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