Heba Jad NFSC 470 Case Study 1 11/15/2013 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 changes in the anatomy of the small intestine? These results are signs of celiac disease. The results mean that damage is occurring in the small intestines. Both inflammatory and innate immune responses damage the villi; height is reduced and they are flattened in appearance. The damage to the enterocytes results in a reduced absorptive surface area and loss of digestive enzymes. (Nelms, Sucher, Lacey, & Long Roth) 2. What is the etiology of celiac disease? Is anything in Mrs. Gainess history typical of patients with celiac disease? Explain. Celiac disease is an autoimmune disorder that damages the intestinal mucosa when the small intestine is exposed to -gliadin and other protein components of gluten. The damage in the small intestines makes it difficult to the body to be able to absorb nutrients, especially fat, calcium, iron, and folate. (Celiac Disease Health Center, n.d.) Mrs. Gaines has a history of diarrhea, current unintended weight loss, fatigue and weakness, moreover, her labs indicate that she has iron deficiency anemia. Looking at symptoms of celiac disease, it is known that patients suffer from diarrhea, abdominal pain and cramping, bloating and gas production. Many individuals also have iron deficiency anemia. So, Mrs. Gainess history is typical of patients with celiac disease. 3. How is celiac disease related to the damage to the small intestine that the endoscopy and biopsy results indicate? The intestinal biopsy showing a damaged, flat surface, is often called the "gold standard" for diagnosing celiac disease. (Celiac Disease, 2010)

4. What are AGA and EMA antibodies? Explain the connection between the presence of antibodies and the etiology of celiac disease. Anti-gliadin antibodies (AGA) appears when a patient consumes gluten, but it is not used as a testing tool for the diagnosis of celiac disease. Endomysial antibodies (EMA) is an excellent indicator for celiac disease. Both these antibodies are used as screening tools for the diagnosis of celiac disease, however, AGA is no longer a good indicator for celiac disease diagnosis. (American Celiac Disease Alliance, 2013) 5. What is a 72-hour fecal fat test? What are the normal results for this test? A 72-hour fecal fat test tests for fat malabsorption (steatorrhea). A person should consume a high fat diet (100 g/day) for three days then stool will be collected and examined. A healthy individual who consumes a 100 g of fat a day should have an average stool fat that is less than 7 g/day, if more than 7 g/day of stool fat is excreted, it would be an indication of steatorrhea. (Fecal Fat Test Protocol, 2003) 6. Mrs. Gainess laboratory report shows that her fecal fat was 11.5 g fat/24 hours. What does this mean? This indicates that Mrs. Gaines has steatorrhea. Fat absorption occurs in the small intestines, if Mrs. Gaines villi are flattened they are no longer functioning and the amount of fat thats being absorbed is decreasing. 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 100-g fat diet to test for fat malabsorption and for the fecal fat test. She was placed on this diet temporarily for the physician to make some tests.

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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 the two proteins, gliadin and glutenin found in wheat endosperm. It is found in most grains such as, wheat, barley, rye, and bulgur. (Gluten Free Whole Grains, n.d.) Gluten can also be available in products that dont actually contain gluten but has been cross contaminated with gluten, such as oats. (Oats, n.d.) 9. Can patients on a gluten-free diet tolerate oats? Oats are gluten-free unless it is processed with wheat then it gets contaminated with gluten. Patients with celiac disease should read food labels and ask their physician or dietitian for advice about consuming oats. (Oats, n.d.) 10. What sources other than foods might introduce gluten to the patient? Make-up, play dough, stamps, envelopes, toothpaste, suntan lotion, bath salts, paints, and medications. (Hlywiak, 2008)

11. Can patients with celiac disease also be lactose intolerant? Yes, lactose intolerance is usually a side effect of celiac disease. When the damage start to happen in the small intestines, lactose cannot be broken down anymore. Symptoms of lactose intolerance may continue after the patient consumes a 100% gluten-free diet for a while. When the small intestines starts to heal, lactose can be added back slowly in the diet. (Adams, 1996)

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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. Percent UBW: 92 lbs/112 lbs x 100= 82% She lost 18% of her weight within three months. BMI: 92 lbs/63 inches/63 inches x 703= 16.3 Classified as underweight, patient is at risk of malnutrition. B. Calculation of Nutritional Requirements 13. Calculate this patients total energy and protein needs using the Harris-Benedict equation or Mifflin-St. Jeor equation. Energy Needs: Using activity factor of 1.3 and injury factor of 1.2 [655 + (9.6 x 41.8 kg) + (1.8 x 160 cm) (4.7 x 36)] x 1.3 x 1.2 [655 + 401 + 288 169] x 1.3 x 1.2= 1833 kcals Protein Needs: 1.2 x 41.8= 50 g C. Intake Domain 14. Evaluate Mrs. Gaines 24-hour recall for adequacy Nutrients: Total Calories: 440 calories Protein: 8 g Carbohydrates: 86 g Fiber: 4g Total fat: 17% of calories Minerals: low in calcium, potassium, copper, iron, magnesium, phosphorus, selenium, zinc. Vitamins: low in vitamin A, B6, B12, C, D, E, K, folate, thiamin, riboflavin, niacin and choline. (Food Tracker, n.d.) Mrs. Gaines diet is lacking energy, protein, vitamins and minerals. However, she is still taking prenatal vitamins. Her low intake is causing her weight loss and lack of energy.

15. From the information gathered within the intake domain, list possible nutrition problems using diagnostic term. Inadequate energy intake (NI-1.4), evident protein-energy malnutrition (NI- 5.2), and 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. - Albumin 2.9 (low), total protein 5.5 (low), prealbumin 13 (low), these values indicates protein energy malnutrition. - AGA and EMA are both positive - Hgb 9.5 (low), HCT 34 (low), ferritin 12 (low), ZPP 85 (somewhat high), these values indicate that she has iron deficiency anemia.

17. Are the abnormalities identified in question 16 related to the consequences of celiac disease? Explain. AGA and EMA are positive in patients with celiac disease. The rest of the abnormalities are due to poor energy and protein intake.

18. Are any symptoms from Mrs. Gainess physical examination consistent with her laboratory values? Explain. Protein energy malnutrition and iron deficiency anemia causes weakness and fatigue. 19. Evaluate Mrs. Gainess other anthropometric measurements. Using the available data, calculate her arm muscle are. ( ( )) ( ( )) = 11.3

Her arm circumference is below the 5th percentile.

20. From the information gathered within the clinical domain, list possible nutrition problems using the diagnostic term. Altered GI function (NC-1.4), Altered nutrition-related laboratory values (NC-2.2), and Underweight (NC-3.1) IV. Nutrition Diagnosis 21. Using the VA nutrition screening form, what is this patients nutrition status level? Her nutrition status level is 3. 22. Select two high-priority nutrition problems and complete the PES statement for each. 1. Inadequate energy intake (NI-1.4) related to patient low intake for fear of chronic diarrhea as evidence by patient weight loss of 18% of UBW. 2. Food and nutrition related knowledge deficit (NB 1.1) related to new diagnosis of celiac disease as evidence by no prior diet education for current diagnosis.

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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). 1. Inadequate energy intake (NI-1.4) related to patient low intake for fear of chronic diarrhea as evidence by patient weight loss of 18% of UBW. Goal(s): - Increase energy intake - Improve albumin, pre-albumin, Hgb and Hct. - No further weight loss Intervention(s): - Modify diet (ND-1.2) to gluten-free diet 2. Food and nutrition related knowledge deficit (NB 1.1) related to new diagnosis of celiac disease as evidence by no prior diet education for current diagnosis. Goal(s): - Consume gluten-free diet Intervention(s): - Nutrition education regarding relationship to disease (E 1.4) 24. What type of diet would you initially begin when you consider the potential intestinal damage that Mrs. Gaines has? The type of diet I would begin with Mrs. Gaines is a low-residue diet which consists of minimizing fiber, lactose, excess sugar alcohols, sucrose and fructose, until diarrhea decreases. I would also put her on a fat malabsorption/stetorrhea diet, which is low fat, low oxalate, water miscible fat-soluble vitamins, and MCT, until her absorption becomes normal.

25. Mrs. Gaines nutritional status is so compromised that she might benefit from high-calorie, high-protein supplementation. What would you recommend? I would recommend Ensure Plus which is a Hi Calorie variety, because she has very low dietary intake of energy and protein. Ensure Plus contains 355 kcals and 13 g of protein per 8 oz serving.

26. Would glutamine supplementation help Mrs. Gaines during the healing process? What form of glutamine supplementation would you recommend? Supplementation of L-glutamine would help speed up the healing process by supporting the intestinal lining and increasing the villous heights. (All About Supplements, 2006) 27. What result can Mrs. Gaines expect from restricting all foods with gluten? Will she have to follow this diet for very long? The first thing she would expect is for her bowel movement to return to normal and have the energy to be able to move around. Also, her lab values should improve since her small intestines will be repairing. Mrs. Gaines would have to follow a gluten-free diet for the rest of her life.

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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. Current Food Substitution Cornflakes Rice Chex or corn Chex Bologna slices Land O Frost is one brand that provides gluten-free lunchmeat Lean Cuisine-Ginger Garlic Stir Use Perdue product instead of lean Fry with Chicken cuisine. Skim milk Allowed Cheddar cheese spread Regular cheese, processed cheese is questionable in containing gluten. Green bean casserole (mushroom Green beans are allowed. soup, onions, green beans) French fried onions contain gluten, it can be made gluten-free using gluten-free flour. Progresso brand mushroom soup is gluten-free Coffee Questionable, use Berres Brothers brand or buffalo and spring. Rice crackers May be questionable, read labels. Blue Diamond Nut Thins crackers is gluten-free. Fruit cocktail Allowed Sugar Allowed Pudding Allowed, double check labels V8 juice Allowed Banana Allowed Cola Allowed (Gluten-Free Directory, n.d.)

References
Adams, S. (1996, July 26). How is lactose intolerance related to celiac disease? Retrieved from Celiac.com: http://www.celiac.com/articles/31/1/How-is-lactose-intolerance-related-toceliac-disease/Page1.html All About Supplements. (2006, January). Retrieved from Life Extension Magazine: http://www.lef.org/magazine/mag2006/jan2006_aas_01.htm American Celiac Disease Alliance. (2013, August 7). Retrieved from American Celiac Disease Alliance: http://americanceliac.org/celiac-disease/diagnosis/ Celiac Disease. (2010, November). Retrieved from American Society for Gastrointestinal Endoscopy: http://www.asge.org/press/press.aspx?id=556 Celiac Disease Health Center. (n.d.). Retrieved from WebMD: http://www.webmd.com/digestive-disorders/celiac-disease/celiac-disease Fecal Fat Test Protocol. (2003, September). Retrieved from Center for Drug Abuse and AIDS Research: http://cdaar.tufts.edu/protocols/Fecal-Fat-Test.pdf Food Tracker. (n.d.). Retrieved from Super Tracker: https://www.supertracker.usda.gov/foodtracker.aspx Gluten Free Whole Grains. (n.d.). Retrieved from Wole Grains Council: http://wholegrainscouncil.org/whole-grains-101/gluten-free-whole-grains Gluten-Free Directory. (n.d.). Retrieved from Gluten-Free Resource Directory: http://glutenfreeresourcedirectory.com/ Hlywiak, K. (2008). Hidden Sources of Gluten. Practical Gastroenterology, 32. Nelms, M., Sucher, K. P., Lacey, K., & Long Roth, S. (n.d.). Nutrition Therapy & Pathophysiology. Oats. (n.d.). Retrieved from Coeliac: https://www.coeliac.org.uk/gluten-free-diet-andlifestyle/gf-diet/oats/