1. Celiac Disease Case Study
Erin McNamara

2. What is Celiac Disease? Inherited autoimmune disease
Once onset occurs, affects individuals for life
Symptoms can appear at any time
Present at birth
Can be triggered by stress, surgery, infection, pregnancy or childbirth
1 out of 133 people in the U.S. is affected
Family members who have an autoimmune disease are at a 25% increased risk of having celiac disease
Also known as celiac sprue or gluten sensitive enteropathy (GSE)
Symptoms can first occur in children when they are introduced to cereal for the first time
Cause is still undetermined
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3. What is Celiac Disease Immune response to the wheat protein, gluten
Causes atrophy and damage to the mucosal villi of small intestine
If left untreated, damage can be chronic and life threatening
Increased risk of other immune and nutritional disorders
Immune system responds to gluten by damaging villi. Normally villi allows nutrients to be absorbed from food, but damaged villi can not absorb vital nutrients, carbs, protein, fats, vitamins, minerals
Not matter how much a person eats they become malnourished
Other autoimmune diseases related to: T1DM, thyroid disease, Lupus, Addison’s Disease, RA, Sjogren’s Syndrome, Raynaud’s Syndrome
Skin manifestation of celiac disease, dermatitis herpetiformis, characterized by blistering, intense itchy rash
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4. Gluten
Found in wheat, rye, barley, and any foods containing these ingredients
Many processed foods contain gluten
Also found in medicines, vitamins and lip balms
Reading food labels is essential
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Foods that may contain wheat, barley or rye: sauces, soups, potato chips, hot dogs, sausages, cold cuts, soy sauce, candy, French fries
Food labels will help identify which products contain gluten. Some packaging may not list wheat, rye or barley. There may be terms like modified food starch or items containing malt or soy are not gluten-free.
Some medications/vitamins use fillers that are made with wheat & rye.
It’s always important to check the label! If in doubt, don’t eat it.
There are many delicious alternative grains that can be included in a gluten-free diet. Use this as a chance to explore new food items.
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5. Signs & Symptoms Multi-symptom, multi-system disorder Direct Symptoms
Indirect Symptoms
abdominal cramping
osteopenia or osteoporosis
gas
infertility
distention of stomach
fatigue, lack of energy
chronic diarrhea
depression
chronic constipation
anemia
fatty/foul-smelling stools
tingling or numbness in hands or feet
unexplained weight loss with large appetite
migraine headaches
- Symptoms vary from person to person, some individuals may not display many symptoms or symptoms may not be gastrointestinal

6. Treatment Life-long adherence to a gluten-free diet
Many foods are naturally gluten-free
Fruits, vegetables, beef, poultry, fish, nuts, eggs
Wide variety of delicious and nutritious gluten-free options available
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Gluten-free Foods:
Amaranth
Corn
Quinoa
Millet
Rice
Lentils
Potato
Buckwheat
Soy
Wild Rice
- Following a gluten – free diet will heal the damage to the villi and prevent any further damage
Avoidance of all products that contain traces of wheat, rye or barley is essential
Replace wheat flour with potato, rice, soy, amaranth, quinoa, buckwheat, and bean flour
This list includes some examples of gluten-free foods. With such a high prevalence of celiac disease, many companies make products without gluten. This helps people adjust and adhere to gluten free diet.
Source: glutenfreeforlifeexpo1

7. Case Study Patient: Rachel Gender: female Ethnicity: Caucasian Age: 33
Height: 62”
Current weight: 105#
Usual weight: 125#
% UBW : 80%
BMI: 18.3
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8. Case Study Patient’s Symptoms
Rachel complains of extreme fatigue and weakness. She contributes these symptoms to stress and says she has been feeling depressed lately because she has been unable to get pregnant. She reports that she experiences intermittent bouts of diarrhea that smell very bad. Her chief concern is that she seems to be hungry all the time but keeps losing weight. Lately, she has noticed that everything she normally eats tends to make her feel bad. She says is tired of feeling bad all the time.
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9. Case Study Patient History
Rachel states that she has been trying to get pregnant for a long time with no success. She says she’s always thought of herself as an energetic person, but thinks that the inability to get pregnant is taking a toll on her and that’s why she is so tired all the time. She has been a relatively healthy person but has a history of diarrhea episodes and occasional constipation. Reports her mom has always had GI issues and had trouble maintaining her weight. Rachel’s niece (her sister’s daughter) was just diagnosed with celiac disease.

10. Case Study Typical Daily Intake Breakfast
1 English muffin or 2 slices whole wheat toast, 1 tbp. peanut butter, 1 sm. apple or orange, 1 c. skim milk, 1 c. coffee, 1tbp. half & half
Snack
handful of pretzels or cut up vegetables & ranch dip
Lunch
½ c. barley mushroom soup or chicken noodle soup , 2 slices whole wheat bread, 2 oz. roast beef, 1 tsp. light mayo, romaine lettuce, 1 bag of potato chips
whole wheat pita with hummus or crackers and cheese
Dinner
1c. regular or whole wheat pasta, 1 turkey sausage link. 1c. canned tomato sauce, 2 oz. italian bread, 1c. steamed broccoli
Dessert
1 chocolate chip cookie or ½ c. ice cream, 1tbp. chocolate sauce
**Diet has consisted of chicken soup and crackers the past few days because of not feeling well.
Rachel says that she has always loved bread & pasta and says that it would be hard to ever think of not eating those things again.
She may be at risk of not complying with the diet.
It would be wise to show her that there are a variety of gluten-free options available on the market so he doesn’t have to feel she is missing out on the foods she likes. Rachel will need some guidance on how to substitute other products for those containing gluten.

11. Case Study Lab Values of Concern
Albumin & prealbumin are used as an indication of inflammation or severity of illness. Low levels suggest inflammation and malnutrition. Based on symptoms pt. has inflamed small intestine and BMI indicates mild malnutrition.
HgB, HCT and ferritin can be used to determine anemia. Low levels suggest iron deficient anemia. Pt.’s low energy and fatigue is due to anemia.
tTG is used to determine if the antibodies are present. This test can be used whether symptoms are present or not because it is the most sensitive test available. A positive result indicates celiac disease.
Fecal fat test is used when a person has diarrhea and signs of malabsorption. Test is used to evaluate fat digestion and absorption. A high amount of fat present suggests absorption is being challenged.

12. Recommendations
The following are EAL recommendations for celiac disease. Provided is the topic and guideline along with the rating of the guideline. The ratings reflect how strong the recommendation is for the topic. The guidelines that I have posted have the following ratings:
- Strong, Imperative: which indicates this recommendation should be followed by everyone unless there is a compelling reason not to and there is an alternative approach.
Strong, Conditional: which indicates this recommendation should be followed by the defined specifics of the individual. For example, only a iron deficient person should follow a recommendation for iron supplements.
Consensus, Imperative: which indicates this recommendation could be followed based on the specifics of the situation and individual; it may be good for some, but not for others. For example, food label reading education may be beneficial to some individuals without prior education, but not necessary for those who already know how to read food labels.
Based on expert opinion, not enough supporting evidence
Next to the EAL recommendations is the supporting evidence along with the strength of the research.
Grade I is good: Results of studies are important, consistent and are free of doubts and flaws in the research.
Grade II is fair: Results of studies are important but there may be some inconsistencies in the conclusions or flaws in the research.

13. Recommendations
Pt.’s values should be continued to be assessed to determine complying with a gluten-free diet. Anemia & malabsoprtion should be monitored. If pt. does not follow the diet, she is at risk for developing other deficiencies.

14. Recommendations
- A gluten free diet is the only treatment for celiac disease.

15. Recommendations
Important to make sure diet includes essential nutrients to avoid further deficiencies.

16. Recommendations
Treating anemia will help pt. feel less tired and have more energy.

17. Recommendations
Many food products contain gluten – it is important to recognize the ingredients to help achieve success in maintaining a gluten-free diet.

18. ADIME Note
A: Pt. appears thin and moderately concerned because of weight loss despite being hungry all the time. States that she is extremely tired and weak and reports bouts of foul-smelling diarrhea with occasional constipation. She has been unsuccessful at getting pregnant and reports feeling depressed over the situation.
Family Hx: Mother - GI issues (possible celiac), Niece (sister’s daughter) celiac disease
Current diet order: 100 g fat for 3 days prior to fecal fat test Medications: kaopectate on occasion
Admit Dx: celiac disease, mild malnutrition, malabsorption & anemia
Gender: Female Age: 33 y/o Height: 62” Current Wt: 100# BMI: 18.3 (underweight, mild malnutrition)
Usual Wt: 125# UBW%: 80%
Labs: Albumin = 2.8, Prealbumin = 5.4, tTG = positive, HgB = 9.4, HCT = 34, Ferritin = 13, Fecal fat - 17g
D: Unintentional weight loss (NC - 3.2) RT newly diagnosed celiac disease AEB current weight 100#, usual weight 125#, 80% of UBW and BMI of 18.3.
Altered GI function (NC -1.4) RT new diagnosis of celiac disease AEB Albumin = 2.8, Prealbumin = 5.4, HCT = 34, Ferritin = 13 and Fecal fat = 17, and tTG = positive.
I: Purpose of nutrition education (E - 1.1) Provide knowledge of adapting a gluten-free diet to manage symptoms of celiac disease to pt. & husband.
Mineral (ND ) Iron supplement intake to treat anemia.
M: Modified diet (FH ) Follow-up on adherence to gluten-free diet. Pt. & husband will follow a gluten-free diet.
E: Weight (AD ), Fecal fat (BD ), Ferritin, serum (BD.10.10), Albumin (BD ), Prealbumin (BD )

19. Treatment Plan
Rachel’s lab results confirm a diagnosis of celiac disease. To relieve her symptoms, I would recommend she follow a gluten-free diet. Strong, imperative evidence from EAL reports that a life-long adherence of a gluten-free diet improves gastrointestinal issues, iron deficiency and quality of life. Due to Rachel’s anemia related to iron deficiency, a strong, conditional recommendation for these individuals includes a diet supplemented with a gluten-free multivitamin containing iron.
It is important to teach Rachel and her husband that many products contain gluten. To ensure complete integration of a gluten-free diet, consensus, imperative EAL evidence recommends educating individuals on label-reading of foods and supplements. This education is to help identify sources of gluten in products to assist with the overall management of celiac disease.
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20. Treatment Plan
Changing to a gluten-free diet may be challenging at first for Rachel. It is important to show Rachel that eating gluten-free does not mean that she can enjoy foods that she loves. I would recommend accompanying her to the grocery store to show her the variety of gluten-free foods available. There are many gluten-free alternatives available for the foods that Rachel likes to enjoy.
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21. Treatment Plan
It would also be beneficial for her to have cooking lessons to help teach her how to use the gluten-free alternatives in her cooking. Learning how to use the gluten-free products to make the foods she loves will help strengthen her adherence to a gluten-free lifestyle.
Once Rachel has been educated on a gluten-free diet and adapted to eating this way, a follow-up evaluation will be scheduled. Biochemical lab value testing and a fecal fat test will be administered to evaluate her adherence to a gluten-free diet.

22. What I learned
The Evidence Analysis Library is a very useful reference tool. Prior to this class, I did not know how to use the information given in the EAL. Now I know how to navigate through the topics, read and understand the recommendations. I find the way the recommendations are rated make it easy to understand which recommendations would be applicable to each individual case. This made it easy for me to identify which recommendations. I could use for my case study. I also learned how each topic undergoes much research to ensure the information is adequate and valid.
The EAL is a tool that I will continue to use now and in the future. There are many resources available for anyone to see, but it is important for the dietetics profession to have accurate, specific information that can be used in practice. The EAL is a great reliable source and feel fortunate to have learned how to use it and have access to it.

23. References
Academy of Nutrition and Dietetics. (2009). “Evidence-based Nutrition Practice Guideline on Celiac Disease.” Academy of Nutrition and Dietetics Evidence Analysis Library. Retrieved from
American Association for Clinical Chemistry. (2012). Celiac disease: Tests. Lab Tests Online. Retrieved from
National Digestive Diseases Information Clearinghouse. (2012). Celiac disease. National Digestive Diseases Information Clearinghouse. Retrieved from
Mahan, L.K., Escott-Stump, S., Raymond, J.L. (2012). Medical nutrition therapy for lower gastrointestinal tract disorders. Krause’s Food and the Nutrition Care Process (pp ). St. Louis, MO: Elsevier.
Ruiz, A.R. (2012). Celiac disease: Malabsorption Syndrome. The Merck Manual. Retrieved from