Case Study #9: Celiac Disease By: Kaili Acosta Joyce Moore Elizabeth Olivares Rosalinda Ruiz  

Overview Celiac Disease and Pathophysiology Nutrition Therapy Nutrition Assessment Intake Domain Clinical Domain Nutrition Diagnosis Nutrition Intervention Monitoring and Evaluation

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!!!

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

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

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

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

Nutrition Assessment BMI=16.3 kg/m2 UBW= 112 # %UBW=82 % IBW=115# % weight change = 18 % weight change in 2 months Nutritional risks

Clinical Domain AFA: 14.4 cm2. Interpretation 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.

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

Intake Domain 24-Hour Recall Evaluation

Clinical Domain - Lab Values MG Value Normal Albumin 2.9 g/dL (L) 3.5 - 5g/dL Total Protein 5.5g/dL (L) 6 – 8 g/dL: Prealbumin 13 mg/dL (L) 16 - 35mg/dL AGA antibodies +  - EMA antibodies Fecal Fat Test 11.5 g / 24 hr less than 7g / 24 hrs HGB 9.5mg/dL (L) 12 - 15 HCT 34 mg/dL (L) 37 - 47 MCHC 30 L 31.5 - 36 Ferritin 12 L 20-120 ZPP 85 H 30-80 Folate 3 L 5-25 B12 21.2 L 24.4-100 Nutritional Significance PEM Celiac Disease Altered GI function, steatorrhea, Malabsorption Iron Deficiency Anemia Iron Deficiency Malabsorption

Which lab values are related to consequences of Celiac disease?

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)

Protein Energy Malnutrition (PEM) Patient meets criteria: Moderate Protein Energy Malnutrition (PEM) Albumin 2.9 g/dL 82 % of UBW

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)

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.

Nutrition Therapy Gluten-free diet What is gluten? Where can it be found? Consumption of oats?

Nutrition Therapy Other sources than food Lactose intolerance Food additives Coloring agents Modified food starch Medications Lactose intolerance Damage to villi affects ability to absorb lactose

Nutrition Intervention Diet to start out on: High-protein supplement recommended: Glutamine supplementation: Length of stay on diet

Mrs. Gains at home

Monitoring and Evaluation Follow-up How can we modify Mrs. Gaines’ diet?

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