Adult Weight Management

AWM: Nutrition Education (2006)


Cavallaro V, Dwyer J, Houser RF, Shores K, Canez I, Hong A, Altman K, Helmick E, Murphy JN. Influence of dietitian presence on outpatient cardiac rehabilitation nutrition services. J Am Diet Assoc, 2004; 104: 611-614.

PubMed ID: 15054347
Study Design:
Cross-sectional study
D - Click here for explanation of classification scheme.
Quality Rating:
Positive POSITIVE: See Quality Criteria Checklist below.
Research Purpose:
To survey outpatient cardiac rehabilitation programs nationwide to describe how the type and amount of nutrition services offered in cardiac rehabilitation programs varied by the presence of an RD.
Inclusion Criteria:
Listed in 1998/1999 Cardiac Rehabilitation Directory of the AACVPR.
Exclusion Criteria:
None specifically mentioned.
Description of Study Protocol:


  • 250 randomly selected centers from 1,111 US outpatient cardiac rehabilitation centers in the 1998/1999 Cardiac Rehabilitation Directory of the American Association of Cardiovascular and Pulmonary Rehabilitation.


  • Cross-sectional study.

Intervention (if applicable)

  • Mailed questionnaire.

Statistical Analysis

  • Data analyzed with SPSS.
Data Collection Summary:

Timing of Measurements

  • Introductory letter and questionnaire mailed to a sample of 250, addressed to program directors. Responses were anonymous. Forms were returned to investigators, postage paid, with separate postcards reporting completion. To increase response rates, two months after the original letter was mailed, a second letter and postcard were sent to all nonresponsive programs.

Dependent Variables

  • The survey instrument was a questionnaire focusing on the nutrition services offered, monitoring, staffing, the role of the RD, perceived importance of nutrition in the cardiac rehab setting, location and setting of the program, the approximate number of patients seen per year and the credentials and title of the respondent. The questionnaire was validated in a preliminary survey conducted on 50 outpatient cardiac rehab programs in Massachusetts in 1999. To improve clarity, some questions were modified.
Description of Actual Data Sample:
  • Initial N: 250 centers randomly selected from 1,111
  • Attrition (final N):  190 surveys returned (76%).  Respondents included nurses (62%), exercise physiologists (26%), RDs (10%), and "other positions" (2%).
  • Age: Not applicable
  • Ethnicity:  Not applicable 
  • Other relevant demographics:  Areas located were urban (40%), rural (32%) and suburban (28%).  Majority of centers were hospital-based (85%); freestanding centers (9%), university-based centers (2%), combinations of the above (4%). 
  • Location:  National sample, 43 states represented.


Summary of Results:


Ways to improve nutrition services


Increase one-on-one counseling with RD 33
More funding for increased hours for RD 23
Offer cooking demonstrations 20
Better monitoring and tracking of outcomes 19
Increase number of classes offered with RD 17
Improve teaching materials 11
Offer grocery store tours


Better insurance coverage


Other Findings

  • 75% of respondents had an RD working in their program. In the majority of centers polled, the RD worked part-time (90%), the mean number of hours worked per week was nine (median =3.5).
  • Respondents reported nutrition services offered by programs polled:
    • Distribution of nutrition pamphlets (99%)
    • One-on-one nutrition counseling (94%)
    • Group nutrition classes (87%)
    • Guest lectures on nutrition (64%)
    • Cooking demonstrations (37%).
  • Cardiac rehabilitation programs with an RD offered significantly more nutrition services, on average (4.2±1.2), than programs without an RD (3.5±1.1, P=0.01).
  • Programs with RDs were more likely to offer one-on-one nutrition counseling than programs without them (98% vs. 80%, respectively, P<0.001) and they were also more likely to offer cooking demonstrations (43% and 17%, respectively, P=0.02).
  • All respondents regarded nutrition in cardiac rehab as highly important, however the programs with an RD rated the role of the RD higher (mean =6.8±1.0) than those without an RD (mean =5.9±1.5 on a scale of zero to eight, with eight being very important, P=0.00).
Author Conclusion:
More, and a greater variety of nutrition services are offered in cardiac rehabilitation programs that have an RD. Without an RD, exercise physiologists and registered nurses often provide some, but fewer and different nutrition services. At present, it seems that the RD is seen as a "food coach" or specialized consultant by some team members or in some outpatient centers, rather than as a part of the broader cardiac wellness team. Dietitians need to market their services so that those who hire and manage personnel in outpatient cardiovascular rehab programs see them as integral parts of their teams.
Funding Source:
Government: Massachusetts Dept. of Public Health
University/Hospital: Tufts University School of Medicine, Laura Hill Inn
Reviewer Comments:
  • High survey response rate of 76%.
  • Questionnaire was validated.
  • National sample.
  • Data analysis not well described.
Quality Criteria Checklist: Primary Research
Relevance Questions
  1. Would implementing the studied intervention or procedure (if found successful) result in improved outcomes for the patients/clients/population group? (Not Applicable for some epidemiological studies) Yes
  2. Did the authors study an outcome (dependent variable) or topic that the patients/clients/population group would care about? Yes
  3. Is the focus of the intervention or procedure (independent variable) or topic of study a common issue of concern to dieteticspractice? Yes
  4. Is the intervention or procedure feasible? (NA for some epidemiological studies) Yes
Validity Questions
1. Was the research question clearly stated? Yes
  1.1. Was (were) the specific intervention(s) or procedure(s) [independent variable(s)] identified? Yes
  1.2. Was (were) the outcome(s) [dependent variable(s)] clearly indicated? Yes
  1.3. Were the target population and setting specified? Yes
2. Was the selection of study subjects/patients free from bias? Yes
  2.1. Were inclusion/exclusion criteria specified (e.g., risk, point in disease progression, diagnostic or prognosis criteria), and with sufficient detail and without omitting criteria critical to the study? Yes
  2.2. Were criteria applied equally to all study groups? Yes
  2.3. Were health, demographics, and other characteristics of subjects described? Yes
  2.4. Were the subjects/patients a representative sample of the relevant population? Yes
3. Were study groups comparable? Yes
  3.1. Was the method of assigning subjects/patients to groups described and unbiased? (Method of randomization identified if RCT) N/A
  3.2. Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline? N/A
  3.3. Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.) N/A
  3.4. If cohort study or cross-sectional study, were groups comparable on important confounding factors and/or were preexisting differences accounted for by using appropriate adjustments in statistical analysis? Yes
  3.5. If case control study, were potential confounding factors comparable for cases and controls? (If case series or trial with subjects serving as own control, this criterion is not applicable.) Yes
  3.6. If diagnostic test, was there an independent blind comparison with an appropriate reference standard (e.g., "gold standard")? N/A
4. Was method of handling withdrawals described? N/A
  4.1. Were follow-up methods described and the same for all groups? N/A
  4.2. Was the number, characteristics of withdrawals (i.e., dropouts, lost to follow up, attrition rate) and/or response rate (cross-sectional studies) described for each group? (Follow up goal for a strong study is 80%.) N/A
  4.3. Were all enrolled subjects/patients (in the original sample) accounted for? N/A
  4.4. Were reasons for withdrawals similar across groups? N/A
  4.5. If diagnostic test, was decision to perform reference test not dependent on results of test under study? N/A
5. Was blinding used to prevent introduction of bias? N/A
  5.1. In intervention study, were subjects, clinicians/practitioners, and investigators blinded to treatment group, as appropriate? N/A
  5.2. Were data collectors blinded for outcomes assessment? (If outcome is measured using an objective test, such as a lab value, this criterion is assumed to be met.) N/A
  5.3. In cohort study or cross-sectional study, were measurements of outcomes and risk factors blinded? N/A
  5.4. In case control study, was case definition explicit and case ascertainment not influenced by exposure status? N/A
  5.5. In diagnostic study, were test results blinded to patient history and other test results? N/A
6. Were intervention/therapeutic regimens/exposure factor or procedure and any comparison(s) described in detail? Were interveningfactors described? Yes
  6.1. In RCT or other intervention trial, were protocols described for all regimens studied? N/A
  6.2. In observational study, were interventions, study settings, and clinicians/provider described? Yes
  6.3. Was the intensity and duration of the intervention or exposure factor sufficient to produce a meaningful effect? N/A
  6.4. Was the amount of exposure and, if relevant, subject/patient compliance measured? N/A
  6.5. Were co-interventions (e.g., ancillary treatments, other therapies) described? N/A
  6.6. Were extra or unplanned treatments described? N/A
  6.7. Was the information for 6.4, 6.5, and 6.6 assessed the same way for all groups? N/A
  6.8. In diagnostic study, were details of test administration and replication sufficient? N/A
7. Were outcomes clearly defined and the measurements valid and reliable? Yes
  7.1. Were primary and secondary endpoints described and relevant to the question? Yes
  7.2. Were nutrition measures appropriate to question and outcomes of concern? Yes
  7.3. Was the period of follow-up long enough for important outcome(s) to occur? N/A
  7.4. Were the observations and measurements based on standard, valid, and reliable data collection instruments/tests/procedures? Yes
  7.5. Was the measurement of effect at an appropriate level of precision? N/A
  7.6. Were other factors accounted for (measured) that could affect outcomes? N/A
  7.7. Were the measurements conducted consistently across groups? N/A
8. Was the statistical analysis appropriate for the study design and type of outcome indicators? ???
  8.1. Were statistical analyses adequately described and the results reported appropriately? ???
  8.2. Were correct statistical tests used and assumptions of test not violated? N/A
  8.3. Were statistics reported with levels of significance and/or confidence intervals? Yes
  8.4. Was "intent to treat" analysis of outcomes done (and as appropriate, was there an analysis of outcomes for those maximally exposed or a dose-response analysis)? N/A
  8.5. Were adequate adjustments made for effects of confounding factors that might have affected the outcomes (e.g., multivariate analyses)? ???
  8.6. Was clinical significance as well as statistical significance reported? Yes
  8.7. If negative findings, was a power calculation reported to address type 2 error? N/A
9. Are conclusions supported by results with biases and limitations taken into consideration? Yes
  9.1. Is there a discussion of findings? Yes
  9.2. Are biases and study limitations identified and discussed? Yes
10. Is bias due to study's funding or sponsorship unlikely? Yes
  10.1. Were sources of funding and investigators' affiliations described? Yes
  10.2. Was the study free from apparent conflict of interest? Yes