CELIAC DISEASE
CASE STUDY
Erin McNamara
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
Source: http://www.webmd.com
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
Source: http://www.celiac.nih.gov/
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
Source: http://www.noglutennaturalgirlproducts.com/
Source: http://www.eatright.org
Source: http://thesavvyceliac.com
Signs & Symptoms
• Multi-symptom, multi-system disorder
Direct Symptoms
• abdominal cramping
• gas
• distention of stomach
• chronic diarrhea
• chronic constipation
• fatty/foul-smelling stools
• unexplained weight loss
with large appetite
Indirect Symptoms
• osteopenia or osteoporosis
• infertility
• fatigue, lack of energy
• depression
• anemia
• tingling or numbness in
hands or feet
• migraine headaches
Treatment
• Life-long adherence to a gluten-
free diet
• Many foods are naturally gluten-
free
• Fruits, vegetables, beef,
poultry, fish, nuts, eggs
•
Source: http://glutenfreeoatmeal.net
Wide variety of delicious and
nutritious gluten-free options
available
Source: glutenfreeforlifeexpo1
Gluten-free Foods:
• Amaranth
• Corn
• Quinoa
• Millet
• Rice
• Lentils
• Potato
• Buckwheat
• Soy
• Wild Rice
Case Study
• Patient: Rachel
• Gender: female
• Ethnicity: Caucasian
• Age: 33
• Height: 62”
• Current weight: 105#
• Usual weight: 125#
• % UBW : 80%
• BMI: 18.3
Source: http://www.eatright.org
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.
Source: http://www.eatright.org
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.
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
Snack
• 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.
Case Study
Lab Values of Concern
Recommendations
Recommendations
Recommendations
Recommendations
Recommendations
Recommendations
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 - 3.2.4) Iron supplement intake to treat anemia.
M: Modified diet (FH - 2.1.1.2) Follow-up on adherence to gluten-free diet. Pt. & husband will follow a gluten-free
diet.
E: Weight (AD - 1.1.2), Fecal fat (BD - 4.12), Ferritin, serum (BD.10.10), Albumin (BD - 1.11.1), Prealbumin (BD 1.11.2)
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 labelreading of foods and supplements. This
education is to help identify sources of gluten
in products to assist with the overall
management of celiac disease.
Source: http://www.gluten.net/
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 glutenfree alternatives available for the
foods that Rachel likes to enjoy.
Source: http://www.webmd.com
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 glutenfree 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 glutenfree diet.
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.
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
http://andevidencelibrary.com/topic.cfm?cat=3726.
•
American Association for Clinical Chemistry. (2012). Celiac disease: Tests. Lab
Tests Online. Retrieved from
http://labtestsonline.org/understanding/conditions/celiac/start/2
•
National Digestive Diseases Information Clearinghouse. (2012). Celiac disease.
National Digestive Diseases Information Clearinghouse. Retrieved from
• http://digestive.niddk.nih.gov/ddiseases/pubs/celiac/
•
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.618-622). St. Louis, MO: Elsevier.
•
Ruiz, A.R. (2012). Celiac disease: Malabsorption Syndrome. The Merck Manual.
Retrieved from
http://www.merckmanuals.com/professional/gastrointestinal_disorders/malabsorpti
on_syndromes/celiac_disease.html