MNT: Gastrointestinal Disorders (2015
Mahadev S, Simpson S, Lebwohl B, Lewis SK, Tennyson CA, Green PHR. Is dietitian use associated with celiac disease outcomes? Nutrients, 2013; 5: 1,585-1,594.PubMed ID: 23676548
- 18 years of age or older
- Diagnosis of biopsy-proven celiac disease
- Affiliated Celiac Disease Center of Columbia University or celiac support group conferences in Iowa, California and New York
- Survey complete with gender, age and dietitian use information.
- Less than 18 years of age
- No diagnosis of celiac disease
- Incomplete survey.
- Patients affiliated with Columbia University Medical Center, recruited by email and at office visits
- Recruited at celiac support group conferences in Iowa, California and New York.
- Adults with celiac disease completed a survey online or on paper between November 2010 and July 2011
- Prior to distributions, the questionnaire was administered to a group of 10 patients and subsequently modified for clarity
- The survey consisted of questions on demographics, celiac disease onset, symptoms and dietitian use, along with three validated celiac disease-specfic instruments to assess quality of life [Celiac disease-specific quality of life instrument (CD-QOL)], disease activity (Celiac Symptom Index) and GFD adherence [Celiac Disease Dietary Adherence Test (CDAT)] respectively
- Patients were asked how many times they had seen a dietitian: Never, once or more than once
- Patients were excluded from the analysis if they did not have biopsy-proven celiac disease or omitted gender, age or dietitian use.
- Univariate analysis used to identify associations between demographics, dietitian use and CD-QOL, CSI and CDAT
- Chi-square and Fisher exact tests were used to compare proportions of categorical variables
- Mann-Whitney U-test used to compare continuous variables
- Logistic regression performed to develop a multi-variate model identifying variables predictive of three outcomes, as determined by validated scores: Poor quality of life, high symptom activity and poor adherence
- Two-sided P-values of <0.05 were considered significant.
Timing of MeasurementsSurvey with all questions and instruments conducted once for each patient.
- Celiac disease onset
- Dietitian use
- Quality of life measured using the validated celiac disease-specific quality of life instrument (CD-QOL); membership in the lowest quartile of CD-QOL was taken to indicate poorer quality of life
- Celiac disease-specific symptom severity measured by Celiac symptom index; cutoff score of at least 35 (suggestive of ongoing disease) used to dichotomize patients
- Adherence to GFD assessed by validated Celiac Disease Dietary Adherence Test (CDAT); scores of at least 13 were taken to be indicative of poor adherence.
413 patients (319 female, 94 male).
Attrition (Final N)
- 18 to 30 years: 80 patients
- 31 to 40 years: 67 patients
- 41 to 50 years: 75 patients
- 51 to 60 years: 93 patients
- 61 to 70 years: 67 patients
- Over 70 years: 31 patients.
Other Relevant DemographicsEducational level
- High school or less: 10% of patients
- College: 48% of patients
- Graduate school: 40% of patients.
AnthropometricsMean body mass index: 24.1kg/m2.
- 49% of patients reported atypical symptoms of fatigue, anemia or osteoporosis; 40% reported classical diarrhea-predominant symptoms; 8% reported no symptoms
- Most patients' symptoms were improved (70%) or somewhat improved (13%) with GFD
- Median time since diagnosis was five to 10 years
- Median delay from onset of symptoms to diagnosis was also five to 10 years.
- 326 (79%) reported having seen a dietitian, with 161 (39%) only having seen a dietitian once
- 40% of patients agreed with the statement "It is hard to find a dietitian knowledgeable about GFD."
- 46% of patients reported gaining weight since starting GFD
- No significant difference in BMI between patients who had and had not seen a dietitian (24.0 vs. 25.6, P=0.45).
- Dietitian use was not associated with CD-QOL, CDAT or CSI on univariate analysis
- Multivariate analysis identified two covariates associated with low CD-QOL, indicative of poor quality of life: A long delay (more than 10 years vs. less than one year) from symptom onset to CD diagnosis (OR, 3.92; 95% CI, 1.45 to 0.63) and underweight vs. normal weight (OR, 3.46; 95% CI, 1.12 to 10.68)
- Advanced age (over 60) and time since diagnosis (more than 10 years vs. less than one year) were protective for disease activity measured by CSI (OR, 0.35; 95% CI, 0.17 to 0.71 and OR, 0.34; 95% CI, 0.13 to 0.87, respectively)
- Dietitian use was not associated with CD-QOL, CSI or CDAT scores on multivariate analysis.
Mean Validated Scores and Use of a Dietitian
Multivariate Analysis of Factors Associated with Low Celiac Disease Quality of Life (CD-QOL), High CD Symptom Index (CSI) and High CD Adherence Test (CDAT)
|OR||95% CI||OR||95% CI||OR||95% CI|
|Seen a Dietitian||1.49||0.68-3.24||0.86||0.45-1.63||0.85||0.47-1.55|
Advanced Age (>60)
Time Since Diagnosis
|Underweight vs. Normal Weight||3.46||1.12-10.68||2.52||0.79-8.04||1.9||0.66-5.51|
|Overweight vs. Normal Weight||1.31||0.62-2.75||0.6||0.31-1.16||0.66||0.36-1.21|
|Obese vs. Normal||0.86||0.33-2.23||0.75||0.32-1.76||0.65||0.29-1.46|
- In this survey of patients with celiac disease, more than 20% of respondents had never seen a dietitian and 39% saw a dietitian only once
- Dietitian follow-up fell short of published guidelines, which may relate to insurance access issues
- Dietitian exposure was not associated with symptom severity, adherence or quality of life, while delay of diagnosis was associated with poorer quality of life
- Further prospective analysis is needed to evaluate the benefits and cost-effectiveness of dietitian referral in the care of patients with celiac disease.
|Other:||No funding sources were used|
Quality Criteria Checklist: Primary Research
|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|
|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?||No|
|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)||Yes|
|3.2.||Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline?||Yes|
|3.3.||Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.)||Yes|
|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?||Yes|
|4.1.||Were follow-up methods described and the same for all groups?||Yes|
|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%.)||Yes|
|4.3.||Were all enrolled subjects/patients (in the original sample) accounted for?||Yes|
|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?||No|
|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?||No|
|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?||Yes|
|6.4.||Was the amount of exposure and, if relevant, subject/patient compliance measured?||Yes|
|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?||Yes|
|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?||Yes|
|7.6.||Were other factors accounted for (measured) that could affect outcomes?||Yes|
|7.7.||Were the measurements conducted consistently across groups?||Yes|
|8.||Was the statistical analysis appropriate for the study design and type of outcome indicators?||Yes|
|8.1.||Were statistical analyses adequately described and the results reported appropriately?||Yes|
|8.2.||Were correct statistical tests used and assumptions of test not violated?||Yes|
|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)?||Yes|
|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|