Jeremy Partsch Lindsay Wexler

Transcription

1 Jeremy Partsch Lindsay Wexler

2 Definition: Celiac disease is an autoimmune disease in which the consumption of gluten containing foods cause a toxic and inflammatory response. This response damages the villi in the small intestine leading to malabsorption and maldigestion. Therefore individuals with celiac disease are unable to tolerate products containing wheat, rye and barley.

3 -intestine.jpg

4 Gas Diarrhea Abdominal pain Bloating Cramping Fatigue Joint pain Weight loss Dermatitis herpetiformis (itchy skin rash) (*Nelms, 2007)

5 Name: Melissa Gaines Sex: Female Age: 36 Height: 5 3 Weight: 92 lbs, UBW 112 lbs (Lost 30 lbs after pregnancy) Smoker Medications Prenatal vitamins Kaopectate (docusate calcium) used to stop diarrhea.

6 Medical History 2 live births w/one miscarriage at 22 wks Diarrhea on and off most of her life DX: Celiac disease with 2 malabsorption & anemia Family History Father: Heart attack Angina/chest pain Heart problems

7 Chief complaint: Patient states having diarrhea on and off for most of her adult life. During pregnancy it got much worse. She gained 11 lbs during this pregnancy and lost 30 lbs after pregnancy. Recently she is always hungry, has terrible foul smelling diarrhea which was worse during pregnancy, fried foods and meat tend to make diarrhea worse. The diarrhea causes her to avoid eating and therefore has no energy.

8 Environmental Factors Lives with her husband and two children Developmental skills Prepares and purchases food for herself Education Bachelor s degree Lifestyle Stay at home mom since birth of recent child

9 Usual diet Likes all foods but has found that she avoids eating because it causes diarrhea 24 hour recall Breakfast:1 slice whole-wheat toast, 1 tsp butter, hot tea w/2 tsp sugar Lunch: 1 cup chicken noodle soup, 2-3 saltine crackers, ½ cup applesauce, 12 oz sprite, sips of Sprite throughout the day Dinner: None *Nelms 2009

10 Biomedical Marker Melissa s Values Normal Values* Reason Albumin 2.9 g/dl g/dl Malnourished Total protein 5.5 g/dl 6-8 g/dl Malnourished Prealbumin 13 mg/dl mg/dl Malnourished Magnesium 1.6 mg/dl mg/dl Malnourished Fecal fat test 11.5g 2-6g Steatorrhea secondary to celiac disease HGB 9.5 g/dl g/dl Iron deficiency anemia, nutritional deficiency HCT 34% 37-47% Iron deficiency anemia, dietary deficiency MCHC 30 g/dl g/dl Iron deficiency anemia Ferritin 12 ng/ml Iron deficiency anemia AGA + - EMA + - Immune response to gluten *Mosby s Diagnostic & Laboratory Test Reference

11 Anthropometrics: BMI: 16 Interpretation: Underweight %IBW : 80% Interpretation: Mildly underweight %UBW: 82% Interpretation: 18% weight loss in <3months Severe unintentional weight loss

12 Caloric needs: 655+ (9.6 x 42) + (1.8 x 160) - (4.7 x 36)= 1177 BEE AF: 1.3, Anabolism: kcals for anabolism/wt. regain Total kcal needs: 2030 kcal Protein needs: 1.4g/kg 42 kg x 1.4 g = 59 g

13 PES Statement Food and nutrition-related knowledge deficit (NB-1.1) related to new diagnosis of celiac disease as evidenced by no prior nutrition education on celiac disease, and 24 hour recall containing significant quantities of gluten. Involuntary wt. loss (NC- 3.2) related to celiac-related malabsorption as evidenced by 30 lb. unintentional wt loss over past 3 months and positive fecal fat test.

14 Comprehensive Nutrition Education (E-2) on temporary low fat and low residue diet. Also on lifelong gluten-free diet, dietary gluten sources and appropriate food substitutes, detecting gluten on food labels, and avoiding cross-contamination. eg. Pt. can identify sources of gluten and gluten crosscontamination on sample food labels Pt. can identify dietary gluten sources and choose gluten free substitutes Food and/or nutrient delivery (ND-1). Change to gluten-free (hospital) diet. Medical food supplement (ND-3.1) Glutamine

15 Temporary diet restrictions: low residue diet Allows for diarrhea minimization low-fat diet ~45-50 g/day can minimize steatorrhea possible lactose intolerance Lactase deficiency common because of damaged villi and enzyme secretion As villi are regenerated and absorptive capability returns, fiber lactose and fat can be added back into diet, slowly, as tolerated. *Nelms, 2009

16 Educate patient on lifelong gluten free diet: Foods to avoid: any containing wheat, rye, barley and some cases oats Give patient sample shopping lists and sample menus Limit lactose during flare ups Supplementations Support services available Reading food labels Educate patient on substitutes for gluten Soy flour, Corn, Rice, Potatoes, Tapioca, Amaranth, Quinoa, Millet, Buckwheat

17 Food Allergen Labeling Other terms for wheat food ingredients that are possibly made from wheat Food products and ingredients made from barley Identifying processed foods that may contain harmful grains Cross-contamination Dietary supplement and medication labels Fillers in OTC meds, toothpastes, mouthwashes

18 Fresh fruits and vegetables Fresh chicken, turkey, fish, and seafood Cream of rice cereal Gluten free frozen waffles Quaker Rice Cakes Fresh eggs Plain beans Plain white rice, brown rice, wild rice Plain nuts and seeds Vegetable, olive or corn oil, butter margarine Sugar, honey, molasses Gluten free pasta s/foodnut/09375.html

19 Breakfasts Cream of rice cereal with banana slices Cottage cheese or yogurt with fresh fruit Scrambled eggs, bacon and gluten free toast Egg, cheese, and vegetable omelet with potatoes Lunches and Dinners Baked potato with cheese and vegetables Corn tortillas with stir-fried meat and vegetables Stir-fried vegetables with rice Broiled chicken with green beans Grilled fish, baked potato and vegetables Snacks Plain gluten-free rice cakes with peanut butter Nachos made with plain corn, chips, cheese and salsa Celery and carrot sticks String cheese Plain popcorn with oil and salt Fresh or canned fruit with yogurt or ice cream (If experiencing lactose intolerance avoid all dairy products in this menu) html

20 A frequent a side effect of celiac disease. Occurs after the villi and microvilli in the small intestine become damaged, and are no longer capable of catching and breaking down the lactose molecule Usually goes away when gluten is removed from the diet because this allows for the damaged villi and microvilli to repair itself. /

21 When the body is under metabolic stress the conditionally essential amino acid L-Glutamine becomes essential. Glutamine is important with metabolism, structure and function of the GI tract. Glutamine is the primary energy source for cells that line intestines, such as cilia and microvilli Glutamine keeps GI tract healthy and functioning properly, reduce inflammation, improve immunity and promote repair Glutamine-rich foods include: beef, fish, poultry, eggs, and dairy. * lglutaminecite

22 Celiac disease prevents body from absorbing nutrients properly since the villi are flattened, the surface area for absorption into the blood stream is minimized. However, a gluten free diet should ameliorate anemia therefore further supplements are usually not required not advised. Iron supplementation may aggravate the inflammation occurring in digestive system by its free radical generation increasing the inflammatory response.

23 Outcome goals Short term: Pt demonstrates knowledge of low residue, low fat and gluten free diet No further weight loss Normalize labs: Prealbumin, ferritin fecal fat test <7g negative test for AGA and EMA antibodies Long term: achieve usual body weight of 112 lbs albumin, HGB, HCT, MCHC, total protein Action goal Educate patient on how to minimize diarrhea and on gluten free diet Increase calorie intake and control diarrhea by adhering to a temporary low residue, low fat diet as well as by adhering to a permanent gluten free diet.

24 Weight gain Labs Albumin, prealbumin, total protein, HGB, HCT, MCHC, ferritin, fecal fat test Adherence to diet 3 day diet record Alleviate diarrhea Improvement in lab values Prealbumin, albumin, ferritin Fecal fat test AGA and EMA Abs. Knowledge retention Patient is able to give us foods they can consume to limit their diarrhea. Patient is able to give us appropriate substitution for foods with gluten. Patient is able to read labels and detect items which contain gluten. List gluten free products in which they have been purchasing and consuming.

25 Food and/or nutrient delivery (ND-1). Change to gluten-free (hospital) diet. Mineral supplement (ND-3.2) Zinc Medical food supplement (ND-3.1) Glutamine Comprehensive Nutrition Education (E-2)

26 &_user=521371&_coverDate=02%2F28%2F2007&_rdoc=1&_fmt=high&_orig=search&_sort =d&_docanchor=&view=c&_acct=c &_version=1&_urlversion=0&_userid= &md5=c6ccc78aec0b2f30611c a42d7 &_orig=search&_cdi=5121&_sort=r&_docanchor=&view=c&_ct=1031&_acct=c & _version=1&_urlversion=0&_userid=521371&md5=0f9a57ad1b7e0430aca650d1d6b6291b Nelms, M., Long, S., Lacey, K. Medical Nutrition Therapy: A Case Study Approach. 3 rd Edition. Wadsworth Pagana, K., Pagana, T. Mosby s Diagnostic and Laboratory Test Reference. 9 th Edition Patel RS, Johlin FC Jr, Murray JA. Celiac disease and recurrent pancreatitis. Gastrointest Enterology 1999;50: Solomons NW, Rosenberg IH, Sandstead HH. Zinc nutrition in celiac sprue. Am J Clin Nutr 1976;29:371-5.