PEN eNews 3(1) June 2013
June 2013 · Volume 3, Issue 1
Momentum builds for best evidence
Have you noticed the momentum building around issues of publication bias? You are not the only ones. All Trials Registered, All Results Reported is an international initiative with the following premise:
- While there have been thousands of clinical trials conducted, not all have their results reported, and some are not even registered.
- Information on what was done and found in these trials could be lost forever to health professionals, resulting in missed opportunities for evidence-based practice, the potential for poor decision-making, and trials being re-conducted.
All Trials is recommending that all clinical trials, past and present, be registered, and full methods and results be reported. They have an on-line petition where organizations can show their support for this initiative. All Trials Registered, All Results Reported is an initiative of Sense About Science, Bad Science, British Medical Journal, James Lind Initiative, the Centre for Evidence-based Medicine and others. All Trials has a blog, and a hashtag #AllTrials that stream in tweets about this important topic.
PEN is a proud supporter of the All Trials Petition. Dietitians use evidence-based dietetic practice and need good data on which to base our decisions. Consumers are becoming more savvy of evidence-based health care and wanting access to information that their tax dollars may have helped to support. To see what supporters are saying about AllTrials, go to http://www.alltrials.net/comments/Publication bias is an issue we have written about in previous eNews issues and is one that we consider in all our evidence analyses. For example, when considering if there is harm from a dietary intervention, we synthesize our recommendations based on published peer-reviewed literature, looking for evidence of benefit and evidence of harm. PEN, in its knowledge pathway development process (Birth of a PEN Pathway), also incorporates expert review of our evidence synthesis. This is where practice-based perspectives and potential concerns can also be threaded in.
We look forward to system-level change to help ensure clinical trials get published, thereby helping health professionals have access to all research conducted in their respective areas of practice. Patients, researchers and health professionals will all benefit from publication of clinical trial results. If you are so compelled, go to www.alltrials.net and click on the red “sign the petition” button.
This issue of eNews has articles that will help you reflect on your decision-making processes in your evidence-based dietetic practice. The Social Life of Knowledge offers a thought-provoking look at the social processes that evidence is subjected to as it becomes integrated into practice, as well as the challenges faced to get best evidence adopted into practice. This article offers specific examples of the science and art of dietetic evidence-based decision making. We highlight a new and accessible professional development tool for dietitians in our article How do I…Use QSS. We also share links to videos on basic statistical concepts that help you to interpret literature. This and more in eNews 3(1).
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.
Submitted by Dr Jayne Thirsk, RD, PhD, FDC
Director, PEN, Dietitians of Canada
Director, PEN, Dietitians of Canada
Social Life of Knowledge
Patients receive care based on the evidence only 55% of the time (1).
- ⅓ of patients do not get treatments of proven effectiveness.
- ¼ of patients get care that is not needed or is potentially harmful.
- Up to ¾ of patients do not get the information they need for decision-making (2).
Statistics like these, while perhaps discouraging, also prompt a call to action:
- That care provided to patients is grounded in the best available evidence.
- That strategies be developed to expedite and enhance the use of best evidence by health practitioners to ensure patients receive consistent care no matter where that care is provided (1).
And so, the terms evidence-based practice and knowledge transfer became part of our practice vocabulary. With this “PUSH” to be evidence-based practitioners came a “PUSH BACK” against the mindless application of evidence-based guidelines without thought to the uniqueness of each patient and the circumstances in which the care is provided.
To explore this issue in more detail, I recently purchased an online book entitled: Practice-based Evidence for Healthcare: Clinical Mindlines by John Gabbay and Andrée le May (3). The book examines how clinicians actually acquire and use their knowledge in practice. They explored this, both at an individual and group level, with the goal of strengthening the use of evidence in day-to-day practice. The illustrative vignettes that form a foundational piece of each chapter provided a “reality check” in terms of the barriers and challenges to adopting evidence into practice. Though mostly focused on a primary care service in the UK, the learnings have much broader application.
Gabbay and le May approach this dynamic tension between wanting to provide the best possible care by applying evidence-based guidelines and the realities of practice from many different angles. Drawing on the literature and their ethnographic observations, they offer a number of explanations of why it can be so hard to get best evidence adopted into practice. Though the authors address many reasons for this, I’d like to focus on a couple that particularly resonated for me:
- Some types of decision-making may be particularly resistant to new evidence
- Evidence, though important, is only part of the decision-making picture and it must be viewed in context of the particular care situation
Some types of decision-making may be particularly resistant to new evidence
Gabbay and le May first describe how practitioners rely on a complex set of psychological processes and patterns of thinking that they call mindlines or mental maps to make many of the “quick” decisions they are required to as part of their day.
They define mindlines as "internalized, collectively reinforced and often tacit guidelines that are informed by clinicians’ training, by their own and each other’s experience, by their interactions with their roles, by their reading, by the way they have learnt to handle the conflicting demands, by their understanding of local circumstances and systems, and by a host of other sources” (4).
Recall the example of taking a diet history described in: Hunting, Foraging and Hot Synching Your Way to Better Decision-Making. My ability to conduct a diet history was grounded in my undergraduate training where I observed trainers performing the skill and then practiced it myself. My performance was evaluated and I incorporated the feedback received. It was enhanced over the years by watching colleagues, adjusting my techniques based on type of client or type of consultation and incorporating style elements based on my experiences of what worked. I just “know” how to get a diet history started and what questions to use to probe for more information. This is my “diet history mindline”.
Some of the typical inputs into mindlines that were identified by Gabbay and le May (3) include:
- Local norms /routines
- Role models’ behavior
- Institutional culture
- communication patterns or norms,
- group norms, values (customer focus, connection to community)
- social climate (degree of formality or informality )
- Trainer/teachers’ norms
- Peer values
- Guidelines (new research or evidence)
- Embedded science
- Heuristics [“common sense”, rules of thumb, or knowledge gained by experience]
- Technical skills
- Soft skills such as professionalism, ethics, cultural competence, reflective learning, use of humour)
- Practical skills such as communication, history taking etc.
- Tacit and experiential knowledge
Clearly, many of these inputs could be considered to be social in nature; relying on interactions with, or observations of peers, trainers or role models. Gabbay and le May make an important observation about this social element (3):
“ Before new knowledge can lead to a behavioural change, clinicians will actively relate it to what they and their trusted colleagues already, possibly implicitly and tacitly, know or believe. They will assess its relevance, benefits and disbenefits and in effect “negotiate” a final position in which they may or may not be persuaded to incorporate the new evidence into what they do. In short, for research evidence to inform practice, it must be subjected to a social process that continually and repeatedly transforms it from the explicit knowledge that emerges from the research works into something suitable for internalization as part of the mindlines, the “knowledge-in-practice-in-context that is used in the clinical world.”
So where does this leave evidence relative to practice decisions? Mindlines are NOT meant to discount the value of applying the very best evidence to one’s practice. To be effective, mindlines MUST also be flexible and constantly modified by new knowledge, evidence and changing practice circumstances. Mindlines must be regularly scrutinized through self-reflection (recall those cognitive biases) and dialogue with peers; they must consider new practice realities and technological advancements and constantly be updated and informed by new, valid, important and applicable research evidence. And herein lies the challenge – what is the process that we, as dietitians, go through to update our mental maps or mindlines? How do we recognize all the factors that helped to create our first mental map, and yet, still update these mental maps with new evidence?
Evidence, though important, is only part of the decision-making picture and it must be viewed in context of the particular care situation.
Many types of evidence, knowledge and skills contribute to evidence-based decision-making. Patient values, experience and context are critical factors in determining what evidence or knowledge is needed at any given time to make the best practice decisions.
Some examples of “other” types of information or knowledge a dietitian might consider when making a practice decision:
|
Adapted from Box 3.1 Examples of what a GP needed to know during a typical surgery (3)
I recently provided a consultation for an individual navigating a low iodine diet prior to radioactive iodine (RAI) treatment for thyroid cancer post thyroidectomy. While familiar with the rationale for the diet, I had no recent experience with counseling patients on this diet. This individual was known to be quite meticulous and approached me with a plan to obsessively “eliminate every μg of iodine” in their diet. She had surfed the Internet and found the guidance contradictory and confusing. The individual was 84 years old and independently caring for her 96 year old husband in the community. A diet history revealed a well balanced diet generally low in sodium due to a previous consultation with a dietitian regarding hypertension management. Weight was stable and BMI was 25. Some of the things I considered prior to providing her with more general guidelines included:
A review of PEN and the practice question: Should a low iodine diet (e.g. ≤50 μg iodine/day) be recommended for adults with well differentiated thyroid cancer for one to two weeks prior to radioactive iodine (RAI) treatment or scanning?
I learned that expert opinion supports following a diet low (< 50ug I/day) for two weeks prior to RAI treatment in order to increase RAI uptake by remnant thyroid tissue. Adverse effects include possible radiation toxicity and hyponatremia.
Most nutrient databases don’t include iodine in the list of reported nutrients therefore accurate nutrient composition data is hard to find.
Iodized salt and foods prepared with it, fish/seafood and dairy products (due to iodine preparations used in sanitation) are major sources of iodine in the diet in Canada.
While fruits and vegetables can vary in their iodine content based on growing conditions, they are generally lower in iodine than most other food groups.
The client’s concerns about the diet were acknowledged and addressed and she was reminded that the goals of the diet were to reduce iodine consumption to less than approximately 50ug for two weeks rather than her intended plan of total elimination. She was encouraged not to be concerned about weighing and measuring her food during the low iodine diet phase. A simplified list of high iodine foods to avoid was provided. Non-iodized salt was discussed as an option and she was encouraged to discuss her risk of hyponatremia with her physician.
In providing care to this individual, I first determined what best practice was by consulting PEN. I then altered this evidence to consider:
- What the client already knows/believes.
- What the client wants and needs.
- Can the patient understand, afford or manage the care plan I recommend?
- Are the practice guidelines realistic and practical? Do they apply to my client?
- What are the risks/benefits and costs of the treatment?
- Do I have knowledge to adequately care for this patient? Where can I go to get more information or whom can I refer the patient to?
Practitioners are “science-using, information-sorting interpreters” (5) of situations and need to use their judgment to make informed decisions regarding the care they provide. As evidence-based decision-makers, dietitians must continually revise their existing knowledge with new evidence relevant to their client, the groups in which they practice and the institutions or organizations in which they work. In the context of dietetics, I might describe this as part of the “art” of evidence-based dietetics.
References
- Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Committee on Quality of Health Care in America. Washington DC. National Academies Press. 2001 [accessed 2013 May 27]. Available from: http://www.iom.edu/Reports/2001/Crossing-the-Quality-Chasm-A-New-Health-System-for-the-21st-Century.aspx
- Straus SE, Tetroe J, Graham ID, Leung E. Knowledge to Action: What It Is and What It Isn’t. Available from: http://www.cihr-irsc.gc.ca/e/40618.html
- John Gabbay and Andrée le May. Practice-based Evidence for Healthcare: Clinical Mindlines. New York, New York: Routledge; 2011.
- Gabbay J, le May A. Evidence based guidelines or collectively constructed “mindlines”? Ethnographic study of knowledge management in primary Care. BMJ. 2004 [cited 2013 May 27];329:1013-16. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC524553/
- Montgomery K. How doctors think: clinical judgment and the practice of medicine. Oxford: Oxford University Press; 2006.
Glossary
Tacit knowledge: intuitive knowledge or know how which is rooted in experience and practice. It resides in the mind of the practitioner and is hard to communicate. It is passed along through socialization and mentoring. As opposed to explicit knowledge which is codified knowledge found in documents and databases. From: http://www.knowledge-management-tools.net/different-types-of-knowledge.html
Ethnography: The study and systematic recording of human cultures. See http://www.merriam-webster.com/dictionary/ethnography for further descriptions
how do I...use quick Synch service?
Written by Kristyn Hall, MSc, RD PEN eNews Editor and Social Media Lead
The benefits of bariatric surgery in carefully selected patients outweigh the risks associated with the procedure – right? Vitamin C and B complex vitamin supplements have demonstrated positive effects on secondary prevention of CVD – so I should recommend them to my clients, shouldn’t I?
Between monitoring electronic journal table of contents, daily scanning of nutrition headlines, using the knowledge that I need in my daily work, staying on top of peripheral nutrition areas that I should know as a dietitian, and actually working, I often feel time-crunched to fit in any extra professional development! When I first heard about the Quick Synch Service (QSS), I nearly jumped for joy – now, I can hot-synch my brain, just like my smart phone with this online professional development tool.
QSS is a Dietitians of Canada professional development service offering short (1-2 hours) learning modules from information contained within Practice-based Evidence in Nutrition (PEN).
Each module is structured to enhance learning and build your professional practice portfolio using quick and easy access to evidence-based, authoritative practice guidance.
A QSS orientation document is provided to subscribers so they can effectively and efficiently use QSS. Module navigation is made simple with a navigation bar, allowing users to move throughout the module.
Using IDNT as an organizing principle, each QSS module provides:
- Background, providing supplemental reading and resources.
- A PEN Tool Kit
- Opportunity to test your knowledge
- Certificate of completion
Once you have reviewed the topic Background, Tool Kit and other support tools, you can access a self-administered quiz to evaluate your knowledge and comprehension of the information. You will receive immediate feedback on knowledge gained. QSS also supports self-reflection on what you learned and how you will apply it to your practice. Upon successful completion of the quiz (80% or better), you can print a Certificate of Completion to use in your professional practice portfolio!
QSS modules available include:
- Bariatric Surgery
- Healthy Weights/Obesity – Dietary Supplements
- Cardiovascular Disease – Secondary Treatment
- Child Growth
- Complementary Feeding – Infant Nutrition
- Lactation
- Osteoarthritis
- And more are on their way!
All QSS modules are “PEN approved”. Once purchased, you will have 90 days to complete the module. And, you can return to your module any number of times!
If you are looking for accessible professional development 24 hours a day, 7 days a week, go to www.dietitians.ca/elearning, housed under Learning on Demand. Professional development just got a whole lot easier and more accessible!
* Due to technical difficulties, QSS will likely not be accessible until early July. When they are ready watch for tweets and Facebook postings.
News-making Evidence:
Choline and Cardiovascular Disease
Did you see the latest addition to News-making Evidence? A Canadian newspaper article, Omnivore's Other Dilemma: Eating Meat and the Link Between the Gut's Bacteria and Heart Disease referred to associations noted between choline (either from eggs or from pure phosphatidylcholines) and cardiovascular events from an observational study.
What is PEN’s take on this new research? Login to http://www.pennutrition.com/NewsMakingEvidence.aspx
Insufficient Evidence – Preliminary Findings
It is important to realize that this new study (1) has documented associations. Initially cholesterol was noted to be associated with CVD, but it has gone through actual testing, in randomized controlled trials, to examine whether reducing cholesterol intake actually improves CVD outcomes. Choline and also carnitine (recently found associated with CVD (2)) have not had this proof step yet. So far, a cause-and-effect relationship has not been proven, so this area is worth additional study.In contrast, systematic reviews of randomized controlled trials indicate that CVD risk in men can be reduced by reducing saturated fat intake with partial replacement by unsaturated fat, and the mechanism is likely through the effects of these changes on serum cholesterol and triglycerides (3). Of importance, the reduction of serum cholesterol using statins reduces all-cause mortality, CVD events, and revascularisations, and stroke (4). This evidence together provides confidence that serum cholesterol is a true risk factor for CVD. This level of evidence is not yet available for choline and carnitine as risk factors for these diseases, and so these factors should be considered at the hypothesis stage at this point. Thus, like the dietitian who wrote the article, we conclude that these are preliminary findings and thus, the evidence is not sufficient to recommend dietary changes based on this preliminary work.
Do you have an article or book analysis that you have completed that you would like to share? Email us at: eNews@pennutrition.com
Written by Dr Tanis Fenton RD, PhD
PEN Evidence Analyst
References
- Tang WH, Wang Z, Levison BS, Koeth RA, Britt EB, Fu X, et al. Intestinal microbial metabolism of phosphatidylcholine and cardiovascular risk.N Engl J Med. 2013 Apr [cited 2013 May 2];368(17):1575-84. Abstract available from: http://www.ncbi.nlm.nih.gov/pubmed/23614584
- Koeth RA, Wang Z, Levison BS, Buffa JA, Org E, Sheehy BT, Britt EB, et al. Intestinal microbiota metabolism of l-carnitine, a nutrient in red meat, promotes atherosclerosis. Nat Med. 2013 Apr [cited 2013 May 2]. Abstract available from: http://www.ncbi.nlm.nih.gov/pubmed/23563705
- Hooper L, Summerbell CD, Thompson R, Sills D, Roberts FG, Moore HJ, et al. Reduced or modified dietary fat for preventing cardiovascular disease. Cochrane Database Syst Rev. 2012 May [cited 2013 May 2]16;5:CD002137. Abstract available from: http://www.ncbi.nlm.nih.gov/pubmed/22592684
- Taylor F, Huffman MD, Macedo AF, Moore TH, Burke M, Davey Smith G, et al. Statins for the primary prevention of cardiovascular disease. Cochrane Database Syst Rev. 2013 Jan [cited 2013 May 2];31;1:CD004816. Abstract available from: http://www.ncbi.nlm.nih.gov/pubmed/23440795
student corner
Updating a Knowledge Pathway and gaining a wealth of knowledge along the way
Lindsay Thompson, Dietetic Intern
Saskatoon Health Region Dietetic Internship - 2013
Saskatoon Health Region Dietetic Internship - 2013
The project had two objectives. The first was to gain experience in research methods by completing an extensive literature review, critically appraising the scientific evidence, and synthesizing the evidence into key practice points. We started this process by meeting individually with some experts in the area of search strategies – librarians of the Saskatoon Health Region. I thought I had a pretty good idea about how to search for evidence through the different databases like Ovid MEDLINE and PubMed, but it became clear quite quickly that there was much I did not know. Critically appraising the studies and reviews was another learning need I identified quickly. Although I had always understood that not everything in print can be trusted, a more critical evaluation of the literature was a perspective I did not have much experience with. It is something that has taken practice.
The second objective was to learn about the efficacy and safety of various strains of probiotics used in various disease states and health situations. The questions I was responsible for included the efficacy of probiotics in the treatment of inflammatory bowel disease, both ulcerative colitis and Crohn`s disease, as well as the treatment and prevention of pouchitis, and constipation in both adults and children.
Among other learning, what I enjoyed most of this research project was the practical application of knowledge as a result of the research. Being able to see the entire process - the numerous studies and systematic reviews from which the evidence was derived, and how that evidence is then translated into bite-sized key practice points from which health professionals can draw recommendations - was interesting. Being able to contribute to that process was rewarding.
It has been an exciting and challenging journey to come from where we started. This project was a great opportunity to work with a nutrition information network like PEN that serves to support dietitians and other health professionals. I have a much better understanding – and respect – for PEN and all of its contributors. I was able to learn what PEN has to offer and as a result I now have a great resource to use to my advantage moving forward in my career!
Need a writing opportunity for nutrition students? Want to share an innovative way you use PEN to support student learning? Why not get the student to write it up for PEN eNews! For article guidelines, email us at eNews@pennutrition.com.
Introducing…Social Media Corner
Throughout all issues in PEN eNews Volume 2, we were fortunate to have been able to share the thought leadership offered from the Dietitians Association of Australia on how dietitians can professionally use social media. We received positive feedback from our readers on this topic.
We have found that social media provides a real-time opportunity to interact with our followers and readers and because of this, we have created a new section, Social Media Corner, in PEN eNews. The purpose of Social Media Corner is to share, with our PEN eNews readers, some of what we are hearing through interacting with our social media followers.Twitter Followers - we have created a new hashtag, #pennutrition, which we would invite you to follow and use when tweeting about evidence-based dietetic practice. Dietitians need to be able to offer credible opinions on current topics in nutrition. While our responses may not be what sensationalists are looking for, as our colleagues from the British Dietetic Association have coined, consumers trust a dietitian to know about nutrition.
PEN has three social media accounts to help you connect with dietitians from around the world around evidence-based dietetic practice. Like us on Facebook (1828 do already) , follow us on Twitter @pennutrition (1784 do already) and connect with us on LinkedIn (join your 759 colleagues) , all of which provide forums to continue the conversation about evidence-based dietetic practice. If you prefer to send us feedback by email, you can reach us at: eNews@pennutrition.com. We look forward to continuing the conversation in whatever media you prefer!
Written by: Kristyn Hall, RD, MSc
PEN Social Media Lead
Announcements from PEN
Congratulations to the PEN team!
PEN has been accepted for a poster presentation at IUNS (International Union of Nutritional Sciences) 20th International Congress of Nutrition taking place in Granada (Spain), September 15-20, 2013. We will be represented by Annette Byron from the Dietitians Associaiton of Australia. Title of the poster: PEN – The Global Resource for Nutrition Knowledge Translation http://www.iuns.org/
This abstract was also chosen for a poster presentation at the 2013 Cochrane Colloquium in Quebec City, Quebec. This will be presented by Beth Armour, PEN Content Manager. The focus for this year’s Colloquium is “Better Knowledge for Better Health” and how evidence informs health care decisions from patients, to practitioner, to organization and government. http://colloquium.cochrane.org/colloquium-2013
These two opportunities allow us to showcase dietitians as evidence-based practitioners to international, multi-disciplinary audiences. Congratulations!
7 Reasons why you want to attend the Dietitians New Zealand 2013 conference, ‘Increasing the Voice, Impacting the Future’ September 1-4:
- It meets the voiced interests and needs of New Zealand Dietitians
- It is held at the heart of the very vibrant Auckland City
- Unravel the concept of organisational change management with renowned expert Dr Rosalie Boyce
- Get the best out of your profession under the guidance of Sylvia Escott-Stump, distinguished dietitian and Past President at the Academy of Nutrition and Dietetics
- Engage with your audience via social media with Emma Stirling, Accredited Practising Dietitian, health writer and blogger
- Challenge your thinking of innovative ways to improve health and wellbeing with Frances Guyett, CEO of the Health Innovation Hub who has 20 years of international experience
- Discover recent information and practical skills on wide-ranging topics such as food intolerances, cultural competency, nutrigenomics, dementia, food service, consumer behaviour, scientific updates, how to write for PEN and much more
Early bird registration closes on the 19th of July. For more information and to get registered, visit http://dietitians.org.nz/conferences/dietitians-nz-2013-conference/
40 PEN PETs Have been Unleashed
Have you looked at the new PETs (Practice-based Evidence Toolkits)? The information within each PET is broken down into accessible chunks of information, with separate Nutrition Care Process sections, as shown in this article’s image. While exploring a PEN PET, be sure to explore the Toolkit Table of Contents on the right hand side of the screen. There is succinct practice-guidance contained within each section of the PEN PET.
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.
We would love to hear what you think. Take the PEN PETs survey: http://fluidsurveys.com/surveys/dietitians-of-canada/pen-pets-survey/
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 stories!
Articles should be ~ 350 words and include a
- Strong headline/article title
- Opportunity for multi-media – include a photo or link to a video
- Main points/body of article + article teaser/lead-in
- Resources/links
- Call to action.
To view sample articles, go to http://www.pennutrition.com/enews.aspx?id=9#102
For an article writing template, please contact us at: eNews@pennutrition.com. We look forward to hearing about dietetic / nutrition student and dietetic intern experiences!
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PEN eNews
June 2013 ·
Volume 3
(1)
June 2013 ·
Volume 3
(1)
A Publication of the PEN System Global Partners,
a collaborative partnership between International Dietetic Associations.
Copyright Dietitians of Canada. All Rights Reserved.