NFSC 470 Deb McCafferty Case Study Case Questions: I.

Understanding the Disease and Pathophysiology

Christina Drobisch November 14, 2013

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? The results from this biopsy show a severe change in the anatomy of the small intestine. A typical healthy small intestine contains many tiny hair-like structures (villi) in the mucosal lining, which helps to absorb nutrients. If the mucosal lining is not rigged and the structure of these villi has changed, malabsorption can occur. For example, this biopsy shows the villi to be partially or completely wasted away, flattened and blunted. When the villi are flattened the crypts (glands in epithelial lining of small intestine) are exposed and enlarged (crypt hyperplasia). These hyperplastic crypts are an indicator of celiac disease. Due to the damaged villi, there will be less absorption in the small intestine, causing nutrients to be excreted in stool. (NFCA and MayoClinic) 2. What is the etiology of celiac disease? Is anything in Mrs. Gaines history typical of patients with celiac disease? Explain. Celiac disease (CD) damages the intestinal mucosal lining of the small intestine, causing malaborption of nutrients to occur. The reason the villi become damaged (or atrophy) is caused by an autoimmune response to gluten consumed in food. This damaged intestinal mucosa causes the infiltration of white blood cells in response to the antigens in the mucosa lining. The immune system struggles to fight off the antigens, unfortunately, these antigens or self-antigens. Since the body cannot distinguish between self and non-self antigens, the body continues to atrophy cells and prevents healing to this viscous cycle. Some influential environmental factors that contribute to celiac disease show a shorter length of breastfeeding, being exposed early to gluten, and the presence of viral infections during infancy all contribute to increase risk of CD. Mrs. Gaines history shows that her family has similar symptoms of diarrhea. Some believe that celiac disease is somewhat correlated with genetics and this might be another explanation pointing to this disease. (MayoClinic) 3. How is celiac disease related to the damage to the small intestine that the endoscopy and biopsy results indicate? The damage in the small intestine is caused by an autoimmune response, triggered by gluten. When those with celiac disease consume gluten in the diet, their immune system attacks healthy viable cells on the villi of the small intestine. The endoscopy will show the villi to be damaged, flattened and destroyed. Mrs Gainss chronic diarrhea symptoms are a result of the malabsorption and maldigestion from the cell atrophy in her small intestine (Anderson, 2013 and Nelms 2007).

4. What are AGA and EMA antibodies? Explain the connection between the presence of antibodies and the etiology of celiac disease. AGA is an antigliadin andibody, and an EMA is an antiendomysial antibody. These antibodies serve as a component of the diagnostic procedure for celiac disease. The presence of these antibodies are linked to the etiology of celiac disease by showing the bodys immune reaction to gluten in the diet. (Celiac.com) 5. What is a 72-hour fecal fat test? What are the normal results for this test? A 72-hour fecal fat tests measures the amount of fat present in stool, which helps to calculate the amount of dietary fat that the body did not absorb. Stool samples are collected for 72 hours. Large amounts of fat being excreted in the stool, indicates fat malabsorption or steatorrhea. Three days leading up to this fecal fat test, the patient will be instructed to consume 100g per day. Normal stool sample results show less than 7 grams of fat per 24 hours (Dugdale 2013, MedlinePlus). 6. Mrs. Gainess laboratory report shows that her fecal fat was 11.5 g fat/24 hours. What does this mean? A normal individual will have less than 7 grams of fat in the stool over 24 hours. Mrs. Gainess laboratory report shows that her fecal fat test was 11.5 g of fat in a 24 hour period, which indicates that she is experiencing fat malabsorption. 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. Mrs. Gainess was places on a 100-g fat diet three days prior to her fecal fat test. This was in order to observe the amount of fat being absorbed into the body and excreted in the stool. The stool was collected for visual examination and grease and oil were detected in the stool using a Sudan black B fat stained, lipid stain (Akagi, T 2012). Fecal fat indicates Steatorrhea and malabsorption, which is common with patients with celiac disease (Dugdale 2013). 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 composed of Gliadins and glutenins. Gluten is found in foods containing wheat, barley, rye, and sometimes oats. Some foods may not directly contain gluten but could be cross-contaminated with gluten products. People with celiac diease may also experience lactose intolerance and be sensitive to other foods (Anderson 2013). 9. Can patients on a gluten-free diet tolerate oats? Oats can be tolerated if they are processed in a facility that contains no wheat, rye or barley. Oats are gluten-free, however, they are often contaminated by other grains during the manufacturing process. Check label and research oats before consuming (Medline Plus 2013).

10. What sources other than foods might introduce gluten to the patient? There are many unsuspecting places that gluten can hide. The glue seal on stamps and envelops, the casein of vitamins and medications, toothpaste and cornstarch. Latex and rubber gloves can also contain wheat flour and can often come into contact with nongluten foods. Everyday products such as, lipstick, lotion, shampoos and deodorants can also contain gluten. Its important for Mrs. Gainess to check the label on all her products and replace products if necessary (WebMD Hidden Sources of Gluten 2013). 11. Can patients with celiac disease also be lactose intolerant? Patients with celiac disease can be lactose intolerant. Due to the damage caused by the villi of the small intestine, nutrient absorption is inhibited, often including lactose. When the gut is distressed, lactase, the enzyme that breaks down lactose is often the first to leave, making lactose difficult to digest and absorb (Celiac Sprue Association 2013). Part 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: 112 lbs ABW/UBW x 100 = %UBW 92 lbs/112lbs x 100 = 82% UBW 100%-82%= 18% weight loss, indicates severe weight loss. BMI: (weight in lbs/[height in inches x ht in inches] x 703 92lbs / (63 in x 63 in) x 703 = 16.3 BMI which is underweight. B. Calculation of Nutrient Requirements 13. Calculate this patients total energy and protein needs using the Harris-Benedict equation or Mifflin-St. Jeor equation. Calories: 655 + (9.6 x weight in kg) + (1.8 x height in cm) (4.7 x age) = BEE (x 1.3 x 1.2) 655 + (9.6 x 41.8) + (1.8 x 160) (4.7 x 36) = 655 + (401.28) + (288) (169.2) = 1175 x 1.3 = 1527 x 1.2 = 1833 kcals Protein: 1.5 x 41.8 = 62.7 g/day

C. Intake Domain 14. Evaluate Mrs. Gainess 24-hour recall for adequacy Mrs. Gainess 24 hours recall precise and amounts were listed appropriately. The 24 hour recall was entered into Myplate for analysis. Whole-wheat toast, 1 slice (69 calories) Sugar in tea, 2 tsp (32 calories) Butter, 1 tsp (36 calories) Chicken noodle soup, 1 cup (63 calories) Saltine crackers, 2-3 (30-45 calories) Applesauce, cup (51 calories) Sprit, 8-12 oz (148 calories) Total estimated calories: (437) This calorie amount is severely low and does not meet Mrs. Gainess adequate calorie needs. This low calorie intake positively correlates with her serve weight loss. Mrs. Gainess nutrient intake is also very low in protein, carbohydrate, fat (omega 3 and 6) and fiber. Her daily intake indicates that she is not consuming adequate amounts of calcium, potassium, iron, B12, folate, Vitamin C, D, E, K, A, thiamin, niacin and riboflavin. While some of these micronutrients are supplied with Mrs. Gainess pre-natal vitamin, her labs still indicates that she is low in iron, folate and B12 (Myplate.gov). 15. From the information gathered within the intake domain, list possible nutrition problems using the diagnostic term. Possible Nutrition Problems: 1. Inadequate oral intake (NI 2.1) 2. Malnutrition (NI- 5.2) 3. Food and nutrition related deficit (NB-1.1) D. Clinical Domain 16. Evaluate Mrs. Gainess laboratory measures for nutritional significance. Identify all laboratory values that support a nutrition problems using the diagnostic term. -Mildly depleted albumin (2.9 g/dL) -Mildly depleted pre-albumin (13 mg/dL) -Low HCT (34%) -Low HgB (9.5 g/dL) *Low H&H can indicate iron deficiency -Low total protein (5.5 g/dL) -Mildly depleted Folate (3 ug/dL) *Even with prenatal vitamin -Low Ferritin (12 mg/mL) -High MCV (90 um^3) *Macrocytic Anemia B12, Folate def. -Severe weight loss 18% in 3 months

17. Are the abnormalities identified in question 16 to the consequences of the celiac disease? Explain. The abnormalities listed above and symptoms that Mrs. Gaines is experiencing are all consequences of the celiac disease. Her low serum protein levels are due to her severe malnutrition. The celiac disease causes an inflammatory response, which damages the mucosal lining, causing nutrients to not be absorbed, leading to Mrs. Gainess malnutrition. Mrs. Gainess labs show she is low in many micro and macronutrients due to her malabsorption from the celiac disease (MayoClinic 2013). 18. Are any symptoms from Mrs. Gainess physical examination consistent with her laboratory? Mrs. Gainess general appearance was described as thin, pale fatigued and weak. This is consistent with her low serum protein levels indicating depleted visceral protein stores. Low energy and pale skin without lesions in combination with her low H&H levels could indicate anemia (Fauci 2008 and MedicineNet 2013). The physical examination stated diminished bowel sounds, indicating blocked blood vessels, decreasing blood to intestine which could be an indicator of low H&H levels (PubMed 2012). Mrs. Gainess labs also indicate high MCV levels which suggest anemia and possible inflammation in the intestine due to the intestinal obstruction related to celiac disease (MayoClinic2013). 19. Evaluate Mrs. Gaines other anthropometric measurements. Using the available data, calculate her arm muscle area. Interpret this information for nutritional significance. AMA= [MAC/4 ( x TSF)^2 ] 180cm 18 mm 75 cm .75 cm 18mm (3.14 x .75mm)2 = 13.29 = AMA An AMA of 13 is very low. This value is significant because it indicates Mrs. Gainess muscle and fat deficit, which reflects her wasting condition. This calculation is important for a PEM diagnosis. 20. From the information gathered within the clinical domain, list possible nutrition problems using the diagnostic term. Inadequate oral intake Food and nutrition related knowledge deficit Impaired nutrient utilization Altered GI Function Unintended weight loss Malnutrition

Part IV. Nutrition Diagnosis 21. Using the VA nutrition Screening Form, what is this patients nutrition status level? Mrs. Gainess overall nutrition status level was a 3 indicating moderately compromised nutritional status. This nutrition status is defined as the patients nutritional status at a point in time. This nutrition status will determine the priority nutrition intervention and reassessment (Department of Veterans Affairs, 2010). 22. Select two high-priority nutrition problems and complete the PES statement for each. PES #1: Inadequate oral intake (NI-2.1) related to chronic diarrhea as evidenced by severe weight loss of 18%, patient is at 82% of usual body weight has low albumin 2.9g/dL, low total protein 5.5g/dL, low pre-albumin 13mg/dL, low HgB 9.5g/dL and low HCT 34%. PES #2: Food and Nutrition Knowledge Deficit (NB-1.1) related to no previous diet education on celiac disease as evidenced by patients 24-hour food recall, and consuming foods containing gluten. Part 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 etiology) Ideal Goal: To educate the patient on how to eat gluten free in order to increase patient to 100% usual body weight. 24. What type of diet would you initially begin when you consider the potential intestinal damage that Mrs. Gaines has? Considering Mrs. Gaines has severe intestinal damage, I would start her on a clear liquid diet (sugar-free) until the diarrhea has subsided. I would slowly and gradually start adding gluten-free, lactose-free foods that are low in sugar and fat and adjust based on her tolerance. Once she has begun tolerating these foods, I would slowly start adding in more calorically dense gluten-free foods to promote weight gain. Once Mrs. Gaines feel comfortable she can attempt to add back lactose, however she will need to monitor her tolerance. 25. Mrs. Gainess nutritional status is so compromised that she might benefit from high-calorie, high-protein supplementation. What would you recommend? Since Mrs. Gainess nutrition status is so compromised I would recommend a high Calorie Ensure plus supplementation to increase her calorie and protein intake. One 8 oz serving of Ensure plus contains 355 calories and 13 grams of protein. The Ensure plus is gluten free and helps promote weight gain by increasing calories and added protein to promote healing and increase muscle mass. (Ensure Website)

26. Would glutamine supplementation help Mrs. Gaines during the healing process? What form of glutamine supplementation would you recommend? I would recommend a glutamine supplementation to help Mrs. Gaines during the healing process. Glutamine helps to support the height of the mucosal villi and improve the overall health of the intestinal lining. I would recommend glutamine in the L-glutamine form, in either liquid or powder form since some capsules caseins may contain gluten. 27. What results can Mrs. Gaines expect from restricting all foods with gluten? Will she have to follow this diet for very long? If Mrs. Gaines cautiously follows a gluten-free diet, her clinical symptoms should subside within two to eight weeks. She should expect her lab values to return to normal in three to six months. Celiac disease is incurable and Mrs. Gaines will have to follow a gluten-free diet 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. *Mrs. Gainess cant tolerate items containing gluten and should avoid lactose until her gut is healed and is digesting foods normally again. Thus below are suggestions that are gluten and lactose free.
Food Item
Cornflakes Bologna slices Lean Cuisine- Ginger Garlic Stir Fry with Chicken Skim Milk Cheddar cheese spread Green bean casserole (mushroom soup, onions, green beans) Coffee Rice Crackers Fruit Cocktail Sugar Pudding V8 juice Banana Cola

Tolerated/Not Tolerated
Not tolerated Not Tolerated Not Tolerated: Contains gluten Lactose probably not tolerated Not Tolerated Not Tolerated: Mushroom soup contains both lactose and gluten. Questionable Questionable (be careful for contamination) Tolerated Questionable: due to cross-contamination during processing Tolerated if lactose free. Tolerated Website states non of their products contain gluten Tolerated: Questionable-No gluten however may have crosscontamination

Substitution
Gluten-free Rice Chex Cereal Fresh meat only; Reduce processed meats. Substitution for deli slices Boars Head Products Amys Thai Stir-Fry TV dinner- No dairy or gluten- Microwavable in mins. Almond Smooth Non-Dairy Beverages (Chocolate, Original, Unsweetened Vanilla) Sheese Cheddar Style SpreadGluten and lactose free Alternative: For mushroom soup sub Amys Thai Coconut soup Fresh Brewed Coffee, No grains added No Instant coffee Marys Gone Crackers Wheat free and gluten free Del Monte Fruit Cups- Gluten Free Domino Sugar Kozy Shack Lactose Free Chocolate Pudding More Alternative Juices: Dole, Fuzze, Izze, Cool-aid Fresh fruit all recommended; oranges, grapes, Apples Coca cola, Dr. Pepper, A&W Root Beer all contain less than or equal to 20 ppm of gluten.

Source Cited
General Mills Massachusetts hospital Amys Kitchen Trader Joes Bute Island foods Amys Kitchen Massachusetts Hospital Marys Gone Crackers Conscious Eating Del Monte Foods ASR Group Manufacturing Sugar only Mills reducing cross-contamination. Kozy Shack Celiacsdiseaseabout.com Colorado State University Celiacsdiseaseabout.com

*Caution: Some latex gloves are dusted with wheat or oat flour. Latex gloves are frequently used to handle foods, and in hospitals and dentist offices. Request powder-free gloves from your doctor or dentist and look on food product company websites that use powder-free gloves.

Works Cited: Akagi , T. (2012). Santa cruz biotechnology. Retrieved from http://www.scbt.com/datasheet-203760-sudan-black-b.html. Amys Kitchen Inc. (2013). Natural and organic foods: Thai stir fry. Retrieved from http://www.amys.com/products/product-detail/gluten-free/000132. Anderson, D. (2013) retrieved November 7, 2013, Retrieved from http://celiacdisease.about.com/od/glutenfreefoodshoppin1/ss/Gluten-Free-FoodList_4.htm. Anderson, J. (2013, April 19). Gluten-free diet guide for people with newly diagnosed celiac disease. Retrieved from http://www.ext.colostate.edu/pubs/foodnut/09375.html. ASR Group. (2013). Domino sugar . Retrieved from http://www.asrgroup.com/?utm_source=Domino&utm_medium=sitelink&utm_campaign=FamilySites. Celiac Sprue Association/United States of America, Inc. (2013). Celiac sprue association. Retrieved from http://www.csaceliacs.info/index.jsp Conscious Eating. (2013). Organic marys gone crackers. Retrieved from http://www.marysgonecrackers.com. David C. Dugdale, III (2012). Fecal Fat. [ONLINE] Available at: http://www.nlm.nih.gov/medlineplus/ency/article/003588.htm. [Last Accessed November 10, 2013]. Del Monte Corporation. (2013). Del monte foods. Retrieved from http://www.delmonte.com/recipes/search-results.aspx?t=28. Department of Veterans Affairs. (2010). VHA HANDBOOK 1100.01. Retrieved 2013 13November from Department of Veterans Affair : http://www1.va.gov/vhapublications/viewpublication.asp?pub_id=1465. Ensure (2013). Ensure complete balanced nutrition. Retrieved from http://ensure.ca/en/products. Fauci, A., et al. (2008) Pale Skin Symptoms, MedicineNet. Retrived November 11, 2013 from http://www.medicinenet.com/pale_skin/symptoms.htm. Freshway Distributors Inc. (2013). Kozy shack lactose free chocolate pudding. Retrieved from http://www.kozyshack.com/lactose-free-chocolate. General Mills (2013). Chex gluten free. Retrieved from http://www.chex.com/Recipes/GlutenFree.aspx. HealthWise (Updates June 23, 2008). What Causes Celiac Disease? . retrieved November 7, 2013, from WebMD Web Site: http://www.webmd.com/digestivedisorders/celiac-disease/celiac-disease-cause.

Massachusetts General Hospital. (n.d.). Retrieved from http://www.massgeneral.org/digestive/assets/pdf/gluten_free_diet.pdf Mayo Clinic Staff (May 22, 2013). Celiac disease . retrieved November 9, 2013, from Mayo Clinic Web Site: http://www.mayoclinic.com/health/celiacdisease/DS00319/DSECTION=symptoms. Medline Plus, A Service of the U.S National Library of Medicine (2013). Retrieved November 11, 2013 from http://www.nlm.nih.gov/medlineplus/celiacdisease.html. NFSD Staff (November 11, 2013). Celiac disease DIAGNOSIS & TREATMENT. retrieved November 9, 2013, from National Foundation for Celiacs Awareness Web Site: http://www.celiaccentral.org/Celiac-Disease/Diagnosis-Treatment/33/ Nelms, M Sucher, K, Lacey, K, & Roth, S (2011). Nutrition Therapy & Pathophysiology . Belmont, Ca: Wadsworth. Sheese. (2013). Bute island foods 100% vegan cheese. Retrieved from http://www.buteisland.com/index.htm Trader Joes. (2013). Trader Joes no gluten ingredients used. Retrieved from http://www.traderjoes.com/lists/no-gluten.asp USDA. (2013). Myplate.gov super tracker. Retrieved from https://www.supertracker.usda.gov/foodtracker.aspx