Recommendation Ratings

Recommendation Ratings

Academy Evidence-Based Nutrition Practice Guidelines published on the EAL are assigned a rating of: strong, fair, weak, consensus, or insufficient evidence based on the following criteria.

Criteria for Recommendation Ratings   

Statement
Rating		 Definition Implication for Practice
Strong A Strong recommendation means that the workgroup believes that the benefits of the recommended approach clearly exceed the harms (or that the harms clearly exceed the benefits in the case of a strong negative recommendation), and that the quality of the supporting evidence is excellent/good (grade I or II).* In some clearly identified circumstances, strong recommendations may be made based on lesser evidence when high-quality evidence is impossible to obtain and the anticipated benefits strongly outweigh the harms. Practitioners should follow a Strong recommendation unless a clear and compelling rationale for an alternative approach is present.
Fair A Fair recommendation means that the workgroup believes that the benefits exceed the harms (or that the harms clearly exceed the benefits in the case of a negative recommendation), but the quality of evidence is not as strong (grade II or III).* In some clearly identified circumstances, recommendations may be made based on lesser evidence when high-quality evidence is impossible to obtain and the anticipated benefits outweigh the harms. Practitioners should generally follow a Fair recommendation but remain alert to new information and be sensitive to patient preferences.
Weak A Weak recommendation means that the quality of evidence that exists is suspect or that well-done studies (grade I, II, or III)* show little clear advantage to one approach versus another. Practitioners should be cautious in deciding whether to follow a recommendation classified as Weak, and should exercise judgment and be alert to emerging publications that report evidence. Patient preference should have a substantial influencing role.
Consensus A Consensus recommendation means that Expert opinion (grade IV) supports the guideline recommendation even though the available scientific evidence did not present consistent results, or controlled trials were lacking. Practitioners should be flexible in deciding whether to follow a recommendation classified as Consensus, although they may set boundaries on alternatives. Patient preference should have a substantial influencing role.
Insufficient
Evidence		 An Insufficient Evidence recommendation means that there is both a lack of pertinent evidence (grade V)* and/or an unclear balance between benefits and harms. Practitioners should feel little constraint in deciding whether to follow a recommendation labeled as Insufficient Evidence and should exercise judgment and be alert to emerging publications that report evidence that clarifies the balance of benefit versus harm. Patient preference should have a substantial influencing role.
Recommendations are categorized in terms of either imperative or conditional statements.
  • Imperative statements are broadly applicable to the target population and do not impose restraints on their pertinence. Imperative recommendations may include terms such as “should” or “may” and do not contain conditional text that would limit their applicability to specified circumstances.
  • Conditional statements clearly define a specific situation or population. Conditional recommendations are often presented in an if/then format, such that

                                        if CONDITION than ACTION(S) because REASON(S)
Fulfillment of the condition triggers one or more guideline-specified actions.


 
Adapted by the Academy of Nutrition and Dietetics from the American Academy of Pediatrics, Classifying Recommendations for Clinical Practice Guidelines, Pediatrics.       2004;114;874-877s


Recommendations Rating Table in PDF format