Crystal Vasquez

NFSC470 MNT
Celiac Case Study Questions
November 14, 2012

I. Understanding the Disease and Pathophysiology

1. The small bowel biopsy results state, flat mucosa with villa 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 mean that the anatomy of the small intestine has been damaged. The
villi in the small intestine have weakened are no longer functioning properly and the
crypts have become enlarged. Absorption has been impaired due to loss of surface
area and loss of digestive enzymes. (Nelms, Sucher, Lacey, & Long Roth, 2011, p.
402) These results are signs of possible celiac disease.

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. In individuals with celiac disease, when

their intestines are exposed to -gliadin (found in gluten), an immune response is
triggered. This immune response causes inflammation and damage to the small
intestines, specially to the villi and evterocytes. When the small intestines are
damaged, nutrients cannot be absorbed properly.

Patients with celiac disease will have symptoms such as abdominal cramping,
constipation, diarrhea, irritable bowel, fatigue, weakness, weight loss, joint pain and
mouth sores. Iron-deficiency anemia and other nutrient deficiencies will also be
present. (Celiac Sprue Association, 2012)

Mrs. Gaines has a history of diarrhea (most of her adult life), current unintended
weight loss, fatigue and weakness. Mrs. Gaines also has a family history of intestinal
problems. Her labs indicate that she also has iron-deficiency anemia.

3. How is celiac disease related to the damage to the small intestine that the endoscopy
and biopsy results indicate?

The biopsy results show that the villi have atrophied and flattened. Individuals with
celiac disease will have an immune response triggered by gluten that causes an
inflammatory response and damages the small intestine. Villi become atrophied, an
increased amount of leukocytes are found in the lamina propria and crypts become
enlarged. When the villi in the small intestine are damaged, absorption is impaired.

4. What are AGA and EMA antibodies? Explain the connection between the presence of
antibodies and the etiology of celiac disease.

AGA (anti-gliadin antibodies) is produced in individuals with gluten sensitivity. EMA

(endomysial antibodies) is highly specific marker for celiac disease. The presence of
these antibodies is used as a screening tool for celiac disease. (American Celiac
Disease Alliance, 2012) However, AGA testing is no longer considered a sensitive tool
 to diagnosis adults for celiac disease. It can still be used to diagnosis children under 2
years old. (Celiac Disease Foundation, 2012)

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 steatorrhea (lipid is not digested or absorbed
properly). Symptoms of fat malabsorption are loose, greasy, and foul smelling stools.
During this test, a person would consume a high fat diet (100g/day) for 3 days. Stool
would be collected and examined for fat.
A person who is normally absorbing fat would excrete less than 7 grams of fat in a 24-
hour period. If more than 7% of the fat intake was excreted than steatorrhea is likely
to be present. (Fecal Fat Test - CDAAR)

6. Mrs. Gaines laboratory report shows that her fecal fat was 11.5g fat/24 hours. What
does this mean?

This means that Mrs. Gaines is having fat malabsorption problems and steatorrhea is
present. Lipid is absorbed in the small intestine; if Mrs. Gaines villi have atrophied
they are no longer properly functioning and the amount of lipids absorbed is
decreased.

7. Why was the patient place on a 100-g fat diet when her diet history indicates that her
symptoms are much worse with fried foods?

This was necessary to test for lipid malabsorption and only temporary for the
duration of the fecal fat test.

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 comprised of gliadin and a glutelin. Gluten is a protein found in the

endosperm of most grains, such as wheat, barley, rye, spelt, kamut, and triticale.
(Gluten Free Whole Grains, 2012)

9. Can patients on gluten-free dirt tolerate oats?

Oats do not have gluten in them. However, they are often processed in plants that
process other grains. (Gluten Free Whole Grains, 2012) If oats are processed in a
gluten-free processing plant, it may be possible for patients to tolerate oats.
However, it is recommended that patients wait until they are symptom-free
before introducing oats into the diet (could be a year or longer). It is important to
read the label to insure that the oats are gluten-free. Adult patients should not
consume more than 50g/day until sensitivity is determined. (Considerations
about oats, 2009)

10. What sources other than foods might introduce gluten to the patient?

! Alcohol
Malt beverages
Beer (some beers may be gluten-free)
 Wine coolers and hard lemonades
! Medications, vitamins and minerals (ask your pharmacist if they contain
gluten)
! Lickable postage stamps and envelopes
! Latex gloves (may be dusted with wheat flour)
Request that your doctor and dentist use powder-free gloves
! Some personal products, such as makeup, sunscreen shampoos, soaps
and toothpaste

Many flavorings used in foods (particularly processed foods) contain gluten, so it

can be difficult to determine if a particular contains gluten or not. There are
Internet resources to determine if your products contain gluten. (www.celiac.com
is one source). (Hidden Sources of Gluten)

Areas of concern for cross-contamination:

! You will need your own toaster
! Separate butter dishes, condiments (crumbs can get in to peanut butter,
mayonnaise, mustard anything in a jar that is shared)
! Dedicate upper shelves in pantry and refrigerator to gluten-free foods
(concern of gluten crumb falling on to your foods)
! Use separate pasta water.
(Celiac Solution)

11. Can patients with celiac disease also be lactose intolerant?

Yes, lactose intolerance can be a side effect of the villi becoming damaged and
due to decreased lactase production. Lactose intolerance symptoms can continue
after patient has been on a 100% gluten-free diet for some time. However, as the
small intestine and villi heal lactose can be slowly added back in to the diet as
tolerated. (Adams, 1996)

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: 82%
Loss of 18% within 12 months is an indication of moderate weight loss.
However, Mrs. Gaines recently had a baby, so her current weight does not
accurately reflect the degree of her weight loss. Three months ago, at the end of
her pregnancy, Mrs. Gaines was 123 pounds (she gained 11 pounds during her
pregnancy). However, during a healthy pregnancy, 25-35 pounds is expected
weight gain. (Mayo Clinic, 2012)
Given Mrs. Gaines circumstance, I would classify her weight loss as severe.

BMI: 16.3
Patient is underweight and at risk for malnutrition.
B. Calculation of Nutrient Requirements
13. Calculate this patients total energy and protein needs using the Harris-Benedict
equation or Mifflin-St. Jeor equation.
Energy Needs:
[655+ (9.6 x 41.8kg) + (1.8 x 160cm) (4.7 x 36)]x 1.3 (AF) x 1.2 (IF)
[655+ 401+ 288 169] x 1.3 x 1.2 = 1833kcals
Protein Needs:
Severe (due to unintended weight loss, malnourishment, and anemia)
1.5 2.0 g/kg/day
62.7 83.6 g protein/day

C. Intake Domain
14. Evaluate Mrs. Gaines 24-hour recall for adequacy.
Calories: 440
Protein: 8g
Carbohydrate: 86g
Fiber: 4g
Fat: 17% of calories
Minerals: low in calcium, potassium, copper, iron, magnesium, phosphorus,
selenium, and zinc
Vitamins: low in vitamin A, B6, B12, C, D, E, K, Folate, Thiamin, Riboflavin, Niacin,
and Choline
(Choose My Plate, 2012)

Mrs. Gaines diet is lacking overall in energy and protein needs. Vitamins and
minerals are also severely lacking, however Mrs. Gaines is taking a prenatal vitamin.
Low intake is contributing to Mrs. Gaines weight loss and decreased energy.

15. From the information gathered within the intake domain, list possible nutrition
problems using the diagnostic term.

Inadequate energy intake (NI-1.4)

Malnutrition (NI-5.2)
Inadequate protein-energy intake (NI-5.3)

D. Clinical Domain
16. Evaluate Mrs. Gaines laboratory measures for nutritional significance. Identify
all laboratory values that support a nutrition problem.

Abnormal Lab Values

Albumin 2.9 Low
Prealbumin 13 Low
Total Protein 5.5 Low
AGA antibodies Positive
EMA antibodies Positive
Hgb 9.5 Low
Hct 34 Low
MCHC 30 Low
Ferritin 12 Low
 Low Albumin, prealbumin and low total protein indicates protein energy
malnutrition.
Low Hgb/Hct, MCHC and Ferritin indicate that patient has iron deficiency anemia.

17. Are there abnormalities in question 16 related to the consequences of celiac

disease? Explain.

AGA and EMA antibodies are present in individuals with celiac disease.
Other abnormalities are likely due to poor energy and protein intake and a cause of
malabsorption due to villus atrophy.

18. Are any symptoms from Mrs. Gainess physical examination consistent with her
laboratory values? Explain.

Yes, iron deficiency anemia can cause weakness and fatigue. Protein energy
malnutrition will also cause weakness and fatigue.

19. Evaluate Mrs. Gaines other anthropometric measurements. Using the available
data, calculate her arm muscle area.
Interpret this information for nutritional significance.

AMA= [18/(.75 x 3.14)]2 / 4 x 3.14

Minus 6.5 for correction
AMA= 13.0
Mrs. Gaines arm circumference is below average. It is likely an indication of
malnutrition. However, measurements of her arm circumference over time would
give a better interpretation of this data.

20. From the information gathered within the clinical domain, list possible nutrition
problems using the diagnostic term.

Altered GI Function (NC-1.4)

Unintended weight loss (NC-3.2)

IV. Nutrition Diagnosis

21. Using the VA Nutrition Screening Form, what is this patients nutrition status
level? (Please attach your screening form to the back of your case study)

Patients Overall Nutrition Status is: 3 (moderate nutrition risk)

This means that Mrs. Gaines needs to have a full nutrition assessment from an
RD.

22. Select two high-priority nutrition problems and complete the PES statement for
each.
 Inadequate energy intake (NI-1.4) related to patient restriction for fear
of chronic diarrhea as evidenced by patient weight loss of 18% UBW and
patient 24-hr recall.
Malnutrition (NI-5.2) related to malabsorption and villous atrophy as
evidenced by low albumin, low prealbumin, low Hgb levels and low Hct
levels.

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)

Goals (for unintended weight loss):

! No further weight loss
! Increase energy intake
Goals (for malnutrition):
! Increase levels of albumin, prealbumin, Hgb and Hct.

Intervention:
! Modify diet (ND-1.2) to a gluten-free diet
! Nutrition education regarding nutritional relationship to disease (E-1.4)
(gluten-free diet required)
! Nutrition Counseling based on Transtheoretical model (C-1.4) using
motivational interviewing (C-2.1).

24. What type of diet would you initially begin when you consider the potential
intestinal damage the Mrs. Gaines has?

I would initially recommend that Mrs. Gaines go on a low-reside diet, avoiding

foods high in fiber, excess sugar alcohols, sucrose and fructose until diarrhea has
subsided. In addition, I would also recommend a steatorrhea diet (low fat, low-
oxalate, MCT oil supplementation) until absorption is normal. (Nelms, Sucher,
Lacey, & Long Roth, 2011, pp. 391, 400)

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 (Hi Calorie variety) because her dietary intake
of energy and protein is very low. Ensure Plus has 355 kcals and 13 g of protein
per 8oz serving.
Resource Fruit Beverage (standard variety) contains 250 kcals and 9g of protein
per 8oz serving and may be used if cost is a factor. (Enloe Medical Center)

26. Would glutamine supplementation help Mrs. Gaines during the healing process?
What form of glutamine supplementation would you recommend?

Glutamine is known to support healing and speed recovery of the intestinal lining
and increase villous height. Supplementation of L-glutamine could help Mrs.
Gaines heal faster. (Life Extention Magazine, 2006)
 27. What result can Mrs. Gaines expect from restricting all foods with gluten? Will
she have to follow this diet for very long?

Mrs. Gaines can expect her energy levels to return to normal and bowel
movements to return to normal. Lab values should improve as small intestine is
repaired over time. However, she will need to follow a gluten-free diet for the rest
of her life.

VI. Nutrition Monitoring and Evaluation

28. Evaluate the following excerpt from Mrs. Gaines 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 Substitute

Cornflakes General Mills Corn Chex (or other Chex cereals,
except Wheat Chex or Multi-Bran Chex)
Bologna slices *Read individual brand labels.
One brand of lunchmeat that is gluten-free is Land
OFrost.
Lean Cuisine Ginger Most processed meals will contain gluten, however,
Garlic Stir Fry with some brand may be labeled gluten-free. It would be
Chicken safer for Mrs. Gaines to pack a lunch rather than
rely on frozen meals.
Skim Milk Allowed on a gluten-free diet, as tolerated
Cheddar cheese spread Instead of processed cheese spread, which can be
questionable, use regular cheese
Green bean casserole ! Greens beans are allowed.
(mushroom soup, ! French Fried Onions contain gluten,
onions, green beans) however, you could make your own using
gluten-free flour or substitute Funyuns
! Progresso brand mushroom soup is gluten-
free.
Coffee Allowed
Rice crackers ! May be allowed, read labels for barley malt
flavoring or seasonings with wheat.
! Blue Diamond Nut Thins are gluten-free
crackers.
Fruit cocktail Allowed
Sugar Allowed
Pudding Allowed (however, double check labels)
V8 Juice Allowed
Banana Allowed
Cola Allowed

(Celiac Disease Foundation, 2012)

(Nelms, Sucher, Lacey, & Long Roth, 2011, pp. 404-410)

References
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