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CELIAC DISEASE Molly Jennings
Deb McCafferty MS, RD
WHAT IS CELIAC DISEASE?
In short… ‘In this disease, exposure to gluten results in damge
to the intestinal mucosa.’ Immune-mediated disorder
Also known as… Non-tropical Sprue Gluten-sensitive enteropathy Gluten Intolerance
Nelms, 2007
WHAT IS CELIAC DISEASE
Gluten Ingestion Wheat, rye, barley, oats Gliadin absorbed into lamina propia
Binds to receptors stimulating antibody response Cytokines are released destroy micro villi and brush
border
Compromised sm. intestinal wall poor absorption Malabsorption of essential nutrients
Iron def. anemia Early onset osteoporosis
↵ GLIADIN
Nelms, 2007
WHAT IS CELIAC DISEASE
PREVALENCE
Much more common than previously predicted 1:133 Americans or 2-3 million people in the US!
Strong evidence for occurrence in kids with Dermatitis herpetiformis Dental enamel defects Type 1 Diabetes IgA deficiency Down, Turner, or William syndrome 1st degree relative diagnosed
Hill, 2005 Nelms, 2007
CAUSES
Three factors contribute Genetic predisposition gluten ingestion
Immune-mediated response
Genetic Predisposition Presence of human leukocyte antigen (HLA) 90% have HLA-DQ2 10% have HLA-DQ8
Nelms, 2007 Wolters, 2008
IN THE INTESTINE
Aafp.org
Celiacdisease.about.com
SYMPTOMS
Typical Celiac Disease Recurrent abdominal pain Constipation Vomiting Persistent diarrhea Bloating Chronic Fatigue Failure to thrive (in kids)
SYMPTOMS
Atypical Celiac Disease Osteoporosis Iron Def. anemia Peripheral Neuropathy Dermatitis Herpetiformis
15-25% of people
http://digestive.niddk.nih.gov/ddiseases/pubs/dh/index.htm Hill, 2005
DIAGNOSIS
Test for tissue transglutaminase (TTG) IgA antibodies Deficiency is common in those with celiac disease so
test may not show elevated levels
Endomysial Antibody (EMA) Antigliadin Antibodies (AGA) – IgA, IgG
Inferior accuracy, no longer recommended
Intestinal (duodenal) Biopsy Required for final diagnosis
Hill, 2005
DIAGNOSIS
http://members.cox.net/hal.kraus/glossary.htm
MEDICAL NUTRITION THERAPY
Low fat, low fiber, lactose free diet For first few days after diagnosis To alleviate diarrhea
Gluten Free Diet <50mg gluten/day for treatment
Life-long avoidance of gluten Wheat, Rye, Barley, Oats?
Oats 30g a day did not cause atrophy Intestinal swelling and cases of diarrhea or
constipation were more common
Peraaho, 2004 Catassi, 2007 Nelms, 2007
NUTRITION CARE PROCESS UNIVERSITY HOSPITAL Meet our Patient: Melissa Gaines
MELISSA GAINES
Age: 36
Caucasian Female
Secretary for hospital administrator
Married with 2 sons age 4 and 3 months
Height: 5’3” Current Wt: 92lbs
CHIEF COMPLAINT
Extreme unintentional weight loss along with “terrible diarrhea.”
Very low energy Hard to “get off the couch right now”
PATIENT HISTORY
On and off diarrhea throughout adult life Intensified during recent pregnancy Mom and Grandmother have same symptoms
Diarrhea is ‘foul smelling’ no matter what she eats
Delivered son 3 months ago Stopped breastfeeding 3 weeks ago because she ‘felt
so bad’
Gained 11 lbs during recent pregnancy and has lost 30 lbs since.
PATIENT HISTORY
Meds: Prenatal vitamins, Kaopectate
Smoker? Yes
Father has CAD
PHYSICAL EXAM
Skin: Pale without lesions
Abdomen: Not distended; diminished bowel sounds
NUTRITION HISTORY
Likes all foods Generally avoids
eating because of subsequent diarrhea
Breakfast: Whole Wheat toast
1 tsp butter Hot tea, 2tsp sugar
Lunch: 1c chicken noodle soup 2-3 saltine crackers ½ cup applesauce 12oz Sprite + sips
600 kcals total
Usual Dietary Intake 24 Hour Recall
NUTRITION HISTORY
Reported Triggers Any food in large amounts Fried foods Meat – especially beef Allergy – maybe Nutrasweet?
PATIENT DIAGNOSIS
Celiac Disease with secondary malabsorption and anemia
TREATMENT PLAN
24 hour stool collection for visual examination Upper gastrointestinal endoscopy
Small bowel biopsy and possible duodenal aspirate
Diet: 100-g fat diet for 3 days Result: 11.5g = steatorrhea!!
ADIM/E - ASSESSMENT
Harris Benedict Equation
655 + (9.6*41.8kg) + (1.8*160.02cm) – (4.7*36) = 1,176 BEE (1,176)(1.3) = 1,529 kcal + 250kcals (for anabolism) = 1,779 kcals (41.8kg)(1.2) = 50.6g protein/day
Usual Wt: 112Pregnancy Wt: 123Now: 92lbs 18% unintentional weight loss
92/112 = 82% UBW
ADIM/E – ASSESSMENT
Normal Patient
Albumin 3.5-5 2.9 L
Total Protein 6-8 5.5 L
Prealbumin 16-35 13 L
Folate 5-25 3 L
B12 24.4-100 21.2 L
Magnesium 1.8-3 1.6 L
Osmolality 285-295 275 L
Lab values indicating malnutrition
ADIM/E - ASSESSMENT
Lab values indicating iron deficiency anemia
Normal Patient
HGB 12-15 (women) 9.5 L
HCT 37-47 (women) 34 L
MCHC 31.5-36 30 L
Ferritin 20-120 (women) 12 L
ZPP 30-80 85
http://www.labtestsonline.org/understanding/analytes/zpp/sample.html
ADIM/E - DIAGNOSIS
Food and Nutrition related knowledge deficit (NB – 1.1) related to no prior education as evidenced by new diagnosis.
ADIM/E INTERVENTION
Comprehensive Nutrition Education (E – 2) of gluten-free diet.
ADIM/E - INTERVENTION
Encourage whole/enriched grains! Brown and wild rice, quinoa, buckwheat, rice flour
Multivitamin with focus on Iron If reduced bone densityencourage Ca and Vit D
Education of the Gluten Free Diet!!!
ADIM/E - INTERVENTION
Initiate gluten-free diet
Heal villous atrophy
Normalize prealbumin
No further weight loss
Maintain gluten-free diet
Normalize hematological ranges Albumin, transferrin
Weight gain to UBW
Short-term outcome goals Long-term outcome goals
SCOPE OF PRACTICE M
odel/figure from
readings
Providing nutrition education about a gluten-free diet.
ADIM/E – MONITOR/EVALUATE
Compliance with gluten-free diet Strong correlation between gluten intake (lack of
adherence to celiac diet) and intestinal cell damage and atrophy.
Antibody levels Cross-Contamination Hidden sources of gluten in foods, medications,
and supplements Quality of Life
Physical, social, emotional
Ciacci, 2002
REFERENCES Catassi C. A prospective, double-blind, placebo-controlled trial to establish a safe gluten
threshold for patients with celiac disease. Am J Clin Nutr 2007; 85: 160-6. http://www.celiac.org/cd-research.php
Ciacci C, Cirillo M, Cavallaro R, Mazzacca G. Long-term follow-up of celiac adults on gluten-free diet: prevalence and correlates of intestinal damage. Digestion 2002; 66(3): 178-185. PubMed ID: 12481164
Evidence-based Nutrition Practice Guideline on celiac disease published 2009 at http://www.adaevidencelibrary.com/topic.cfm?cat=3677&library=EBG and copyrighted by the American Dietetic Association.
Hill ID, Dirks MH, Liptak GS, et al: Guideline for the diagnosis and treatment of celiac disease in children: recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr 2005; 40: 1–19. http://journals.lww.com/jpgn/Fulltext/2005/01000/Guideline_for_the_Diagnosis_and_Treatment_of.1.aspx
Peraaho M, Kaukinen K, Mustalahti K, Vuolteenaho N, Maki M, Laippala P, Collin P. Effect of an oats-containing gluten-free diet on symptoms and quality of life in celiac disease. A randomized study. Scand J Gastroenterol 2004; 39:27-31.PubMed ID: 14992558
Wolters VM, Wiimenga C. Genetic background of celiac disease and its clinical implications. Am J Gastroenterol 2008; 103(1): 190-195. http://www.celiac.org/cd-research.php
www.celiac.org National Digestive Diseases Information Clearinghouse. Dermatitis Herpetiformis: Skin
Manifestation of Celiac Disease. Digestive Diseases 2009. http://digestive.niddk.nih.gov/ddiseases/pubs/dh/index.htm
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