Case Questions 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? Her intestine has been damaged due to an immune response to the protein gliadin (found in wheat, rye, barley, and also possibly in oats that have been crosscontaminated). While her intestine is damaged like this she will have maldigestion/malabsorption. Once gluten is completely removed from her diet the damage done to her intestine will most likely heal all the way back to normal. (National Foundation for Celiac Awareness, 2013) 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 disease caused by the ingestion of gluten. Classic symptoms include wasting and diarrhea. Adults have diarrhea as a major symptom of celiac disease approximately 50% of cases. (Barker & Liu, 2008) Mrs. Gainess chief complaints are severe unintentional weight loss, recurring terrible diarrhea, and lack of energy. Her symptoms are consistent with celiac disease symptoms. Celiac disease is hereditary and the patients account of her family having a history of funny stomachs may suggest her condition runs in her family. 3. How is celiac disease related to the damage to the small intestine that the endoscopy and biopsy results indicate? Celiac disease causes an immune response to the protein gliadin which specifically damages the villi of the small intestine. This phenomena is a serious complication of celiac disease. (National Foundation for Celiac Awareness, 2013) 4. What are AGA and EMA antibodies? Explain the connection between the presence of antibodies and the etiology of celiac disease. Tests for the AGA and EMA antibodies are used clinically to diagnose celiac disease in place of a biopsy of the small intestine mucosa. Celiac disease is an autoimmune disorder and people with these antibodies have autoimmune reactions to gliadin. (Nelms, Sucher, Lacey, & Roth, 2011) 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 see whether a person is malabsorbing fat. Adult patients are fed 100 grams of fat every day for three days before stool collection and the three days (72 hours) during stool collection. Normal results are equal to 2-6 grams

of fat per 24 hours. The more fat that is retained in the body rather than excreted through the stool the better the fat is being digested by the patient. 6. Mrs. Gainess laboratory report shows that her fecal fat was 11.5 g fat/24 hours. What does this mean? This means that she is having malabsorption issues with fat and she is not retaining enough fat through her diet to support adequate nutrition. It is likely that she is not absorbing other nutrients as well. Her GI tract is not working as well as it should. 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? Her symptoms are being caused by gluten, not by fat. Althought malabsorption may be giving her some diarrhea, because of her symptoms of celiac disease (flattened intestinal villi) it was necessary to see the extent of her malabsorption of fat. Her energy stores are already moderately depleted therefore it is important to look into all dietary factors that may inhibit her ability to recover. 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. People who have Celiac disease are really allergic to one of the amino acids present in gluten, gliadin. Gluten is found in wheat, rye, and barley. These foods containing gluten and any foods with the possibility of being contaminated gluten, must be completely avoided in order for patients with celiac disease to get better. 9. Can patients on a gluten-free diet tolerate oats? Yes, they can tolerate oats because oats do not contain gluten. Often times products containing oats may be manufactured in a facility that also manufactures products with gluten in them. People with celiac disease can be extremely sensitive to gluten crosscontamination so it is very important for patients to check the labels of products to see if there is an allergy statement. 10. What sources other than foods might introduce gluten to the patient? Gluten can also be found in sunscreen, make-up, shampoo, conditioner, soaps, and medicine. Label reading and product research is very important for patients with celiac disease.

11. Can patients with celiac disease also be lactose intolerant? Patients with celiac disease usually are lactose intolerant while their intestine is damaged. People may regain the ability to digest lactose after their gut is completely healed. Patients should consume dairy substitutes instead to avoid symptoms of lactose intolerance. 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. Current BW: 92 lbs UBW: 112 lbs %UBW: 82% = moderate weight loss IBW: (100 + 3 x 5) = 115 lbs %IBW: 80% = Mildly depleted energy stores. The patient does not have adequate energy stores to fight off an infection or heal as efficiently as possible. BMI: 16.3. Less than 18.5 is considered underweight. B. Calculation of Nutrient Requirements 13. Calculate this patients total energy and protein needs using the Harris-Benedict equation or Mifflin-St. Joer equation. BEE= 655+ (9.6 x 41.8kg) + (1.8 x 160cm) - (4.7 x 36yrs) = 1175 x 1.3 (AF) x 1.2 (IF) = 1833 kcal/day Protein = 41.8kg x 0.1gm/kg/day = 41.7 grams protein/day She needs moderate protein intake to allow her to gain weight and heal from her disease. C. Intake Domain 14. Evaluate Mrs. Gainess 24-hour recall for adequacy. Based on MyPlate.gov the patient consumed: 2 oz of whole grains (32%; 6oz required) no vegetables (0%) 0.5 cup fruit (25%; 2 required) no dairy (0%) no protein foods (0%, minimal from Chicken Noodle Soup). 440 kilocalories (24% of the recommended 1831 kcal/day estimate), 225 of the kilocalories were empty.

15. From the information gathered within the intake domain, list possible nutrition problems using the diagnostic term. Inadequate energy intake (NI-1.4) Inadequate oral intake (NI-2.1) Increased nutrient needs (NI-5.1)(increased need for kcals and protein for repair) Malnutrition (NI-5.2) Inadequate protein-energy intake (NI-5.3) Inadequate protein intake (NI-5.7.1) Inadequate carbohydrate intake (NI-5.8.1) Inadequate fat intake (NI-5.6.1) Inadequate fiber intake (NI-5.8.5) D. Clinical Domain 16. Evaluate Mrs. Gainess laboratory measures for nutritional significance. Identify all laboratory values that support a nutrition problem. B12 21.2 ng/dl, Folate 3mm Albumin: 2.9 2.9 g/dL (normal range is 3.5-5 g/dL) Low albumin indicates poor protein status over a period of time. Prealbumin: 13 mg/dl (normal range is 16-35 mg/dL) Low prealbumin is a better indicator of a patients current protein status than albumin because it is highly sensitive to nutrition and will change based on protein intake in days rather than weeks. Hemoglobin: 9.5 g/dl (normal range is 12-15 g/dL), Hematocrit: 34 % (normal range is 37-47%), Low hemoglobin and hematocrit indicate anemia. Ferritin 12 mg/ml (normal range is 20-120mg/ml) Ferritin is an intercellular protein that stores and releases iron. Low ferritin status may indicate low iron status. B12: 21.2 ng/dL (normal range is 24.4-100ng/dL), Folate: 3micro-g/dL (normal range is 5-25 micro-g/dL) The low levels of vitamins are probably due to the patients poor oral intake and the decreased absorption of nutrients from the damage to her small intestine.

17. Are the abnormalities identified in question 16 related to the consequences of celiac disease? Explain. Diarrhea and decreased absorptive abilities due to damaged intestinal villi will affect her protein, hemoglobin, hematocrit, and ferritin status because she is deficient in all nutrients. This is what is showing up in her labs.

18. Are any symptoms from Mrs. Gainess physical examination consistent with her laboratory values? Explain. She is thin from poor protein status. She looks pale and has fatigue and weakness associated with anemia for that reason as well as the fact that her iron, hemoglobin, hematocrit, and B12 status are also low. 19. Evaluate Mrs. Gainess other anthropometric measurements. Using the available data, calculate her arm muscle area. AMA = ((MAC/4pi)(pi x TSF)) TSF=7.5mm (.75cm), MAC = 180mm (18cm) AMA=((18cm/4pi)(pi x .75cm))= 11.38cm Interpret this information for nutritional significance. She is below the 5th lowest percentile. This means that she has extremely low muscle mass. Her condition is making her malnourished. Wasting is a symptom of celiac disease. 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 laboratory values (Albumin 2.9g/dl, Prealbumin 13 mg/dl, Hemoglobin 9.5 g/dl, Hematocrit 34%, Ferritin mg/ml, B12 21.2 ng/dl, Folate 3 micro-g/dL) Underweight (NC-3.1) Unintended weight loss (NC-3.2) Food- and nutrition-related knowledge deficit (NB-1.1) Physical inactivity (NB-2.1) Impaired ability to prepare foods/meals (NB-2.4) IV. Nutrition Diagnosis 21. Using the VA nutrition screening form, what is the patients nutrition status level? According to the VA nutrition screening form the patients nutrition status level is a 3. 22. Select two high-priority nutrition problems and complete the PES statement for each. 1. Inadequate oral intake (NI-2.1) related to patients aversion of food because it causes her diarrhea as evidenced by severe unintentional weight loss.

2. Food and nutrition-related knowledge deficit (NB-1.1) related to a new diagnosis of celiac disease as evidenced by the patients 24-hour diet recall where consumption of gluten-containing foods was reported.

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). 1. Modify distribution, type, or amount of food and nutrients within meals (ND-1.2) To get the patient to eat and adequate amount of food it will be necessary to give her a low-redisue, high calorie, gluten-free diet with a glutamine supplement so she will regain adequate nutrition status. Goals: The patient will regain a normal PO intake adequate for her size and nutrition needs. 2. Nutrtition relationship to health/disease (E-1.4). Nutrition education about foods and products that contain gluten is necessary. Goals: The patient will be able to explain what gluten is, how to read a food label to see if food may contain/be contaminated by gluten, and know gluten-free substitutions for products she already eats.

24. What type of diet would you initially begin when you consider the potential intestinal damage that Mrs. Gaines has? I would recommend a gluten-free and lactose-free diet. She will also need to consume low residue foods such as foods low in: fiber, lactose, excess sugar alcohols, excess sucrose/fructose to decrease residue left in the GI tract while it is healing. Foods which increase GI secretions will also need to be limited initially, such as: caffeine and alcohol. Once she regains normal GI functioning, she can progress to higher-residue foods. Farther down lactose containing foods and beverages could be added back into her diet as tolerated. 25. Mrs. Gainess Nutritional status is so compromised that she might benefit from a high-calorie, high-protein supplementation. What would you recommend? I would recommend the Hi Calorie Ensure Plus (8oz) because it provides high amounts of kcalories and protein which is essential for her right now to heal and return to normal body weight.

26. Would glutamine supplementation help Mrs. Gaines during the healing process? What form of glutamine supplementation would you recommend? Glutamine is not normally an essential amino acid but it may become conditionally essential for patients that are critically ill, such as for patients with celiac disease. During stress the need for glutamine increases substantially due glutamines responsibilities related to healing. The need for glutamine may exceed the amount that the body can produce on its own, therefore glutamine becomes conditionally essential and supplementation is needed. (Lacey & Wilmore, 1990) I would recommend a powdered form that she could mix into liquids for ease of consuming. 27. What result can Mrs. Gaines expect from restricting all foods with gluten? Will she have to follow this diet for very long? Treatment of celiac disease involves a lifelong gluten-free diet. The only thing that can cure an autoimmune disease is avoiding the trigger to the autoimmune reaction. Eating any amount of gluten no matter how small the amount can cause damage to the villi of the small intestine and prevent patients from absorbing nutrients into the bloodstream. (National Foundation for Celiac Awareness, 2013)

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. Excerpt from Trader Joes Gluten Free products section:

Always read the labelfoods that do not contain gluten may have been manufactured with products that do and therefore will likely be contaminated. Gluten is a protein found in wheat, barley and rye and their derivatives such as malt or spelt. As a general rule of thumb, dairy, juice, meat and produce do not contain gluten or any gluten derivatives. Use common sense and remember the motto: When in doubt, leave it out.

Cornflakes: might contain gluten. Barbara's Multigrain Puffins, Trader Joes Bologna slices: most bologna does not have gluten. Busseto Premium Genoa Salami, Trader Joes Lean-Cuisine-Ginger Garlic Stir Fry with Chicken: Contains gluten. Chicken Masala, Trader Joes

Skim milk: skim milk is gluten free but dairy products should be avoided because it is very likely that she has lactose intolerance right now. Cheddar cheese spread: Gluten-free. Queso Cheese Dip from trader Joes is gluten free, or she could try some of the other dips or sauces they have that is lactose free. Green bean casserole (mushroom soup, onions, green beans): Contains gluten. Coffee: Plain coffee that has not been cross-contaminated is gluten free. Creamers and additives still may contain gluten. Rice crackers: Some rice crackers contain gluten. Lundberg Organic Brown Rice Cracker, Trader Joes Fruit cocktail: Most canned fruits and vegetables are gluten-free but read the label. Sugar: Sugar is gluten-free. Cross-contamination may happen during manufacturing. Read the label to see if there is a danger of cross-contamination. Pudding: Puddings (Chocolate, Rice, Tapioca), Trader Joes V8 juice: gluten-free. Banana: gluten-free. Cola: gluten-free. (Trader Joe's, 2013)

Works Cited
Barker, J. M., & Liu, E. (2008). Celiac Disease: Pathophysiology, Clinical Manifestations and Autoimmune Conditions. Retrieved from US National Library of Medicine National Institutes of Health: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2775561/ Lacey, J., & Wilmore, D. (1990, August). Is glutamine a conditionally essential amino acid? Retrieved from PumMed.gov: http://www.ncbi.nlm.nih.gov/pubmed/2080048 National Foundation for Celiac Awareness. (2013, November 14). what is celiac disease? Retrieved from National Foundation for Celiac Awareness: http://www.celiaccentral.org/SiteData/docs/NFCAWhatis/97976cf09194b9 86/NFCA%20-%20What%20is%20Celiac%20Disease%202-2011.pdf Nelms, M., Sucher, K. P., Lacey, K., & Roth, S. L. (2011). Nutrition Therapy & Pathophysiology: Second Edition. Belmont: Brooks/Cole Cengage Learning. Trader Joe's. (2013). No Gluten Ingredients Used. Retrieved from Trader Joe's Grocery Store: http://www.traderjoes.com/lists/no-gluten.asp#1