Medical Nutrition Therapy: A Case Study Approach 3rd Ed. Case Study 12- Celiac Disease

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1 Medical Nutrition Therapy: A Case Study Approach 3rd Ed. Case Study 12- Celiac Disease I. Understanding the Disease and Pathophysiology 1. The small bowel biopsy results state, flat mucosa with villus atrophy and hyperplastic crypts inflammatory infiltrate in lamina propria. What do these results tell you about the change in the anatomy of the small intestine? These results indicate that inflammatory and innate immunity responses have damaged the small intestinal mucosa. Exposure to gluten results in a toxic and inflammatory response which causes cytotoxic T-cells to damage the enterocytes. This damage causes a decrease in surface area required for absorption and loss of digestive enzymes by flattening and reducing the height of intestinal villi (Nelms 2011). 2. What is the etiology of celiac disease? Is anything in Mrs. Gaines s history typical of patients with celiac disease? Explain. Exposure to the prolamin fraction (the protein components of gluten) causes damage to the intestinal mucosa observed in celiac disease. The etiology of celiac disease stems from a combination of genetic, autoimmune, and environmental factors. Mrs. Gaines is positive for AGA and EMA antibodies which regulate the autoimmune response characterizing CD (Nelms 2011). Mrs. Gaines has lost a large amount of weight and has had diarrhea on and off for the entirety of her adult life. She also notes that her mother and grandmother both have had problems with chronic diarrhea. Family history, fatigue, and anemia are also indicative of celiac disease. 3. How is celiac disease related to the damage to the small intestine that the endoscopy and biopsy results indicate? Consumption of food products containing gluten is directly responsible for the inflammatory autoimmune response which causes damage to the small intestine. Many CD patients continue to experience intestinal damage even though they adhere to a gluten-free diet. This damage is thought to be associated with unknown gluten contamination and the possible presence of other diseases such as irritable bowel syndrome (Nelms 2011). 4. What are AGA and EMA antibodies? Explain the connection between the presence of antibodies and the etiology of celiac disease. Anti-gliadin (AGA) and endomysial IgA (EMA) antibodies are components of the autoimmunity associated with CD. IgA antibodies are the primary antibodies present in gastrointestinal secretions. Both AGA and EMA are autoantibodies produced during the body s immune response to gluten and its protein components, including gliadin (NCM 2012). 5. What is a 72-hour fecal fat test? What are the normal results for this test? A fecal fat test helps determine the amount of fat in the stool which indicates the percentage of fat being absorbed by the body. The test helps determine fat malabsorption. Before performing the test, the patient should consume a normal diet including 100 grams of fat per day for 3 days. 6. Mrs. Gaines s laboratory report shows that her fecal fat was 11.5 g fat/24 hours. What does this mean? Normal results are less than 7 grams of fat per 24 hours. Mrs. Gaines results indicate fat malabsorption which is most likely secondary to CD. Malabsorption is often caused by damage to intestinal mucosa and villi as well as a loss of digestive enzymes (UHHS 2012). II. Understanding the Nutrition Therapy 8. Gluten restriction is the major component of the medical nutrition therapy for celiac disease. What is gluten? Where is it found? Gluten is a protein component of wheat and wheat-related grains and is composed of gliadin and glutenin. It is responsible for giving dough elasticity and is found in many grain-based products. Gluten can be found in all varieties and forms of wheat, barley, rye, and varieties of grain which are cross-breeds of wheat. These grains are commonly found in flours, breads, pasta, cereals, cakes, and cookies (NCM 2012). 9. Can patients on a gluten-free diet tolerate oats? Why have recommendations concerning consumption of oats changed over time? Oats which are uncontaminated with glutencontaining products are now considered safe for most patients with CD if consumed in moderate amounts (up to 50 g/day). Oat consumption for those with CD is still a danger because many oat products are contaminated with wheat, barley, or rye. Patients interested in safe consumption of oats should read labels very carefully and buy products manufactured by companies who specifically state that their products are gluten-free oats (NCM 2012).

2 III. 10. What sources other than foods might introduce gluten to the patient? Gluten is often found in supplements, medications, infant formulas, medical foods, and beer. 11. Can patients with celiac disease also be lactose intolerant? Lactose intolerance often occurs in celiac disease due to secondary lactase deficiency caused by damage to intestinal villi and loss of digestive enzymes. Usually this deficiency is temporary and subsides as intestinal mucosa is repaired and regenerated which increases absorptive ability and normalizes enzyme secretion (NCM 2012). Nutrition Assessment 12. Calculate the patient s percent UBW and BMI, and explain the nutritional risk associated with each value. UBW= 112, lb % UBW= 82.14% % weight change= [(112 lb - 92 lb)/ 112 lb] x 100= 17.86% weight change in approximately 3 months; Weight loss >7.5% UBW in 3 months is strongly associated with nutritional risk and health complications. BMI= wt (lbs) / [ht (inches) 2 ] x 704.5= 92 lbs / (63 inches) 2 x 704.5= 16.33; A BMI of is considered underweight (<18.5). This patient s BMI is nearing 16; a BMI <16 is associated with a higher risk for disease, including malnutrition (Nelms 2011). 13. Calculate this patient s total energy and protein needs using the Harris- Benedict equation or Mifflin-St. Jeor equation. Mifflin-St. Jeor REE for females: 10 W H - 5 Age W= kg, H= cm, age= 36 years 10(41.73kg) ( cm) - 5(36) - 161= kcal/d; then multiply by activity factor and an injury factor of 1.3 due to the patient s significant disease state and weight loss= ~1819 kcals/d Protein requirements: 0.8 g protein/ kg body weight= g protein/d This protein requirement may be insufficient due to malabsorption and excessive weight loss and may need to be increased from 0.8 g protein/ kg body weight to 1.75 g protein/ kg body weight. At this level the patients protein need would be increased from 33 g protein/d to 73 g protein/day (Nelms 2011). 14. Evaluate Mrs. Gaine s 24-hour recall for adequacy. Mrs. Gaines dietary recall indicates energy inadequacy due to low calorie consumption, low protein intake, low carbohydrate intake as well as low fat intake. Specific nutrients which are low in the patient s diet include fiber and almost all vitamins and minerals, specifically calcium, iron, and B vitamins. The patient s diet is lacking overall due to inadequate food consumption. See attached pages for evaluation (USDA 2012). 15. From the information gathered within the intake domain, list possible nutrition problems using the diagnostic term. Inadequate energy intake, inadequate protein-energy intake, inadequate fat intake, inadequate protein intake, inadequate carbohydrate intake, inadequate fiber intake, inadequate vitamin intake, inadequate mineral intake, inadequate iron intake (IDNT 2013) 16. Evaluate Mrs. Gaines s laboratory measures for nutritional significance. Identify all laboratory values that support a nutrition problem. *PEM= protein energy malnutrition Lab Test Normal Range Patient s Results Possible Reason Albumin g/dl 2.9 g/dl may reflect illness or PEM* Total protein 6-8 g/dl 5.5 g/dl can reflect poor protein intake, illness or infection, change in metabolism or hydration Prealbumin mg/dl 13 mg/dl illness or PEM Magnesium mg/dl 1.6 mg/dl low dietary intake or malabsorption Osmolality mml/kg/h2o low serum proteins due to illness or PEM

3 IV. Lab Test Normal Range Patient s Results Possible Reason CHOL mg/dl 119 mg/dl low dietary intake or malabsorption HGB g/dl 9.5 hemoglobin content of RBC, aids anemia diagnosis HCT 37-47% 34 aids anemia diagnosis MCHC g/dl 30 helps to distinguish iron-deficiency anemia Ferritin ug/l 12 illness or PEM, iron deficiency Vitamin B ng/dl 21.2 low intake or malabsorption Folate 5-25 ug/dl 3 low intake or malabsorption 19. Evaluate Mrs. Gaines s other anthropometric measurements. Using the available data, calculate her arm muscle area. Interpret this information for nutritional significance. AMA= [(18 cm - (3.14 x 0.75 cm)) 2 / 4 x 3.14] = = 13 cm2 An AMA of less than 15 cm2 in women indicates muscle mass is wasted. This indicates the patient has a muscle deficit and is at nutritional risk (Nelms, 2011). 20. From the information gathered within the clinical domain, list possible nutrition problems using the diagnostic term. Altered GI function, Altered nutrition-related laboratory values, Impaired nutrient utilization, Underweight, Unintended weight loss (IDNT 2013) Nutrition Intervention 24.What type of diet would you initially begin when you consider the potential intestinal damage that Mrs. Gaines has? Patients with CD must adhere to a strict gluten-free diet for life. Initially, Mrs. Gaines should also be on a lactose-free diet due to secondary lactase deficiency. After mucosal damage is repaired, lactose-containing foods can slowly be added back into her diet. Due to the severity of the patient s intestinal damage, a low-residue diet may be beneficial until the intestinal mucosa heals. A low-residue diet avoids foods which are difficult to digest. 25.Mrs. Gaines s nutritional status is so compromised that she might benefit from highcalorie, high-protein supplementation. What would you recommend? Due to Mrs. Gaines compromised nutritional status an injury factor of 1.3 should be included in estimated energy requirements. This factor increases her recommended calorie intake by approximately 420 kcals/ day. Due to her excessive weight loss, Mrs. Gaines should also consume 1.75 g protein/kg body weight instead of the RDA recommendation of 0.8 kg protein/kg body weight (Nelms 2011). 26.What result can Mrs. Gaines expect from restricting all foods with gluten? Will she have to follow this diet for very long? Patients with CD must follow a life-long gluten-free diet. Gluten-free products are generally not enriched with B-vitamins and iron. Therefore gluten-free diets may often be low in thiamin, riboflavin, niacin, folate, iron and fiber. Mrs. Gaines should try to choose whole grain and enriched gluten-free products and follow the recommended number of servings from the grain food group each day. She should also consider taking a gluten-free multivitamin and mineral supplement if she can not consume adequate amounts through her daily intake (NCM 2012). V. Nutrition Monitoring and Evaluation 28. Evaluate the following excerpt from Mrs. Gaines s food diary. Identify the foods that might not be tolerated on a gluten/gliadin-free diet. For each food identified, provide an appropriate substitute. Cornflakes Bologna- some brands of bologna do contain gluten so be sure to check label carefully; Boar s Head offers gluten-free bologna Lean Cuisine Ginger Garlic Stir Fry with Chicken- contains gluten; substitute with baked or grilled chicken breast Skim milk

4 Cheddar cheese spread- cheese spreads may contain gluten due to cross-contamination; consume low-fat real or processed cheese Green bean casserole (mushroom soup, onions, green beans)- many mushroom soups do contain gluten; substitute green bean casserole for green beans Coffee- pure form is gluten-free, but flavored coffees may contain gluten read label carefully Rice crackers- check ingredients to make sure they are gluten free, sometimes flavored rice crackers may contain gluten Fruit cocktail Sugar Pudding- all Swiss Miss puddings are gluten free, check label; may substitute with all natural yogurt V8 juice- most of Campbell s V8 juices are gluten free Banana Cola Extra questions: Can patients with celiac disease consume buckwheat? Patients with CD can consume buckwheat because it is not closely related to wheat. Members of the dicot class of flowering plants such as buckwheat, amaranth and quinoa are not harmful to patients with CD. Be sure to read labels of buckwheat flour to make sure it is not mixed with wheat flour (NCM 2012). When cooking a baked item with substitute flours, what does a patient need to do to assure that the food will rise adequately? Usually a mix of several gluten-free flours is required to get the right texture in gluten-free baking. A combination of starches and stabilizers such as xanthan and guar gum must also be added (NFCA, 2012). Xanthan gum and guar gum are used to improve structure and texture. Ingredients should also be room temperature before baking (Nelms, 2011). Complete the Nutrition Care Process form for this patient (See form under case study on elc). Select 2-3 PES statements. Remember to use the standardized language for the Diagnosis, Intervention and Monitoring and Evaluation. Look in the Standardized Language Manual to find appropriate terminology and to select an appropriate etiology and appropriate signs and symptoms for each diagnosis that you select. See the NCM under Nutrition Care for typical nutrition diagnoses and goals for these patients.

5 References International Dietetics & Nutrition Terminology (IDNT) Reference Manual 4th ed. Chicago: Academy of Nutrition and Dietetics, National Foundation for Celiac Awareness. Version current 11 November Internet: (accessed 11 November 2012). Nelms M, Sucher K, Lacey K, Roth S. Nutrition Therapy and Pathophysiology 2nd ed. California: Wadsworth, Cengage Learning, Nutrition Care Manual. Academy of Nutrition and Dietetics. Version current Internet: (accessed 5 November 2012). US Department of Agriculture. Food-A-Pedia. Version current 31 July Internet: foodapedia.aspx (accessed 9 November 2012). US Department of Health and Human Services, National Institute of Health, Medline Plus. Version current 2 September Internet: (accessed 10 November 2012).

2. What is the etiology of celiac disease? Is anything in Mrs. Gaines s history typical of patients with celiac disease? Explain

2. What is the etiology of celiac disease? Is anything in Mrs. Gaines s history typical of patients with celiac disease? Explain Pauline Huang NFSC 470 Case Study I. Understanding the Disease and Pathophysiology 1. The small bowel biopsy results state, flat mucosa with villus atrophy and hyperplastic crypts inflammatory infiltrate