Nutrition Support Blog: Nutrition Support Guidelines
May 17, 2012
Imagine that you are lost, at a crossroads and your phone/GPS does not work (Egads!) when you happen along a stranger. The stranger readily admits that he has no idea which of the 3 roads in front of you is the correct way, but then the stranger points to a road and says, “go that way.” It would be hard to put a lot of faith into that recommendation, wouldn’t it?
Now, if this were a movie and the stranger was sporting a wizard’s hat, nifty staff and ZZ Top beard, then it might be wise to heed his advice. However, in the real world people are rarely gifted with supernatural insight, and a recommendation that is not based on good information can lead you astray as often as it helps. In the world of nutrition support, we often don’t have great information, and because of this lack of data, we are not always sure about the best way to get our patients where they need to go (healthy and home). Frequently the information we do have is incomplete, conflicting and as hard to sort out as an old map.* (* see below)
Regularly, teams of clinicians who have seen and done much are called on to try to make some sense out of the limited information available (“handed down intelligence”). Often, for some topics, there is such limited, or poor quality evidence, that it is hard to make any kind of recommendation at all. Nevertheless, because there is such a demand for some guidance, these teams of experts will make a recommendation (“go that way”) and then qualify their recommendation by stating that it is a low quality, weak, or expert-opinion recommendation. Compounding the difficulty is the fact that frequently these experts have a different interpretation of the available data, and they must compromise on a recommendation they can all live with.
It is not particularly surprising that at times different teams of learned and admirable experts arrive at different conclusions, even while scrutinizing the same research. What is surprising, perhaps, is that some clinicians will read the guidelines, take note of the fact that the world’s experts decried the sorry state of available research, but then feel uncomfortable deviating from a weak recommendation.
Clinicians have a responsibility to be able to differentiate between strong recommendations based on robust data, and suggestions based on very limited information. We also have an obligation to our patients to identify when the individual clinical circumstances or history are so unlike the original data that the guidelines may not apply. Knowing the methods, exclusion criteria and limitations of the original research is like having a map* so that you can get your patient where they need to go.
*map: for younger folks, a map in this context does not stand for “mean arterial pressure.” A map is an ancient device that was like a GPS that was printed on paper and never needed batteries…but was hard to fold, especially while driving. Before cell phones and GPS, the reading or folding of maps while driving (or watching your spouse try to read or fold a map while driving) was a common Darwin-tempting experience.
“...for advice is a dangerous gift, even from the wise to the wise, and all courses may run ill.”
- J. R. R. Tolkien
“I know what you would say, and it would seem like wisdom, but for the warning in my heart.”
- J.R.R. Tolkien