Nutrition Therapy for Lower Gastrointestinal Disorders

Celiac Disease
Case Questions
I. Understanding the Disease and Pathophysiology
1. What is the etiology of celiac disease? Is anything in Mrs. Talbot’s history typical of patients with
celiac disease? Explain.
You can look at the DQ2 and the DQ8-HLA genes. These genes can undergo an environmental trigger
and turn into an autoimmune disorder which is celiac disease. This autoimmune disorder makes the body
reacts badly to gliadin which is a component of gluten. Mrs. Talbot has been suffering from diarrhea and
stomach pain for years and occasionally joint pain. She also had a miscarriage. 1
2. tTG antibodies are used in serological testing to diagnose celiac disease. Each test is sensitive and
specific for the antibody it measures. The tTG test has a sensitivity of more than 90%. What does this
mean? It also has a specificity of more than 95%. What does this mean?
The tTG antibody test must be done when on a gluten containing diet. The sensitivity of the test measures
how correctly it measures those with the disease. The test having a specificity of more than 95% means
that the test will come back negative in 95% of the healthy people that take it and don’t have celiac
disease. The 90% sensitivity rate means that most will test positive if they have it, but there is that rre
chance that someone with celiac disease gets a negative test back. 3
3. Mrs. Talbot presents with some nondescript symptoms of celiac disease. List the nongastrointestinal
as well as the gastrointestinal clinical manifestations of celiac disease.
- Non-gastrointestinal symptoms: fetal loss, anemia, dermatitis herpetiformis, osteoporosis, neuropathy,
spinocerebellar syndrome, folate or iron deficiency, glycemic control difficulties, seizures, or depression 1
- Gastrointestinal symptoms: osmotic diarrhea, secretory diarrhea, weight loss, bloating, gas, abdominal
pain, failure to thrive, vomiting, dyspepsia, duodenal obstruction, pancreatitis, constipation 1
4. Biopsy of the small intestine continues to be the “gold standard” for diagnosis of celiac disease.
Briefly describe this procedure.
The doctor will place a tube with a camera and put it down your mouth. It will go down the digestive tract
down to the small intestine. The physician will then examine the duodenum which is the entryway to the
small intestine. They will then take several cell samples to test. Sedatives are used on adults and general
anesthesia is used on kids.4
5. How does celiac disease damage the small intestine?
When gluten is eaten, the lamina propria in the small intestine goes into an inflammatory response. When
it becomes inflamed the intestinal villi flattens and elongates the crypt cells. 1
II. Understanding the Nutrition Therapy
6. Gluten restrictions is the major component of the medical nutrition therapy for celiac disease. What is
gluten? Where is it found?
Gluten is found in wheat, rye and barley. It is composed of peptide fractions of proteins. The proteins
found in wheat are glutenin and gliadin. Rye contains secalin. Barley contains hordein. 1
7. Can patients on a gluten-free diet tolerate oats?
Pure oats can be okay and ingesting a normal amount of oats won’t necessarily trigger an immune
response. It also depends on where the oats are processed. If they are processed in a factory where they
could be cross contaminated with gluten, then those oats could give a patient with celiac disease that
inflamed response in the small intestine. 5
8. Are there any known health benefits of the following a gluten-free diet if a person does not have celiac
disease?
There are benefits to going on a gluten free diet. Gluten free diets can improve digestion and still may
help with inflammation, even if you don’t have celiac disease. Also switching to a gluten free diet can
help you lose weight, boost your energy, and feel healthier. 6
9. Can patients with celiac disease also be lactose intolerant?
It can be common for someone with celiac to develop a lactose intolerance as well. This happens because
of the loss of the lactase enzyme in the small intestine that digest milk and sugar. Gluten causes damage
in the small intestine, as we discussed earlier, which is the biggest contributor to losing the lactase
enzyme. This can be temporary if you keep up with a gluten free diet. You can still consume some low
lactose foods and still be able to tolerate it. 7
10. There is a high prevalence of anemia among individuals with celiac disease. How can this be
explained? What test are used for anemia?
Anemia of chronic and inflammatory disease (ACD), this is caused by inflammatory conditions. This type
of anemia doesn’t respond to iron supplementation. This type of anemia can also prevent red blood cell
production.1 Mrs. Talbot’s labs can be looked at to determine this. You would want to look at, WBC,
RBC, RBC distribution, Hgb, Hct, MCV, MCH, MCHC, platelet count, transferrin, Ferritin, Iron, Iron
saturation, Vitamin B12 and Folate.
III. Nutrition Assessment
11. Calculate this patient’s total energy and protein needs
RMR: 1278.64 kcals/daily
TEE: 1278.64 x 1.2 = 1534.37 kcals/daily
Protein Requirement: 45.44-56.8 grams/daily
12. Evaluate Mrs. Talbot’s laboratory measures for nutritional significance. Identify all laboratory values
that are indicative of a potential nutrition problem.
RBC Ref. Range 4.2-5.4 3.9
Hgb Ref. Range 12-16 10.5 g/dL
Hct Ref. Range 37-47 34%
Ferritin Ref. Range 20-120 17 ng/dL
Transferrin Ref. Range 250-380 395mg/dL
Iron Ref. Range 65-165 54 mg/dL
13. Are the abnormalities identified in questions #12 related to the consequences of celiac disease?
Explain.
Her iron deficiency is related to her anemia and common to the celiac disease. Also, her low RBC count
contributes to her celiac due to her inflamed small intestine.
14. Are any symptoms from Mrs. Talbot’s physical examination consistent with her laboratory values?
Explain.
She had pale skin and complained about fatigue, diarrhea, abdominal pain, and joint pain. Her eyes were
also sclera pale. Her strength was also reported as 4/5 which relates to her Hgb and Hct lab values.
IV. Nutrition Diagnosis
15. Select two nutrition problems and complete the PES statement for each.
P: Inadequate iron intake related to
E: malabsorption in the small intestine as evidenced by
S: her celiac disease diagnosis

P: Food and nutrition knowledge deficit related to

E: her new diagnosis of celiac disease as evidenced by
S: low iron levels
V. Nutrition Intervention
16. For each of the PES statements that you have written, establish an ideal goal (based on the signs and
symptoms) and an appropriate nutrition intervention (based on the etiology).
Goal 1: Modify diet to decrease gluten intake and follow a gluten-free diet.
Goal 2: Increase iron diet to keep up with her celiac disease.
17. What type of diet would you initially prescribe, considering the possibility that Mrs. Talbot has
suffered intestinal damage?
I would prescribe her to follow a gluten-free and dairy-free, because of her inflamed small intestine. The
gluten-free diet can potentially help heal her inflamed small intestine. 2 If she follows this diet, then the
lactase enzyme could possibly return. Her diet should be high in fiber to help with the GI distress. To
begin, she should consume easily digestible foods to hopefully stop the GI distress and once her
abdominal pain is under control, she can increase her protein intake and eat foods higher in fiber.
VI. Nutrition Monitoring and Evaluation
18. Evaluate the following excerpt from Mrs. Talbot’s food diary. Identify the foods that might not be
tolerated on a gluten-/gliadin- free diet. For each food identified, provide an appropriate substitute.
Breakfast- cornflakes, milk, banana, coffee with half and half
Corn flakes: check the nutrition label. You can substitute with a rice cereal.
Milk: Not tolerated. Substitute with almond, soy, coconut milk.
Banana: Tolerated.
Coffee: Tolerated.
Half & Half: Not tolerated. Substitute with dairy-free creamer.
Lunch- hot dog on a bun, French fries, chocolate milk
Hot dog: check nutrition label. Substitute with fresh meats.
Bun: Not tolerated. Substitute for a gluten free bun.
French fries: Check label. Substitute with potatoes.
Chocolate milk: Not tolerated. Substitute with dairy free milk substitute. Check label on chocolate.
Dinner- stir-fry chicken nuggets with soy sauce, mixed vegetables, rice, pudding, ice tea
Stir-fry chicken nuggets with soy sauce: Not tolerated. Chicken nuggets are breaded, use plain chicken
breast. Soy sauce could contain gluten.
Mixed vegetables: Tolerated.
Rice: Tolerated.
Pudding: Check the label to make sure it doesn’t contain gluten.
Snacks- gluten-free graham crackers with peanut butter; cookie dough ice cream
Gluten-free graham crackers: tolerated.
Peanut Butter: Check label.
Cookie dough ice cream: Not tolerated. Substitute with dairy free option and make sure there is no gluten
in the add-ins.
19. Mrs. Talbot asks what steps she should take to keep herself from being exposed to gluten in her
kitchen since her family does not have celiac disease. What advice could you give her? Are there other
potential environmental sources of gluten that you would alter Mrs. Talbot too?
Educating Mrs. Talbot and her family will be very important in this transition. I would suggest having a
section of her kitchen that is purely free of gluten. Using proper labels and containers to separate foods is
important. Also, preparing her food separately or before her family’s will help her to not get
contaminated. Make sure to thoroughly clean pans and other cooking ware. When eating out at
restaurants, talk to the waiter about foods being prepared gluten free. Also, warn them about the allergy,
so they take extra precaution or warn you beforehand of any contaminations.
VI. ADIME
Assessment
CH
26-year-old female. Caucasian and speaks English. Lives with husband and one son. She is a kindergarten
teacher who works 8-hour days. Has had abdominal and joint pain. She’s had fatigue and diarrhea. She
has had two pregnancies, 1 live birth and 1 miscarriage.

FH
No appetite issues
- Breakfast: 2 whole wheat slices of toast, 1 tsp. butter, hot tea and 2 tsp. sugar
- Lunch: 1 cup, chicken noodle soup, peanut butter and jelly sandwich, (2 slices of whole wheat
bread, 2 tbsp. pb, and 2 tsp. grape jelly), 1 cup applesauce, and 12 oz. sprite
- Dinner: 1 cup of whole wheat pasta, ½ cup marinara sauce (no meat), 1 cup sauteed green beans,
1 slice garlic bread, ½ cup rainbow sherbet
- Takes multivitamin
- Allergies: nutrasweet (possibly)

BD
RBC Ref. Range 4.2-5.4 3.9
Hgb Ref. Range 12-16 10.5 g/dL
Hct Ref. Range 37-47 34%
Ferritin Ref. Range 20-120 17 ng/dL
Transferrin Ref. Range 250-380 395mg/dL
Iron Ref. Range 65-165 54 mg/dL

AD
Height: 63” or 160cm
Weight: 125 lbs. or 56.8 kg
BMI: 22.2 kg/m2
IBW: 115 lbs. or 52.3 kg
IBW%: 109%
Weight range: 103.5-126.5 lbs. or 47-57.5 kg.
UBW:125 lbs. or 56.8 kg
PD
Pale skin, eyes are sclera pale

CS
RMR: 1278.64 kcals/daily
TEE: 1278.64 x 1.2 = 1534.37 kcals/daily
Protein Requirement: 45.44-56.8 grams/daily
Fluid Requirement: 1500 mL/daily or 6 cups/daily

Diagnosis
P: Inadequate iron intake related to
E: malabsorption in the small intestine as evidenced by
S: her celiac disease diagnosis

P: Food and nutrition knowledge deficit related to

E: her new diagnosis of celiac disease as evidenced by
S: low iron levels

Intervention
Goal 1: Modify diet to decrease gluten intake and follow a gluten-free diet.
Goal 2: Increase iron diet to keep up with her celiac disease.
Nutrition prescription: Follow a gluten free and dairy free diet to help get rid of GI distress and
abdominal pain. Educate on food sources rich in iron and potentially suggest an iron supplement.

Monitor/Evaluation
Monitor labs again. Watch iron levels, if not improved then suggest an iron supplement. Take a 24-hour
recall to assess her following her new diet.
References:

1. Mahan LK, Raymond JL. Krause's Food & the Nutrition Care Process. St. Louis, MI:
Elesevier; 2017.
2. American Dietetic Association. Nutrition Care Manual®. Consistent Carbohydrate Diet.
https://www.nutritioncaremanual.org/client_ed.cfm?ncm_client_ed_id=123. Accessed
March 29, 2021.
3. Celiac Disease Screening. Celiac Disease Foundation. https://celiac.org/about-celiac-
disease/screening-and-diagnosis/screening/. Accessed April 12, 2021.
4. Diagnosis of Celiac Disease. Celiac Disease Foundation. https://celiac.org/about-celiac-
disease/screening-and-diagnosis/diagnosis/. Accessed April 12, 2021.
5. Oats and the Gluten-Free Diet. Celiac Disease Foundation. https://celiac.org/about-the-
foundation/featured-news/2014/12/oats-and-gfd/. Published August 11, 2016. Accessed
April 12, 2021.
6. Strawbridge H. Going gluten-free just because? Here's what you need to know. Harvard
Health Blog. https://www.health.harvard.edu/blog/going-gluten-free-just-because-heres-
what-you-need-to-know-201302205916. Published January 30, 2020. Accessed April 13,
2021.
7. Celiac Disease and Lactose Intolerance. Beyond Celiac.
https://www.beyondceliac.org/celiac-disease/related-conditions/lactose-intolerance/.
Published February 9, 2021. Accessed April 13, 2021.