Celiac Disease
Answer 1. Eating gluten triggers a reaction in which the body generates autoantibodies that
damage the small bowel, causing inflammation. There are established connections between some
autoimmune diseases such as thyroid and celiac. Starchl et al reported, up to 30% of first-degree
relatives of patients with celiac disease and/or autoimmune thyroid diseases are afflicted by the
other disease, respectively.1 The genes predisposing endocrine autoimmunity, such as diabetes
type 1 or autoimmune thyroid diseases, namely DR2-DQ2 and DR4-DQ8 are substantial genetic
parameters of CD, which is an HLA-linked disease as well.1 Meghan’s mother has a history of
thyroid disease, therefore predisposing Meghan to celiac disease. As with most things,
technological advancements in research and testing are contributing factors to the increase of
celiac disease diagnoses. According to the Celiac Disease Foundation, the introduction of blood
testing towards the end of the 20th century has made diagnosing celiac disease easier and more
cost-effective. Additionally, an increase in awareness among physicians has led to evaluating
patients with “non-classical” symptoms, rather than only testing patients with traditional
gastrointestinal symptoms.2
Answer 2. The tTG sensitivity means 95-98% positive results for someone with celiac disease.
The specificity means 94-95% negative results for a person who does not have celiac disease. If
the initial blood sample has a very strongly positive tTG-IgA result that is greater than 10 times
the upper limit of normal and a subsequent blood sample has a positive EMA-IgA3, then a small
intestine biopsy is not necessary.
Answer 3. Inappropriate T-cell-mediated immune response against ingested gluten in genetically
predisposed people, leads to characteristic histological lesions, as villous atrophy and
intraepithelial lymphocytosis. Nevertheless, celiac disease is a comprehensive diagnosis with
clinical, serological and genetic characteristics integrated with histological features. Biopsy of
duodenal mucosa remains the gold standard in the diagnosis of celiac disease with the
recognition of the spectrum of histological changes and classification of mucosa damage based
on updated Corazza-Villanacci system.4
Answer 4. Gluten is found in wheat, rye, malt, and barley.5 Gluten is a naturally occurring
combination of proteins such as gliadin and glutenin. As it relates to celiac disease, gliadin is the
leading cause of adverse effects. Gliadin contains certain compounds that the body cannot
breakdown.6 So, the body views the amino acids as adversaries. During the fight between the
body and its adversaries, the intestinal villi become unfortunate casualties of the war.
Answer 5. Patients with celiac disease can also be lactose intolerant. The damage to the small
bowel disables the ability to digest enzymes in some dairy products. However, removing gluten
from the diet helps repair damaged villi. Therefore, dairy products could possibly be tolerated at
some point.
Answer 6. If a child is well under or extremely over the “normal” growth percentile, their
growth is calculated using a conversion scale referred to as a z-score. A z-score is a statistical
measure that indicates how far a given value is from the mean (or average).7 Z-scores track the
child’s growth over time by incorporating anthropometric measurements (i.e., weight, height).
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Celiac Disease
Answer 7. Pediatric malnutrition has characteristics such as appetite loss, weight loss, paleness,
or gastrointestinal illness. Based on Meghan’s symptoms, lab results, and celiac diagnosis; she is
at risk. Additionally, Anderson writes untreated celiac disease can cause malnutrition because
you may not have been absorbing many of the nutrients in the foods you were eating.8 A
diagnosis requires a physical examination, food intake history, and possibly blood tests and/or
imaging.
Answer 8.
Estimated Needs per kg
Energy: 112 kcal/kg
Protein: 1.08 g/kg
Fluid: 90 mL/kg
Daily Estimated Needs
Energy: 1,401 kcal
Protein: 13.50 g
Fluid: 1,125 mL (37.50oz)
Results are for current weight. If catch-up growth is needed, use ideal body weight (IBW)
estimates to re-calculate estimated energy needs.
Current BMI = 14.45, z-score = -1.15
IBW at 50% BMI for Age = 13.6 kg
IBW at 25% BMI for Age = 12.9 kg
Protein needs will also increase when catch-up growth is needed. Assume 0.2 g /(kg/day) above
predicted needs, which for this child is approximately 13.7g/(kg/day) for a total 171g/day.9
Answer 9. Meghan’s laboratory results reflect abnormalities in both the chemistry and
hematology categories. However, the hematology deficiencies (hemoglobin, hematocrit, and
vitamin D) are indicative of a nutritional problem.
Answer 10. Yes, the abnormalities identified in the above questions are related to the
consequences of celiac disease. Meghan has a diminished appetite. Therefore, she is not eating
enough food to provide substantial nutrient intake. Furthermore, celiac disease affects the ability
to absorb nutrients. Based on her laboratory results, Meghan is not getting enough iron or
vitamin D.
Answer 11. I would prescribe a gluten and dairy free diet consisting of soup/broth, lean meat,
fish, vegetables, fruit, rice, etc. I would also ensure her meal plan was in accordance with
recommended dietary allowance guidelines.
Answer 12. I would provide the following substitutions while being mindful of the fact that
certain compounds or additives could alter gluten free properties. So, Meghan’s parents should
pay attention to nutrition labels.
BREAKFAST—cornflakes, milk, banana
*Cornflakes: gluten free cereal such as Cheerios, or oatmeal
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Celiac Disease
*Milk: Coconut or almond milk
LUNCH—hot dog on bun, French fries, chocolate milk
*Hot dog bun: gluten free bun
*Chocolate milk: chocolate almond milk, water
DINNER—stir-fry chicken nuggets with soy sauce, mixed vegetables on rice; pudding, milk
*Stir-fry chicken nuggets: grilled chicken nuggets
*Pudding: Jello
*Milk: Juice, water, coconut milk, almond milk
SNACK—gluten-free graham crackers with peanut butter; cookie dough ice cream
*Cookie dough ice cream: non-dairy ice cream
Answer 13. Nutrition therapy and education focuses on a gluten free diet, learning identification
of gluten-containing foods, label reading, steps to prevent cross-contamination, identification of
gluten in nonfood items, and selection of an overall healthy diet with avoidance of gluten.5
Answer 14. Meghan’s mother, grandmother, and father should incorporate the components of
nutrition education therapy. Additionally, one article states caregivers cooking for a celiac child
need to make sure they use dedicated gluten-free utensils and pans and guard carefully against
gluten cross-contamination in the kitchen.10 For daycare, her parents and grandmother should
pack gluten free meals and snacks for Meghan.
Answer 15. Yes. A major potential long-term nutritional concern is micronutrient and
macronutrient deficiencies. I would recommend routine laboratory testing to detect any abnormal
results. In the event of nutrient deficiency, I would recommend nutritional supplements. I would
also monitor her growth rate to ensure she reaches and remains in the proper percentile.
Answer 16. God’s original diet for man consisted of fresh, whole foods. According to Genesis
1:29, then God said, “I give you every seed-bearing plant on the face of the whole earth and
every tree that has fruit with seed in it. They will be yours for food.11 Plant-based diets (PBDs),
rich in high-quality plant foods, offer multiple benefits for overall and gastrointestinal health.
Recently, it has been demonstrated that the positive effects of PBDs on gastrointestinal health
can be mediated by the gut microbiota, in particular, by inducing a greater diversity of bacteria.12
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Celiac Disease
References
1. Starchl C, Scherkl M, Amrein K. Celiac disease and the thyroid: highlighting the roles of
vitamin d and iron. May 21, 2021. Accessed June 9, 2023.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8224353/.
2. Celiac Disease Foundation. Incidence of celiac disease steadily increasing. February 20, 2020.
Accessed June 9, 2023.
https://celiac.org/about-the-foundation/featured-news/2020/02/incidence-of-celiac-disease-
steadily-increasing/.
3. National Institute of Diabetes and Digestive and Kidney Diseases. Celiac disease tests.
February 2021. Accessed June 11, 2023.
https://www.niddk.nih.gov/health-information/professionals/clinical-tools-patient-
management/digestive-diseases/celiac-disease-health-care-professionals.
4. Villanacci V, Vanoli A, Leoncini G, et al. Celiac disease: histology-differential diagnosis-
complications. A practical approach. September 2020. Accessed June 11, 2023.
https://pubmed.ncbi.nlm.nih.gov/33179621/.
5. Nelms M, Sucher KP. Nutrition Therapy & Pathophysiology. 4th ed. Boston, MA: Cengage;
2020.
6. Bjarnadottir A. What is gluten, which foods have lots, and how to tell if it is an intolerance vs.
sensitivity. May 17, 2023. Accessed June 11, 2023.
https://www.medicalnewstoday.com/articles/318606.
7. Centers for Disease Control and Prevention. Growth chart training. December 12, 2022.
Accessed June 11, 2023. https://www.cdc.gov/nccdphp/dnpao/growthcharts/training/.
8. Anderson J. Why untreated celiac disease can cause malnutrition. November 4, 2022.
Accessed June 11, 2023. https://www.verywellhealth.com/untreated-celiac-disease-can-cause-
malnutrition-562631.
9. Knowing Nutrition. Nutrition calculators. Accessed June 11, 2023.
https://www.knowingnutritionhub.com/nutrition-calculators.
10. Anderson J. Caring for children and teens with celiac disease. From going gluten-free to
follow-up care, here’s what you need to know. June 26, 2022. Accessed June 11, 2023.
https://www.verywellhealth.com/caring-for-children-and-teens-with-celiac-disease-4155835#.
11. Genesis 1:29 (RSV). Accessed June 11, 2023. https://www.biblegateway.com.
12. Mazzocchi S, Visaggi P, Baroni L. Plant-based diets in gastrointestinal diseases: which
evidence? February 18, 2023. Accessed June 11, 2023.
https://pubmed.ncbi.nlm.nih.gov/37094909/.
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