3. Celiac Disease
● An autoimmune disorder that creates inflammation
in the mucosa lining of the small intestine that may
result in atrophy of intestinal villi, malabsorption,
and a variety of clinical symptoms.
● Inflammation occurs after the ingestion of the
protein:
4. Etiology
• Genetic Predisposition
• Family History
• HLA-DQ Gene Typing
• Exposure to gluten
• Breastfeeding
• Environmental trigger
• Surgery
• Autoimmune response
• Type 1 Diabetes, Down Syndrome
http://www.healthyhappyft.com/2014/08/dietas-
gluten-free/
6. What’s the difference between celiac
disease, gluten intolerance, gluten
sensitivity and wheat allergy?
Gluten Sensitivity
●Causes the body to
mount a stress
response (often GI
symptoms).
● Pt should be advised
not to follow a gluten
free diet without the
diagnosis.
Wheat Allergy
● Immune system
response
● This immune response
is often time-limited
and does not cause
lasting harm to body
tissues.
7. Prevalence
● Now considered to affect 1 in 133 people in the US.
● Infancy-adulthood
● May be triggered by GI surgery, stress, pregnancy,
viral infection.
● 20% of cases dx after age of 60 y/o.
8. Symptoms
Children
● Diarrhea
● Steatorrhea
● Malodorous stools
● Abdominal bloating
● Apathy, Fatigue
● Poor wt. gain
* 50% of CD pt has few or no
symptoms
Adults
* less likely to have digestive
symptoms.
● iron-deficiency anemia
● Fatigue
● bone pain or loss
● depression or anxiety
● tingling numbness in the
hands and feet
● seizures or migraines
● missed menstrual periods
● infertility or recurrent
miscarriages
● Dermatitis Herpetiformis
9. Screening
●Tissue Transglutaminase
Antibodies (tTG):
● Test will be positive in about
98% of patients with celiac
disease who are on a gluten-
containing diet.
●Endomysial antibody (EMA):
● Not as sensitive as the tTG-
IgA test. About 5-10% of
people with celiac disease do
not have a positive EMA test.
http://theconversation.com/everything-you-need-to-
know-about-coeliac-disease-and-whether-you-really-
have-it-4928
10. Diagnosis
If blood tests and symptoms suggest celiac
disease, a biopsy of the small intestine is
performed to confirm the diagnosis.
http://celiac2051.wordpress
.com/cause/
12. MNT
● Lifelong, strict adherence to a GF diet is the only
known treatment.
● The GF diet greatly diminishes the autoimmune
process, allowing the small intestine mucosa to
revert to normal or near normal within 2-8 wks.
● Improvements may take months to years depending
age, duration of disease and degree of dietary
compliance.
13. Mayo Clinic Study
The American Journal of Gastroenterology.
Joseph A. Murray, M.D.,
● Studied the effect of a gluten-free diet on mucosal tissue recovery
● 241 adults—176 women and 65 men with an average age of
47—with celiac disease.
● confirmed by intestinal biopsy.
● 2 yr mark: about one-third had intestinal villi that had
recovered fully.
● 5 yr mark: about two-thirds had fully recovered intestinal
villi.
● “Good adherence to a gluten-free diet is necessary for mucosal
recovery, but doesn’t guarantee mucosal recovery in all adults
with celiac disease.”
14. MNT
If usual food intake shows nutritional inadequacies, the
RD should recommend a daily gluten free and sex
specific multivitamin and mineral supplement.
Common deficiencies:
● Ca
● Impaired lactase secretion
● Lactose Intolerance
● Iron, folate, niacin, vitamin B12, phosphorus, zinc
● Fat soluble Vitamins (D,A,E,K)
18. Cleaning Your Cabinets of Gluten
-Soy Sauce
-Salad Dressings
-Gravies, Sauces and
Marinades
- Soups
-Puddings and Pie Fillings
-Reduced-Fat Products
-Processed Meats
-Ready-Made Meals and Fast
Foods
19. Barriers to Compliance
● Ability to manage emotions – depression, anxiety
● Ability to resist temptation – exercising restraint
● Feelings of deprivation
● Fear generated by inaccurate information!
20. What We Can Do As RD’s
- Knowledge about the gluten-free diet/CD
- Understand the risk factors and serious complications
that can occur
- Ability to break down big changes into smaller steps
- Provide positive coping skills
- Build a trusting relationship between client and dietitian
22. GERD
Gastroesophageal Reflux Disease
● When gastric content of the stomach refluxs up into
the esophagus.
● Heartburn
● Burning sensation in
esophagus.
● Inflammation with erosion
of the lining of esophagus.
● 20-40% of adults report
symptoms of GERD weekly
26. Symptoms
● Reflux of gastric
secretions
● Heartburn
● Difficulty/pain
swallowing
● Belching
● Chronic sore throat
● Sour taste
● In children
● Vomiting
● Dysphasia
● Refusal to eat
● Abdominal pain
27. Esophagitis
● inflammation of esophagus
● Types
● Reflux- GERD- Most common cause
● infectious esophagitis- in patients who are
immunocompromised
● Radiation esophagitis
● Esophagitis from direct erosive effects of ingested
medication or corrosive agents (Antibiotics, anti-
inflammatory drugs)
30. Nutritional Implications
● Side effects that could affect nutritional status
- Trouble Swallowing
- Impaired ability to consume adequate diet
● Interfere with sleep, work, social events and quality
of life (exercise) .
http://www.zantacsideeffects.net/wp-
content/uploads/2013/07/heartburn-effects-300x294.jpg
http://www.webmd.com/heartburn-
gerd/ss/slideshow-heartburn-overview
32. EAL recommendations
1. Avoid large, high
fat meals.
2. Avoid eating 3-4
hours before lying
down.
3. Avoid smoking.
4. Avoid alcohol.
5. Avoid caffeine.
6. Stay upright and avoid
activity soon after eating.
7. Avoid tight clothes.
8. Consume adequate fiber.
9. Avoid acidic and spicy
foods.
10. Lose weight if overweight.
33. Case Study
Assessment
● A 31 y/o man
● Sedentary lifestyle
● 5-6 beers every night
● Eats out often
● Consumes high fat/ high sodium foods.
● Patient experiences pain as “burning” in the middle of his chest.
● Reports trouble swallowing and “food is getting stuck in his throat.”
● Reports frequent regurgitation.
● Family hx of DM, HTN, MI, and wt issues.
• Height: 5 ft 10 in
• Weight: 182 lb
• Blood pressure: 135/80 mm Hg
At home medications: None
34. A/D...
Abnormal Lab Values
• Total cholesterol: 210 mg/dL
• Low-density lipoprotein cholesterol: 145 mg/dL
• High-density lipoprotein cholesterol: 47 mg/dL
• Triglycerides: 160 mg/dL
Diagnosis
1. Excessive fat intake (NI-5.6.2) r/t food and nutrition related knowledge
deficit concerning appropriate amount of dietary fat aeb total cholesterol of
210 mg/dL, LDL 145 mg/dL, and TG 160 mg/dL, reports of epigastric pain
and frequent high-fat meals.
2. Food and nutrition related knowledge deficit (NV-1.1) r/t lack of prior
nutrition related education aeb pt verbalizing unwillingness or disinterest in
learning information regarding diet change.
35. Intervention
Caloric needs: Mifflin-St. Jeor-- (10x95) + (6.25 x 177.8) - (5 x 31) + 5
950 + 1111.25- 155 +5
= 1,911 kcals
Protein needs: (1.2-1.5 g/kg) = 89-111 g/kg pro
Fluid: (30-35 mL/kg)= 2.8-3.3L
Nutrition Education - Content E-1 was provided to help manage symptoms of
GERD with lifestyle changes, including low-fat options, food purchasing tips,
and physical activity recommendations.
Nutrition Counseling (C-1) based on transtheoretical model including MI
strategies to help Chuck identify behaviors that may be causing GERD
symptoms. Goal setting and self monitoring were used to help client progress
to contemplation stage.
36. CONTINUED...
Specific goals set by client:
1. Reduce alcohol consumption to 2-3 beers per night.
2. Prepare two meals at home this week.
Monitoring/Evaluating
Weight, oral intake and lipid panel labs. Pt will complete a
food log to monitor symptom occurrence with intake and
time of day. Schedule follow up with client in 1 week.
37. References
1. Sonia S. Kupfer and Bana Jabri. Celiac Disease Pathophysiology. NIH (online.) Aug 30, 2012. doi:
10.1016/j.giec.2012.07.003. Accessed 10/31/2014.
2. Shaheen NJ, Weinberg DS, Denberg TD, Chou R, Qaseem A, Shekelle P, et al. Upper Endoscopy for Gastroesophageal
Reflux Disease: Best Practice Advice From the Clinical Guidelines Committee of the American College of Physicians.
Annals of Internal Medicine. 2012;157:808-816. doi:10.7326/0003-4819-157-11-201212040-00008
2. Mahan, L. Kathleen., Sylvia Escott-Stump, Janice L. Raymond, and Marie V. Krause. Krause's Food & the Nutrition Care
Process. St. Louis, MO: Elsevier/Saunders, 2012. Print.
4. "CD: EXECUTIVE SUMMARY OF RECOMMENDATIONS (2009)." Eatright.org Evidence Analysis Library. The Academy
of Nutrition and Dietetics, 2009. Web.
5. Alberto R, Mussarat R, Jacalyn A. Lahr B, Tsung-Teh W, and Murray J. Mucosal Recovery and Mortality in Adults with
Celiac Disease after Treatment with a Gluten-Free Diet. Am J Gastroenterol. Jun 2010; 105(6): 1412–1420. Accessed
October 29, 2014.
5. "Celiac Disease Guidelines." Evidence Analysis Library. The Academy of Nutrition and Dietetics, 2009. Web. 13 Oct. 2014.
38. 6. Celiac Disease Foundation. What is Celiac Disease. 2014. Available at http://celiac.org/celiac-disease/what-is-celiac-disease/.
7. Celiac Support Association. How is Celiac Disease Diagnosed. 2013.
8. International Foundation for Functional Gastrointestinal Disorders. Signs and Symptoms of Gerd. February 17, 2014.
9. Mayo Clinic. Diseases and Conditions: Hiatal Hernia. December 8, 2011.
10. Gupta, Puneet, Murray J. Favus, Haikaeli Andrew, and Stefano Guandalini. "Prevalence of Celiac Disease in Patients with
Osteoporosis in United States." Gastroenterology 118.4 (2000): A367. Web.
