information sought to gather from Survey Monkey
included:
Which guidelines were observed being implemented
Frequency of implementation of these guidelines
Which guidelines RDNs were aware of
Reasoning behind why guidelines were or were not applied
This information then provided statistics such as:
Percent frequency of implementation
Percentage of guidelines RDNs are familiar with
Mode: guidelines implemented most often
Mean: average frequency of guidelines implemented
Subjects
Recruitment of subjects involved reaching out via e-mail to all
inpatient RDNs employed at XYZ Hospital
Dietitians who met all criteria and agreed to participate were
invited to attend a webinar explaining the study
Dietitians were given information about potential risks and
benefits of the study as well as the guarantee of confidentiality
Two dietitians met all criteria, and two dietitians agreed to
participate in the research study after attending the webinar

Results

Below is a list of the most frequently implemented guidelines,

which, for the purposes of this research study, were organized into
three sections:

The average frequency of implementation was determined to be

greater than what was hypothesized, being 41%
Although guidelines are being implemented more often than what
was theorized based on the lack of research, this percentage still
indicates that, on average, RDNs are utilizing guidelines created
by the Academy less than half of the time
RDNs are utilizing at least one guideline in every encounter

Nutrition Assessment
1. Nutrition Screening
4. Assessment of Food, Fluid, and Nutrient Intake
6. Assessment of Nutritional Status

The only three guidelines implemented 100% of the time were

related to the Nutrition Assessment step of the Nutrition Care
Process
The guidelines implemented least frequently were all related to
RDNs interacting with other members of the health care team

Nutrition Intervention
3. Medical Nutrition Therapy
21. Indications for Medical Food Supplements

Many barriers to the implementation of guidelines were related to

the support of the inter-disciplinary team, as stated by the RDNs

Nutrition Monitoring and Evaluation

27. Monitor and Evaluate Food, Fluid, and Nutrient Intake
26. Monitor and Evaluate Nutritional Status

Results showed that RDNs are not familiar with all EBNPGs

Comparison of guidelines implemented during initial assessment

versus during monitoring and evaluation can be seen here:
Assessment VS. M&E Guideline Implementation
120
100
80

Results also showed that RDNs did have a strong familiarity with
the guideline: Indication for Medical Food Supplements
Limitations
Not at guidelines apply to all patients in the inpatient setting
No established EBNPG for Total Parenteral Nutrition (TPN) in
patients with UWL

60

Conclusion

Assessment

40

Monitoring and Evaluation

20
0
Food Intake

Fluid Intake

Nutrient
Intake

Nutritional
Status

Guideline Implemented

Overall, the RDNs were only aware of implementing a guideline

8 out of 11 times (73% of the time).
50% of the time that RDNs were aware of implementing a
guideline, that guideline was the addition of nutritional
supplements.
Out of the 28 total Evidence-Based Nutrition Practice Guidelines
for Unintended Weight Loss, only 4 guidelines were not
implemented during any encounter, as seen here:

Frequency of Implementation

100
91

100

91

87

EBNPGs were created to help RDNs better implement effective

nutrition therapy, and so need to be able to be utilized in a variety
of settings to be successful
This study was able to assist in determining the extent of
utilization and implementation of the EBNPGs for UWL in the
clinical setting
Frequency of Implementation of guidelines depends on the
familiarity that any RDN has with guidelines
In order for guidelines to be effective in a health care setting, all
members of the inter-disciplinary team needed to be actively
involved in the implementation.
Future research should focus on RDN familiarity with EBNPGs
and the support of inter-disciplinary teams while also taking into
consideration various patient circumstances and appropriateness
of guideline implementation

Overall UWL EBNPG Implementation

100

Resources
The author took no longer than sixty minutes to observe,
collect data for, and interview the RDN for each RDN-patient
encounter
Maximum eleven hours of work time during the 9-week period
This study received no funding

Discussion

The author observed a total of eleven (n=11) RDN-patient

encounters in the inpatient setting. All patients had experienced
Unintended Weight Loss.

% Observed

The demanding world of clinical dietetics has great need for specific
guidelines to help dietitians implement effective nutrition therapy.
Evidence-based nutrition practice guidelines (EBNPGs) were created
for this reason. Lack of research created the need to analyze which
guidelines were being used, and why, so that guidelines could be
adjusted accordingly. This was a 9-week research study conducted
from January to March 2015. A total of two Registered Dietitian
Nutritionists (RDNs) met inclusion criteria and agreed to participate in
the study. The author observed a total of 11 RDN-patient encounters
in patients with unintended weight loss (UWL). Each encounter
observed was recorded on a data collection sheet and analyzed
through Survey Monkey. This information provided statistics such as
percent frequency of implementation and percentage of guidelines
that RDNs were familiar with. The author also conducted a postencounter interview with the RDN in order to learn about RDN
familiarity with guidelines. Results found the average frequency of
implementation of all guidelines to be 41%. The RDNs implemented
at least one guideline in 100% of encounters, although they were
unaware of this 27% of the time. 24 out of the total 28 guidelines
were implemented at least once throughout the study. This shows
that the frequency of implementation depends on the familiarity that
any RDN has with the guidelines. Data also showed that the
cooperation and support of an inter-disciplinary team is critical to the
success of implementation of guidelines.

Methodology

Average % Implemented

Abstract

82
69

61
50

45

45

36
27

27
18

14
5
1

Contact Information

41

10

11

12

13

18
9

14

15

16

17

18

19

5
20

For Additional Information, please contact:

0
21

22

23

24

25

26

27

28

Guidelines by Number

The average frequency of implementation of all guidelines

was 41%

Julie Frazee, BS, Nutrition & Dietetics

Dietetic Intern
ARAMARK Distance Learning Dietetic Internship Program
JAFrazee1r@gmail.com