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TRANSCRIPT
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:
Glut
en
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/
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.
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.
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
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
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/
http://celiac2051.wordpress.com/cause/
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.
Mayo Clinic StudyThe 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.”
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)
Safe Grains and Plant Foods:
● Corn
● Soy
● Potato
● Flax
● Beans
● Chia
● Millet
● Nuts
●Nut Flours
●Quinoa
●Rice
●Sorghum
●Tapioca
●Yucca
Avoid!
● Wheat
● Rye
● Barley
● Oats (unless pure, uncontaminated)
● Battered/deep fried foods, noodles, flour tortillas, most baked goods with wheat flour.
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
Barriers to Compliance
● Ability to manage emotions – depression, anxiety
● Ability to resist temptation – exercising restraint
● Feelings of deprivation
● Fear generated by inaccurate information!
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
GERDGastroesophageal 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
http://www.webmd.com/digestive-disorders/picture-of-the-esophagus
Pathophysiology
● Reduced LES pressure
● Inadequate esophageal tissue defense
● Direct mucosal irritants
● Increased intraabdominal pressure
● Anti-inflammatory drugs
Symptoms
● Reflux of gastric secretions
● Heartburn
● Difficulty/pain swallowing
● Belching
● Chronic sore throat
● Sour taste
● In children● Vomiting● Dysphasia● Refusal to eat● Abdominal pain
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)
Causes/Risk Factors
● Pregnancy● Obesity● Scleroderma● Smoking● Certain medications (eg, beta-blockers, NSAIDs,
theophylline, nitrates, alendronate, calcium channel blockers)
● Spinal cord injury● Immunocompromised state● Radiation therapy
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
Management
● Antacids● Tums, Rolaids.
● Proton pump inhibitors● Prilosec, Protonix
● Histamine 2 receptor antagonists● Zantac
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.
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
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
Diagnosis1. 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.
Intervention
Caloric needs: Mifflin-St. Jeor-- (10x95) + (6.25 x 177.8) - (5 x 31) + 5950 + 1111.25- 155 +5
= 1,911 kcalsProtein needs: (1.2-1.5 g/kg) = 89-111 g/kg proFluid: (30-35 mL/kg)= 2.8-3.3LNutrition 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.
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.
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
3. 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.
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.