Naomi Stamper

Case Study #1






Case Study 1
NFSC 470

Naomi Stamper
11/13/13

Naomi Stamper
Case Study #1
Case 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?
The villi are the projections in the intestine that are made up of enterocytes (Small Intestine
Regions and Structures, n.d.). This biopsy showed that the mucosa (the lining of the intestine)
was flat because these projections were not sticking out into the lumen as they do in normal
anatomy. This is caused by an immune response which damages the cells of the villi and causes
them to flatten decreasing the surface area that allows for normal nutrient absorption (Celiac
disease Causes, 2013). The body compensates for this by increasing the number of crypt cells
(the cells at the bottom of the villi) (Coeliac Disease, n.d.). The inflammatory response leads
to lymphocytes and other cells entering the lamina propria (the layer beneath the enterocytes);
this leads to inflammation in the small intestine (Rouse, 2012).

2. What is the etiology of celiac disease? Is anything in Mrs. Gainess history typical of patients
with celiac disease? Explain.
Celiac disease is caused by the bodys abnormal response to gluten which causes the immune
system to attack the intestinal cells (Celiac Disease Symptoms, Causes, Diagnosis and
Treatment, n.d.). This leads to inflammation and destruction of the villi which affects the
bodys ability to digest and absorb nutrients, which leads to malabsorption (Celiac Disease,
2012). The damage to the intestine caused by celiac disease results in symptoms such as foul-
smelling diarrhea, which Mrs. Gaines states she has had recurrently as an adult; she also has lost
weight which is typical due to malabsorption (Celiac Disease, 2012). Mrs. Gaines also
complains of fatigue and weakness which are typical of patients with celiac disease due to
malabsorption of nutrients (Celiac Disease Symptoms Gas, Weight Loss, Fatigue & More,
2010). Mrs. Gaines also stated that her mother and grandmother had stomach and digestive
issues, such as diarrhea, which is consistent with celiac disease as there is a strong heritable
component of the disease (Fasano, n.d.).

3. How is celiac disease related to the damage to the small intestine that the endoscopy and
biopsy results indicate?
In a person with celiac disease, the body creates AGA and EMA antibodies in response to gliadin
and endomysium proteins; when the antibodies bind to their respective antigens, it signals the
body to mount an immune response (Celiac Disease Defined, n.d.). This causes damage to the
lining of the intestine including destruction of the villi (which is compensated for by an increase
in the number of crypt cells) and inflammation (Celiac Disease Symptoms, Causes, Diagnosis
and Treatment, n.d., Coeliac Disease, n.d.).

4. What are AGA and EMA antibodies? Explain the connection between the presence of antibodies
and the etiology of celiac disease.
Anti-gliadin antibodies and endomysium antibodies are class A immunoglobulin proteins (Bao,
Green, & Bhagat, 2012). AGA is produced in response to the presence of gliadin (a component
of gluten) and EMA is produced in response to ongoing intestinal damage, such as that seen in
celiac disease; AGA is not an antibody produced exclusively in celiac disease and is currently not
thought to be specific enough for diagnosing celiac disease on its own (Bao et al., 2012). The
presence of these antibodies, along with their antigens, causes an immune response that leads
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to the destruction of the enterocytes and the initiation of the inflammatory response (Celiac
Disease Tests, 2013).

5. What is a 72-hour fecal fat test? What are the normal results for this test?
The 72-hour fecal fat test is used to determine if a person in malabsorbing fat. For the test, the
patient consumes 100 grams of fat per day for three days. The patients stools are then
collected and the fat content is measured. Normal results are less than seven grams of fat in a
24 hour period; more than 7 grams of fat indicates fat malabsorption.

6. Mrs. Gainess laboratory reports show that her fecal fat was 11.5 g fat/24 hours. What does this
mean?
Her fecal fat test result indicates fat malabsorption.

7. Why was the patient placed on a 100-g fat diet when her fecal fat diet when her diet history
indicates that her symptoms are much worse with fried food?
The patient was placed on the fecal fat diet to test for fat malabsorption. She was not placed on
the diet to alleviate her symptoms and was only placed on this diet for the 72-hour testing
period.

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?
Gluten is a component in wheat, barley, and rye; it is made up of two proteins, gliadin and
glutenin (Dewar, Pereira, & Ciclitira, 2004). Gluten is also found in triticale which is a cross
between wheat and rye (Gluten-free diet: Whats allowed, what's not, 2011). Gluten is
present in any product that contains any of these ingredients. It can also be found in any
product that is processed in a facility where gluten-containing foods are processed. Gluten can
be found in the following foods: baked goods (including bread), pasta, beer, candy, lunch meat,
sauces, soups, gravy, and malt flavoring (Gluten-free diet: Whats allowed, what's not, 2011).
Some foods, such as oats, can become contaminated with gluten during processing (Oats,
n.d.).

9. Can patients on a gluten-free diet tolerate oats?
There is a subset of patients who cannot tolerate oats; oats contain a prolamine (avenin) similar
to the prolamine found in wheat (gliadin) which can cause a reaction in some patients (Fric,
Gabrovska, & Nevoral, 2011). Of those patients who can tolerate oats, the recommended
amount is 50-70 grams per day for adults and 20-25 grams per day for children of
uncontaminated oats (Butzner, 2011). Patients on a gluten-free diet need to consume gluten-
free oats (defined as containing less than 20 PPM gluten) because oats can become
contaminated with gluten from other sources during production, harvesting, or processing
(Oats, n.d.).

10. What sources other than foods might introduce gluten to the patient?
Gluten can also be found in vitamins, medications, food additives, thickeners and play dough
(Gluten-free diet: Whats allowed, what's not, 2011).



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Case Study #1
11. Can patients with celiac disease also be lactose intolerant?
If a patient with celiac disease is not lactose intolerant and is not having gastrointestinal
distress, the patient can most likely tolerate lactose. However, if the patient is having
gastrointestinal issues, the patient will most likely not be able to tolerate lactose because
lactase production usually decreases under gastrointestinal distress.

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?
(

) (

)


Weight loss of 17.9% over a three month period indicates severe unintentional weight loss and
risk for malnutrition.

A BMI of 16.3 indicates the patient is underweight and could be at risk for malnutrition.

B. Calculations of Nutrient Requirements
13. Calculate the patients total energy and protein needs using the Harris-Benedict equation or the
Mifflin-St. Jeor equation.
(

)




(


) This is above the upper range for energy
needs for anabolism (35-40 kcal/kg). Adjusted to the upper range for anabolism her energy
needs are:

The patient can be started at 1672 kcal/day and this can be increased to 1833 (or more based on
any weight changes observed in the patient) as tolerated by the patient.

Protein needs (1.25 g/kg/day):

C. Intake Domain
14. Evaluate Mrs. Gainess 24-hour recall for adequacy.
Mrs. Gainess diet is not providing adequate kilocalories, protein, fat, or carbohydrates. Based
on her 24-hour recall and analyzed using diet analysis software her energy intake is
approximately 30% of her energy requirements. Her protein intake is approximately 20% of her
needs. Her diet is also low in most micronutrients, including calcium, potassium, iron, copper,
magnesium, phosphorous, selenium, zinc, vitamins A, B6, B12, C, D, E and K, folate, riboflavin,
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and niacin (Food Tracker, n.d.). However, she is taking a prenatal vitamin and her actual
intake of these nutrients is higher than just her nutrient intake from food. The micronutrients
listed above are nutrient deficiencies she is at risk for due to celiac disease (Symptoms of Celiac
Disease, n.d.).

15. From the information gathered within the intake domain, list possible nutrition problems using
the diagnostic term.
Increased energy expenditure (NI-1.2)
Inadequate energy intake (NI-1.4)
Inadequate oral intake (NI-2.1)
Malnutrition (NI-5.2)
Inadequate protein-energy intake (NI-5.3)
Inadequate fat intake (NI-5.6.1)
Inadequate protein intake (NI-5.7.1)
Inadequate carbohydrate intake (NI-5.8.1)
Inappropriate intake of types of carbohydrate-gluten-containing foods (NI-5.8.3)
Inadequate vitamin intake (NI-5.9.1): A, C, D, E, K, thiamin, riboflavin, niacin, folate, B6,
B12
Inadequate mineral intake (NI-5.10.1): calcium, iron, magnesium, potassium,
phosphorus, zinc

D. Clinical Domain
16. Evaluate Mrs. Gainess laboratory measures for nutritional significance. Identify all laboratory
values that support a nutritional problem.
Low albumin (2.9 g/dL) indicates mildly depleted visceral protein
Low total protein (5.5 g/dL) indicates depleted visceral protein
Low prealbumin (13 mg/dL) indicates mildly depleted visceral protein
Low hemoglobin (9.5 g/dL) indicates iron-deficient anemia (late stage)
Low hematocrit (34%) indicates iron-deficient anemia (late stage)
Low ferritin (12 mg/ml) indicates iron-deficient anemia
High ZPP (85 mol/mol) indicates iron-deficient anemia (ZPP, n.d.)
Low vitamin B
12
(21.2 ng/dL)
Low folate (3 g/dL)
Fecal fat (11.5 g) indicates fat malabsorption
(+) AGA, EMA supports a positive diagnosis for Celiac Disease (Celiac Disease Tests,
2013)

17. Are the abnormalities identified in question 16 related to the consequences of celiac disease?
Explain.
The low albumin, prealbumin, and total protein indicate inadequate intake of protein and/or
calories and malabsorption; the low hemoglobin, hematocrit, and ferritin and high ZPP indicate
iron-deficient anemia (ZPP, n.d.). The low vitamin B
12
and low folate indicate decreased
digestion and/or absorption of vitamin B
12
and folate. The fecal fat test result indicates fat
malabsorption. All of these lab values could be due to malabsorption due to damage to the
intestine due to celiac disease. The patient also states that she is not eating because it worsens
her diarrhea; since the diarrhea is likely due to celiac disease, the disease is also resulting in
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decreased food intake because the patient is avoiding eating. This could be contributing to the
nutrient deficiencies discussed above.

18. Are any symptoms from Mrs. Gainess physical examination consistent with her laboratory
values? Explain.
Her thin/pale appearance, along with her complaints of fatigue and weakness are consistent
with low hemoglobin, hematocrit, and ferritin and high ZPP (ZPP, n.d.). It is also consistent
with low albumin, prealbumin, and total protein because low serum proteins indicate protein-
energy malnutrition. Diarrhea is consistent with the laboratory values because it could be
causing decreased transit time through the intestine and therefore a decreased amount of time
for nutrient absorption.

19. Evaluate Mrs. Gainess other anthropometric measurements. Using the available data, calculate
her arm muscle area. Interpret this information for nutritional significance.
(

An AMA of 11.4 cm
2
for the patients gender and age places her in the fifth percentile which is
indicative of a muscle deficit.

20. From the information gathered within the clinical domain, list possible nutrition problems using
the diagnostic term.
Altered GI function (NC-1.4)
Altered nutrition-related laboratory values (NC-2.2) [low: albumin (2.9 g/dL), total
protein (5.5 g/dL), prealbumin (13 mg/dL), Hgb (9.5 g/dL), Hct (34%), ferritin (12 mg/ml),
vitamin B
12
(21.2 ng/dL), folate (g/dL); high: ZPP (85 mol/mol)]
Underweight (NC-3.1)
Unintentional weight loss (NC-3.2)

IV. Nutrition Diagnosis
21. Using the VA Nutrition Screening Form, what is this patients nutrition status level?
The patients nutrition status is level 3.

22. Select two high-priority nutritional problems and complete the PES statement for each.
1. Inadequate oral intake (NI-2.1) related to avoidance of eating as evidenced by severe
unintentional weight loss (17.9% weight loss over three months), low albumin (2.9 g/dL),
low total protein (5.5 g/dL) and low prealbumin (13 mg/dL), and diet history.
2. Food- and nutrition-related knowledge deficit (NB-1.1) related to lack of education (new
diagnosis) as evidenced by diet recall (e.g. patient is consuming foods that contain gluten).

V. Nutrition Intervention
23. For each of the PES statement that you have written, establish an ideal goal (based on the signs
and symptoms) and an appropriate intervention (based on the etiology).
Goals:
1. No further weight loss
2. Eliminate foods containing gluten (and lactose temporarily) from patients diet
Intervention:
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Case Study #1
1. Modify distribution, type, or amount of food and nutrients within meals or at a specified
time (ND-1.2)provide the patient with small, frequent, appropriate meals (gluten-free,
lactose-free) throughout the day and provide an oral supplement (Ensure Plus) to increase
energy intake
2. Recommended modifications (E-1.5)educate the patient on how to remove gluten from
her diet how to temporarily remove lactose from her diet; provide substitutions for gluten-
containing foods currently in her diet.

24. What type of diet would initially begin when you consider the potential intestinal damage that
Mrs. Gaines has?
Mrs. Gaines should begin a gluten-free diet. She should be started on a GI soft diet which will be
gentler on her damaged intestinal tract. She should temporarily exclude lactose from her diet
until her symptoms improve.

25. Mrs. Gainess nutritional status is so compromised that she might benefit from high-calorie,
high-protein supplementation. What would you recommend?
Mrs. Gaines might benefit from an Ensure Plus (8 oz) nutritional supplement.

26. Would glutamine supplementation help Mrs. Gaines during the healing process? What form of
glutamine supplementation would you recommend?
Glutamine supplementation may benefit Mrs. Gaines during the healing process because
glutamine is a major energy source for intestinal cells (Camilleri et al., 2012). Supplementation
of L-glutamine as a powder or capsule at a dose of 500 mg three times per day under the
supervision of a physician would be recommended (Ehrlich, 2011).

27. What results can Mrs. Gaines expect from restricting all foods with gluten? Will she have to
follow this diet for very long?
Once Mrs. Gaines removes gluten-containing food the damage and inflammation in the intestine
should begin to reverse which should improve her gastrointestinal tract symptoms (such as
diarrhea); Mrs. Gaines will have to follow this diet for the rest of her life (Celiac Disease,
2012).

VI. Nutrition Monitoring and Evaluation
28. Evaluate the following excerpt from Mrs. Gainess food diary. Identify foods that might not be
tolerated on a gluten/gliadin-free diet. For each food identified, provide an appropriate
substitute.

Food Tolerated (yes or no) Substitute/Notes
Cornflakes No-Kelloggs Corn Flakes contain malt
flavoring (Kelloggs Corn Flakes
Cereal, 2011)
Natures Path Fruit Juice
Sweetened Corn Flakes (Fruit
Juice Sweetened Corn Flakes
Natures Path, 2012)
Bologna slices Yes-Oscar Mayer Beef, Chicken, and
Pork Bologna is gluten-free (List of
Name-Brand Gluten Free Foods,
2013)
Check packages of other brands
for gluten/gluten-containing
products
Lean Cuisine
Ginger Garlic Stir-
No (Nutrition Facts - Ginger Garlic
Stir Fry with Chicken, n.d.)
Amys Asian Noodle Stir-Fry
(Natural and Organic Foods Asian
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fry with Chicken Noodle Stir-Fry, 2013)
Skim milk Yes-as long as the patient is not
having a flare-up and it may not be
tolerated immediately because of the
lactose (Gluten-free diet: Whats
allowed, what's not, 2011)

Cheddar cheese
spread
Yes-Kraft Old-English Cheddar Cheese
Spread is gluten free; it does contain
lactose so it may not be tolerated
immediately or during a flare-up
(Kraft Old English Cheese Spread, 5-
Ounce (Pack of 6), n.d.)
Check packages of other brands
for gluten/gluten-containing
products
Green bean
casserole
(mushroom soup,
onions, green
beans)
Yes-green beans (fresh) and onions
(fresh) (Gluten-free diet: Whats
allowed, what's not, 2011)
No-mushroom soup; some brands
contain gluten (CREAM OF
MUSHROOM SOUP, n.d.)
Mushroom soup-some brands
have gluten-free mushroom soup,
for example, Progresso cream of
mushroom-gluten free; this does
contain lactose and may not be
tolerated initially or during a flare-
up (Progresso Vegetable Classics
Creamy Mushroom, n.d.)
Coffee Yes-plain coffee is tolerated (Basic
Diet Choices, n.d.)
Flavored or instant coffee may
contain gluten so the labels must
be checked (Basic Diet Choices,
n.d.)
Rice crackers Yes (Basic Diet Choices, n.d.)
Fruit cocktail Yes-most are gluten-free, but labels
need to be checked for
thickeners/additives that may
contain gluten (Basic Diet Choices,
n.d.)
Del Monte Fruit Cocktail is gluten-
free (FAQs, n.d.)
Sugar Yes (Basic Diet Choices, n.d.)
Pudding Yes-as long as the product does not
contain any additives with gluten
(Basic Diet Choices, n.d.); it may
not be tolerated immediately or
during a flare-up because of the
lactose (Gluten-free diet: Whats
allowed, what's not, 2011)
Kozy Pudding is gluten free
(Product FAQs, n.d.)
V8 juice Yes (FAQ V8 100% Vegetable Juice,
n.d.)

Banana Yes (Basic Diet Choices, n.d.)
Cola Yes (Basic Diet Choices, n.d.)



Naomi Stamper
Case Study #1

Nutrition Assessment
Patient Interview: Patient states recent weight loss and severe diarrhea (debilitating)-occurs no matter
what she eats and it is foul-smelling; lack of energy
Diet recall: AM-1 slice whole-wheat toast, 1 tsp butter, hot tea with 2 tsp sugar; lunch-1 c chicken
noodle soup, 2-3 saltine crackers, c applesauce, 12 oz Sprite and sips throughout the rest of day;
dinner-none

Admitting Dx: Celiac disease with secondary malabsorption and anemia
PMH: recurrent diarrhea (on and off) throughout adult life; family history of diarrhea/gastrointestinal
complaints
Patient is a 36 y/o Caucasian female
Ht. 63 in Wt. 92 lbs BMI 18.3% %IBW 80% %UBW 82.1% UBW timeframe: 3 months (severe
unintentional weight loss)
Diet order: 72-hour fecal fat test diet
Average Meal Intake: NA
I/Os: NA
GI: diarrhea (frequent, foul-smelling), fat malabsoprtion, diminished bowel sounds
Pertinent Labs: low 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), high ZPP (85 mol/mol), low vitamin B
12
(ng/dL), low
folate (g/dL), AGA (+), EMA (+)

Pertinent Medications: prenatal vitamins, kaopectate
Physical exam/skin: thin, pale, TSF 7.5 mm, MAC 180 mm
Other info: small bowel biopsy indicates flat mucosa with villous atrophy and hyperplastic crypts
inflammatory infiltrate in lamina propria. Fecal fat test indicates steatorrhea and malabsorption (11.5
g); positive for AGA, EMA antibodies

************************************************************************
Nutrition Diagnosis/Diagnoses: (PES Statements)

1. Inadequate oral intake (NI-2.1) related to avoidance of eating as evidenced by severe
unintentional weight loss (17.9% weight loss over three months), low albumin (2.9 g/dL), low
total protein (5.5 g/dL) and low prealbumin (13 mg/dL), and diet history.
2. Food- and nutrition-related knowledge deficit (NB-1.1) related to lack of education (new
diagnosis) as evidenced by diet recall (e.g. patient is consuming foods that contain gluten).

************************************************************************
Nutrition Intervention:
Individualized Treatment Goals to Address Nutrition Diagnosis
1. No further weight loss
2. Improved average intake to 75% of energy needs
3. Improved albumin
4. Eliminate foods containing gluten (and lactose temporarily) from patients diet
5. Patient can identify gluten-containing and lactose-containing foods


Naomi Stamper
Case Study #1
Intervention Statements (Use Intervention Sheets)
1. Modify distribution, type, or amount of food and nutrients within meals or at a specified time
(ND-1.2)provide the patient with small, frequent, appropriate meals (gluten-free, lactose-free)
throughout the day and provide an oral supplement (Ensure Plus) to increase energy intake
2. Recommended modifications (E-1.5) educate the patient on how to remove gluten from her
diet how to temporarily remove lactose from her diet; provide substitutions for gluten-
containing foods currently in her diet.

************************************************************************
Monitoring and Evaluation

Weight
Labs (albumin, prealbumin, Hgb, Hct, ferritin, ZPP, vitamin B12, folate)
Frequency of diarrhea
Diet composition
Diet tolerance
Diet adherence

Signed _____________________________________ Date: ______________________








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Case Study #1
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