Case Study: Celiac Disease
Kim MacGregor
HLTH 643
February 4, 2022
1. Celiac disease is an autoimmune disorder predominantly affecting those who have the disease
within their genetics1. It affects the small intestine when those affected eat any gluten, which is
found in wheat, rye, and barley1. The true component of gluten that damages the small intestine
are the protein components like gliadin2. When the small intestine is merely exposed to gliadin
component of gluten, the small intestine creates an inflammatory reaction, which thus damages
the intestine’s mucosa2. The repeated response the small intestine creates causes greater
destruction over time and negatively impacts the way the small intestine is able to absorb
nutrients1 and consequently can cause significant health concerns if left untreated2.
As mentioned above, celiac disease typically affects those with the disease in their lineage.
Individuals who have a first-degree relative such as a mom, child, or sibling, with celiac disease
are 10% more likely to develop the disease1. While no first-degree relative of Meghan has
diagnosed celiac disease, her mother suffers from a thyroid disease, a different autoimmune
disorder. There have been studies to show links between autoimmune thyroid disease and celiac
disease, as well as links between celiac disease and type 1 diabetes mellitus3 which Meghan’s
aunt has. The links between these autoimmune disorders exist because the genes identified with
celiac disease associate with the genes for type 1 diabetes or thyroid disease2.
Genetics play a factor in the diagnosis of celiac disease, but so do environmental factors2.These
factors can include introduction of gluten at a younger age, either no or extremely limited time
being breastfed, and/or the presence of a viral infection while an infant2. The constant changes in
infections and the increased consumption of gluten foods such as pizza, bagels, and high fiber
breads can be the causal factors of the increased incidence of celiac disease4. However, we
cannot ignore the improvements of science and testing within the past few years and how that
could potentially be a cause for greater prevalence of celiac disease. The introduction of blood
testing at the start of the 20th century helped to improve accuracy of diagnosis as well as make it
more cost-effective1. There is also a greater awareness and education of symptoms among
physicians, leading to more testing for the disease1.
2. tTG antibodies show whether or a not a person has celiac disease via the serological test1. The
test occurs and if enough of the tTG antibodies appear, it can be determined the individual does
have celiac disease. The tests will be positive for 98% of patients who have celiac disease, who
are also on a gluten-containing diet1. The 98% highlights the tests’ sensitivity and measures how
correctly its diagnosis those with the disease1. This is a relatively accurate test as it comes back
negative in 95% of those without celiac disease1. The 95% refers to the specificity and how
accurate the test is at determining those without the disease1. It is important to note, however,
that the tTG test is not perfect and still could produce a false negative. A positive test result for
either tTG test or an EMA test will allow a physician to infer the patient has celiac disease,
though it cannot be absolutely confirmed without a biopsy of the small intestine1.
3. The intestinal biopsy is more than just the “gold standard” for diagnosis of celiac disease. The
biopsy will also tell an individual if their symptoms improve on a “gluten-free diet due to a
placebo effect,” or if you have an alternative GI disorder that could also be respondent for a
change in diet1. The biopsy allows a physician to physical see inside of the small intestine and
witness any damage or inflammation caused from celiac disease1. The physician can also take
samples of the duodenum and the duodenal bulb1 to confirm the diagnosis.
Because celiac disease causes an inflammatory response within the small intestine, it overtime
destroys its walls composed of the villi and crypts. The villi are the small “fingerlike” projections
along the wall of the small intestine that help absorb nutrients, and celiac disease can shrink or
flatten them after repeated exposure of gluten1. There are spaces between the villi called crypts,
and over time these crypts can become elongated causing “crypt hyperplasia”1. Additional
physical changes may also be observed in the epithelial tissue that lines the small intestine1.
White blood cells are incredible tellers to disease and that holds true with celiac disease as well.
When there is a certain density if IELs, a type of white blood cells in the immune system,
concern should be noted. If there are more than 25 IELS per 100 epithelial cells that line the
intestines, a physician would acknowledge that1.
4. Currently, obtaining a gluten-free diet is the only treatment for celiac disease. This involves
avoidance of all gluten from a diet for longevity of a person’s life. Gluten itself is a protein found
in wheat, rye, barley, and triticale1. It is primarily used to add protein, texture or flavor to food
but also can be used to give foods shape and help them bind together5.
Wheat can be found in bread, baked goods, pasta, cereal, salad dressings, or sauces1. Barley can
be found in malt, beer, and some food coloring, and rye can be found in bread and cereals1.
Triticale, which is a cross of barley and rye5, can also be found in bread, pasta and cereals1.
Overall gluten is an abundant protein found in a variety of nutrient dense and vital foods for diet.
5. Patients with celiac disease can also develop secondary malabsorption or be deemed lactose
intolerant. Lactose intolerance is the inability of the body to digest or absorb lactose the sugar
from milk or other dairy products6. This secondary malabsorption occurs due to the potential
damage in the small intestine and the failure for any lactase, an enzyme the works to digest milk
sugar6, to exist within the organ. However, because the following of a gluten-free diet can help
repair and treat the small intestine, the sensitivity and intolerance to sugars in dairy can also be
reversed through a strict gluten-free diet6.
6. A z-score is used to measure a person’s height or weight to classify nutritional status7. It is
technically the standard deviation “above or below the mean”7.The person’s weight or height is
compared to the weight or height of another person of the same metrics and sex7. In order to find
their weight or heigh z-score, a provider or parent would need to find the CDC chart the
correlates with their gender and then determine if it is looking at weight-for-length or another set
of numbers. In order to calculate one’s z-score, you do have to do a calculation for standard
deviation or follow the charts provided by the CDC.
Meghan is 3 years and 5 months, making her 43 months. She is currently 11 kg in weight, and
when you find that number on the CDC z-score chart, she falls within the -2 category, meaning
she is that number of standard deviations below the mean or average7. For her height, Meghan is
90 cm, which puts her in between two z-scores and standard deviations, -2 and -1.5. This means
Meghan is below the mean for heigh as well. When we look at her height and weight z-score, she
is well below the mean at more than -2 z-score. Her BMI is also at the very end of the negative
deviations at -2. This would prompt a physician to be concerned about her development since
Meghan is far behind in both regards and would put her at considering for malnutrition.
7. Pediatric malnutrition uses indicators such as z-scores, mid-upper arm circumference, weight-
gain velocity, weight loss, deceleration in weight for length/heigh z-score and/or insufficient
nutrient intake8. It is best to use as many data points as possible for diagnosis. Some
characteristics of pediatric malnutrition are low amounts of energy, lack of appetite or interest in
food or drink, weight loss, fatigue or feeling tired all the time, changes in behavior, poor
concentration, and low mood or depression9. In my opinion, I would classify Meghan as at-risk
given her low z-scores, falling within the lowest range for each category, as well as the
symptoms noted in the case study such as: refusal to eat, weight loss or inability to put on
weight, and appearing lethargic.
8. The calculate your protein intake, you need to look at the RDA, Recommended Dietary
Allowance, for your age. Meghan is 3 years old, so it is recommended that protein intake be
around .9 grams per kilogram of weight per day10. Meghan weighs 11 kg, so she should try to
obtain 9.9 grams of protein each day since .9 x 11 = 9.9.
As for optimal energy requirements, TEE= 135.3 – [30.8 x age(y)] + PA x [(10.0 x weight(kg)) +
(934 x height(m)] + 20; where PA stands for physical activity coefficient11. Since Meghan is only
3 and her chart does list any excessive physical activity, I would put her at an active life seeing
that she plays at daycare and at home. This means the PA value would be a 1.27.
TEE= 135.3 – [30.8 x 3] + 1.27 x [(10.0 x 11) +( 934 x .9)] + 20
TEE= 135.3 – 92.4 + 1.27 x (110 + 840.6) + 20 = 1270.16
9. Meghan’s antibodies are high which raises concern because that means the body is trying to
fight an infection. On the contrary to levels being high, her hemoglobin, hematocrit and Vitamin
D levels are all quite below the reference numbers provided. This is still significant because low
hemoglobin ad hematocrit can indicate that Meghan is anemic, again reinforcing that she is
almost certainly not absorbing all the nutrients within her small intestine due to the damage from
gluten. The same concept applies to low Vitamin D; Meghan’s small intestine may no longer be
equipped to fully absorb all the nutrients her food is giving her. The genuinely concerning lab
result is the positive result of the DQ2 and DQ8, or the “celiac genes”2. Of course, having a
positive result for a gene for celiac disease is concerning since Meghan is likely damaging her
small intestine and causing her not only great pain, but the increased inability to absorb food
nutrients.
10. I would agree that the abnormalities observed in the previous question are associated to the
consequences of celiac disease. Because the repeated introduction of gluten damages the surface
and walls of the small intestine, it becomes difficult for the organ to completely absorb all the
nutrients the food is providing. Without the diagnosis of celiac disease, Meghan will continue to
ingest gluten and further damage her small intestine, thus affecting the nutrient levels and her
body’s ability to put on weight, grow muscle, or have bone density.
11. I would recommend a gluten-free diet because that would help for Meghan’s intestine to
repair itself and be able to absorb nutrients again while allowing her to gain back weight, feel
comfortable, and be an energized child again.
12. BREAKFAST—Meghan’s cornflakes may possibly be causing some intolerance issues. If
she enjoys the taste of cornflakes, I recommend trying gluten-free versions or trying a different
cereal such as puffed rice or any other gluten-free substitution.
LUNCH—The hot-dog bun is presumably not gluten-free so that would be a concern. I would
recommend her not ingest any wheat product and try instead a gluten-free bun with her hot-dog.
She could also try a potato bun made with potato flour instead of wheat or barley. Her hot-dog
may also be questionable, so to stay safe, I would encourage her to try a chicken sausage or some
type of poultry sausage that could mimic hotdog shape and texture.
DINNER—Often times chicken nuggets are breaded with wheat or gluten products. She can
absolutely enjoy chicken nuggets still, but when they are breaded with something like potato or
corn chips, or a GF bread crumb.
SNACK—The gluten-free graham crackers are a desirable choice for snack, as is peanut butter
since peanuts are considered naturally gluten-free. It would be important to double check a food
label on the peanut butter to ensure no gluten was added to the peanut butter during production
or procession. I would replace the cookie dough ice cream as I would assume the cookie dough is
made with some type of gluten and instead try plain vanilla or chocolate ice cream or a sherbet.
13. The first aspect to consider when addressing a celiac disease gluten-free diet is the
seriousness of the damage in the small intestine2. This will determine how much malabsorption
there is currently2, and how much of a specific nutrient may be necessary to add to a diet. Celiac
disease can play into other altered GI functions such as other intolerances, and a diet would want
to also acknowledge any restrictions or substitutes there. It is important to recognize a person on
a gluten-free diet should be encouraged to optimize their nutrition in other aspects beside whole
grains since gluten-free foods are not required to fortify or enrich the products2. Likewise,
consideration should go into the fact that a gluten-free diet will be required for life if the patient
does get a celiac disease diagnosis. Understanding how to read food labels is vital, as well as
having caution that not all foods will be labeled gluten-free if imported from outside the United
States, as well as voluntary labeling from the USDA on meats and poultry and the Tobacco Tax
and Trade Bureau2.
14. Meghan’s mom can work to take steps in full education for Meghan’s dad including
resources such as celiac.org, a chart listing which foods to avoid and which foods are appropriate
to consume, as well as have her father join in on the nutrition therapy education. Meghan’s mom
can speak with her daycare’s instructors to enforce a gluten-free zone in the classroom so that
way the kids have an opportunity to learn about Meghan’s disease, and so Meghan feels she has a
safe space. She can always ensure Meghan has own snack or treat for special occasions, so
Meghan does not feel left out, and so there is no other added pressure on any other classmates
and their parents. I would encourage Meghan’s mom to provide her daughter’s daycare with
information from celiac.org and their training program they have for schools and how they can
help their students be successful and healthy1.
Meghan’s mom should be aware of how to address eating out or social gatherings, and that
communication is key. Allowing the wait staff to know her diagnosis as well as previewing
menus online can be helpful1. It is important for Meghan’s mom to know as well that some
cosmetics, including soups or lotions, can contain extracts from wheat, barley, and rye, meaning
they have gluten in them. While there is no proof yet that putting on these products on skin level
affects those with celiac, it would be concerning if Meghan would put her hands in her mouth12.
15. Unfortunately many whole grain foods are enriched with a surplus of vitamins and minerals.
However, due to a gluten-free diet, Meghan may not get as many vitamins and minerals as
recommended because of lack of extra enrichment. This is especially prominent for fiber, iron,
and calcium13. Instead, Meghan should focus on eating nutrient-rich foods such as fruits and
vegetables, and of course, gluten-free grains. Meghan also is at risk of weight gain in her future
as gluten-free foods come processed and are higher in fat, sugar, and calories13. An over
consumption of fat, sugar and calories does in fact lead to added weight. Furthermore, a study
found that those who have high intake of whole grains compared to those without have a lower
risk of heart disease13. Meghan should not eat whole grains that are not gluten free, so she does
have increased risk of heart disease per some studies. The British Medical Journal states, “long
term dietary intake of gluten was not associated with risk of coronary heart disease. However, the
avoidance of gluten may result in reduced consumption of beneficial whole grains, which may
affect cardiovascular risk. The promotion of gluten-free diets among people without celiac
disease should not be encouraged.”13
As Meghan’s RDN, I would monitor her fruit, vegetable, and fiber intake, ensuring she is getting
the recommended amounts, but not so much it becomes toxic to her body. Meghan is
underweight currently, and probably experiencing some weakness, so I would ensure she is
getting optimal amounts of protein and calories to help build up her energy and muscles again. I
would also encourage her to eat plenty of fruits and vegetables to make up for any lost nutrients
in her body.
16. God’s original diet consisted of a plentiful garden, abundant with fresh fruits, vegetables,
herbs, and seeds. We read in Genesis 1:29, “Behold, I have given you every herb bearing seed,
which is upon the face of all the earth, and every tree, in the which is the fruit of a tree yielding
seed; to you it shall be for meat”14. This diet would be considered today as vegetarian, as God
intended us to use the trees planted for not only food, but for life’s joy as well, “And out of the
ground made the LORD God to grow every tree that is pleasant to the sight, and good for food;
the tree of life also in the midst of the garden, and the tree of knowledge of good and evil”14.
Having a vegetarian diet is beneficial in helping promote a “diverse ecosystem of beneficial
bacteria” in the gut15. God’s original diet did not include abundant sources of gluten as the only
source of good, so the likelihood of overconsuming gluten and potentially developing an
intolerance as a child would be minimal. Without the consumption of meat, there is less
opportunity for other disease and infection within the body as consuming sick, dirty, raw, or bad
meat can lead to various disease and poor health outcomes within the gastrointestinal system.
God emphasizes the risk of meat consumption in Romans 14:21, “It is good not to eat meat or
drink wine or do anything that causes your brother to stumble”14.
References:
1. Celiac Disease Foundation. (n.d.). Retrieved February 5, 2022, from https://celiac.org/
2. Nelms, M., & Sucher, K. P. (2020). Chapter 15: Diseases of Lower Gastrointestinal Tract.
In Nutrition therapy and pathophysiology (pp. 379–435). essay, Cengage.
3. Ch'ng CL, Jones MK, Kingham JG. Celiac disease and autoimmune thyroid disease. Clin Med
Res. 2007;5(3):184-192. doi:10.3121/cmr.2007.738
4. Ludvigsson JF, Rubio-Tapia A, van Dyke CT, et al. Increasing incidence of celiac disease in a
North American population. Am J Gastroenterol. 2013;108(5):818-824. doi:10.1038/ajg.2013.60
5. Rajagopal, S. (n.d.). What is gluten and what does it do? Johns Hopkins Medicine. Retrieved
February 5, 2022, from https://www.hopkinsmedicine.org/health/wellness-and-prevention/what-
is-gluten-and-what-does-it-do
6. Celiac disease and lactose intolerance. Beyond Celiac. (2021, February 9). Retrieved February
5, 2022, from https://www.beyondceliac.org/celiac-disease/related-conditions/lactose-
intolerance/
7. Centers for Disease Control and Prevention. (2009, August 4). Growth charts - Z-score data
files. Centers for Disease Control and Prevention. Retrieved February 5, 2022, from
https://www.cdc.gov/growthcharts/zscore.htm
8. Assessing growth of very large and very small children. Ellyn Satter Institute. (n.d.). Retrieved
February 5, 2022, from https://www.ellynsatterinstitute.org/family-meals-focus/66-
understanding-and-using-z-scores-to-track-childrens-growth/
9. NHS. (2020, February 7). Symptoms: Malnutrition . NHS choices. Retrieved February 5,
2022, from https://www.nhs.uk/conditions/malnutrition/symptoms/
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its relation to health: a systematic literature review for the 5th Nordic Nutrition
Recommendations. Food Nutr Res. 2013;57:10.3402/fnr.v57i0.21083. Published 2013 May 23.
doi:10.3402/fnr.v57i0.21083
11. 4. Energy Requirements of children and adolescents. Human energy requirements. (n.d.).
Retrieved February 5, 2022, from https://www.fao.org/3/y5686e/y5686e06.htm#:~:text=The
%20sum%20of%20energy%20deposition,per%20kilogram%20of%20body
%20weight.&text=Boys%3A%20y%20%3D%201.298%20%2B%200.265,%3D
%200.982%2C%20see%20%3D%200.518.
12. Dennis, M. (n.d.). Are gluten-free skin and body products important for people with celiac
disease? National Celiac Association. Retrieved February 5, 2022, from
https://nationalceliac.org/celiac-disease-questions/using-gluten-free-skin-body-products-
someone-celiac-disease/
13. Holovitz, A. (n.d.). 3 risks of a gluten-free diet. 3 Risks of a Gluten-Free Diet | Mohawk
Valley Health System. Retrieved February 5, 2022, from
https://www.mvhealthsystem.org/downtown-blog/3-risks-of-a-gluten-free-diet
14. Eden and man's original Diet. White Throne Ministries. (n.d.). Retrieved February 5, 2022,
from https://whitethroneministries.org/resources/lessons/eden-and-mans-original-diet
15. Tomova A, Bukovsky I, Rembert E, et al. The Effects of Vegetarian and Vegan Diets on Gut
Microbiota. Front Nutr. 2019;6:47. Published 2019 Apr 17. doi:10.3389/fnut.2019.00047
