1. Case Study #9: Celiac Disease
By:
Kaili Acosta
Joyce Moore
Elizabeth Olivares
Rosalinda Ruiz

2. Overview Celiac Disease and Pathophysiology Nutrition Therapy
Nutrition Assessment
Intake Domain
Clinical Domain
Nutrition Diagnosis
Nutrition Intervention
Monitoring and Evaluation

3. Panel Rules Directions 2 teams - panel style
First group to raise hand will be given 30 seconds to deliberate the answer and choose a spokesperson for each question (rotating spokesperson) (both groups will deliberate answer and spokesperson in case of incorrect answer made by other team)
If first team answers incorrectly question will fall to other panel and answer immediately
One point per question
No minus points
Panel with highest points wins!!!

4. Patient Information Patient name: Melissa Gaines DOB: 3/14 Age: 36
Sex: female
Ethnicity: Caucasian
Height: 5’3”
Weight: 92#
Referring MD: Roger Smith, M.D., gastroenterologist
Chief complaints: Weight loss, diarrhea, lack of energy

5. Patient History Delivered a healthy baby boy (5 lb. 2 oz.)
Gained weight during pregnancy (11 lbs.)
Greatest pre-pregnancy weight: 112#
Current weight: 92#
Diarrhea on and off for most of her adult life
Mother and grandmother also had diarrhea

6. What is Celiac Disease?
Abnormal immune response to the consumption of gluten
Etiology and Immune response:
Gliadin component of gluten triggers inflammatory response
Presence of antibodies – autoimmune response
IgA - anti-tissue transglutaminase
AGA – antiendomysial antibodies
EMA – antigliadin antibodies

7. Test Results Endoscopy and Biopsy
Flat mucosa with villus atrophy and hyperplastic crypts –inflammatory infiltrate in lamina propria
Antibodies: Positive AGA, EMA
72-Hour Fecal Test
Results:
Steatorrhea and malabsorption
11.5 g fat/24 hours

8. Nutrition Assessment BMI=16.3 kg/m2 UBW= 112 # %UBW=82 % IBW=115#
% weight change = 18 % weight change in 2 months
Nutritional risks

9. Clinical Domain AFA: 14.4 cm2. Interpretation
Anthropometric measurements
TSK=7.5 mm.
She is under the 5th percentile of TSF below average.
MAC= 180 mm
AMA = [(18 cm/12.56) x (3.14 x 0.75 cm)]2
(1.43 x 2.35)2 = = 11.4 cm2
Interpretation
AFA: 14.4 cm2.
She is between the 5th and 10th percentile which classifies her as below average fat.

10. Nutrition Assessment Nutrient requirements:
Calculation: Mifflin-St. Jeor equation:
Activity Factor: (1.2)
Injury Factor: (1.2)
EEN = (10 x 52.3kg) + (6.25 x cm) - (5 x 36) – 161 = 1182 x (1.2) = 1418 (1.2)=1843 = kcal /day
EPR: (IBW 1.2 g/kg)
52.3 kg x 1.2g/kg = = 63 g/d

11. Intake Domain
24-Hour Recall
Evaluation

12. Clinical Domain - Lab Values
MG Value
Normal
Albumin
2.9 g/dL (L)
g/dL
Total Protein
5.5g/dL (L)
6 – 8 g/dL:
Prealbumin
13 mg/dL (L)
mg/dL
AGA antibodies +  -
EMA antibodies
Fecal Fat Test
11.5 g / 24 hr
less than 7g / 24 hrs
HGB
9.5mg/dL (L)
HCT
34 mg/dL (L)
MCHC
30 L
Ferritin
12 L
20-120
ZPP
85 H
30-80
Folate
3 L
5-25
B12
21.2 L
Nutritional Significance
PEM
Celiac Disease
Altered GI function, steatorrhea, Malabsorption
Iron Deficiency Anemia
Iron Deficiency
Malabsorption

13. Which lab values are related to consequences of Celiac disease?

14. Clinical Domain Breastfeeding difficulty (NC-1.3)
Altered GI function (NC-1.4)
Impaired nutrient utilization (NC-2.2)
Altered nutrition related lab values (NC-2.2)
Underweight (NC-3.1)
Involuntary weight loss (NC-3.2)

15. Protein Energy Malnutrition (PEM)
Patient meets criteria:
Moderate Protein Energy Malnutrition (PEM)
Albumin 2.9 g/dL
82 % of UBW

16. Intake Domain Inadequate energy expenditure (NI-1.4)
Inadequate oral food/beverage intake (NI-2.1)
Inadequate fluid intake (NI-3.1)
Inadequate mineral intake (sulfate, iron, Ca)(NI )
Inadequate vitamin intake (Folate)(NI-5.9.2)
Malnutrition (NI-5.2)
Inadequate protein energy intake (NI-5.3)
Inadequate fat intake (NI-5.6.1)
Inadequate protein intake (NI-5.7.1)
Inadequate carbohydrate intake (NI-5.8.1)
Inadequate fiber intake (NI-5.8.5)

17. PES Statements
Inadequate oral and beverage intake (NI-2.1) RT altered GI function and food- and nutrition-related knowledge deficit secondary to CD AEB 24-hour recall reveals 440 kcals, consuming 24% EEN, BMI kg/m2, 80 % IBW, 82 % UBW, 30# weight loss and18% weight change past 2 months revealing severe weight loss.
Altered GI function (NC-1.4) RT intolerance to foods containing gluten AEB diarrhea, weight loss (30#) altered lab values: ferritin:12 mg/mlL (L), HGB: 9.5g/dL (L), HCT: 34% (L), Alb: 2.9 g/dL (L), Total PRO: 5.5 g/dL (L), PAB: 13 mg/dL (L), ZPP : 85 umol/mol(H), Folate:3 ug/dL(L), B12:21.2 ng/dL (L) and positive AGA and EMA.

18. Nutrition Therapy Gluten-free diet What is gluten?
Where can it be found?
Consumption of oats?

19. Nutrition Therapy Other sources than food Lactose intolerance
Food additives
Coloring agents
Modified food starch
Medications
Lactose intolerance
Damage to villi affects ability
to absorb lactose

20. Nutrition Intervention
Diet to start out on:
High-protein supplement recommended:
Glutamine supplementation:
Length of stay on diet

21. Mrs. Gains at home

22. Monitoring and Evaluation
Follow-up
How can we modify Mrs. Gaines’ diet?

23. References
Nelms, MN, Sucher, K, Long,S. Nutrition Therapy and Pathophysiology, 2nd ed. Belmont, CA: Wadsworth/Thomas Learning; 2011.
National Institutes of Health. What People With Celiac Disease Need to Know About Osteoporosis. NIH Osteoporosis and Related Bone Diseases ~ National Resource Center Web site. Available at: Published January Accessed February 28, 2013.
Celiac-disease. Gluten Free Diet – Do You Eat Oats? Celiac-disease Web site. Available at: disease.com/gluten-free-diet-do-you-eat-oats/. Accessed March 2, 2013.
Serra S, Jani PA. An approach to duodenal biopsies. Journal of Clinical Pathology. 2006(11);
MedlinePlus. National Institutes of Health. Available at: Accessed March 2, 2013.
Fecal Fat. Lab Tests Online. Available at: Accessed on March 2, 2013.
Mayo Clinic. Gluten-free diet: What's allowed, what's not. Mayo Clinic Website. Available at: Accessed March 2, 2013.
Thompson T. The celiac disease & lactose intolerant connection. Gluten Free Dietitian Website. Available at: Accessed March 2, 2013.
Evidence Analysis Library. Academy of Nutrition and Dietetics. Eatright.org. Available at: Accessed March 2, 2013.
MyPlate. SuperTracker. Myplate Website. Available at: Accessed March 2, 2013.
Improving patient outcomes with nutrition therapy Abbott Nutrition Product Reference.
International Dietetics & Nutrition Terminology (IDNT) Reference Manual, 4th ed. eat right. Academy of Nutrition and Dietetics.
Herzig L. Identifying Celiac Disease. Valley Health Magazine. 9:12.
Hlywiak K.. Hidden Sources of Gluten. Celiac Disease: a comprehensive review and update. Series #2. Available at: Accessed March 3, 2013.
Escott-Stump S. Nutrition and Diagnosis Related Care. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2012.