Mrs. Gaines presents with symptoms of celiac disease including a rash, joint pain, and fatigue. Laboratory tests show low levels of nutrients like magnesium and iron as well as elevated antibodies indicating an immune response to gluten. The student dietitians recommend a gluten-free diet and lifestyle counseling to address Mrs. Gaines' nutrition problems and support healing of the intestinal lining. They will monitor her symptoms and labs over time to evaluate the impact of dietary changes.

1. Name(s):Marisa Gutierrez, Laurie Hill, Jessica Leslie, Ashley Marsh
Date:4/17/2014
Class period:TR 1:30-2:45
NTR 341
Due: On the date stated in your syllabus by 10:00 pm via Blackboard
Case Study #9 – Celiac Disease
Understanding the Disease and Pathophysiology
1. (1 point – 1 or 2 sentences) What is the etiology of celiac disease?
Celiac disease is an autoimmune disease that when the body is exposed to
components of gluten, including α-gliadin, causes the intestinal mucosa to become
damaged (1, pg. 402).
2. (2 points) What are AGA and EMA antibodies? Explain the connection between the
presence of antibodies and etiology of celiac disease.
AGA are antigliadin antibodies and EMA are antiendomysial antibodies. These
antibodies are produced as an inflammatory response when gluten is consumed,
along with the response of white blood cells into the mucosa. The presence of these
antibodies can be used to help diagnose the presence of celiac disease via blood tests
as EMA is a highly specific marker for the disease (1, pg 402).
3. (2 points) Mrs. Gaines presents with many nongastrointestinal symptoms of celiac
disease. List the nongastrointestinal and gastrointestinal clinical manifestations of celiac
disease.
The nongastrointestinal manifestations that have been associated with celiac disease
are pain in the joints and muscles, skin rashes, fatigue, muscle cramping, peripheral
neuropathy, seizures, mouth ulcerations, and anemia. The gastrointestinal
manifestations include diarrhea, abdominal pain, cramping, bloating and gas
production (1, pg 402).
4. (1 point) Biopsy of the small intestine continues to be the “gold standard” for
diagnosis of celiac disease. Briefly describe the procedure.
A biopsy is done using an esophagogastroduodenoscopy. An endoscope is inserted via
the mouth and once it has reached the duodenum an instrument is placed in the
endoscope channel that will be able to do a small biopsy of the mucosa. The mucosa
is then evaluated and loss of villi and lymphocyte presence are noted to confirm the
diagnosis of celiac disease (2).

2. 5. (1 point) How does celiac disease damage the small intestine?
When inflammation and immune responses occur in the small intestine in response
to the consumption of gluten damage is done to the villi. The villi become flattened
which decreases their height, this decrease affects their absorption area and causes a
loss in digestive enzymes (1, pg 402).
Understanding Nutrition Therapy
6. (2 points) Gluten restriction is a major component of the medical nutrition therapy
for celiac disease.
a. What is gluten? A combination of the two proteins gliadin and glutenin.
b. Where is it found? Wheat, rye, and barley. Therefore it is found in any foods
containing these grains such as breads, cereals, and malts. It is also found in
numerous products such as condiments and and food additives as a thickener
or stabilizing agent.
7. (2 points) Identify at least 4 sources other than food and beverages that might
introduce gluten to the patient.
Medications, Make-up, shampoo, skin lotions
8. (5 points) Are there any known health benefits of following a gluten-free diet if a
person does not have celiac disease?
*Requirement - Please cite at least one review article from a peer reviewed
medical/nutrition journal that is no more than 5 years old. Your reference(s) must be
properly cited, and a pdf copy of the full article you used must uploaded separately when
you submit your case study online. *
From the review article, there are some benefits of a gluten free diet, but only for
patients suffering from other diseases. There seems to be evidence that a gluten-free
diet can help those suffering from dermatitis herpetiformis, irritable bowel
syndrome, neurologic disorders, rheumatoid arthritis, diabetes mellitus, HIV-
associate enteropathy, and autism. The benefits vary based on the disease and
symptoms. A gluten free diet can be helpful to relieve certain symptoms because in
these diseases, the etiology is similar. For example a gluten sensitivity may cause IBS
and therefore either reducing or eliminating gluten intake would aid in reducing
symptoms (3).
9. (2 points) Can patients with celiac disease also be lactose intolerant?
Yes. Patients with celiac disease may have damaged brush border cells of the small
intestine from eating products with gluten in them. These cells are also the cells that
contain lactase, which breaks down lactose in foods. If a person has damaged brush
border cells, they may not contain sufficient lactase and therefore they may also be
lactose intolerant.

3. 10. (2 points) There is a high prevalence of anemia in individuals with celiac disease.
How can this be explained? What tests are used for anemia?
The body is not absorbing the iron from the diet due to the lining of the small
intestine being damaged. The body does not make iron and therefore the iron stores,
in the body, begin to be depleted as well.
The tests for anemia are TIBC, Ferritin, Fe, RBC, CBC.
11. (1 points) What type of diet would you initially prescribe, considering the possibility
that Mrs. Gaines has suffered intestinal damage?
The patient should follow a gluten and lactose free diets as well as a low-residue diet.
This would allow time for her intestines to heal if damage has occurred.
Nutrition Assessment
12. (4 points) Evaluate Mrs. Gaines’s laboratory measures for nutritional significance.
Identify all laboratory values that are indicative of a potential nutrition problem.
Biochemical
Value
Patient’s
Value
(Indicate
high or
low)
Reason for Abnormality Nutrition Implication
Mg 1.6↓ not absorbing Mg from
diet and vitamins
calcium absorption
and metabolism
Alkaline
Phosphatase
125↑ found in intestine mucosa
as well as liver and many
tissues. Intestines not
absorbing
minerals and vitamins,
specifically vitamin D
osteomalacia
cholesterol 117↓ not absorbing cholesterol
from the diet
helps manufacture
vitamin D in the skin

4. AGA
antibody
+↑ should be negative. A
positive test results
indicates that there is a
presence of anti-glycans
inflammation of the
bowel, damage to
small bowel. May not
absorb nutrients
EMA
antibody
+↑ gluten and gliadin build
up in the intestinal
mucosa causing damage
inflammation of the
bowel, damage to the
small bowel. May not
absorb nutrients.
tTG IgA
antibody
units
41↑ indicates antibodies are
present
inflammation of the
bowel, damage to the
small bowel. May not
absorb nutrients
Hemoglobin
Hgb
9.5↓ decreased in Hgb
indicates anemia
decrease in RBC =
decrease in oxygen to
the tissues. Anemia is
associated with a
number of diseases.
Iron deficiency
Hematocrit 34 ↓ decrease in RBC
indicating anemia
decrease in RBC =
decrease in oxygen to
the tissues. Iron
deficiency
Mean cell
Hgb
30↓ a decrease in the mean
cell hemoglobin due to
poor iron and a general
healthy diet
inadequate
absorption
Transferrin 395↑ an increase in Transferrin
is common in iron-
deficiency anemia.
Transferrin is an iron
binding protein
inadequate
absorption
Ferritin 18 ↓ iron-storage protein is
low
inadequate
absorption
Iron 60 ↓ decreased hemoglobin
production, inadequate
absorption, loss of blood
(menses), poor po of iron
rich foods and a general
healthy diet
inadequate
absorption

5. Total iron
binding
capacity
475 ↑ an increase in TIBC is
common in iron-
deficiency anemia.
decreased
hemoglobin
production,
inadequate
absorption, loss of
blood (menses)
Iron
saturation
12 ↓ low due to poor po intake
of iron rich foods and a
general healthy diet
low iron which leads
to less hemoglobin
leading to less oxygen
to tissues
Folate 3↓ low due to poor po intake
of iron rich foods and a
general healthy diet
inadequate
absorption
13. (1 point) Are any symptoms from Mrs. Gaines’s physical examination consistent
with her laboratory values? Explain.
Yes, low Mg levels can create a sluggish, fatigued body. Low iron levels mean that not
enough RBC’s are being produced in order to carry oxygen to the cells creating a sluggish,
fatigued body. Cholesterol is necessary for the production of many hormones and other
cell function. A low cholesterol affects hormone function and could contribute to fatigue.
The tTg levels relate to the dermatitis herpetiformis observed during the exam. The AMA,
EMA, tTg IgA are all tests that indicate inflammation and may explain her muscle aches
and joint pain.
14. (4 points) Evaluate the following excerpt from Mrs. Gaines’s food diary. Identify the foods
that might not be tolerated on a glute-free diet. For each food identified, provide an appropriate
substitute.
Food State OK, or if not OK, an appropriate substitute
Cornflakes no for Kellogg’s brand but Erewhon Cornflakes are ok (corn and
salt) or amaranth breakfast porridge
Bologna slices ok for some--read labels--otherwise opt for fresh meat such as
chicken or turkey
Lean Cuisine –Ginger
Garlic Stir Fry with
Chicken
no--garlic chicken stir fry served on a bed of rice with non-
starchy vegetables
Skim milk avoid milk if treatment is just beginning to allow the intestine to
heal then slowly add it back in. Use Rice or nut milks if necessary
or if lactose intolerant.

6. Cheddar cheese
spread
ok avoid any spread made with beer or gluten products though
Green bean casserole
(mushroom soup,
onions, green beans)
no--use a gluten free mushroom soup or make your own from
gluten free flours (recipes are online). Make your own fried onions
with gluten free flours for breading.
Coffee ok, however, omit in the beginning and add later if tolerated.
Check ingredient list to make sure there is no gluten or gluten
products in it. Some flavored coffees may contain gluten in them.
Use plain milk or cream if desired and not lactose intolerant.
Rice crackers ok but make sure the ingredients are gluten free such as in the
tamari sauce and check there is no maltodextrin in it. Sesmark
tests for less than 20 ppm gluten and would be a good brand.
Fruit cocktail ok
Sugar ok however, watch for cross-contamination
Pudding Jell-O premade ok, if a mix read the label first
V8 juice ok
Banana ok
Cola ok
Nutrition Monitoring and Evaluation
(20 points) Write your nutrition care form from the standpoint of an initial nutrition consult and
initial dietary recommendations.

7. Sun Devil Nutrition Care Form (Total = 20 Points)
DATA & ASSESSMENT:
Subjective Data: Patient, a 46-year-old female reports an itchy rash over her scalp and
torso. Patient complains of muscle and joint aches, tingling in hands and feet as well as
ongoing depression. Patient reports onset of symptoms as one year ago. Patient is currently
a smoker. Patient works as a secretary and does not indicate any exercise regimen. Family
medical history of CAD: paternal. Patients diet currently includes a variety of foods.
Patient follows regular mealtime habits and prepares most foods at home. Patient reports
only significant weight gain as accompanying pregnancy. Patient has no known food
allergies.
Age: 46 Gender: Female Height: 5 ft 3 in/ 1.6 m Weight: 125 lbs/56.7 kg
Weight History: 150 Lbs after pregnancy, No excessive weight loss or weight gain pertinent
to case
Medical Diagnosis: Possible Celiac disease and Anemia
Reason for Consult: Patient presents with rash, neuropathy, muscle cramps, mouth sores,
joint pain and general depression
Medications: Vitamins (unspecified)
Current Diet Order: Gluten Free Diet; Modify current diet to reflect altered dietary needs
Past Medical/Surgical History: 3 pregnancies, 2 live births. No other medical history
Lab Values and Assessment: Na, K, and Cl within nml range. Mg, Folate, B12, Iron and
Ferritin levels below nml range. Note Important: AGA, EMA, and tTG antibodies above
nml range indicating possible immune response. Hematocrit below normal range
indicating possible anemic conditions
Weight Assessment (BMI and/or Hamwi Range - not just IBW):
BMI: 56.7 kg/ (1.6m)2
= 22.15

8. Hamwi 100lbs + (5 x 3) = 115 lbs + 10% = 126.5 lbs -10% = 103.5 lbs
Range: 103.5 lbs – 126.5 lbs
Energy Needs: 25-30 kcal/kg/day 56.7 x 25 = 1417.5 kcal per day
*note: patient is assumed to be sedentary
Protein Needs: 0.8 g pro/kg/day 0.8g x 56.7kg = 43.36 g protein/day
Fluid Needs:
100ml x 10 kg = 1000
50ml x 10kg = 500
Kg remaining = 36.7kg x 20 = 734
Total fluid needs = 2234 mL fluids/day
NUTRITION ASSESSMENT NARRATIVE - Be specific so your audience (MD, RN, staff RD,
etc) understands your assessment.
Patient presents with ongoing symptoms including rash, muscle aches and depression.
Patient has no history of medical abnormalities associated with presenting symptoms.
Patient is within normal weight range for height and has no other medical complications.
Patient’s dietary recall provides indication of a general normal diet and a variety of foods.
Labs show an immunological indicator of allergic symptoms. Laboratory values also
indicate likely anemic conditions. Referring to the patient’s symptoms and the
accompanying diet recall, incidence of celiac disease is assumed. Will counsel patient
regarding dietary modifications in relation to avoidance of gluten containing foods.
Additionally, will monitor patient and report any changes in symptoms as associated with
dietary modifications.
NUTRITION DIAGNOSIS:
Problem (Terminology): Predicted suboptimal energy intake (NI-1.4)
Related To: Food and nutrition related knowledge deficit (NB-1.1)
As Evidenced by: Altered nutrition related lab values (NC-2.2)
NUTRITION INTERVENTION NARRATIVE - Be specific so your audience (MD, RN, staff
RD, etc) understands your desired intervention, what it provides and why this needs to take
place.

9. Patient will receive counseling and educational support regarding dietary changes
pertaining to celiac disease. Patient will adapt meal plans and be educated about alternate
nutrient rich food choices. Will recommend nutrient focused eating to assess anemia.
Nutrition Intervention (Terminology):
Goals: Recommended modifications (E-1.5)
Healthful food choices(ND-1.1)
Composition of meals/snacks (ND-1.2) Diet modified for specific foods or ingredients (ND-
1.2.8)
NUTRITION MONITORING NARRATIVE - Be specific so your audience (MD, RN, staff RD,
etc) understands your desired monitoring plans and why this needs to take place.
Patient will follow up in three weeks to discuss results of dietary modifications and
continue diet modification education. Emphasis will be placed on changes in initially
reported symptoms. Additionally, comparative laboratory testing against initial values will
be requested at this time.
Nutrition Monitoring (Terminology):
Goals:
Self reported adherence score (FH-5.1.1)
Willingness to try new foods (FH-5.4.9)
Ability to recall nutritional goals (FH-5.1.3)
RD Signature:Marisa Gutierrez, Laurie Hill, Jessica Leslie, Ashley Marsh (students)Date:
4/17/2014
References
1. Nelms, M., Sucher, K. P., Lacey, K., & Long Roth, S. (2011). Nutrition Therapy and
Pathophysiology (2nd ed.). Belmont, CA: Wadsworth Cenage Learning.
2. Celiac Disease Diagnosis:Tests & Results. Retrieved April 13, 2014, from WebMD
website:http://www.webmd.com/digestive-disorders/celiac-disease/celiac-disease-
diagnosis-tests
3. Danner, Elaine & El-Chammas, Khalil. (2011). Gluten-Free Diet in Nonceliac
Disease. Nutrition in Clinical Practice 26: 294. Sage Publications.