Case Study #9: Celiac Disease

1. Case Study #9:Celiac Disease By: KailiAcosta 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# • % IBW= 80 % • % weight change = 18 % weight change in 2 months • Nutritional risks

9. Clinical Domain • 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 = 3.362 = 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 160.0 cm) - (5 x 36) – 161 = 1182 x (1.2) = 1418 (1.2)=1843 = 1800 kcal /day • EPR: (IBW 1.2 g/kg) • 52.3 kg x 1.2g/kg = 62.76 = 63 g/d

11. Intake Domain 24-Hour Recall Evaluation

12. Clinical Domain - Lab Values

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-5.10.1) • 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 16.3 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 • 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: http://www.niams.nih.gov/Health_Info/Bone/Osteoporosis/Conditions_Behaviors/celiac.asp. Published January 2012. Accessed February 28, 2013. • Celiac-disease. Gluten Free Diet – Do You Eat Oats? Celiac-disease Web site. Available at: http://celiac-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);1133-1150. • MedlinePlus. National Institutes of Health. Available at: http://www.nlm.nih.gov/medlineplus/ency/article/003588.htm. Accessed March 2, 2013. • Fecal Fat. Lab Tests Online. Available at: http://labtestsonline.org/understanding/analytes/fecal-fat/tab/test. Accessed on March 2, 2013. • Mayo Clinic. Gluten-free diet: What's allowed, what's not. Mayo Clinic Website. Available at: http://www.mayoclinic.com/health/gluten-free-diet/MY01140. Accessed March 2, 2013. • Thompson T. The celiac disease & lactose intolerant connection. Gluten Free Dietitian Website. Available at: http://www.glutenfreedietitian.com/newsletter/dietcom-blog-the-celiac-disease-lactose-intolerant-connection/. Accessed March 2, 2013. • Evidence Analysis Library. Academy of Nutrition and Dietetics. Eatright.org. Available at: http://andevidencelibrary.com/topic.cfm?cat=3253. Accessed March 2, 2013. • MyPlate. SuperTracker. Myplate Website. Available at: https://www.supertracker.usda.gov/NutrientsReport.aspx. Accessed March 2, 2013. • Improving patient outcomes with nutrition therapy. 2013 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: http://www.practicalgastro.com/pdf/September08/HlywiakArticle.pdf . Accessed March 3, 2013. • Escott-Stump S. Nutrition and Diagnosis Related Care. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2012.