Question 2
A patient of yours was recently diagnosed with celiac disease, but told you they didn’t think they had a severe form because they were mostly asymptomatic. What education related to diet would you give to this client?
posted by Julie @ 11:00 AM
32 comments
32 Comments:
Even though the patient is experiencing little symptoms, they still have celiac disease and need to follow a gluten-free diet. They might feel like they can eat anything because the food may not make them feel bad, but consuming wheat, barley and rye can damage the mucosa of the small intestine, eventually leading to nutrient malabsorption. Following a strict gluten-free diet is very important for celiac patients, this will reduce the likelihood of other problems or complications. Planning a diet that includes some grains and starches that celiac patients can consume include: arrowroot, beans, black-eyed peas, lentils, corn, gluten-free bread, hominy, potato, rice, soy, tapioca, and wild rice. Careful label reading on food products is important when adhering to a strict-gluten free diet. I would also recommend this patient taking a daily multivitamin because there are also risks for vitamin and mineral deficiencies.
Some individuals with celiac disease do not have many symptoms, and can feel relatively healthy most of the time. However, it is imperative that these individuals still adhere to the gluten-free diet. With strict dietary control, those with celiac disease can experience some recovery related to their antibodies. For this reason, this patient needs to have a gluten-free diet just as a person with a more severe form. Diet education for a person with celiac disease would include deleting gluten sources from the diet (wheat, rye, barley), and substituting these with corn, potato, rice, soybean, and tapioca. I would provide recipes that include the types of grains he/she can have so that it is easier to relate the education to what he can actually eat. Obviously, reading food labels will be extremely important for this patient, as in all individuals with the disease. Extra protein should also be stressed to replenish nutrient stores.
Sam-I completely agree with you on recommending a multivitamin-mineral for patients with celiac disease. Because the microvilli become flattened and atrophy in this disease, malabsorption of vitamins and minerals is likely to occur. The supplement would definitely help this patient nutritionally.
If a patient was diagnosed with celiac disease and they don’t necessarily have symptoms after eating gluten containing foods I would still strongly recommend that they follow a gluten free diet. Whether or not they can feel the symptoms of eating gluten, the gluten is still affecting their intestines which may create even more problems in the future. I would explain the pathophysiology of the disease and the damage that gluten containing foods cause as well as how a gluten free diet can help. I would also explain what foods contain gluten and what foods do not contain gluten. I would also help the client find different products in stores or ways in which they need to change their cooking techniques.
I would still recommend the patient strive for a gluten-free diet. I would explain the health consequences of poorly managing the disease. Some of these complications include dermatitis herpetiformis, decreased absorption of Ca, with increased likelihood for bone fractures. Others include thyroid disorders, neurological complications. Severe nutrient malabsorption is common in those who continue to consume gluten-containing foods.
Brittney, I think it's a great idea to provide the pt with recipes that utilize gluten-free products. I also agree with Stephanie- help the pt find stores in their area that carry gluten-free products. It is important to let the client know that changes are necessary to their diet and lifestyle, but that the disease doesn't have to ruin the pleasures of eating. There are many foods out there, especially these days, that are much more sensitive to people with gluten intolerance.
kat-good idea on being aware of the complications and problems that could occur if this patient does not adhere to a gluten-free diet.
Brit- gread ideas on how to substitute for the gluten-free products and providing recipes for the patient is also something to consider since they probably are unaware or discouraged about how to change their diet.
I would inform the patient that the absence of symptoms does not mean there is an absence of damaging problems going on. I would try to educate them on the negative impact celiac disease has on the digestive tract and absorption of important nutrients. I would try to educate them on why these nutrients are necessary to aid their body. I would point out the risks that can be associated with compromising their immune/digestive system with this disease. Hopefully this would be enough to get the patient to follow the diet. However, it is my experience that if symptoms are absent then their is a lack of motivation to following such a strict diet.
I would definitely let them know that asymptomatic does not equal damage-free! That’s a major point to bring up when educating a client on celiac disease, just because they aren’t experiencing negative symptoms, doesn’t mean that they aren’t causing further damage to their intestinal tract. As the article mentioned, many patients can take up to an entire year before their GI tract really begins to heal and their inflammatory blood markers return to normal, and with each re-introduction of gluten in the diet, there is further regression in terms of small bowel healing and disease resolution.
Annie- I think you bring up an excellent point about how “un-motivating” it can be to continue to follow a strict diet once you begin to see improvements. At this point, people might begin to slack off on their efforts to remain gluten-free, so for dietetics professionals, this would be the most critical time to make sure that patients understand the importance of remaining gluten-free for life, and the negative impacts that go along with re-introducing gluten in the diet.
In a very simplified way, I would emphasize the fact that they can still cause damage to their intestines even if they feel they are symptom-free. I would explain that the recovery phase is timely (up to a year) as the GI tract has to heal and rebuild. I would also discuss the key components of their new gluten-free diet and stress the importance of adherence. Sharing celiac-friendly resources (and support groups) may help as they make these dramatic diet changes in which they may learn more about what "works" and what doesn't work for celiac individuals.
I agree with everyone else about still following a gluten free diet! Following the diet all the time will make it easier to adhere to when they do have a flare up.
Tori
This patient is more or less looking for a way to not have to follow the gluten free diet and wants me to tell them that it is okay and it isn't. Consuming gluten destroys the microvilli of the SI and just makes the disease even worse. I would then discuss the barriers that they were facing and find ways to help over come the problems.
tori
I would tell them it's great that they have a mostly asymptomatic form, but ignoring the fact that they have celiac disease will lead to undesirable consequences down the line. Although they may not feel or notice symptoms, there are things going on in the SI that they cannot see. If damage continues, they may see deficiencies and consequences from those. (Show patient picture of internal damage). Following a gluten-free diet is going to protect them from damage and perhaps symptoms from occuring in the future. I think it's OK to "scare" the patient a little bit here.
Tori,
Nice, matter-of-fact. Way to call them out. I like the psychological approach you would use. It is important to figure out WHY they feel they cannot or do not what to follow the diet. Do they think it would be too hard? Taste bad? Be too restricting? Would they be embarassed in front of their friends? Too expensive? That's a really good point! It's much easier to help a client if you know exactly what is stopping them from following through with a diet, especially one as important as this.
I would still recommend the client adhere to a gluten free diet even if they were mostly asymptomatic they have still been diagnosed. They may not be absorbing all of the nutrients they need by not allowing their intestines to heal. Therefore they need to avoid any future damage or complications they need to comply to a gluten free diet.
Susan
Sam and Brit,
I agree they should try taking a multivitamin because of deficiencs. And of course recipes would be a great idea for the client to have!
Susan
I would stress to them that even though they don't experience any symptoms, damage is still being done to the body. I would use pictures of flattened intestinal lining to show them what happens when the gluten destroys the villi. The pt needs education on what gluten is, where it can be found, and most importantly, reasons why they need to cut it out of their diet. I would help them find recipes on healthy alternatives to gluten-containing products, and several ideas of foods that don't contain gluten.
One of the most important parts of this type of education would be to make sure the patient understands the consequences they could face if they continue eating a diet containing gluten. I think it is very hard for people to be compliant to such a strict diet when they feel healthy and are not experiencing symptoms. Helping the patient to understand what could happen to them in the future and the horrible symptoms they may develop may help them to understand the importance of adhering to this diet now. From there it would be necessary to educate the patient on gluten containing foods and how to read labels to determine if products are gluten free.
The education I would offer would probably be very similar to a patient with classic symptoms of celiac disease but I would stress more heavily on the need to follow a gluten restricted diet. If they aren't getting all of the painful symptoms that are associated with eating gluten, they are less likely to be bothered by gluten and therefore may not adhere to a gluten free diet.
Karlie,
Good point about how many patients can take up to an entire year before their GI tract really begins to heal and their inflammatory blood markers return to normal. If they keep eating normally (with gluten) they aren't fully going to heal.
I would give the same education to the patient that was asymptomatic as I would to a patient that had severe symptoms. I would have to emphasize how important it was even though they were “asymptomatic” that any amount of gluten is damaging their intestines. I was able to assist in a Celiac Disease education with a patient that was asymptomatic. The patient thought since they did not have a great deal of symptoms the patient did not appear to understand how crucial it was to stick to this strict diet. The patient was older and living with her daughter, who did not believe her mother had this disease and was not about to purchase separate food for her mother. As we discussed the symptoms with the patient, she had been showing symptoms for over 20 years, she just thought it was “normal” for her.
I would explain that there is always the chance of cross contamination with manufactures. The threshold for which gluten-contamination is still being determined and agreed upon. I would suggest that a strict gluten-free diet would be difficult however, it can be done with concentrating on the other food groups. Improved food labeling would almost give patients with Celiac Disease a false sense of security-with the cross contamination factor. Also, for those that are asymptomatic would probably never know if the product was definitely gluten-free. Walmart does have on their products labeled whether it is gluten-free, I wonder if the company has the Gluten-free Certification mark.
Even though they are not showing symptoms, there still could be underlying problems. There could be a gradual flattening of the villi in the lining of the intestine. Eventually, if the pt continues eating gluten containing food they could develop into the typical symptoms. These possible future problems could be completely avoided by taking the appropriate precautions.
Lauren
I agree competely with you, patients often times do not understand the extent of damage gluten does to their bodies. If that is the one thing they remember from the counseling session, that is great. Gluten free diet can be very overwhelming, but it seems that there are more and more resources and references for these patients and their families to use.
Because the general consensus is that the pt should be made aware of the damage that can still occur with asymptomatic celiac disease, as others have said, we should do as much as we can to motivate those pts to comply with the diet. This can be done by giving them several solutions to problems that may arise with the diet, such as dining out, cooking for others and themselves, providing them with alternate recipes of their favorite dishes, etc. This will increase motivations, and therefore compliance.
Even though this client may not be feeling symptoms of Celiac's, they still need to follow the glute-free diet. Explain to the client that even though they do not feel the symptoms, eating the average diet can still do damage to their GI system. I would strongly encourage following the gluten-free diet. These types of clients would be hard to motivate, especially since it may seem to them that there isn't anything wrong with them. I would thoroughly explain the reasons why they should follow the diet and then give consequences. Always encourage clients.
Sam, You made and excellent point about recommending a multivitamin to clients with Celiac's disease. Due to the damage of the intestinal tract, extra nutrients are definitely needed.
I would explain that many people with celiac disease are asymptomatic but they still incur the same amount of intestinal damage as someone who does have traditional symptoms of the disease.
For diet education I would teach them about the gluten-free diet and explain how to read food labels to avoid gluten (which is found it rye, wheat, barely and sometimes oats).
Carrie,
Showing them pictures from asymptomatic people who still had intestinal damage is a great idea. Sometimes pictures say more than words.
Although asymptomatic, it is very important for a pt with Celiac to follow a gluten free diet. This includes cutting out food products that contain wheat, rye, and barley. If they do not adhere to the diet, they can still be promoting harm to the intestional mucosa which could cause even worse problems in the future. I would make sure that my pt understands the Celiac diet as well as how Celiac affects the GI tract.
Lauren,
You bring up a great point that pt do not always understand the effects that a disease has upon their future health. It is a wonderful idea that you make sure that you are helping the pt understand that they must follow a specific diet in order to promote overall health, even if they do not experience any unhealthy feeling at the current moment.
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