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 GLIADIN Compromised sm. intestinal wall poor absorption Malabsorption of essential nutrients Iron def. anemia Early onset osteoporosis 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 1 st 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 Wolters, 2008 Nelms, 2007
Aafp.org IN THE INTESTINE
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 Hill, 2005 http://digestive.niddk.nih.gov/ddiseases/pubs/dh/index.htm
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 Usual Dietary Intake Likes all foods Generally avoids eating because of subsequent diarrhea 24 Hour Recall 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
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: 112 Pregnancy Wt: 123 Now: 92lbs 18% unintentional weight loss 92/112 = 82% UBW
ADIM/E ASSESSMENT Lab values indicating malnutrition 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
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 density encourage Ca and Vit D Education of the Gluten Free Diet!!!
ADIM/E - INTERVENTION Short-term outcome goals Long-term outcome goals Initiate gluten-free diet Heal villous atrophy Normalize prealbumin No further weight loss Maintain glutenfree diet Normalize hematological ranges Albumin, transferrin Weight gain to UBW
SCOPE OF PRACTICE Providing nutrition education about a gluten-free diet. Model/figure from readings
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