PEN eNews 2(6) April 2013
April 2013 · Volume 2, Issue 6
Dietitians share evidence-based Guidance
In the month of March, we saw dietitians showcase their evidence-based approaches to every day questions. Canadian dietitians showed leadership in Nutrition Month, with this year’s theme focusing on practical, and evidence-based tips for grocery shopping to better health. We saw UK dietitians show their unique knowledge base on concerns related to processed meats. We saw Australian dietitians translate updated national healthy eating guidelines to consumers.
Sometimes dietitians share evidence-based guidance that is in contrast to popular trends. Take coconut oil – PEN’s evidence analyses has shown that, compared to other fat sources, coconut oil does not raise total cholesterol and LDL cholesterol levels to the same extent as butter; but does increase total cholesterol and LDL levels to a greater extent than vegetable oils. As such, coconut oil cannot be recommended as a suitable alternative to non-hydrogenated vegetable oils despite its positive effects on HDL-cholesterol. http://ow.ly/hAU8l
Nutrition is filled with controversy. Dietitians cut through the nutrition clutter. Our foundational knowledge, training, critical thought and approach underpin a dietitian’s skill to separate fact from fiction. We are accountable to our regulatory bodies, we are supported by our country’s professional association, and PEN, our decision-support tool.
This issue of eNews has articles that will help you explore factors that may influence your decision-making. …. and another thing…about bias highlights how we believe things that can get in the way of the truth of the evidence. Hunting, Foraging and Hot-Syncing Your Way to Better Decisions highlights two systems of thinking and how they are both involved in our decision-making. We share our final tip in the series social media. This and more in eNews 2(6).
Kristyn Hall MSc, RD
Editor, PEN eNews
PEN eNews may contain links to other external websites. Pennutrition.com is not responsible for the privacy practices or the content of such external websites. Dietitians of Canada, Dietitians Association of Australia, Dietitians New Zealand and the British Dietetic Association do not endorse the content, products or services on other websites.
What's New in PEN
40 PEN PETs have been Unleashed! 
The new PETs (Practice-based Evidence Toolkits) will replace Practice Guidance Summaries and make access to practice information and tools more accessible through separate Nutrition Care Process sections, and are presented in a format consistent with International Dietetics & Nutrition Terminology (IDNT). Other great features include calculators (BMI for Adults, BMI for Children, a Metric Converter), and country-specific information available for Canada, Australia, New Zealand and the United Kingdom where appropriate.
To Access PETs, Click on the Toolkits icon on the PEN home page; or on the Knowledge Pathways Table of Contents page, click on the any of the magnifying glasses under the Toolkit/Practice Guidance Summary (PGS) column.
Wondering what else is new in PEN? Here is a list of our updated content in PEN, including updated knowledge pathways, new practice questions, updated practice questions, new professional tools, updated professional tools, and new handouts available.
News-making Evidence
- The Global Burden of Disease Study 2010 is the result of collaboration of almost 500 researchers from 50 countries. Comprised of a series of seven articles as well as commentaries, the reports examine the distribution and causes of diseases, injuries and health risk factors in countries around the world. Also available from: http://www.healthmetricsandevaluation.org/gbd
Professional Tools
- Pestering Parents: How Food Companies Market Obesity to Children
- Sugar-Sweetened Beverages: Marketing Unveiled (Canada)
- DC Position: Advertising of Food and Beverages to Children (Canada)
- Media Skills - Media Literacy Web Links
- Social Media Overview
- Media Advocacy Workbook
- Sharing Your National Service Story
- Australian Dietary Guidelines (2013) (Australia)
- Waist Circumference Measurement
- Infant Feeding Guidelines: Information for Health Workers (Australia)
- Children's Food Trust - Eat Better, Do Better (UK)
Client Tools
- How to Track Your Eating and Physical Activity Choices (Canada)
- Setting SMART Goals (Canada)
- Plan Shop Cook Enjoy! Create Your Own Factsheet (Canada, must be a DC member to access)
- Healthy Eating Guidelines for Lower Sodium Eating (Canada) Fr Ch Pun Sp Vi
- Fr: Offrir des aliments solides à votre bébé allaité (Canada)
- Fr: Offrir des aliments solides à votre bébé allaité ou nourri avec une préparation pour nourrissons (Canada)
How Do I …. Access the New PEN PETs?
The PEN PETs have been Unleashed! Have you seen the new PETs (Practice-based Evidence Toolkits)? Forty have just been unleashed to their respective Knowledge Pathway “homes”.
PETs (Practice-based Evidence Toolkits):
- Make the access to essential information on nutrition assessment, diagnosis, intervention, monitoring, associated tools and education materials based on nutrition-related conditions / diseases more 'up-front' and easier to retrieve; and
- Present information in a format consistent with International Dietetics & Nutrition Terminology (IDNT) with direct access to succinct information dietitians can use in their practice.
- Other GREAT features include:
- Separate sections with focused topic areas based on the Nutrition Care Process
- Calculators, a new tab on PEN's Home page and will include: BMI for Adults, BMI for Children and a Metric Converter
- Direct links to your favourite PEN Client handouts and other related tools and resources
- Country-specific information available, where appropriate, for Canada, Australia, New Zealand and the United Kingdom.
How To Access the New PETs:
- On the PEN Home page, click on the Toolkits icon that leads to all available PETs.
- On the Knowledge Pathways Table of Contents page, click on the any of the magnifying glasses under the Toolkit/Practice Guidance Summary (PGS) column. You can only access either a Toolkit or PGS. PETs will eventually replace all the PGSs in PEN.
- Within a knowledge pathway, click on the “Toolkit “ tab on the right hand side of the page. The Toolkit tab will only display as an option if the knowledge pathway has a new toolkit. Here are a couple of toolkit links to get you started:
- Click on any of the items on the Table of Contents of the right hand side of a toolkit to get quick, direct access to any section within the toolkit.
- Headings with a “+” beside it means that there are other contents hidden underneath the heading. Be sure to click on it to see other topics.
- Flags! Where information is specific to a particular country, you have the option of seeing only your country’s information or viewing other’s information as well. Simply click the box at the top of the page for the country information that you would like to view and it will be displayed (or alternatively unclick the box to hide it).
Here is a screen shot demonstrating the key titles and subtiles within the toolkits:
We hope this helps you to get to know your PET(s). More PETs and calculators will be added regularly to PEN so we welcome your feedback. Contact us directly, or take our short survey.
Kerri Staden – kerri.staden@dietitians.ca
Written by the PEN Team April 2013
…and another thing…about bias
Previous issues of PEN eNews have addressed publication bias and more recently, how study design can contribute to a high or low risk of bias. There is another kind of bias that has been described by Ben Goldacre author of Bad Science in a chapter brilliantly entitled: Why Clever People Believe Stupid Things (1). He and others refer to this kind of bias as “cognitive illusions”.
As consumers or users of evidence, we do/see/ believe all kinds of things that get in the way of the truth of the evidence – these cognitive illusions can affect researchers also. Here are some examples that Goldacre explores:
We are wired to see patterns where none exist – it is why statistical analyses are so important! - Regression to the mean describes the situation when things are bad or extreme, they generally tend to return to normal or to the mean. We also tend to act or intervene with a treatment when things are at their worst and in these circumstances we may attribute the improvement in our condition to our intervention rather than the phenomenon of regression to the mean. For example, if I am ill with the flu and my husband makes me a cup of lemon tea and I feel better, I may ascribe the improvement to the tea rather than the flu simply following a normal course and gradually improving with time. A formal trial with a control group might help sort out a true effect from regression to the mean.
- We favour positive information or evidence and publishers do too! This may mean that we are more likely to take studies that confirm our beliefs at face value while we carefully scrutinize and criticize those that differ.
- We are biased by our prior beliefs and we selectively expose ourselves to situations and information that conforms to our beliefs. In research, we might be tempted to seek out confirmatory evidence for a given hypothesis – this is also known as cherry picking. It is one of the reasons why narrative reviews are not ranked as highly as systematic reviews in terms of the evidence hierarchy. Without a systematic approach to locating research evidence we may be more likely to select evidence which matches our beliefs or hypotheses while ignoring evidence that challenges them.
- In communal reinforcement “a claim becomes a strong belief, through repeated assertion by members of a community” or particular group (1). A good example of this phenomenon in our own practice domain might include the longevity of clear fluid diets though evidence for their efficacy in most refeeding situations remains elusive.
- We are drawn to the exceptional, the interesting, the theatrical or the miraculous anecdote or story. Our emotional response influences us more than facts and can affect our judgment. This is also called availability heuristic and it can lead to bias (2). Quite simply, we are more likely to recall or place importance on personal experiences, pictures or dramatic stories compared with statistics or objective narrative.
- Storytelling can add richness to describing an experience or the impact of the experience and can be a valuable research tool. However, Newman in his article The power of stories over statistics draws our attention to the need to be aware of situations where stories and the emotional response they elicit can overwhelm evidence during guideline or policy development.
Asking ourselves “Why do I believe this?” or “How do I know this to be true?” might help us uncover cognitive illusions at work in our own judgment or decision-making.
Written by Dr. Jayne Thirsk, RD, PhD, FDC
Director, Practice-based Evidence in Nutrition
References
- Ben Goldacre. Bad Science, London: Fourth Estate; 2009 p. 242-255.
- Daniel Kahneman. Thinking, Fast and Slow, Canada: Doubleday Canada; 2011 p. 129-136.
Hunting, Foraging and Hot Synching Your Way to Better Decision-Making
Daniel Kahneman is a psychologist who has spent much of his life studying judgment and decision-making for which he won the Nobel Prize. His ideas about system 1 and system 2 thinking have been applied to the fields of economics, medicine and politics and shared beyond academic circles in his award winning book: Thinking, Fast and Slow (1).
System 1 thinking is about our quick, intuitive thinking or decision-making. It refers to the construction and use of mental maps, rules of thumb, or internalized tacit guidelines (1,2). After I was in clinical practice for a number of years, I could obtain a diet history from a patient without having to “think” much about it. I just “knew” how to start, what prompts to use and how to probe for more information. Our system 1 thinking is usually developed from our undergraduate training, our experience and from talking to, or observing colleagues. It uses only a small bit of available evidence and so is subject to all those cognitive illusions or biases described in another PEN eNews article… things like - being drawn to evidence that agrees with what we already believe or being strongly influenced by stories or personal experience etc.
System 2 thinking refers to analytical thinking. It involves the rationale analysis of all available evidence or information. It is time consuming and requires skill (1,2). Again, thinking back to my clinical practice, very occasionally a child would be admitted with an inborn error of metabolism. Aside from the momentary sense of panic (perhaps an example of system 1 thinking) I would carefully scrutinize the chart, obtain and review previous admission notes, consult with the pediatrician, the family, the child (not necessarily in that order) and the latest research evidence to come up with my nutrition recommendations. This was system 2 thinking being called into play.
It is NOT a case of one system being better than the other – both serve important purposes. If you rely too much on system 2 thinking, you may encounter analysis paralysis… too much thinking or analyzing and a failure to act in a timely way. If you rely too much of system 1 thinking, you may encounter more errors (making decisions too quickly and without considering all the important information) and you may fail to adopt new evidence into your practice (3).We human beings are a bit of a lazy lot. If faced with a patient or situation that we even remotely recognize, we tend to slip into system 1 thinking or decision-making; relying on what we were taught, what we have always done, or what we see others doing (3). Our preference for system 1 thinking makes it hard for us to incorporate new information into our decision-making processes (especially if it conflicts with previous assumptions and knowledge).
Clinical decision-making can be improved if we make appropriate use of both system 1 and system 2 processing and take steps to keep both of these systems up to date with the latest and best evidence.
Building on the initial work of Slawson et al (4) and Maskrey et al (5) the British National Health Service (3) described a system for practitioners to keep both system 1 and system 2 decision-making up-to-date. They framed it in terms of hunting, foraging, and hot syncing your way to information mastery.
Hunting: have a system in place to help you find the best answer (not just any answer) to specific questions quickly and efficiently. PEN is perfectly suited to this kind of information gathering.
Foraging: have a system in place that alerts you to new, valid, important and applicable information that should change your practice. Some databases of systematic reviews have alerting systems whereby they notify you of new systematic reviews in areas you identify when you register. PEN is considering such a system – we’d like to hear from you if you think this would be a valuable service.
Hot synching: involves deliberately checking and updating your personal mental maps or checklists of knowledge and skills once or twice a year in the areas that you work in. This will ensure your automatic processes and mental maps (system 1 thinking) are in line with best evidence. “So just as we might “hot synch” our Blackberry with our emails, appointments and contact – or our iPod with our music playlists - we can do the same for the evidence we need to know to be able to manage the conditions we see commonly” (5).
PEN was designed to help dietitians manage the vast amount of nutrition research published every year. By answering practice questions, preparing evidence summaries, creating new toolkits of succinct practice guidance and tools to translate this new information to your clients it efficiently supports effective decision-making. Why not spend a little time with the new PEN Table of Contents to locate the tools best suited to your practice needs.
“An essential part of all three components is that health professionals should preferentially use trustworthy, pre-appraised summaries of information which set new evidence in the wider context, rather than reading and attempting to critically appraise primary research.” (3)
Written by Dr Jayne Thirsk RD, PhD, FDC
Director, Practice-based Evidence in Nutrition
References
- Daniel Kahneman. Thinking, Fast and Slow, Canada: Doubleday Canada; 2011
- Supporting Adoption of Evidence into Practice. MeReC Bulletin. 2011[cited 2013 Feb 20] 22(2). Available from: http://www.npc.nhs.uk/merec/therap/other/merec_bulletin_vol22_no2.php
- Making Decisions Better. MeReC Bulletin. 2011 [cited 2013 Feb 20];22(1). Available from: http://www.npc.nhs.uk/merec/mastery/mast3/merec_bulletin_vol22_no1.php
- Slawson D, Shaughnessy A, Bennett J. Becoming an information master: feeling good about not knowing everything. J of Fam Pract. 1994 [cited 2013 Feb 20];38: 505-13. Abstract available from: http://www.ncbi.nlm.nih.gov/pubmed/7964548
- Maskrey N, Underhill J, Hutchinson A, Shaughnessy A, Slawson D. Getting a better grip on research; a simple system that works. InnovAiT. 2009[cited 2013 Feb 20]2:739-49. Available from: http://ino.sagepub.com/content/2/12/739
Coming Soon: QUICK-SYNCH Service…another way to get fast, easy access to best evidence for practice
Now you can hot-synch your brain – just like your smart phone with a new professional development tool from Dietitians of Canada!
FEATURES
- Focused overview of single practice topic from Practice-based Evidence in Nutrition (PEN)
- Designed for the busy health practitioner with an hour or less to spend per week on continuing professional development
- Self-scoring quiz with immediate feedback on knowledge gained
- Certificate of completion for your professional development portfolio
- Supports self-reflection on what you learn and how you will apply it to practice
What reviewers are saying about Quick-Synch Service (QSS)
“These modules are great! They capture all the highlights that a novice would find useful.” “A great tool for learners.”Quick-Synch Service will be released in Dietitians of Canada’s Learning on Demand.
Watch for updates and announcements - coming soon! What QSS module topic do you most wish for? Email us at enews@pennutrition.com
Do you help shape our future?
Do you work with dietetic / nutrition students or dietetic interns? Want to share an innovative way you use PEN to support student / intern learning? We have published articles highlighting how students use PEN in their projects and how PEN is impacting their education and training. We would like to hear YOUR student's stories!Write a Article for PEN eNews! Articles should be ~ 350 words and include a
1) Article title
2) Include a photo or link to a video
3) Main points/body of article
4) Resources/links and references (where appropriate)
To view sample articles, go to http://www.pennutrition.com/enews.aspx?id=9#102
We look forward to hearing about dietetic / nutrition student and dietetic intern experiences!
Student corner
Spotlight on Bo Tang
Bo Tang – Level IV - McGill Dietetic Stagiaire
Montreal, Quebec, Canada with Beth Armour, PEN
Content ManagerI had heard of PEN many times before, from both professors in school and dietitians in the field. It was defined to me as a tool to find answers to nutritional-related questions I might encounter in day-to-day life. For various reasons, my use of PEN in the past was very limited. Could I trust what PEN had to offer? Now I realize how hard the PEN team, including the editor, content and resource managers and evidence analysts work behind the scenes to find the most reliable and most up-to-date research to include in PEN.
My supervising dietitian and I were busy in December 2012. It is a very dynamic working environment even though I worked at her dining room table at her home every day. New topics pop up every day and content gets renewed on a regular basis. Most of the time, I felt like an octopus with each tentacle doing different things at the same time. One knowledge pathway could split into multiple other pathways, and they all offer evidence-based guidance to nutrition- practice questions we encounter as dietitians every day.
PEN follows a PEN protocol for finding the evidence. “In developing the content for PEN, validated and refined filtered information sources including synopses, well-conducted systematic reviews (such as Cochrane Reviews) and reputable practice guidelines are used to form the basis for the evidence synthesis. PubMed is also used to identify any scientifically valid and relevant articles for analysis.” (1).
In a PEN evaluation survey, 92% of respondents indicated that they were confident with the quality of PEN information (2). This reputation is earned through the hard work and collaboration of the PEN team. Together, they ensure current, uniform authoritative guidance on food and nutrition is delivered in an easily accessible, timely manner.
Through my experiences as a writer of PEN content, I have learned how to more effectively research the sea of contradicting evidence. It is extremely important to assess the accuracy of the information we as health practitioners gather, especially when it comes to a resource, or teaching material, or a consumer handout that is recognized globally. Nowadays, it has become difficult for consumers to build trust in us when they receive mixed messages from the media and the internet. It is our role, as dietitians, to clarify the cloud of mixed messages. PEN will guide me in my coming days as a newly graduated, well-informed dietitian. How will it guide you?
Written by Bo Tang – Level IV - McGill Dietetic Stagiaire, Montreal, Quebec, Canada
References:
- The Global Resource for Nutrition Practice [PEN]. PEN Protocol for Finding the Evidence. 2012. [cited 2012 Dec 20] from http://www.pennutrition.com/aboutpen.aspx
- Evaluation of Practice-based Evidence in Nutrition [PEN]. Final Report to the Canadian Council on Learning. April 2009 [cited 2012 Dec 20]
thank you to our pen volunteers
Our global PEN partnership has benefited from volunteer efforts around the world! Please take a moment to read and acknowledge your colleagues who have served as authors or peer reviewers for PEN content since November 2012. If you would like to be a PEN author or reviewer, please click here to send us your contact information.
Australia 
Catherine Ryan
Aditi Patwardhan
Judy Nation
Lina Breik
Carmel Smart
Sally Marchini
Kim Faulker-Hogg
Emma Osland
Mel Reid
Alan Barclay
Ruth Vo
Janet Martin
Helen Vidgen
Evelyn Volders
Karen Fry
Roslyn Giglia
Maria Chan
Trudy Williams
United Kingdom 
Dr. Carina Venter
Dr. Eleana Papadopoulou
Karen Green
Karen Hyland
Maryanne Wilson
Dr. Marion Summerville
Dr. Julie Lanigan
Kathy Cowborough
Sylvia Turner
Sue Kellie
Yvonne Jeanes
Eleanor Baldwin
Elaine Gardner
Yvonne McKenzie
Anita Bowes
Dr. Deb Lycett
Canada 
Sue Behari-Mcginty
Christina Katsagoni
Melanie Reid
Crystal Wells
Maria Kalergis
Tom Wolever
Shannon Grant
Marisa LeBlanc
Jordan Mak
Julie Lanagan
Thida Ith
May Jung
Andree Gagne
Maria Ricupero
Brenda Hotson
Marlis Atkins
New Zealand 
Lyn Gillanders
PEN Insider
Spotlight on Susan Firus
Susan Firus
PEN Evidence Analyst
PEN Evidence Analyst
- fine tuning volunteer PEN content submissions
- ensuring that information in different sections of the PEN website is consistent
- updating content to reflect new guidelines or DRIs
- updating knowledge pathways, including the Gastrointestinal System – Pediatric/Paediatric Constipation Knowledge Pathway.
Most recently I’ve been working with Kerri and Jane, the PEN Resource Managers, on the new PEN Toolkits.
Biggest learning from evidence-based practice, and what’s the impact of evidence-based practice on nutrition and dietetics…
My biggest learning experience and my understanding of the impact of evidence-based practice on dietetics actually came in the position that I held before joining the PEN team. I worked for many years in a nutrition call centre, where consumers could phone in their question, and have it answered by a registered dietitian. At this call centre, we had a rudimentary database that we consulted when answering callers’ questions and developing consumer handouts. When we partnered with Dietitians of Canada to develop a customized version of PEN for the call centre in 2006, one of the first knowledge pathways that was developed was on gout; we revised our gout handout against this. The revision resulted in fewer dietary restrictions than we had been suggesting, allowing callers with gout to enjoy a wider variety of foods.
The other Knowledge Pathway that had a similar impact was on allergy prevention. For years, we had been counselling moms to delay introducing many foods to their infants if they were at high risk for developing allergy, in an effort to try to prevent future allergies. I remember feeling bad that these babies had much less food variety compared to their low risk counterparts, and I often wondered if there would be long-term (undesirable) consequences of these restrictions. When the knowledge pathway was completed, the evidence just wasn’t there to support the delay in introducing solid foods as a means to prevent allergy. So, like the callers with gout, these babies were able to eat a much wider variety of foods because of practice-guidance synthesized in PEN.
Reflection/thought about dietitians as leaders in evidence-based practice…
I think one of the biggest challenges we have as dietitians is that so much of the evidence in nutrition is limited or inconclusive. This limits our ability to make firm recommendations for dietary interventions, and yet, the public is usually looking for ‘black and white’ type guidance – should I take this supplement, or not? And of course, there are many other professionals dispensing nutrition information who have no such qualms about providing very specific guidance when the evidence is not clear. It is one thing to write ‘the evidence is mixed and inconclusive’ but that becomes challenging when you have an individual on the phone, or sitting in your office, looking for direction. If dietitians want to be the ‘go to’ source for nutrition information for the public, we somehow have to straddle both sides – not an easy task.
My favourite thing about PEN is…
It’s hard to narrow that down, but I’d have to say the depth and breadth of the nutrition information it has – and it just keeps on growing! I realize now how many hours go into maintaining it, and I have the utmost respect for the whole PEN team, and especially the other PEN Evidence analysts. Appraising the evidence and distilling it down into practice points is hard work! They’ve been doing this for many years, and they do it so well.
Strategies to stay on top of topic areas…
Be part of a professional network. One of the great things about PEN is the team. Even though we don’t work together physically – the team spans from west to east, across Canada, the team is constantly in touch by e-mail and phone. Articles and “have you seen this” e-mails are constantly crossing the country. So along with the usual sources, if you’ve missed something, one of the team members is likely to see it and pass it along.
How to reach me…
I can be reached at my e-mail – sfirus@shaw.ca
PEN eNews
April 2013 ·
Volume 2
(6)
April 2013 ·
Volume 2
(6)
A Publication of the PEN System Global Partners,
a collaborative partnership between International Dietetic Associations.
Copyright Dietitians of Canada. All Rights Reserved.