Changes in practice with a coeliac disease dietician led clinic over a 30 year period, should we be measuring vitamin D?

Abstract

IntroductionMorbidity surrounding Coeliac disease is usually a consequence of malabsorbtion of minerals and vitamins leading to anaemia and metabolic bone disease. In January 2002 a Dietetic led clinic was introduced at Manchester Royal Infirmary to improve patient care. We conducted an audit to compare the practice of the initial management of Coeliac disease to assess the introduction of the Dietetic led clinic. Practice was compared to the current 2010 BSG guidelines.Methods
We chose 50 cases at random from the dietician led Coeliac clinic, 25 patients were diagnosed prior to 2002 and 25 cases selected after 2002. We focused our audit on the time from diagnosis to 4 years follow up. Date of diagnosis ranged from 1976 to 2010. Age, symptom control, antibody, duodenal pathology, body weight, haemoglobin, vitamin D level, DEXA T and Z scores, fracture history, calcium and bisphosphonate prescriptions were all recorded.ResultsAverage age at diagnosis was similar, 42.5 (SD 19) (pre 2002) and 45.9 years (SD 18.6) (post 2002). Females accounted for 64% and 84% respectively. Antibody results were available in 48% and 76%, positive in 92% and 100% respectively. Diagnostic duodenal biopsies were available in 52% and 84% respectively. Body weight was recorded in 52% and 92% and haemoglobin levels recorded in 56% and 85%. Weight, symptoms and Haemoglobin improved in both groups. Initial bone densitometry was performed in 28% and 64% and repeated at 4 years in 50% and 67% respectively. Bone density reduced slightly over the 4 year follow up. Vitamin D levels were measured in 20% and 50% at the time of diagnosis and levels increased over a 4 year period (pre 2002: 17.8 (SD11.6) to 25.4 (SD 8.8); post 2002: 16.9 (SD 12.6) to 24.3 (SD 10.3)). Bisphosphonates were prescribed appropriately in 33% and 100% in the respective groups. Fractures were present in 10% of all patients.ConclusionA Dietetic led service has led to favourable changes in practice. Disease response measured by symptoms, weight and haemoglobin improved in both groups; in the post 2002 cohort, more data is available and this may indicate improved clinic attendance at the Dietetic led clinic. The fracture incidence of 10% is comparable to the general population incidence, much lower than studies of previous UK and South American Coeliac cohorts. This low fracture incidence may be to be due the judicious use of bone density assessment and treatment with calcium and vitamin D. Vitamin D is not in the BSG 2010 guidelines, the low fracture incidence in this cohort may partly be reflected by the correction of vitamin D levels. This raises questions whether routine measurement vitamin D should be advocated?

Full text

BSG abstracts
Gut April 2011 Vol 60 Suppl I A85
PTU-048 CHANGES IN PRACTICE WITH A COELIAC DISEASE
DIETICIAN LED CLINIC OVER A 30 YEAR PERIOD,
SHOULD WE BE MEASURING VITAMIN D?
doi:10.1136/gut.2011.239301.176
R R Keld,1* E Shutt lewort h,1 S Burden,2 S Camp bell1 1Department of Gastroenterology,
Manchester Royal Infirmary, Manchester, UK; 2Dietetic Department, Manchester
Royal Infirmary, Manchester, UK
Introduction Morbidity surrounding Coeliac disease is usu-
ally a consequence of malabsorbtion of minerals and vitamins
leading to anaemia and metabolic bone disease. In January
2002 a Dietetic led clinic was introduced at Manchester Royal
Infi rmary to improve patient care. We conducted an audit to
compare the practice of the initial management of Coeliac
disease to assess the introduction of the Dietetic led clinic.
Practice was compared to the current 2010 BSG guidelines.
Methods We chose 50 cases at random from the dietician led
Coeliac clinic, 25 patients were diagnosed prior to 2002 and
25 cases selected after 2002. We focused our audit on the time
from diagnosis to 4 years follow up. Date of diagnosis ranged
from 1976 to 2010. Age, symptom control, antibody, duodenal
pathology, body weight, haemoglobin, vitamin D level, DEXA
T and Z scores, fracture history, calcium and bisphosphonate
prescriptions were all recorded.
Results Average age at diagnosis was similar, 42.5 (SD 19) (pre
2002) and 45.9 years (SD 18.6) (post 2002). Females accounted
for 64% and 84% respectively. Antibody results were avail-
able in 48% and 76%, positive in 92% and 100% respectively.
Diagnostic duodenal biopsies were available in 52% and 84%
respectively. Body weight was recorded in 52% and 92% and
haemoglobin levels recorded in 56% and 85%. Weight, symp-
toms and Haemoglobin improved in both groups. Initial bone
densitometry was performed in 28% and 64% and repeated at 4
years i n 50% and 6 7% respecti vely. Bone densit y reduced slig htly
over the 4 year follow up. Vitamin D levels were measured in
20% and 50% at the time of diagnosis and levels increased over
a 4 year period (pre 2002: 17.8 (SD11.6) to 25.4 (SD 8.8); post
2002: 16.9 (SD 12.6) to 24.3 (SD 10.3)). Bisphosphonates were
prescribed appropriately in 33% and 100% in the respective
groups. Fractures were present in 10% of all patients.
Conclusion A Dietetic led service has led to favourable
changes in practice. Disease response measured by symptoms,
weight and haemoglobin improved in both groups; in the post
2002 cohort, more data is available and this may indicate
improved clinic attendance at the Dietetic led clinic. The frac-
ture incidence of 10% is comparable to the general population
incidence, much lower than studies of previous UK and South
American Coeliac cohorts. This low fracture incidence may
be to be due the judicious use of bone density assessment and
treatment with calcium and vitamin D. Vitamin D is not in the
BSG 2010 guidelines, the low fracture incidence in this cohort
may partly be refl ected by the correction of vitamin D levels.
This raises questions whether routine measurement vitamin
D should be advocated?
Competing interests None.
Keywords BSG guidelines, Coeliac Disease, DIETICIAN
CLINIC, vitamin supplementation.
01_gut.2011.023301_60_1.indd Sec1:8501_gut.2011.023301_60_1.indd Sec1:85 2/21/2011 8:36:17 PM2/21/2011 8:36:17 PM
group.bmj.com on August 21, 2015 - Published by http://gut.bmj.com/Downloaded from

should we be measuring vitamin D?
dietician led clinic over a 30 year period,
Changes in practice with a coeliac disease
R R Keld, *, E Shuttleworth, S Burden and S Campbell
doi: 10.1136/gut.2011.239301.176
2011 60: A85 Gut
http://gut.bmj.com/content/60/Suppl_1/A85.1
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