Xotchil Medina NFSC 470 11/15/13 Celiac 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 in lamina propria. What do these results tell you about the change in the anatomy of the small intestine? These results tell me that the anatomy of the small intestine has changed dramatically. Normal anatomy of the small intestine includes tall villi that resemble a carpet, but the damage stated consists of villus atrophy and flat mucosa that resemble tile flooring (Mayo Clinic, 2013). Flat mucosa, villus atrophy and hyperplastic crypts are conditions that occur in the presence of celiac disease as a result of an immune response. Hyperplastic crypts are when the crypts become enlarged and decrease the villi height to crypt height ratio. Gluten triggers T-lymphocytes to produce cytokines that direct an inflammatory response, which damages the enterocytes. The damaged enterocyte and shorter villi lead to a reduction in absorptive surface area and digestive enzymes (Nelms, Sucher, Lacey, & Roth, 2011). 2. What is the etiology of celiac disease? Is anything in Mrs. Gainess history typical of patients with celiac disease? Explain. The etiology of celiac disease (CD) can have genetic, environmental, and autoimmune factors. The overall prevalence of CD is 1% worldwide. People are more likely to develop CD if it is part of their family history, especially if they are first or second degree relatives. There is a much higher prevalence in Argentina, Italy, Germany, Denmark, and Finland. Some environmental factors that can affect the risk of developing CD include a younger age when gluten is introduced, a shorter length of breastfeeding, and the presence of viral infections during infancy. Consumption of gliadin causes damage to the intestinal mucosa which creates an inflammatory immune response. This response signals an infiltration of white blood cells into the mucosa. The production of antibodies is increased, and antibodies produced include anti-tissue transglutaminase (anti-tTG), antiendomysial antibodies (EMA), and antigliadin antibodies (AGA). Some genes related to CD have been isolated and are present in 95% of patients containing CD. These genes include HLA-DQ2 and HLA-DQ8 (Nelms, Sucher, Lacey, & Roth, 2011). In Mrs. Gainess patient history, she mentions that her mother and grandmother have always had funny stomachs and problems with diarrhea off and on. This may mean that CD is part of her family history, but her family members are not yet diagnosed.

3. How is celiac disease related to the damage to the small intestine that the endoscopy and biopsy results indicate? Celiac disease is related to the damage of the small intestine because exposure to gluten leads to an inflammatory response that causes flat mucosa with villus atrophy and hyperplastic crypts-inflammatory infiltrate in lamina propria. Since an endoscopy and biopsy are the gold standard for diagnosing CD, the damage to her intestine can be analyzed to determine a conclusion. A positive finding of CD contains all of the manifestations found in Mrs. Gainess small intestine. Mrs. Gaines now has a confirmed diagnosis of CD (Nelms, Sucher, Lacey, & Roth, 2011). 4. What are AGA and EMA antibodies? Explain the connection between the presence of antibodies and the etiology of celiac disease. AGA is an anti-gliadin antibody that that is directed against gliadin in gluten. EMA is an endomysial antibody that is developed when there is continuous damage done to the intestinal lining. These antibodies are a product of the inflammatory response caused when someone with CD consumes gluten, and are only present when gluten is in the diet. Identifying these antibodies can be useful in diagnosing patients with CD since they are indicative of this disease. (Celiac Disease Tests, 2013). 5. What is a 72-hour fecal fat test? What are the normal results for this test? A 72-hour fecal fat test is used to test for steatorrhea or fat malabsorption. It requires the patient to consume 100 grams of fat per day for 3 days. Stools during these three days are collected and the amount of fat present is measured. The normal results for this test are less than 7 grams of fat in a 24 hour period. If more than 7 grams of fat is present, then steatorrhea can be diagnosed (Roth, 2012). 6. Mrs. Gainess laboratory report shows that her fecal fat was 11.5 g fat/24 hours. What does this mean? This means that Mrs. Gaines has steatorrhea because her fat output was greater than the normal 7 grams in 24 hours. CD is causing shorter villi, which decreases the surface area available for absorption, and a decreased amount of fat digestion enzymes. She is no longer efficient at absorbing fat so it is being lost in the stools.

7. Why was the patient placed on a 100-g fat diet when her diet history indicates that her symptoms are much worse with fried foods? The patient was placed on a high fat diet because she indicated that her stools smelled foul, which can be an indication of fat malabsorption. In order to test for fat malabsorption, she must consume 100 grams per day for three days. 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 found in wheat, and is formed by gliadin and glutenin being mixed together. It is thought to only be found in wheat products, but rye, malt, and barley have proteins with a similar structure that can cause an inflammatory response (Castro, 2013). People usually have an inflammatory response to the gliadin portion of gluten that causes damage to the intestinal mucosa. 9. Can patients on a gluten-free diet tolerate oats? It is controversial, but it has been found that patients on a gluten-free diet can usually tolerate pure oats that have not been contaminated by wheat, barley or rye. Oats are not a source of gluten, but they can be processed in factories that process products containing gluten and cross contamination is likely. Gluten-free oats can be purchased and this guarantees that the product is not contaminated (Mayo Clinic, 2013). 10. What sources other than foods might introduce gluten to the patient? Some other sources of gluten can include vitamins, medications, lipstick, and play-dough (Jackson, 2013). 11. Can patients with celiac disease also be lactose intolerant? Yes, patients can also be lactose intolerant because the damaged villi and altered enzyme secretion can cause a lactase deficiency. This type of intolerance is called secondary lactose intolerance. Once patients eliminate gluten from their diets, the villi and absorptive capacity usually return to normal. However, returning back to normal function can take 6 months or longer. Lactose should be added back into the diet slowly to test tolerance and doesnt usually require a lifelong restriction (Fitterman, 2013). III. Nutrition Assessment A. Evaluation of Weight/Body Composition 12. Calculate the patients percent UBW and BMI, and explain the nutritional risk associated with each value. %UBW= (actual/usual) x 100= (92lbs/112lbs) x 100= 82%

82% of her usual body weight means that she has experienced moderate weight loss. She also has an 18% weight loss over 3 months which means she has had severe weight loss. BMI= weight(lbs)/height(inches)/height(inches) x 703= 92lbs/63in/63in x 703= 16.3 Her BMI is under 18.5 which means that she is underweight. B. Calculation of Nutrient Requirements 13. Calculate the patients total energy and protein needs using the Harris-Benedict equation or Mifflin-St. Jeor equation. BEE= 655 + (9.6 x W) + (1.8 x H) (4.7 x A) x AF x IF = 655 + (9.6 x 41.8) + (1.8 x 160) (4.7 x 36) x 1.3 x 1.4 = 2,140 kcals Protein= 1.0g/kg/day = 1.0g x 41.8kg/day = 41.8g/day C. Intake Domain 14. Evaluate Mrs. Gainess 24-hour recall for adequacy. o AM: 1 slice whole-wheat toast, 1 tsp butter; hot tea with 2 tsp sugar o Lunch: 1 cup chicken noodle soup, 2-3 saltine crackers, c applesauce, 12 oz sprite; throughout rest of day, sips of sprite o Dinner: None Mrs. Gainess diet is not adequate for her caloric needs since she is consuming 451 calories compared to a need of 2,140 calories. This is only a 21% consumption which is causing her to be deficient in many of her nutrients. Her macronutrient intake is significantly low in protein, carbohydrates, and fat. Low micronutrient levels include iron, vitamin B12, and folate. 15. From the information gathered within the intake domain, list the possible nutrition problems using the diagnostic term. Inadequate energy intake (NI-1.4) Inadequate oral intake (NI-2.1) Inadequate fluid intake (NI-3.1) Malnutrition (NI-5.2) Inadequate protein-energy intake (NI-5.3)

D. Clinical Domain 16. Evaluate Mrs. Gainess laboratory measures for nutritional significance. Identify all laboratory values that support a nutrition problem. Lab Albumin Total Protein Prealbumin Magnesium Osmolality Cholesterol TLC Hemoglobin Hematocrit MCHC Ferritin B12 Folate Fecal Fat Test AGA, EMA Value(Interpretation) 2.9 (Low) 5.5 (Low) 13 (Low) 1.6 (Low) 275 (Low) 119 (Low) 1,112 (Low) 9.5 (Low) 34 (Low) 30 (Low) 12 (Low) 21.2 (Low) 3 (Low) 11.5 (High) Positive

17. Are the abnormalities identified in question 16 related to the consequences of celiac disease? Explain. Yes, most of the abnormalities in her lab values are relate to CD mainly due to malabsorption. Her albumin, prealbumin, and total protein are low because she is not eating enough protein and what she does eat is not being absorbed efficiently. Her hemoglobin, hematocrit, MCHC, and ferritin are low because her small intestine is damaged and cannot absorb iron properly. The fecal fat test indicated steatorrhea because her small intestine is not producing the enzymes necessary for absorption nor is it absorbing fat that is being consumed. The low B12 and folate are a result of malabsorption in the intestine. 18. Are any symptoms from Mrs. Gainess physical examination consistent with her laboratory values? Explain. Mrs. Gaines complains of fatigue and weakness and these symptoms are related to anemia. Her labs indicate anemia by low hemoglobin, hematocrit, MCHC, and ferritin levels. Diarrhea and fatigue are also symptoms of CD which is indicated with a positive AGA and EMA lab test. She has diminished bowel sounds which are due to the decreased amount of food being processed and a lack of absorption taking place. The lack of absorption is shown through the fecal fat test which indicates steatorrhea and malabsorption. Most of the skewed lab values are because of the CD diagnosis.

19. Evaluate Mrs. Gainess other anthropometric measurements. Using the available data, calculate her arm muscle area. AMA= ( ( )) = ( ( )) = 11.4cm2

MAC= 180mm= 18cm

TSF= 7.5mm= .75cm

Interpret this information for nutritional significance. Mrs. Gaines is below the 5th percentile which means that she is experiencing muscle depletion. 20. From the information gathered within the clinical domain, list possible nutrition problems using the diagnostic term. Altered GI function (NC-1.4) Impaired nutrient utilization (NC-2.1) Altered nutrition-related lab values: Hct, Hgb, Total protein, fecal fat (NC-2.2) Unintended weight loss (NC-3.1) IV. Nutrition Diagnosis 21. Using the VA Nutrition Screening Form, what is the patients nutrition status level? Mrs. Gaines overall nutrition status level according to the VA Nutrition Screening Form is 3. 22. Select two high-priority nutrition problems and complete the PES statement for each. a. Inadequate oral intake (NI-2.1) related to diarrhea and food aversions as evidenced by 17% weight loss in 3 months, alb 2.9, prealb 13, Hgb 9.5, Hct 34 and ferritin 12. b. Food- and Nutrition-related knowledge deficit (NB-1.1) related to new diagnosis of celiac disease as evidenced by steatorrhea, diarrhea and no prior education of current diagnosis. V. Nutrition Intervention 23. For each of the PES statements that you have written, establish an ideal goal (based on the signs and symptoms) and an appropriate intervention (based on the etiology). a. Inadequate oral intake (NI-2.1) i. Goal: No further weight loss ii. Intervention: Modify diet- gluten free, lactose free, increase calorie and fluid intake

b. Food-and Nutrition- related knowledge deficit (NB-1.1) i. Goal: Resolve knowledge deficit ii. Intervention: Nutrition education- gluten and lactose free diets 24. What type of diet would you initially begin when you consider the potential intestinal damage that Mrs. Gaines has? I would start Mrs. Gaines on a gluten and lactose free diet because CD can cause secondary lactose intolerance. At the same time, I would recommend that she goes on a steatorrhea diet. This entails low fat, low oxalate, MCT oils, and water miscible fat soluble vitamins to reduce the amount of fat in her stools. After the removal of gluten, the functionality of the intestine usually returns back to normal. At this time fat and lactose can be added back into the diet slowly while assessing her tolerance. 25. Mrs. Gainess nutritional status is so compromised that she might benefit from highcalorie, high-protein supplementation. What would you recommend? I would recommend Ensure Plus. This is an 8 oz ready to drink shake that has 350 calories and 13 grams of protein. It is suitable for lactose intolerance and is gluten free (Ensure Plus, 2013). 26. Would glutamine supplementation help Mrs. Gaines during the healing process? What form of glutamine supplementation would you recommend? Yes, glutamine supplementation would help Mrs. Gaines in this healing process because glutamine is a vital fuel source to the intestines and immune system. When these cells are being nourished with glutamine, the integrity of the GI tract can return to normal and remain healthy (Andrews). I would recommend an L-Glutamine supplement that is pure glutamine at a 500mg dose, 3 times a day until her small intestine has healed back to normal. An example of a specific supplement would be Spring Valleys L-Glutamine 500mg tablets (Spring Valley Herbs, 2011). 27. What result can Mrs. Gaines expect from restricting all foods with gluten? Will she have to follow this diet for very long? Restricting all foods with gluten will allow Mrs. Gaines to feel more energized because her body is absorbing the energy and nutrients from the food she is eating. The anatomy of her small intestine will mostly likely return to normal, which will decrease the diarrhea and fatigue she has been experiencing. She will have to remain on a gluten-free diet for the rest of her life because any amount of gluten can cause the inflammatory response that was causing all of her previous symptoms.

VI. Nutrition Monitoring and Evaluation 28. Evaluate the following excerpt from Mrs. Gainess 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 slices Lean Cuisine--Ginger Garlic Stir Fry with Chicken Skim milk Cheddar cheese spread Green bean casserole (mushroom soup, onions, green beans) Coffee Rice crackers Fruit cocktail Sugar Pudding V8 juice Banana Cola Chex Cereal (Chex, 2013) Oscar Mayer Bologna (Lewis, 2009) Artisan Bistro Ginger Chicken Meal (Artisan Bistro, 2013) Soy or Almond Milk (Trader Joe's, 2013) Blue Cheese With Roasted Pecan Dip (Trader Joe's, 2013) Del Monte Green Beans (Del Monte Foods) and Progresso Cream of Mushroom (Progresso) No Gluten Lundberg Organic Brown Rice Cracker (Trader Joe's, 2013) Del Monte Mixed (Del Monte Foods) No Gluten Jell-O Brand Pudding as tolerated (Jello) No Gluten No Gluten No Gluten

Bibliography
Andrews, R. (n.d.). All About Glutamine. Retrieved November 12, 2013, from Precision Nutrition: http://www.precisionnutrition.com/all-about-glutamine Artisan Bistro. (2013). Retrieved November 13, 2013, from Artisan Bistro: Our Meals: http://www.theartisanbistro.com/ginger_chicken.html Castro, J. (2013, September 17). What is Gluten. Retrieved November 12, 2013, from Live Science: http://www.livescience.com/39726-what-is-gluten.html Celiac Disease Tests. (2013, September 16). Retrieved November 12, 2013, from Lab Tests Online: http://labtestsonline.org/understanding/analytes/celiac-disease/tab/sample Chex. (2013). Retrieved November 12, 2013, from Chex: http://www.chex.com/Recipes/GlutenFree.aspx Del Monte Foods. (n.d.). Retrieved November 13, 2013, from Del Monte Foods: FAQs: http://www.delmontefoods.com/FAQs.aspx Ensure Plus. (2013). Retrieved November 12, 2013, from Ensure: Nutrition in Charge: http://ensure.com/products/ensure-plus-retail Fitterman, L. (2013, March 26). Celiac Disease: When Dairy Intolerance Joins Celiac Disease. Retrieved November 12, 2013, from Allergic Living: http://allergicliving.com/index.php/2013/03/26/when-dairyintolerance-joins-celiac-disease/print/ Jackson, C. (2013, July 26). Sources of Gluten. Retrieved November 11, 2013, from Celiac Disease Foundation: http://celiac.org/live-gluten-free/gluten-free-diet/sources-of-gluten/ Jello. (n.d.). Retrieved November 13, 2013, from Jello: Chocolate Pudding Snacks: http://www.jello.com/product/pudding-mousse-snacks/chocolate Lewis, R. (2009, 23 October). List of Name Brand Gluten Free Foods. Retrieved November 13, 2013, from Livestrong: http://www.livestrong.com/article/29083-list-namebrand-gluten-foods/ Mayo Clinic. (2013, May 22). Celiac Disease. Retrieved November 12, 2013, from Mayo Clinic: http://www.mayoclinic.com/health/celiac-disease/DS00319 Nelms, M. N., Sucher, K., Lacey, K., & Roth, S. L. (2011). Nutrition Therapy and Pathophysiology. Belmont: Brooks/Cole Cengage Learning. Progresso. (n.d.). Retrieved November 13, 2013, from Progresso: Gluten Free Products: http://progresso.com/Products/Gluten-Free Roth, E. (2012, August 7). Fecal Fat Testing. Retrieved November 12, 2013, from Healthline: http://www.healthline.com/health/fecal-fat

Spring Valley Herbs. (2011). Retrieved November 14, 2013, from Spring Valley Herbs: http://springvalleyherbs.com/l-glutamine-500-mg.html Trader Joe's. (2013). Retrieved November 13, 2013, from NO GLUTEN INGREDIENTS USED: http://www.traderjoes.com/pdf/lists/list-no-gluten.pdf

CHART NOTE Nutrition Assessment Patient Interview: Terrible diarrhea for a while now and lost a tremendous amount of weight. Her diarrhea is foul smelling and symptoms are not affected by what she eats. She doesnt have energy to get off of the couch. Admitting Dx: __Celiac Disease__ PMH: 3 pregnancies- 2 live births, 1 miscarriage at 22 weeks Patient is a _36_ y/o _C_ _F_ Ht. __5 3 Wt. 92 lbs. BMI 16.3 %IBW80% %UBW__82%__ UBW timeframe: 3 months Diet order: Regular Average Meal Intake: N/A I/Os: N/A GI: Diarrhea and steatorrhea Pertinent Labs: November 12th: Alb (2.9), Prealb (13), Hgb (9.5), Hct (34), Ferritin (12), positive AGA and EMA, fecal fat of 11.5g, B12 (21.2), and Folate (3). Pertinent Medications: Prenatal vitamins, Kaopectate Physical exam/skin: fatigue, weakness, thin, pale skin without lesions, and no edema. No distended stomach and diminished bowel sounds. Other info: GI endoscopy for small bowel biopsy

************************************************************************ Nutrition Diagnosis/Diagnoses: (PES Statements) Inadequate oral intake (NI-2.1) related to diarrhea and food aversions as evidenced by 17% weight loss in 3 months, alb 2.9, prealb 13, Hgb 9.5, Hct 34 and ferritin 12. Food- and Nutrition-related knowledge deficit (NB-1.1) related to new diagnosis of celiac disease as evidenced by steatorrhea, diarrhea and no prior education of current diagnosis. ************************************************************************

Nutrition Intervention: Individualized Treatment Goals to Address Nutrition Diagnosis 1. 2. 3. 4. No further weight loss Increase average meal intake Improve lab values: Hgb, Hct, Alb, Prealb, Ferritin, folate, B12 Decrease diarrhea

Intervention Statements (Use Intervention Sheets) 1. Modify diet- gluten and lactose free 2. Nutrition education- gluten and lactose free diets 3. Increase caloric intake ************************************************************************ Monitoring and Evaluation 1. 2. 3. 4. Monitor weight loss Monitor labs: Hgb, Hct, Alb, Prealb, Ferritin, folate, B12 Monitor tolerance: lactose and gluten free diet Monitor adequacy: caloric intake-pt. to complete 3 day food log/ review with pt.

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