DLM: Referral to a Registered Dietitian for Medical Nutrition Therapy (MNT) 2005
Click here to see the explanation of recommendation ratings (Strong, Fair, Weak, Consensus, Insufficient Evidence) and labels (Imperative or Conditional). To see more detail on the evidence from which the following recommendations were drawn, use the hyperlinks in the Supporting Evidence Section below.
DLM: MNT and Referral to a Registered Dietitian
Referral to a registered dietitian for Medical Nutrition Therapy (MNT) is recommended whenever an individual has an abnormal lipid profile, based on ATPIII Risk category and LDL-C goals, or has CHD. A planned initial visit lasting from 45-90 minutes and at least two to six planned follow-up visits (30-60 minutes each, with an RD) can lead to improved dietary pattern; improved lipid profile; reduced plasma total cholesterol, LDL-C, and triglycerides; and improved weight status.
DLM: MNT Number and Duration of Visits
The number and duration of visits in the course of Medical Nutrition Therapy will need to be greater if the client is in a higher risk category, if there is a large number of Therapeutic Lifestyle Changes (TLC) that need to be made, and if the individual is not motivated to make TLC changes. Increasing the number of visits and length of time spent with a dietitian can improve serum lipid levels and CVD risk.
DLM: Lipid-Lowering Medication Re-evaluation
Re-evaluate the dosage and necessity of lipid-lowering medications throughout the course of Medical Nutrition Therapy. Medical Nutrition Therapy may successfully improve the lipid levels to the point where medication doses can be lowered or discontinued.
Risks/Harms of Implementing This Recommendation
Conditions of Application
Potential Costs Associated with Application
- Seven studies (four RCT, two retrospective chart reviews, and one nonrandomized trial with use of historic controls) describe individualized Medical Nutrition Therapy that results in improved cardioprotective dietary pattern changes and/or subsequent plasma lipid changes, thereby decreasing cardiac heart disease risks. Reductions in total fat and saturated fat intake were seen in three studies (two high- and one neutral-quality). Decreases in TC and LDL-C were reported in five studies (three high- and two neutral-quality). Three of these studies found reductions in body weight. Four studies looked at the impact on TG and HDL-C and found varying results.
- Two studies (one neutral-quality retrospective chart review and one neutral-quality RCT) found that decreases in total cholesterol correlated with time spent with a dietitian. A third high-quality RCT found that individuals who went to three or four MNT sessions had lower LDL-C compared to those that attended fewer than three sessions.
- Two retrospective chart reviews (one high- and one neutral-quality) found that MNT obviated the need for lipid-lowering medications in some patients
- One study identified a trend that the dietitian group had lower attrition compared to the control group (MD counseling), possibly indicating preferences for services provided by a dietitian.
Recommendation Strength Rationale
Studies were of a variety of populations. Studies represented individuals (21-75 years of age) who had ischemic heart disease, hypercholesterolemia, hyperlipidemia (high LDL-C), combined hyperlipidemia (high LDL-C and TG), or hypertriglyceridemia; but excluded familial hypertriglyceridemia (FH).
Sufficient time was provided to see outcomes (six weeks was the shortest intervention, with the longest intervention lasting more than six months).
Consistent findings across a variety of study designs.
Conclusion statements were Grade I, III and V.
- Risks/Harms of Implementing This Recommendation
The recommendations were created from the evidence analysis on the following questions. To see detail of the evidence analysis, click the blue hyperlinks below (recommendations rated consensus will not have supporting evidence linked).
In patients with disorders of lipid metabolism, does medical nutrition therapy (MNT) given by a registered dietitian result in changes in levels of dietary fat, saturated fat, serum cholesterol, and cardiac risk factors?
Do additional medical nutrition therapy (MNT) visits with a registered dietitian (RD) result in further reductions in total and LDL cholesterol in adults?
(2005) What is the optimal duration and frequency of follow-up visits for an adult patient by a registered dietitian using medical nutrition therapy (MNT)?
In patients with disorders of lipid metabolism, does MNT result in reduced need for lipid lowering medications?
Dalgard et. al. Saturated fat intake is reduced in patients with ischemic heart disease 1 year after comprehensive counseling but not after brief counseling. J Am Diet Assoc.. 2001;101:1420-1424, 1429.
Dallongeville J, Leboeuf N, Blais C, Touchette J, Gervais N, Davignon J. Short-term response to dietary counseling of hyperlipidemic outpatients of a lipid clinic. JADA. 1994;94:616-621.
Delahanty LM, Sonnenberg LM, Hayden D, Nathan DM. Clinical and cost outcomes of medical nutrition therapy for hypercholesterolemia: A controlled trial. J Am Diet Assoc. 2001 Sep; 101(9): 1,012-1,023.
Elson RB, Splett PL, Bostick RM, Aeppli D, Haberman M. Dietitian practices for adult outpatients with hypercholesterolemia referred by physicians. The Minnesota Dietitians Survey. Arch Fam Med. 1994; 3: 1,073-1,080.
Geil P, Anderson JW, Gustafson NJ. Women and men with hypercholesterolemia respond similarly to an American Heart Association step 1 diet. JADA. 1995; 95: 436-441.
Hebert JR, Ebbeling CB, Ockene IS, Ma Y, Rider L, Merriam PA, Ockene JK, Saperia G. A dietitian-delivered group nutrition program leads to reductions in dietary fat, serum cholesterol and body weight: The Worcester area trial for counseling in hyperlipidemia (WATCH). J Am Diet Assoc. 1999; 99: 544-552.
Henkin Y, Shai I, Zuk R, Brickner D, Zuilli I, Neumann L, Shany S. Dietary treatment of hypercholesterolemia: Do dietitians do it better? Am J Med. 2000: 109: 549-555.
McGehee MM, Johnson EQ, Rasmussen HM, Salryoun N, Lynch MM, Carey M. Benefits and costs of medical nutrition therapy by registered dietitians for patients with hypercholesterolemia. JADA. 1995; 95: 1,041-1,043.
Plous S, Chesne RB, McDowell AV. Nutrition knowledge and attitudes of cardiac clients. JADA. 1995; 95: 442-446.
Prosser LA, Stinnett AA, Goldman PA, Williams LW, Hunink MGM, Goldman L, Weinstein MC. Cost-effectiveness of cholesterol-lowering therapies according to selected patient characteristics. Ann Intern Med. 2000; 132: 769-779.
Sheils JF, Rubin R, Stapleton DC. The estimated costs and savings of medical nutrition therapy: The Medicare population. J Am Diet Assoc. 1999; 99: 428-435.
Sikand G, Kashyap ML, Yang I. Medical nutrition therapy lowers serum cholesterol and saves medication costs in men with hypercholesterolemia. JADA. 1998; 98: 889-894.
Sikand G, Kashyap ML, Wong ND, Hsu JC. Dietitian intervention improves lipid values and saves medication costs in men with combined hyperlipidemia and a history of niacin noncompliance. JADA. 2000; 100: 218-224.
Thompson RL, Summerbell CD, Hooper L, Higgins JPT, Little PS, Talbot D, Ebrahim S. Dietary advice given by a dietitian versus other health professional or self-help resources to reduce blood cholesterol (Cochrane Review). In: The Cochrane Library, Issue 3, 2004. Chichester, UK: John Wiley & Sons, Ltd.