NFSC 470 Deb McCafferty Case Study Case Questions: Part 1: Understanding the Disease and Pathophysiology

Alexandra Shew November 15, 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, or villi, in the mucosal lining, which helps to absorb nutrients. When a patient goes untreated with celiac disease they typically have a flat mucosal surface with absence of normal intestinal villi. The thickness of the mucosa is reduced only slightly. This is due to crypt hyperplasia which compensates for the absence or shortening of the villi. This biopsy shows the villi to be partially or completely wasted away and flat. Due to the damaged villi, there will be less absorption in the small intestine, causing nutrients to be excreted in stool (Celiac disease, 2013). 2. What is the etiology of celiac disease? Is anything in Mrs. Gaines history typical of patients with celiac disease? Explain. - Celiac Disease is an auto-immune condition. This disease is usually inherited, although it is associated with the AGA/EMA antibodies. Celiac disease is an immune response to gluten, a wheat protein which causes damage to the intestinal villi. There is no cure for this disease. Mrs. Gaines has dealt with diarrhea on and off throughout her adult life. She has typical Celiac disease symptoms which include weakness, weight loss, diarrhea, fatigue and anemia. She has a past family history in which her mother and grandmother have had problems with diarrhea (Celiac disease, 2013). 3. How is celiac disease related to the damage to the small intestine that the endoscopy and biopsy results indicate? - Celiac disease (CD) is an auto-immune disease which in serious cases if gluten is consumed the small intestine responses by destroying the microvilli. The endoscopy and biopsy results show flattened mucosa with atrophied and hyperplasic crypts which is a good indicator that a person has celiac disease (Celiac disease, 2013). 4. What are AGA and EMA antibodies? Explain the connection between the presence of antibodies and the etiology of celiac disease. - AGA is an anti-gliadin antibody that is produced as an autoimmune response to the consumption of gluten in patients with celiac disease. EMA stands for antiendomysial antibodies, which are antibodies that are produced by the body and attack its tissue. Testing for the presences of AGA and EMA antibodies is commonly used in the diagnosis of celiac disease. Using the EMA test is considered the most accurate blood test for celiac disease (Anderson, 2013).

5. What is a 72-hour fecal fat test? What are the normal results for this test? - A 72- hour fecal fat test measures the amount of fat in feces or stools. The concentration of fat in a stool can tell doctors how much fat your body absorbs during digestion. Fecal fat tests usually cover a span of 24 hours, but can also last for three days. Normal range for fecal fat testing is < 7 grams over a 24 hour period, and 21 grams over a 72 hour period (Roth, 2012). 6. Mrs. Gainess laboratory report shows that her fecal fat was 11.5 g fat/24 hours. What does this mean? - Mrs. Gainess laboratory report shows her fecal fat test was 11.5 g fat. The normal range is < 7 g. This would indicate steatorrhea, malabsorption, and/or maldigestion. Fat is unable to be absorbed or digested which results in these symptoms (Steatorrhea, 2013). 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. Gaines was placed on a 100-g fat diet in order to determine if fat malabsorption was present. This procedure helps measure the amount of fat you are eliminating in for stool, and will allow doctors to know how much fat you are digesting or absorbing properly. Although she did experience worse symptoms and pain with fried food she needed an intake of 100g of fat to test for these symptoms (Paterson, 2012). Part 2: Understanding the Nutrition Therapy 8. Gluten restrictions are the major component of the medical nutrition therapy for celiac disease. What is gluten? Where is it found? - Gluten is a substance present in cereal grains, especially wheat. Gluten is a mixture of two proteins which cause illness in people with celiac disease. Gluten can be found in wheat, rye, malt, barley, and, in smaller amounts, oats (Nelms, 2011). 9. Can patients on a gluten-free diet tolerate oats? - Patients on a gluten-free diet can tolerate oats in most cases. However, restrictions of oats are still controversial. As long as the oats are coming from a pure, uncontaminated source most individuals can tolerate oats. Patients need to be well established on a gluten free diet before adding oats into the diet (Nelms, 2011). 10. What sources other than foods might introduce gluten to the patient? - There are several places other than food that gluten can hide. Anything that has been processed can obtain gluten, such as tooth paste, vitamins, stamps, an even medication. It has also been found in products used on skin, such as sunscreen, lip balm and shampoos (Hlywiak, 2008). 11. Can patients with celiac disease also be lactose intolerant? - Lactose intolerance is a frequent side effect of celiac disease. Lactose intolerance usually occurs after the villi and microvilli in small intestine become damaged and are no longer capable of catching and breaking down lactose molecules. However, lactose intolerance in celiac disease often improves after patients start a gluten-free diet, which allows them to tolerate lactose (Lapid, 2009).

Part 3: 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. - Usual body weight (UBW) has been strongly linked to nutritional risk and health complications. A patient can be considered at nutritional risk if there is a >5% unexplained weight change in less than one month. Mrs. Gaines UBW is 82.1%. Body mass index (BMI) has been correlated with overall mortality and nutritional risk. A person is considered overweight if their BMI is > or = to 25, and a person is considered underweight is their BMI is <18.5. Mrs. Gaines BMI currently is 16.3 which places her underweight (Nelms, 2011). - UBW: (92/112)100=82% this indicates moderate weight loss - BMI: (92/63/63x 703=16.3kg/m this indicates the patient is underweight with moderately depleted energy stores. B. Calculation of Nutrient Requirements 13. Calculate this patients total energy and protein needs using the Harris-Benedict equation or Mifflin-St. Jeor equation. - 655+ (9.6x42)+(1.8x160)-(4.7x36)=1176 AF: 1.3 1176 x 1.3= 1,529 + 350 kcals (additional kcal added) = 1,879 kcal Protein needs: 42 x 1.4= 58.8g/d protein, adequate amount of protein C. Intake Domain 14. Evaluate Mrs. Gaines 24-hour recall for adequacy. - Mrs. Gaines 24 hour recall shows she is not consuming enough food to support her energy needs. This is resulting to her extreme weight loss. Her current intake consist of 444 calories, 7.25 g/f, 158 g/CHO, 4.6 g/fiber, 104.5 g/sugar, 15.1 g/protein, 2,284 mg/sodium, 174.7 mg/K. - Whole wheat toast, 1 slice (69 calories) - Sugar in tea, 2tsp (32 calories) - Butter, 1 tsp (36 calories) - Chicken noodle soup, 1 cup (63 calories) - Saltin cracker 2-3 (30-45 calories) - Applesauce, half a cup (51 calories) - Sprit, 12 oz (148 calories) Mrs. Gaines calorie consumption is very low and is not meeting her adequate calorie needs. Her low calorie intake is whats causing her severe weight loss. Mrs. Gaines daily intake tells us she is not consuming adequate amounts of vitamin C,D,E,K,A, thiamin, niacin, riboflavin, B12, folate, iron, potassium, and calcium. Mrs. Gaines is taking a prenatal vitamin which will supply some of these micronutrient, although her labs do indicate 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. - Inadequate protein energy intake NI-5.3 Inadequate oral intake NI-2.1 Inadequate energy intake NI-1.4 Malnutrition NI-5.2 Inadequate fat intake NI-5.6.1 Food and nutrition related knowledge deficit NB-1.1

D. Clinical Domain 16. Evaluate Mrs. Gaines laboratory measures for nutritional significance. Identify all laboratory values that support a nutrition problem. - Albumin levels 2.9= below normal, malabsorption due to low intake, weight loss, metabolic stress Total protein level 5.5 g/dl= below normal due to low intake and due to abd. Pain Prealbumin level 13mg/dl= below normal due to weight loss, muscle wasting, inadequate protein intake Folate levels low 3 mcg/dl= hemolytic anemia Ferritin low 12 mg/ml= iron deficiency anemia HCT of 34% indicator of iron deficiency anemia, dietary deficiency HGB low 9.5 g/dl = deplete iron stores and late stage anemia Folate and B12 mildly low due to prenatal vitamins AGA/EMA antibodies + = Abnormal autoimmune response to gluten 17. Are the abnormalities identified in question 16 related to the consequences of celiac disease? Explain. - All of Mrs. Gaines abnormalities identified in question 16 relate to the consequences of celiac disease. Flattening of the microvillus can lead to malabsorption of fats, proteins, folate, iron and several other minerals which would cause the values listed above to be low. This is due to nutrients being unable to cross the intestinal wall. Anemia is present because of low folate, ferritin, HCT, and HGB. Mrs. Gaines poor intake and diet may be another possible reason for some of the low values. 18. Are any symptoms from Mrs. Gaines physical examination consistent with her laboratory values? Explain. - Mrs. Gaines physical examination reported her being thin, fatigued, and having weakness as well as diarrhea. These symptoms are consistent with her laboratory values. Diarrhea can decrease transit time which would cause weight loss due to the lack of nutrient being absorbed. Both anemia and protein deficiency have symptoms of weakness, fatigue, and weight loss. Diarrhea can increase the severity of anemia and protein deficiency (Ciaran & Melinda, 2013). 19. Evaluate Mrs. Gaines other anthropometric measurements. Using the available data, calculate her arm muscle area. AMA= (18/4(3.14)X(3.14x.075))^2= 11.83 Mrs. Gaines value is 11.83 which indicates muscle wasting 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 Unintended weight loss NC-3.2 Inadequate fat intake NI-5.6.1 Inadequate oral intake NI-2.1 Malnutrition NI-5.2

E. Nutrition Diagnosis 21. Using the VA Nutrition Screening Form, what is this patients nutrition status level? - The patients nutrition status level is 3. This indicates Mrs. Gaines will need a full nutrition assessment. With a status level of 3 this indicates Mrs. Gaines nutrition status is moderately-compromised (Nutrition status classification, 2006). 22. Select two high-priority nutrition problems and complete the PES statement for each. - Food and nutrition related knowledge deficit (NB-1.1) related to no previous diet education as evidenced by 24 hour recall diarrhea and weight loss. Unintended weight loss (NC-3.2) related to inadequate energy intake and untreated celiac disease as evidenced by recent weight loss of 30 pounds and BMI of 16.3%.

F. 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). - Ideal goal: Identify foods that lead to diarrhea, no further weight loss - Intervention: Nutrition education: Gluten free diet, dietary modification high protein 24. What type of diet would you initially begin when you consider the potential intestinal damage that Mrs. Gaines has? - I would put Mrs. Gaines on a gluten-free diet consuming nothing that contains wheat, rye or barley. I would also recommend a lactose free diet until her symptoms are better managed and under control. I would also recommend a high protein diet with easily digested foods. 25. Mrs. Gainess nutritional status is so compromised that she might benefit from highcalorie, high-protein supplementation. What would you recommend? - I would recommend that Mrs. Gainess consume a Hi-Calorie Ensure Plus (8oz). Ensure plus is a high calorie, ready to drink shake. It can easily be used as a meal replacement to promote weight gain for malnourished or ill clients. Ensure plus is vitamin and mineral fortified protein rich shake. It is also gluten free which is suitable for individuals who suffer from lactose intolerance (Turcotte, 2010). 26. Would glutamine supplementation help Mrs. Gaines during the healing process? What form of glutamine supplementation would you recommend? - Glutamine has the ability to support the intestinal lining and increase villous height. Glutamine is important with metabolism, structure and function of the GI tract. This amino acid keeps the GI tract healthy and functioning properly, as well as reduces inflammation. The form of glutamine supplementation I would recommend is Lglutamine in a liquid or powder form. Glutamine rich foods include beef, fish, poultry and eggs (Glutamine). 27. What result can Mrs. Gaines expect from restricting all foods with gluten? Will she have to follow this diet for very long? - Mrs. Gaines can expect to start feeling like her normal self once her diet is controlled. By restricting all foods with gluten the discomfort, diarrhea and pain she is having in her gut will start to slowly disappear once her villi begin to regenerate. Celiac disease still has no known cure, so in order for Mrs. Gaines to maintain her gastrointestinal health she will need to follow a gluten free diet the rest of her life.

G. Nutrition Monitoring and Evaluation 28. Evaluate the following excerpt from Mrs. Gainess food diary. Identify the food that might not be tolerated on a gluten/gliadin-free diet. For each food identified, provide an appropriate substitute. (Gluten free diet), (Anderson, 2013) - Always check food labels and look for gluten free products Cornflakes Not tolerated: Substitute gluten free Chex Bologna slices LandO Frost bologna gluten free Found at SaveMart/Safe Way Not tolerated: Substitute Amys packaged gluten free meals San J Organic gluten free sauce with chicken and vegetables is tolerated Lactose free skim milk or soy milk Not tolerated: Cheddar cheese block, cottage cheese, swiss Tolerated, make sure mushroom soup is gluten free Tolerated, avoid cross contamination
With no gluten-containing additives

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 crackers

Tolerated, make sure gluten free Rice work chips at Trader Joes are gluten free Watch out for filling containing thickeners; canned Products with preservatives contain gluten, check labels! Raisin Rosemary Crisp at Trader Joes gluten free Tolerated; just be aware of possible contaminations Tolerated, make sure gluten free Soyummmi dark chocolate pudding gluten free at Trader Joes Tolerated, none of the V8 Fusion contains gluten Tolerated Not tolerated, cola contains malt syrup which has gluten so switch to

Sugar

Pudding

V8 juice

Banana Cola

sparkling soda which can be found at any grocery store. Dr. Pepper is considered gluten free 20ppm

Nutrition Assessment Patient Interview: Lost tremendous amount of weight, terrible diarrhea, no energy to get off couch, GI issues on mothers side, relying on chicken noodle soup, crackers, an sprite for the past few days. Recently the patient is always hungry Admitting Dx: Celiac Disease w/2 malabsorption and anemia PMH: N/A Patient is a 36 y/o Female Ht. 53 Wt. 92 BMI 16.3%IBW 76.6% UBW 82.1 UBW timeframe: 3 months Diet order: 100g fat diet x 3days Average Meal Intake: N/A I/Os: N/A GI: diarrhea and celiac disease Pertinent Labs: Alb 2.9, total protein 5.5, prealbumin 13, AGA/EMA +, fecal fat 11.5, HGB 9.5, HCT 34, ferritin 12 Pertinent Medications: Prenatal vitamins, Kaopectate Physical exam/skin: Thin, pale, fatigue, weakness, abdomen not distended, diminished bowel sounds Other Information: Smoker Nutrition Diagnosis/ Diagnoses: (PES Statement) Food and nutrition related knowledge deficit (NB-1.1) related to no previous diet education as evidenced by 24 hour recall diarrhea and weight loss. Unintended weight loss (NC-3.2) related to inadequate energy intake and untreated celiac disease as evidenced by recent weight loss of 30 pounds and BMI of 16.3%.

Nutrition Intervention Individualized Treatment Goals to Address Nutrition Diagnosis 1. Patient demonstrates knowledge of lactose free diet and gluten free diet 2. No further weight loss 3. Normalize lab values: albumin, prealbumin, total protein, ferritin, fecal fat test <7g 4. Identify gluten containing products

Intervention Statements (Use Intervention Sheets) 1. Modify diet: recommend lactose-free diet, gluten free diet 2. Nutrition education: gluten free shopping 3. Dietary modification: high protein Monitoring an Evaluation 1. Monitor weight gain 2. Monitor meal tolerance, complete two day food record, review with patient 3. Labs: albumin, prealbumin, total protein, HGB, HCT, ferritin, fecal fat test 4. Adherence to diet Signed___________________________ Date:________________

Works Cited: Anderson, J. (2013, April 09). Ema-iga blood test. Retrieved from http://celiacdisease.about.com/od/celiacdiseaseglossaryaf/g/EMA-Iga-Blood-Test.htm

Anderson, J. (2013, April 9). Gluten-free diet guide for people with newly diagnosed celiac disease . Retrieved from http://www.ext.colostate.edu/pubs/foodnut/09375.html
Celiac disease. (2013, July 13). Retrieved from http://www.mayoclinic.com/health/celiacdisease/DS00319/DSECTION=causes

Ciaran, K., & Melinda, D. (2013, October). Patient information: Celiac disease in adults (beyond the basics). Retrieved from http://www.uptodate.com/contents/celiacdisease-in-adults-beyond-the-basics
Glutamine. (n.d.). Retrieved from http://www.lef.org/magazine/mag2006/jan2006_aas_01.htm Gluten free diet. (n.d.). Retrieved from http://www.massgeneral.org/digestive/assets/pdf/gluten_free_diet.pdf Hlywiak, K. (2008, September). Hidden sources of gluten. Retrieved from http://www.practicalgastro.com/pdf/September08/HlywiakArticle.pdf Lapid, N. (2009, June 17). Celiac disease and gluten sensitivity. Retrieved from http://celiacdisease.about.com/od/symptomsofceliacdisease/a/Lactose.htm Nelms, M Sucher, K, Lacey, K, & Roth, S (2011). Nutrition Therapy & Pathophysiology Belmont, Ca: Wadsworth. 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/

Nutrition status classification scheme handbook. (2006, August 14). Retrieved from http://www1.va.gov/vhapublications/viewpublication.asp?pub_id=1465 Paterson, W. (2012, April). Fecal fat test. Retrieved from http://www.hoteldieu.com/fecalfat.pdf Choosemyplate.gov. (n.d.). Retrieved from http://www.choosemyplate.gov/ Roth, E., & (2012, August 7). Fecal fat testing. Retrieved from http://www.healthline.com/health/fecal-fat Steatorrhea. (2013, August 31). Retrieved from http://www.diagnose-me.com/symptomsof/steatorrhea.html Turcotte, M. (2010, November 10). What are the benefits of ensure plus?. Retrieved from http://www.livestrong.com/article/307720-what-are-the-benefits-of-ensure-plus/