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Recommendations Summary

CD: Medical Nutrtion Theapy (2021)

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.


  • Recommendation(s)

    CD: Medical Nutrition Therapy to Improve Outcomes

    In all individuals with celiac disease, it is reasonable for a registered dietitian nutritionist or an international equivalent to collaborate with individuals with celiac disease, their families, and interdisciplinary healthcare teams to design individualized medical nutrition therapy based upon the individual’s overall health and nutritional status, personal preferences, psychological and psychosocial factors, and physiological needs. Medical nutrition therapy for individuals with celiac disease should focus on comprehensive nutrition assessment and appropriate interventions, including individualized modification of diet, to maintain or improve nutrition status, and monitoring over time.

    Rating: Consensus
    Imperative

    • Risks/Harms of Implementing This Recommendation

      • There are no obvious risks or harms associated with medical nutrition therapy.
      • There can be issues with finding a specialized registered dietitian nutritionist for celiac disease, in addition to challenges with long-term follow-up in clinics for both patients and families.
      • There may be time constraints and monetary requirements to implementing medical nutrition therapy suggestions. Gluten-free food availability may be a challenge in some geographical areas.
      • There may be psychological concerns or anxiety regarding consumption of gluten-free foods or contamination of gluten.

    • Conditions of Application

      Medical nutrition therapy (MNT) approach should be individualized according to client needs. Some might require more intensive nutrition care in order to manage nutrition status and co-morbidities.

      In cases of individuals or clients residing in rural areas or having decreased access to insurance or challenges with transportation to medical care, the registered dietitian nutritionist should work on providing feasible solutions like telephone or virtual appointments when necessary.

      Implementation Considerations:

      • Consider providing educational materials in advance of scheduled education
      • Consider assisting with developing patient goals
      • Provide a list of resources
      • Consider keeping a log or diary of where gluten-free products are available.
      • Consider using various forms of educational aids to teach the learning style of the individual.
      • Provide guidance when eating away from home (restaurants, other people’s homes, school).
      • MNT may be delivered through telehealth options, in order to improve patient education and successful maintenance of nutrition interventions and adherence.
      • Refer to the Nutrition Care Manual for Client Education documents for Education on Gluten-Free Nutrition Therapy, Label reading tips, and healthy eating tips. https://www.nutritioncaremanual.org/client_ed.cfm?ncm_client_ed_id=162

    • Potential Costs Associated with Application

      Although costs of medical nutrition therapy sessions (MNT) and the level of reimbursement vary, MNT sessions are essential for improved outcomes. The cost of MNT depends on access to a registered dietitian nutritionist, the employment place of the registered dietitian nutritionist, and insurance reimbursement. Insurance reimbursement policies vary from state to state and can lead to sub-optimal quality of care and consequently, health inequities and disparities. However, MNT associated costs are markedly less than the costs associated with celiac disease complications that may result from non-adherence to a strict gluten-free diet.  

    • Recommendation Narrative

      A total of eight studies were examined that explored the effects of medical nutrition therapy (MNT), compared to a control, on nutrition-related outcomes in patients with celiac disease. Three neutral-quality randomized controlled trials (Haas et al, 2017; Ring Jacobbson et al, 2012; Sainsbury et al, 2013), three neutral-quality cross-sectional studies (Cheng et al, 2010; Mahadev et al, 2013; Muhammad et al, 2017) and two neutral quality cohort studies (Johansson et al, 2019; Rajpoot et al, 2015) were included. Three included studies were conducted in the United States, one was conducted in Australia, one was conducted in India and three were conducted in Europe (two in Sweden and one in the United Kingdom). Six studies included adults with celiac disease and two studies included children with celiac disease as their target population. Sample sizes of participants analyzed ranged from 30-224 per group (some studies included additional participant groups not considered for this review). All intervention groups investigated the effect of medical nutrition therapy, or nutrition counseling provided by a registered dietitian nutritionist, compared to a control, on nutrition-related outcomes among patients with celiac disease. 

      Of the studies that examined the effects of medical nutrition therapy, compared to a control, on nutrition related outcomes in patients with celiac disease, one reported on nutrition-related laboratory measures (Rajpoot et al, 2015). Three studies (Cheng et al, 2010; Mahadev et al, 2013; Rajpoot et al, 2015) reported on anthropometrics. Four studies (Mahadev et al, 2013; Rajpoot et al, 2015; Ring Jacobsson et al, 2012; Sainsbury et al, 2013) reported on indicators of quality of life. Six studies (Haas et al, 2017; Johansson et al, 2019; Mahadev et al, 2013; Muhammad et al, 2013; Rajpoot et al, 2015, Sainsbury et al, 2013) reported on adherence to a gluten-free diet. Three studies (Mahadev et al, 2013; Rajpoot et al, 2015; Ring Jacobsson et al, 2012) reported on indicators of gastrointestinal health and gastrointestinal symptoms.

      Results Overview
      The effects of medical nutrition therapy, compared to a control, on nutrition-related laboratory measures among patients with celiac disease is inconclusive. One study (Rajpoot et el, 2015) concluded that there was a significant improvement in mean hemoglobin and serum albumin among both groups who received dietary counseling by a registered dietitian nutritionist, even though one group received one more counseling session than the other. 

      The effect of medical nutrition therapy on anthropometrics among patients with celiac disease in comparison to a control unclear. While Mahadev et al, 2013 concluded that there was no significant difference in BMI between celiac patients who had received treatment from a registered dietitian nutritionist and patients who had not, Cheng et al, 2010 found that the length of follow-up with a registered dietitian nutritionist was associated with BMI class, and that among the underweight groups, increasing follow-up years was associated with an increase in BMI. Additionally, Rajpoot et al 2015, concluded that both treatment-naïve and follow-up groups that received nutrition counseling from a registered dietitian nutritionist experienced a significant improvement in weight from baseline to 6 months.

      The effect of medical nutrition therapy on indicators of quality of life among patients with celiac disease in comparison to a control is unclear. While Ring Jacobsson et al, 2012 concluded that participants in a 10-week ‘Celiac School’ experienced significant improvements in well-being, self-control and general health scores in comparison to those who received information via mail, Sainsbury et al, 2013 found that there was no impact on measures of quality of life when patients who took part in a dietitian-involved theory-based intervention were compared to a waitlist control. Additionally, Mahadev et al, 2013 determined that patients who reported receiving treatment from a registered dietitian nutritionist did not have significantly different scores in celiac disease quality of life in comparison to patients who reported not receiving treatment from a registered dietitian nutritionist. However, Rajpoot et al, 2015 concluded that both treatment-naïve and follow-up patients who received 6-months of nutrition counseling from a registered dietitian nutritionist experienced significant improvements in self-reported general health from baseline scores. 

      The effect of medical nutrition therapy on gluten free dietary adherence among patients with celiac disease in comparison to a control is unclear. In Sainsbury et al 2013, patients who took part in a dietitian-involved theory-based intervention reported significant improvements in gluten-free diet adherence in comparison to a waitlist control. Rajpoot et al, 2015, both treatment-naïve and follow-up patients who received 6-months of nutrition counseling from a registered dietitian nutritionist, experienced a significant improvement in the number of patients who reported good or excellent dietary adherence. These findings align with those of Muhammad et al 2017, which concluded that, among adult celiac disease patients, those who reported not understanding food labels also were more likely to report poorer gluten-free diet adherence. However, Mahadev et al 2013, found that dietitian usage was not associated with dietary adherence. Johansson et al, 2019 also concluded that, when patients who received care from either a dietitian or a pediatrician, dietary compliance was similar regardless of who provided treatment. Finally, Haas et al, 2017 found that, when comparing a group who participated in a text message intervention with dietitian involvement to a group who received standard outpatient consultation with a physician, there was no significant difference in TTG IgA or DGP IgA as an indicator of dietary compliance.

      The effect of medical nutrition therapy on indicators of gastrointestinal health and gastrointestinal symptoms among patients with celiac disease is unclear. While Ring Jacobsson et al, 2012 concluded that participants in the 10-week ‘Celiac School’ experienced significant improvements in gastrointestinal symptoms related to abdominal pain, Mahadev et al 2013, found that dietitian usage was not associated with celiac disease symptoms. However, Rajpoot et al, 2015 concluded that among both treatment-naïve and follow-up patients who received 6-months of nutrition counseling from a registered dietitian nutritionist experienced a significant improvement in celiac symptoms from baseline.

    • Recommendation Strength Rationale

      The evidence supporting the recommendation is based on Grade III /Grade C evidence. 

    • Minority Opinions

      Consensus reached.