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Brittany Ray NFSC 470 Case Study 1 Questions I. Understanding the Disease and Pathophysiology 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? o There has been an inflammatory response, leading to the attack of intestinal villi. Absorptive surface area is decreased and digestive enzymes are limited, which leads to maldigestion and malabsorption (Nelms, Sucher, Lacey, & Roth, 2011). 2. What is the etiology of celiac disease? Is anything in Mrs. Gainess history typical of patients with celiac disease? Explain. o The exact cause of celiac disease is unknown. It is considered hereditary though, because it tends to run in families (Celiac Disease Foundation, 2013). Certain gene mutations have been identified in increased risk of developing the disease. Studies also show that the disease can be triggered by a variety of things including pregnancy (Mayo Clinic, 2013). o She states, a lot of people in my family have funny stomachs. She claims her mother and grandmother have similar symptoms. This shows that the disease may possibly run in her family. She also said that it got worse after her most recent pregnancy, which could have triggered the disease. 3. How is celiac disease related to the damage to the small intestine that the endoscopy and biopsy results indicate? o In people with celiac disease, certain amino acid sequences in gluten cause an immune response. Antibodies are produced, which proceed to attack the villi of the small intestine (Celiac Sprue Association, 2013). 4. What are AGA and EMA antibodies? Explain the connection between the presence of antibodies and the etiology of celiac disease. o These are the antibodies produced in the abnormal response to gluten. Their presence indicates the incidence of celiac disease. It is part of an autoimmune response (Nelms, Sucher, Lacey, & Roth, 2011).

5. What is a 72-hour fecal fat test? What are the normal results for this test? o It is done to test for fat malabsorption. Patient consumes 100 grams of fat/day for 3 days. The stool is collected and examined. Greater than 7 grams of fat in the stool daily indicates the presence of fat malabsorption (University of Rochester Medical Center, 2013). 6. Mrs. Gainess laboratory report shows that her fecal fat was 11.5 g fat/24 hours. What does this mean? o Her results indicate fat malabsorption (University of Rochester Medical Center, 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? o This is important to determine if fat is malabsorbed. Once this is determined, we can decrease the fat from her diet. Fat malabsorption would worsen her symptoms (University of Rochester Medical Center, 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? o Gluten is a protein found in grains; specifically wheat, rye, and barley (Celiac Sprue Association, 2013). 9. Can patients on a gluten-free diet tolerate oats? o Oats themselves are tolerated. However they are often cross contaminated with wheat due to harvesting and processing with the same equipment. It is important to look for certified gluten-free oats (Celiac Disease Foundation, 2013). 10. What sources other than foods might introduce gluten to the patient? o o o o Lotions Supplements and medications Lipstick, lip gloss, etc. Play dough (Celiac Disease Foundation, 2013)

11. Can patients with celiac disease also be lactose intolerant? o Yes (Celiac Disease Foundation, 2013) 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. o 92 lb/112 lb x 100% = 82% UBW o 41.8kg/(1.6m)2 = 16.3 BMI B. Calculation of Nutrition Requirements 13. Calculate this patients total energy and protein needs using the Harris-Benedict equation or Mifflin-St. Jeor equation. o 655 + (9.6 x 41.8) + (1.8 x 160) (4.7 x 36) = 655 + 401.3 + 288 169.2 = 1175 kcal 1175 kcal x 1.3 AF = 1528 kcal/day o 41.8kg x 1.5g/kg/day = 63g protein/day C. Intake Domain 14. Evaluate Mrs. Gaines 24-hour recall for adequacy. o Using, I found that Mrs. Gainess intake was inadequate. She consumed around 475 kcals and 8 grams of protein. o She also took in 3 mg of iron, which is way below her needs. All of her nutrient needs were not met (USDA, 2013). 15. From the information gathered within the intake domain, list possible nutrition problems using the diagnostic term. o o o o Inadequate oral intake (NI-2.1) Inadequate energy intake (NI-1.4) Inadequate protein-energy intake (NI 5.3) Inadequate iron intake (NI-

D. Clinical Domain 16. Evaluate Mrs. Gainess laboratory measures for nutritional significance. Identify all laboratory values that support a nutrition problem.

o o o o o o o o o

Albumin 2.9 g/dL Low Total protein 5.5 g/dL Low Prealbumin 13 mg/dL Low HGB 9.5 g/dL Low HCT 34% Low Ferritin 12 mg/mL Low Vitamin B12 21.2 ng/dL Slightly Low Folate 3 g/dL Slightly Low Presence of AGA and EMA antibodies

17. Are the abnormalities identified in question 16 related to the consequences of celiac disease? Explain. o The antibodies are a direct consequence of the disease. Iron deficiency anemia is common among celiac patients. Malabsorption leads to low levels of other nutrients, such as folate and vitamin B12 (Nelms, Sucher, Lacey, & Roth, 2011). 18. Are any symptoms from Mrs. Gainess physical examination consistent with her laboratory values? Explain. o Yes. Fatigue and weakness is related to iron deficiency anemia. Low serum protein levels can contribute to low energy as well (Nelms, Sucher, Lacey, & Roth, 2011). 19. Evaluate Mrs. Gainess other anthropometric measurements. Using the available data, calculate her arm muscle area. o ((18cm/4) x ( x 0.75cm))2 = 11.4cm2 Interpret this information for nutritional significance. o Her AMA is in the 5th smallest percentile. She is very underweight (Nelms, Sucher, Lacey, & Roth, 2011). 20. From the information gathered within the clinical domain, list possible nutrition problems using the diagnostic term. o Altered nutrition-related laboratory values (NC-2.2) o Altered GI function (NC-1.4) IV. Nutrition Diagnosis

21. Using the VA Nutrition Screening Form, what is this patients nutrition status level? o Her nutrition status level is at 3. 22. Select two high-priority nutrition problems and complete the PES statement for each. o Food and nutrition related knowledge deficit (NB-1.1) related to no previous diet education as evidenced by unmanaged symptoms of celiac disease. o Inadequate oral intake (NI-2.1) related to diarrhea as evidenced by weight loss and low albumin levels of 2.9 g/dL. 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 the etiology). o No further weight loss, albumin improves o Decrease in diarrhea 24. What type of diet would you initially begin when you consider the potential intestinal damage that Mrs. Gaines has? o I would begin with a gluten-free, lactose-free, low fat, GI soft diet. 25. Mrs. Gainess nutritional status is so compromised that she might benefit from highcalorie, high-protein supplementation. What would you recommend? o I would recommend Ensure Plus. 26. Would glutamine supplementation help Mrs. Gaines during the healing process? What form of glutamine supplementation would you recommend? o There is no research that supports the benefits of glutamine supplementation for celiac patients. I would not recommend it (The University of Chicago Celiac Disease Center, 2013). 27. What result can Mrs. Gaines expect from restricting all foods with gluten? Will she have to follow this diet for very long? o The small intestine will heal itself and her symptoms will subside (Celiac Disease Foundation, 2013).

o She will have to follow the diet for the rest of her life (Celiac Sprue Association, 2013). VI. Nutrition Monitoring and Evaluation 28. Evaluate the following excerpt from Mrs. Gainess food diary. Identify the foods that might not be tolerated on a gluten/gliadin-free diet. For each food identified, provide an appropriate substitute.

Food Given 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 No Yes No

Substitute Chex rice cereal Frozen gluten free entre at Trader Joes (Chicken Pomodoro) Almond Milk Hummus Green bean casserole with gluten free mushroom soup (Progresso)

Source (General Mills, 2013) (Trader Joe's, 2013)

No No No

(Silk, 2013) (Sabra, 2013) (Progresso, 2013)

Yes Yes Yes Yes No Yes Yes Yes

Lactose free, gluten free pudding (Kozy Shack)

(Kozy Shack, 2013)

Works Cited

Celiac Disease Foundation. (2013). Celiac Disease. Retrieved November 14, 2013, from Celiac Disease Foundation: Celiac Sprue Association. (2013). What is Celiac Disease? Retrieved November 14, 2013, from Celiac Sprue Association: General Mills. (2013). Chex Products. Retrieved November 14, 2013, from Chex: Kozy Shack. (2013). Lactose Free Pudding. Retrieved November 14, 2013, from Kozy Shack: Mayo Clinic. (2013, May 22). Celiac Disease. Retrieved November 14, 2013, from Mayo Clinic: Nelms, M., Sucher, K. P., Lacey, K., & Roth, S. L. (2011). Nutrition Therapy & Pathophysiology. Belmont: Brooks/Clole Cengage Learning. Progresso. (2013). Gluten Free Products. Retrieved November 14, 2013, from Progresso: Sabra. (2013). Sabra Classic Hummus. Retrieved November 14, 2013, from Sabra: Silk. (2013). Original Almond Milk. Retrieved November 14, 2013, from Silk: The University of Chicago Celiac Disease Center. (2013). What do you think of using L Glutamine to help heal? Retrieved November 14, 2013, from The University of Chicago Celiac Disease Center: Trader Joe's. (2013). No Gluten. Retrieved November 14, 2013, from Trader Joe's: University of Rochester Medical Center. (2013). Fecal Fat. Retrieved November 14, 2013, from University of Rochester Medical Center: tID=fecal_fat

USDA. (2013). Super Tracker. Retrieved November 14, 2013, from My Plate: