Case Study- Celiac Disease

NFSC 470- MNT I

By: Natasha Paz

Understanding the Disease and Pathophysiology

1. The small bowel biopsy results state, flat mucosa with villus atrophy and hyperplastic crypts inflammatory infiltrate in lamina propria. What do these results tell you about the change in the anatomy of the small intestine? The anatomy of the small intestine is complex, however its complexity allows for maximum utilization of the nutrients we get from dietary sources. Changes to the anatomy in any part of the small intestine can effect proper digestion and absorption of nutrients, and can ultimately lead to malnutrition if not addressed. These pathology results tell us that there is damage to the small intestine that indicates celiac disease. The tissue that lines the small intestine, known as the mucosa, is structurally folded. These folds line the inner surface of the small intestine and increase surface area to expand the total area of absorption (Sherwood, 2006). In healthy individuals the mucosa is lined with projections that protrude into the lumen of the small intestine called villi. These villi are covered with absorptive epithelial cells which are also lined with their own set of microvilli. This is where the nutrients from the small intestine gets absorbed and transported into the blood stream. In some disease states we see the mucosa start to flatten and the villi begin to deteriorate (Feldman, Freidman, & Brant, 2010). If this is the case we see less defined healthy villi, and more collapsed damaged villi, leaving the mucosal lining more flat or smooth in appearance. This can have detrimental effects to proper absorption. Normally cell atrophy in the small intestine is normal because the body can regenerate new cells with the Crypts of Lieberkuhn. These crypts are pockets around the villi where new cells are made to replace the ones that are sloughing off. These crypts continually provide all the epithelial cells on the villi, however if there is crypt hyperplasia due to the change in villi structure they have to compensate for the lack of or shortening of the villi, and can no longer regenerate cells. These changes then decrease the overall surface area available for digestion and absorption. Another change is the inflammation in lamina propria. The lamina propria contains ducts and capillaries opening to the mucosal layer (Sherwood, 2006) . It is also rich in immune cells known as lymphocytes. If this layer is impaired it can lead to fewer secretions and compromise the ability for nutrients to properly be absorbed into the blood since the capillaries are vulnerable. 2. What is the etiology of celiac disease? Is there anything Mrs. Gainess history typical of patients with celiac disease? Explain? Celiac disease has a complicated etiology that originates from a variety of triggers including genetic, environmental, and autoimmune factors. It is brought about by the bodys reaction to the protein portion of gluten call gliadin (or other proteins found in different varieties of gluten). The

reaction leads to damage in the small intestine. This makes it hard for the body to absorb nutrients, especially fat, calcium, iron, and folate (Celiac Disease Health Center, 2011 ). The majority of nutrients from food are absorbed in the small intestine, so the damage causes the patient to end up malnourished, no matter how much he or she eats. There are two genes that are associated with the disease and are prevalent in 95% of all patients diagnosed with celiac disease. These genes include HLA-DQ2 and HLA-DQ8 (Nelms & all, 2011). This indicates that the disease may be genetic and is commonly seen among family members. The expression of these genes, however, is not completely clear. According to researchers at Mayo Clinic, some gene changes or mutations from environmental factors also appear to increase the risk of developing the disease. This means that even if there is no previous family history it is still possible to develop celiac. On the opposite end of the spectrum, having those specific mutations or genes doesn't guarantee a diagnosis, so even if it prevalent in family members it is not ascertained that the disease will develop. There are many other factors are involved and the nutrigenomics behind these theories are still being studied (Mayoclinic, 2003). Sometimes celiac disease can go undiagnosed for years. It can be triggered or become activated for the first time after surgery, pregnancy, childbirth, infections, or stress, but the precise cause of the disease is not entirely known. There are over 300 symptoms of the disease and signs vary among patients. Some symptoms that are considered classic of celiac disease include chronic diarrhea, abdominal pain, frequent cramping, bloating, and gas production (National Foundation for Celiac Awareness, 2011). There are also some other signs that are not related to the GI tract. These include bone problems, muscle cramping, fatigue, peripheral neuropathy, and other conditions that are mainly a result of malnutrition caused by celiac disease. Since the intestinal cells can no longer absorb the nutrients from food, nutrient deficiencies can also become a problem. For example, a lot of patients present with irondeficiency anemia, since iron cannot properly be utilized. These differences make diagnosing celiac very difficult and lead to people going undiagnosed or misdiagnosed with other conditions for years, and sometimes for life. Mrs. Gaines shows many of the common symptoms that are indicative of celiac disease, and her history is typical of patients who have been diagnosed. First, her family has a history of GI disturbances and claims to have funny stomachs. Although nobody else in her family has ever been formally diagnosed, her and her familys symptoms have a strong indication of the disease. Her chronic and foul smelling diarrhea that has been on and off her entire life is another commonly seen symptom in celiac patients. She also shows extreme weight loss, chronic fatigue and weakness, and presents with a pale complexion, which are all results of malnutrition secondary to the disease. Another commonality is the recent birth of her son which worsened her symptoms. Sometimes the biological changes in the body during pregnancy can be a trigger as previously mentioned. 3. How is celiac disease related to the damage of the small intestine that the endoscopy and biopsy results indicate? When an individual with celiac disease is exposed to the protein in gluten, we see damaged mucosa of the small intestines involving the collapsed villi and atrophy of the intestinal cells that the endoscopy and biopsy results indicated. This occurs as a reaction to a specific amino acid sequence of

the protein found in gluten resulting in a toxic and inflammatory response (Nelms & all, 2011). The exposure to the damaged mucosa signals an inflammatory reaction and white blood cells rush to the area to help protect the injury site. T-lymphocytes are one of these cells, which then produce various cytokines and initiate a pro-inflammatory response. This also triggers IA anti-tissue transglutimase (anti-tTG) and antiendomysial (EMA) and antiglidin (AGA) antibodies. This causes an autoimmune response and results in cytoxic T-cells that damage and destroy the bodys own intestinal cells. Both inflammation and autoimmune reactions damage the villi and they can no longer absorb nutrients to their full ability. This also leads to crypt hyperplasia due to the change in villi structure, so they have to become elongated and altered to overcompensate for shortening of the villi. These changes then decrease the overall surface area available for digestion and absorption. 4. What are AGA and EMA antibodies? Explain the connection between the presence of antibodies and the etiology of celiac disease. When people with celiac disease eat foods containing gluten, their immune system forms antibodies to gluten which then attack the intestinal lining. The exposure to the damaged mucosa signals an inflammatory response and white blood cells rush to the area to help protect the injury site. This includes T-lymphocytes which produce various cytokines and initiates a pro-inflammatory response. This also signals antibodies which are substances produced by the immune system to fight harmful invaders. Some of these gliadin-specific antibodies include IA anti-tissue transglutimase (antitTG) and antiendomysial (EMA) and antigliadin (AGA) antibodies, and are subgroups of IgA (Immunoglobulin A) and IgG (Immunoglobulin G). They specifically recognize the gliadin component of wheat (NFCA). These antibodies are designed to attack foreign substances in the body; in this case gluten is the trigger. This causes an autoimmune response and results in cytoxic T-cells that damage and destroy the bodys own intestinal cells. As the exposure to gluten continues this response worsens and the continuous inflammation in the intestines severely damages the villi. A blood test can be performed to measure for high levels of these types of antibodies and is an indication that patient is positive for celiac disease. Testing positive for these antibodies that are produced in response to gluten can help detect celiac disease. In fact, EMA has greater than 90% accuracy for detecting the condition (Nelms & all, 2011). 5. What is a 72-hour fecal fat test? What are the normal results for this test? A 72-hour fecal fat test measures the digestion and absorption of dietary fat by examining the fat content excreted in the stool. This test reveals fat malabsorption, also known as steatorrhea. This is a concern because it can affect how the body uses nutrients. To absorb fat normally, the body needs bile, enzymes, and functional intestines. If there is a condition that affects any of these components, then we might see fat poorly absorbed. The test is non-invasive and consists of the patient consuming 100 grams of fat per day for 3 days. The stool is then collected and the fat content of the stool reveals whether or not it was properly absorbed. Normal results are less than 7 grams of fat per 24 hours.

6. Mrs. Gainess laboratory report shows that her fecal fat was 11.5 g fat/24 hours. What does this mean? Mrs. Gaines is malabsorbing fat. Normal results from a fecal fat test are less than 7 grams of fat per 24 hours, so the fat she is consuming is not being properly absorbed into her body. This is apparent through the increased fat content of her stool sample. This could be related to the damage in her small intestines and the injured villi on the flattened mucosa. Her low total protein levels can also decrease her production of fat digesting enzymes. 7. Why was the patient placed on a 100-g fat diet when her diet history indicates that her symptoms are much worse with fried foods? The patient was put on a 100 gram fat diet to help diagnose her with steatorrhea, or fat malabsorption. Although her symptoms worsen with high intake of fried foods and meats high in fat, it is necessary to continue her regular intake to monitor her lab values and verify that she does in fact have steatorrhea or a problem digesting high-fat foods.

Understanding the Nutrition Therapy

8. Gluten restriction is the major component of the medical nutrition therapy for celiac disease. What is gluten? Where is it found? Gluten is a protein found in foods derived from wheat and grains such as barley, malt, and rye (Nelms & all, 2011). Gluten is the combination of a gliadin and a glutenin, which is joined to starches in the endosperm of these grains. Gluten naturally gives elasticity to products especially dough to help it rise and keep its shape. Thats why the majority of bread and bread related products contain gluten. However, the pliable nature of this product has been utilized by manufacturers in a variety of other products as well. Many manufacturing plants also make other products on the same production lines that gluten filled products are made. If the patient has a severe reaction to the gluten protein, then they will be sensitive to products that have even touched gluten filled products. That is why it is critical for patients with Celiac Disease to carefully read labels to ensure that the product is truly gluten free, and also be extremely cautious when eating out to make sure that cross contamination is not an issue. Some common ingredients that might be listed that imply that there is gluten in the product include durum, semolina, spelt, kamut, einkorn and faro. Many products are derived by grains however some include gluten as an emulsifier or for its thickening properties so they are not commonly thought of when thinking of gluten. MayoClinics Celiac Disease Health Center describes some common gluten containing foods that include: beer, breads, cakes and pies, many candies, cereals, cookies and crackers, French fries, pastas, processed lunch meats, salad dressings, sauces like soy sauce, snack foods such as potato and tortilla chips, many canned soups and vegetables in sauce (Celiac Disease Health Center, 2011 ).

9. Can patients on a gluten-free diet tolerate oats? Pure oats do not contain gluten, however most brands on the market that produce or use oat products are not pure and they have been cross-contaminated with trace amounts of wheat, barley, or rye. Since those grains do have gluten in them, the contamination makes most oats unsafe for celiac patients to consume. It is possible to purchase pure oats and there are companies that produce certified gluten-free oats, so it is important to read the labels on products to ensure it is following the gluten-free diet (Celiac Disease Health Center, 2011 ). 10. What sources other than foods might introduce gluten to the patient? The University of Virginia's School of Medicine revealed that although many are now derived from corn, potato or tapioca, there are certain vitamins, supplements, and even medications that may contain gluten (Plogsted, 2007 ). It is important to research the product or drug to avoid introducing gluten to the patient. Some non-food products that contain gluten include items such as envelopes, stamps, sunscreen, some cosmetics, hair products, and other dermatological products. Although these products are not ingested, they can still cause adverse reactions and should be avoided. 11. Can patients with celiac disease also be lactose intolerant? Lactose intolerance is a common side effect of celiac disease. In many cases patients who eat gluten can become lactose intolerant when villi in their small intestine become damaged. (Adams, 1996) Lactase, the enzyme that breaks down lactose molecules, also tends to be the first enzyme to disappear when GI disturbances are present and are no longer capable of breaking down the lactose molecule. The problem usually disappears when the patient removes gluten from the diet and the damaged villi are able to heal. The lactose intolerance symptoms can continue for quite some time and sometimes the damage can take up to two years to heal completely, but patients should be able to reintroduce lactose into their diet and eliminate any intolerance they had before.

Nutrition Assessment
A. Evaluation of Weight/Body Composition 12. Calculate the patients percent UBW and BMI, and explain the nutritional risk associated with each value. Current wt: 92 lbs. (92/2.2= 41.8 kg) Prepregnancy Weight: 112 lbs Ht: 53 (160 cm) IBW: 100# first 5 + 5*3= 115 %IBW: 92/115= 80% IBW Interpretation: Mildly Depleted Energy Stores %UBW: 92/112= 82% also=20% weight loss over 3 months Interpretation: Severe unintentional weight loss When patients present with severe unintentional weight loss the main concern is does the patient have enough energy stores to maintain bodily functions. In this case Mrs. Gaines has mildly depleted

energy stores which indicate a lack of sufficient energy to support her life. Often times when a person experiences a drastic change in weight there are some health implications that follow. Involuntary weight loss can lead to muscle wasting, decreased immune function, increased risk of secondary diseases, and malnutrition, so it is critical to address this nutrition related diagnosis quickly. BMI: Wt (lbs)/ ht (inches)/ ht (inches) X 703 92 /63 / 63 X 703= 16.3 Interpretation: Underweight BMI is a method of screening for weight status that may lead to health problems. In this case Mrs. Gaines is considered to be underweight and is more likely to be lacking vital nutrients for her body to function properly. B. Calculation of Nutrient Requirements 13. Calculate the patients total energy and protein needs using the Harris-Benedict equation or MifflinSt. Jeor equation. Harris-Benedict equation (for women): 655 + (13.8 x W) + (1.8 x H) (4.7 x A)= BEE wt: 92 lbs. (92/2.2= 41.8 kg) Ht: 53 (160 cm) A: 36 y.o 655 + (13.8 x 41.8) + (1.8 x 160) (4.7 x 36) = around 1351 kcals Activity Factor for ambulatory pts= 1.3 Add approx. 200 kcals for re-nourishment Estimated energy needs: 1956 kcals Protein needs equation: 1.2g/kg/day due to her mild energy depletion, we want to make sure she has both adequate kcals and protein intake to ensure she is anabolic and not experiencing muscle breakdown. 1.2 x 41.8= approx. 50g Estimated protein needs: 50 grams per day

C. Intake Domain 14. Evaluate Mrs. Gainess 24-hour recall for adequacy. Evaluating the 24-hour recall will determine Mrs. Gainess adequacy and nutritional status. This will involve evaluating indicators that reflect her bodys nutrient stores and using a nutrient analysis program to indicate areas of concern. Using MyPlates nutrient analysis as a tool to evaluate Mrs. Gainess adequacy we can see that her caloric intake is extremely low at 559 total kcal (26% of needs). She is also not consuming adequate protein at only 8 g protein/day. She should be consuming at least 2000 kcal and 73 g protein. She is also low in many of the micronutrients including iron, folate and B12.

15. From the information gathered within the intake domain, list possible nutrition problems using the diagnostic terms. 1. Inadequate Energy Intake (NI-1.4) 2. Inadequate Protein-Energy Intake (NI-5.3) 3. Malnutrition (NI-5.2) D. Clinical Domain 16. Evaluate Mrs. Gainess laboratory measures for nutritional significance. Identify all laboratory values that support a nutrition problem. Lab value: Normal values: Mrs. Gainess results: Possible reasons for lab results: Albumin 3.5-5.0 g/dL 2.9 g/dL Related to PEM Pre-albumin Total Protein 16-35 mg/dL 6-8 g/dL 13 mg/dL 5.5 g/dL Mildly depleted protein status r/t PEM PEM, muscle wasting/breakdown for energy Iron deficiency anemia, depleted intake, low ferritin Iron deficiency anemia, depleted intake Small RBC, Iron deficiency, late detection Seen in iron deficiency Malabsorption Low due to malabsorption

Hgb

12-15 g/dL

9.5 g/dL

Hct MCHC Ferritin Vitamin B-12 Folate

37-47 % 31.5-36 g/dL 20-120 mg/mL 24.4 -100 ng/dL 5-25 mg/dL

34 % 30 g/dL 12 mg/mL 21.2 ng/dL 3 mg/dL

17. Are the abnormalities identified in question 16 related to the consequences of celiac disease? Explain. Yes, the abnormalities seen in the lab values are consequences of celiac disease. Many of the lab values indicate malabsorption of a variety of nutrients due to the damaged villi and the inability to properly absorb nutrients from dietary sources. For example, Iron deficiency anemia is prevalent due to the lack or inability of the body to utilize iron. We also see indications of protein-energy malnutrition again due to the lack of functioning villi, and the inability for the body to utilize nutrients for energy. These are all common lab results for a patient suffering from celiac disease. 18. Are any symptoms from Mrs. Gainess physical examination consistent with her laboratory values? Explain. Fatigue, pale skin, and weakness are likely results of iron deficiency. When the body is starved of iron, it is difficult to circulate oxygen through the body so the patient can feel fatigued, weak, and show pale skin due to the lack of oxygen in the blood (Mayo Clinic , 2011). Her lab values for Hgb, Hct and Ferritin are all consistent with a deficiency in iron. Her fatigue and weakness can also be due to

Protein-Energy Malnutrition (PEM). PEM develops in patients who do not consume adequate amounts of protein and energy to meet their nutritional needs. Celiac disease is an example of an illness that can leave patients unable to absorb vital nutrients or convert them to into energy, so we see chronic fatigue and weakness. 19. Evaluate Mrs. Gainess other anthropometric measurements. Using the available data, calculate her arm muscle area. Interpret this information from nutritional significance. AMA=((18cm/4)( x .75cm))^2 = 11.38cm^2 These measurements indicate she is under the fifth percentile which may imply muscle deficit and fat deficit. This also indicates total body wasting. Not only does not have inadequate energy stores, but her body may be going into starvation mode. Her muscle wasting reflects a loss of body mass both in fat and lean tissue. Since Mrs. Gaines is not efficiently utilizing her nutrients, the energy demands of her body are increasing (Nelms & all, 2011). She is turning fat into energy which requires a lot of work for her body. To help her save energy, the body may be going after protein to fuel its energy needs, similar to starvation conditions. This means her body could be breaking down her lean mass or muscle tissue to use it as an energy source. Also, protein is needed to help repair damage done to the villi and to replace immune cells that are involved in the autoimmune response associated with celiac disease. This lack of storage is also a lack of potential energy, which could contribute to Mrs. Gainess fatigue and weakness. This could also make it very difficult for her to breastfeed since her body is deprived of adequate fuel. 20. From the information gathered within the clinical domain, list the possible nutrition problems using the diagnostic term. 1. Breastfeeding difficulty (NC-1.3) 2. Impaired nutrient utilization (NC-2.1) 3. Altered nutrition related lab values: Albumin, Pre-albumin, Total Protein, Hgb, Hct, MCV, Ferritin, Vitamin B-12, and Folate(NC- 2.2) 4. Underweight (NC-3.1) 5. Unintended weight loss (NC-3.2)

Nutrition Diagnosis
21. Using the VA Nutrition Screening Form, what is the patients nutrition status level? Based on the VA Nutrition Screening Form, Mrs. Gainess overall nutrition status is a 3 (Department of Veterans Affairs). According to the VA, nutrition status is the end product of the nutrition assessment and determines the priority for nutrition intervention and reassessment. A level 3 indicates Moderately-compromised Nutrition Status, and should be higher priority.

22. Select two high-priority nutrition problems and complete the PES statement for each. 1. Impaired nutrient utilization (NC-2.1) related to flat mucosa with villus atrophy and hyperplastic crypts as evidenced by 18% weight loss over past 3 mos, mildly depleted energy stores, low lab values of hmg, hct, albumin, prealbumin, transferrin. 2. Nutrition-related knowledge deficit related to new diagnosis of celiac disease as evidenced by no prior education on disease state.

Nutrition Intervention
23. For each of the PES statements that you have written, establish an ideal goal (based on signs and symptoms) and an appropriate intervention (based on the etiology). Individualized Treatment Goals to Address Nutrition Diagnosis 1. No further weight loss/ Improve energy stores 2. Improve lab values of Albumin, prealbumin, Hgb, Hct, MCV 3. Patient consumes foods compliant with gluten-free diet and lactose free diet Intervention Statements 1. Modify diet: Recommend lactose and gluten free diet (ND-1.4). 2. Nutrition education: Nutrition relationship to celiac disease, gluten free diet (E-1.4). 3. Skill development: Identify gluten filled products by reading labels (E-2.2) .

24. What type of diet would you initially begin when you consider the potential intestinal damage that Mrs. Gaines has? Considering the damage that Mrs. Gainess intestines have endured, I would initially start her on a GI soft diet with no gluten or lactose. Since her mucosa and villi are so damaged I would want to make sure that they can begin the initial healing process. This means that gluten and lactose would have to be completely cut out and we would monitor tolerance and digestibility before reintroducing more complex foods. A sample of a GI soft diet from Harbin medical center would include allowable foods such as fruit juices, avocado, banana, orange sections without membranes, baked peeled apple, carrots, potatoes, squash, rice, boiled chicken with minimal fat, fish (Harbin Clinic , 2013). I would also introduce a fat restricted diet to treat the steatorrhea. I would start her off with 35-45 grams per day in small, frequent meals and progress as tolerated. I would also recommend limiting foods that have high oxalates in them such as spinach, beets, nuts and strawberries to help her decrease her fat malabsorption. Oxalates tend to worsen fat malabsorption due to the biochemical reactions between the body and nutrients. This would be a good way to start her off and then slowly reintroduce more fats to determine her tolerance and healing status. I would also recommend some high calorie and protein supplementation to help re-nourish her and start to replenish her energy stores.

25. Mrs. Gainess nutritional status is so compromised that she might benefit from high -calorie, highprotein supplementation. What would you recommend? I would recommend Two Cal HN as a supplementation because it is high in calories and high in protein, but also contains some fiber and no gluten in the formula ingredients. It will help her to meet her goal for repletion and push her in a state of anabolism instead of breaking down her muscle stores for energy. This formula also has some MCT, which is another treatment for steatorrhea. The MCT will enter her blood stream more easily because they are shorter chain fatty acids, and do not require pancreatic lipase or bile. Fat is a good source of energy so this will not only help her meet her lipid needs, but additionally push her in the direction of repletion for both protein and kcals. 26. Would glutamine supplementation help Mrs. Gaines during the healing process? What form of glutamine supplementation would you recommend? Glutamine is an amino acid that is produced in the muscles and helps with GI function, immune system function, and the overall healing processes (WebMd , 2011). If the body uses more glutamine than the muscles can make, muscle wasting can occur. Since Mrs. Gaines is experiencing muscle wasting its possible that she is lacking glutamine to help her with her healing. It is also important for providing fuel to cells in the body, so supplementing glutamine can help to replenish her fuel sources and work towards reducing her fatigue. Taking a glutamine supplements can help keep her glutamine stores up. A study done by ASPEN also showed that intestinal permeability decreases when glutamine supplementation is added to parenteral feedings (Li, 1994). Although Mrs. Gaines is not receiving TPN, she has similar damage to her intestines that TPN patients experience when they have gut atrophy. The results of the study showed improved villus height, mucosal thickness, and villus width when adding glutamine to the formula. If this is the case we can decrease the atrophy and increase healing by adding glutamine to Mrs. Gainess Two Cal HN supplementation formula. This would mean her supplementation would be highly individualized, but very effective in healing the intestinal damage. 27. What result can Mrs. Gaines expect from restricting all foods with gluten? Will she have to follow this diet for very long? Mrs. Gaines can expect her intestines to start to recover when she eliminates foods with gluten. Since the gluten amino acid sequence will no longer trigger the inflammatory response, her villi will start to heal and regain their shape and the crypts will start to function properly to regenerate the epithelial cells. This also means that her absorption of other nutrients will start to improve and we will see less indications of malabsorption. Her lab values should normalize and we should see a substantial weight gain. This will only be the case if gluten isnt present in the diet, so Mrs. Gaines will have to avoid gluten filled products for the rest of her life in order to avoid the reaction and symptoms. Even the slightest intake of gluten can be a trigger, and her intestines will start to deteriorate like before. This also means that if a patient is suspected of celiac disease they should not be on a gluten-free diet before having an endoscopy because the small intestine may be healed and the pathological changes will not be detected and a diagnosis cannot be made.

Nutrition Monitoring and Evaluation

28. Evaluate the following excerpt from Mrs. Gainess food diary. Identify the foods that might not be tolerated on a gluten/gliadin-free diet. For each food identified, provide an appropriate substitute. When trying to assist Mrs. Gaines with finding appropriate substitutions for some regularly consumed food items it is important to take a few factors into consideration. 1. Initially she should restrict both gluten and lactose while the small intestine begins to heal itself. After some time she can start to reintroduce some lactose containing foods to test for tolerance and then progress from there. 2. Mrs. Gaines is a new mother and probably has time restrictions in regards to meal preparation. These substitutions are kept to under an hour long in preparation, and try to closely reflect the preparation time of the original food item. 3. Budget will also be considered since many gluten-free products can be costly, so indications of price and affordability will also be mentioned when suggesting substitutions. Food Item Cornflakes Substitution Although at first thought you would think cornflakes would be okay since they are made of corn, she must be very cautious of production processes. Cornflakes may contain malt flavoring which is usually made from barley (kellogs.com) There are many great affordable gluten free breakfast cereals on the market. Some of these include: -Rice Chex or Rice Krispys -Gluten Freeda Foods -Holy Crap Cereals -Kays Natural -Some Kashi brands -Earths Supergrains (Gluten Free Resource Directory , 2013 ) She should also avoid eating these cereals with milk until her tolerance for lactose returns. Bologna is also a concern because there are many ingredients, preservatives, and wheat fillers that contain gluten, and most lunchmeats are the same. There are brands that are gluten free, Here is a list of lunch meats by brand that are gluten-free and dairyfree: -Applegate Farms cold cuts -Boars Head (they also have gluten free bologna for a reasonable price) -Columbus (some salamis contain dairy so purchase with caution) -Diestel -Dietz and Watson (some rotisserie style meats are not

Bologna Slices

gluten free to take caution) (Sure Foods Living , 2012) Lean Cuisine- Ginger Garlic Stir Fry with Chicken This is not gluten free. Stir frys contains soy sauce, noodles, and other spices that do not comply with a gluten free diet. There are no Lean Cuisines meals that are gluten-free; however there are other frozen or preprepared meals that are gluten free. Some brands include Amys Organic Meals and Garden Lites. These meals tend to be more expensive, however they are convenient and closely reflect the lean-cuisine dinners (Gluten Free Resource Directory , 2013 ). Another alternative would be to make a quick and easy homemade stir fry. This recipe only takes 35 minutes total and is gluten free. Ingredients -2 sesame oil (optional) -2 boneless, skinless chicken breasts, cut into 1/2-inch pieces -(2) 12 oz. bags fresh stir-fry vegetables (like Eat Smart Vegetables) or 3 cups of stir-fry vegetables of your choice (broccoli, snow peas, carrots, etc.) -1/2 medium onion thinly sliced - cup Gluten-Free soy sauce and/or stir fry sauce -One package of gluten-free rice noodles (optional) -For full recipe and instructions visit: http://thepeacefulmom.com/2013/06/06/easy-glutenfree-chicken-stir-fry-recipe/ Skim milk As stated she should initially avoid milk and lactose products until her intestine has had time to heal. In the meantime some milk alternatives could include: Almond milk, gluten-free soymilk, or lactaid. Most Lactaid products do not contain gluten. The only product that does contain gluten is Cookies & Cream Ice Cream (Lactaid.com) Most cheese spreads contain wheat flour and may have seasoning containing gluten. She should only consume cheese spreads that have a gluten-free label on them. She could also use regular cheese and melt it or use it in place of the spread since most brands do not contain gluten or lactose. Boars head has a wide variety of cheeses that are certified gluten-free (Boarshead.com) There are also some alternative spreads that might interest her if she is just looking for a quick snack. Some cheap alternatives that she could try and are

Cheddar cheese spread

certified gluten-free could be: -Peanut butter (from Peanut Butter Co.) -Hummus (from Sabra) -Fruit Spreads (E.D. Smith) -(Gluten Free Resource Directory , 2013 ) Green bean casserole- mushroom soup, onions, green beans The traditional green bean casserole is made with canned soup that is not gluten-free and the fried onions found on top contain wheat flour, however there are recipes that can replace these ingredients so she can still enjoy this favorite. Campbells Classic Green Bean Casserole takes approx. 45 minutes to prepare and bake, and so does the following gluten-free and dairy free Green Bean Casserole. Ingredients -1/8 tsp. pepper -1 20 oz. bag frozen green beans OR 1 1/2 pound fresh green beans -1 can Amys Vegan Mushroom Soup ($3.00) -Fried Onions: 2 large onions, cut in half, thinly sliced, cup Bisquick Gluten Free mix, 3/4 teaspoon salt See full recipe and instructions: www.bettycrocker.com/recipes/gluten-free-greenbean-casserole-with-fried-onions Once she can consume lactose again there are some gluten free soups that she can consume such as Progresso Gluten Free Mushroom Soup or Pacific Foods. These are cheaper and a better substitution but should wait until she can handle dairy. Plain coffee should be gluten-free to low levels, assuming it hasn't been cross contaminated during the processing or in a facility. It is important to read the label to ensure facilities are practicing safe handling. If Mrs. Gaines is interested in flavored coffees she needs to take more precaution. These coffees can be made with a blend of "natural flavors" that are commonly barley-based flavorings, so she needs to make sure to read the labels on those products. Some brands of gluten-free flavored coffees include: Dunkin Donuts, New England Coffee Co., Green Mountain, Zavida, and Gloria Jeans (Gluten Free Living , 2010 ) . Since there is no indication of how she prepares her coffee, we can suggest avoiding milk and cream in the

Coffee

beginning and substituting almond milk at first until she can tolerate lactose again. It is also important to stay away from creamer products since many of them use gluten as an emulsifier. Coffee Mate does make a gluten-free creamer that could be acceptable. Rice Crackers Plain rice crackers are gluten-free, but she should watch for seasonings or flavorings that are not. Del Monte's fruit cocktail snack cups are gluten-free (Delmonte.com). If using other brands make sure to do some research prior to consumption. Sugar is gluten-free. If Mrs. Gaines is at her house she should be okay to consume sugar out of her bowl since she can guarantee that no contamination has occurred, however, when she is in public individual sugar packets should be used to make ensure that no cross contamination has happened. Milk pudding is gluten-free, but again should be avoided until the small intestine is healed before reintroducing. There are some lactose free and gluten free puddings available. Kozy shack has lactose-free pudding that she can substitute until her GI tract has returned to normal, and then brands such as Jell-O can be consumed (theglutenfreebar.com). V8 juice is gluten-free because it contains 100% vegetable juice. There is a concern about fillers and gluten as an additive, but it is approved and labeled as safe to consume by celiac.com Bananas do not contain gluten or lactose, so bananas are okay to consume. There is no gluten or lactose in soda, however while her intestines are healing I would suggest more nutrient dense foods to help her regain her strength. It also causes the body to dehydrate, so I would recommend water in place of sodas to help keep her body hydrated.

Fruit cocktail

Sugar

Pudding

V8 Juice

Banana

Cola

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