Submitted by
Jayne Thirsk* RD, PhD, FDC
Director PEN®: Practice-based Evidence in Nutrition®
Dietitians of Canada
Using GRADE to grade the evidence in
PEN®
knowledge database
Read any good clinical practice guidelines lately? If you have, you may have noticed that they have used the GRADE system to find and evaluate the evidence and to make recommendations regarding health related issues. Grading research allows the user to quickly draw conclusions about the quality of the evidence and use this information to guide their practice decisions.
GRADE is an acronym for:
Grading of
Recommendations
Assessment
Development
Evaluation and it has been endorsed or is
being adopted by guideline groups, organizations etc. all over the world. The GRADE approach is guided by leaders in evidence-based medicine with a desire to create a common evidence grading system that is credible, reproducible and understandable by guideline users everywhere.
Early in September, the PEN
® GRADE working group met in Toronto, Ontario to begin intensive training to transform how the evidence is graded to make practice recommendations for the PEN database. PEN will join over 75 prestigious organisations such as the WHO, the Cochrane Collaboration, National Institute of Clinical Excellence (NICE) in using the GRADE system.
We were fortunate to receive our education from Dr Nancy Santesso (RD, MLIS, PhD) from the McMaster GRADE training centre. Over 4 full days we learned about the GRADE techniques and began to develop what will be the PEN GRADE process. The fact that she began her career as a dietitian meant that she was able to provide illustrative examples to us in “dietetic language” using nutrition evidence examples.
GRADE guidelines are transparent in terms of the processes used to find and evaluate the evidence and they focus on outcomes.
GRADE recommends standards for how to:
- identify the practice questions and outcomes of interest
- use evidence that has been systematically gathered and synthesized
- assess and summarize the evidence for each outcome
- summarize and use the evidence for other factors important to decision making (patient values and preferences, resources, acceptability, equity, feasibility etc.)
- make a recommendation noting the strength of the recommendation and the quality of evidence upon which it is based.
Here is an excerpt from a recent guideline (1) prepared using the GRADE approach:
Recommendations for preventing fracture in long-term care.
“For residents at high risk of fractures who cannot meet the recommended dietary allowance for calcium through dietary intake, we recommend daily supplements of calcium up to 500 mg.”
Strong recommendation; Moderate-quality evidence
Remarks
“The recommendation for residents at high risk places a high value on the reduction in hip fractures and the small reductions in vertebral and non-vertebral fractures and in mortality that can be achieved with calcium supplementation. It places a lower value on the small increased risk of gastrointestinal adverse effects that may occur and the resources required in long-term care to provide calcium supplementation.”
“These recommendations apply to supplementation with any calcium compound, including calcium carbonate or citrate. The recommendation to limit supplementation to 500 mg was based on the uncertainty about harms of calcium supplementation in studies of community-dwelling individuals who received calcium supplementation of 1000 mg or more daily. The benefits of calcium supplementation are closely linked to adequate vitamin D intake.”(1)
1. Papaioannou A, Santesso N, Morin S, Feldman S, Adachi J, Crilly R et al. Recommendations for preventing fracture in long-term care. CMAJ. 2015 Sept 14.
http://www.ncbi.nlm.nih.gov/pubmed/26370055 OR
http://www.cmaj.ca/content/early/2015/09/14/cmaj.141331
Transitioning PEN to using GRADE
Using GRADE will make the key practice points in PEN easier to interpret and quicker to read. PEN has always given dietitians an assessment of the strength of the evidence, moving to a system that is widely recognized by other health professionals will make it easier for dietitians to communicate benefits of treatment to the wider multi-disciplinary team.
Many of our
current PEN processes are in line with the GRADE approach while others will need to be enhanced or made more explicit. GRADE does not simply focus on RCT data, rather it encourages incorporation of many types of studies and information related to patient preferences, equity, feasibility etc. to inform decisions. PEN is a respected source of information for dietitians around the world, gradually incorporating GRADE into PEN’s systems and processes will enable it to maintain and strengthen its influence.
The PEN international collaboration is about more than simply synthesizing the evidence for busy dietetic practitioners. A key objective of the collaborative partnership is to build capacity for dietitians to be not only knowledgeable users of evidence but also skilled contributors to the creation of evidence-based practice recommendations. The PEN team will work closely with the MacGRADE training centre at McMaster University to create a series of short videos/modules to help dietitians understand and use GRADE … whether they are looking at PEN
® evidence or guidelines created by other authoritative sources.
Leaders share their enthusiasm for transitioning PEN® to using GRADE:
“The PEN Collaboration is committed to providing-practice based evidence in nutrition, and now to incorporating GRADE. I’m sure it is why PEN has been and will continue to be an invaluable resource to dietitians!” Dr Nancy Santesso, MacGRADE training Centre
“Using GRADE will help dietitians to present evidence for their practice in a way that is understood by colleagues across the world.” Dr Judy Lawrence, BDA
“Using an internationally recognised system such as GRADE to evaluate the quality of evidence and strength of recommendations for practice based questions allows PEN to clearly communicate evidence related to our profession to dietitians and other health professions.” Dr Judy Bauer DAA
Watch for more information about our plans to transition PEN to GRADE in future PEN eNews issues.
* On behalf of the PEN GRADE Working Group: 
Heather Alaverdy
Beth Armour
Judy Bauer
Jane Bellman
Tanis Fenton
Catherine Freeze
Judy Lawrence
Heather Petrie
Dawna Royall
Mary Anne Smith
Kerri Staden
Jayne Thirsk
Missing from the photograph – Catherine Freeze, Heather Alaverdy and Kerri Staden