Case study: Concentration in decline – searching for clues in cases of unclear malabsorption
Brief description
A 20-year-old female patient with gastrointestinal complaints and concentration problems presents at the nutritional therapy practice in autumn 2023.
Case presentation
1. Medical history
A 20-year-old female patient, student, 1.72 m tall, approx. 65 kg, with years of recurring gastrointestinal complaints, requests an appointment for nutritional therapy counselling. Lactose intolerance is suspected, but the test results from a gastroenterology practice are still pending.
2. Diagnosis
The patient describes recurring, acute gastrointestinal complaints, in particular flatulence and abdominal pain with alternating bowel movements. She also reports increasing difficulty concentrating and fatigue, which severely impairs her daily studies. Initial attempts to eliminate various foods suggest a connection with lactose-containing/lactose-rich products, especially milk. However, the symptoms persist even when she eats lactose-free foods or drinks appropriate plant-based milk alternatives. When asked, she states that coeliac disease has not yet been ruled out.
The patient is specifically seeking nutritional therapy support to identify possible triggers and improve her quality of life. A detailed nutritional history, including a nutritional diagnosis, reveals the following:
Current nutritional situation
- Elimination of all foods containing lactose
- Consumption of predominantly plant-based/vegan foods and products
Existing symptoms
- Gastrointestinal complaints
- Concentration problems
Possible cause(s)
- Failure to consistently avoid other potentially irritating foods (e.g. foods rich in FODMAPs and/or containing gluten)
Resources/risks
- Uncertainty/lack of knowledge about suitable foods
- Risk of nutrient deficiencies and further damage to small bowel if potential coeliac disease is not addressed.
3. Initial treatment recommendation
- After confirmation of diagnosis by the results of a medical lactose test, consistently follow a low-lactose/lactose-free diet.
- Information on lactose intolerance: low-lactose/lactose-free products, hidden sources of lactose, individual tolerance limits.
- Identifying individual triggers of symptoms by keeping a symptom and food diary.
and
- Information on suspected coeliac disease: significance, diagnosis, risks of a gluten-containing diet in coeliac disease.
- Support on the path to diagnosis (referral to a doctor's practice).
- Recommendations for eating gluten-containing foods – despite occurring/perceptible symptoms – for at least four weeks to three months before the examination (in accordance with pre-testing guidelines).
4. Course
- Medically confirmed diagnosis of lactose intolerance in November 2023
and
- Medically confirmed diagnosis of coeliac disease in March 2024.
5. Further therapy
- Training on gluten-free nutrition after medically confirmed coeliac disease for the safe handling of gluten-free foods.
- Reduction of uncertainty when choosing foods, especially when shopping, including understanding ingredient lists, trace information and the seal for gluten-free goods.
- Practising critical everyday situations, for example in the canteen or shared kitchen.
- Guidance on a wholesome, nutrient-rich diet despite the necessary restrictions, especially with regard to the supply of calcium, iron, folic acid and other B vitamins.
- Evaluation of symptoms and, if necessary, adjustment of measures during the course of therapy (e.g. with regard to a possible secondary lactose intolerance, which would improve under a gluten-free diet).
- Promotion of self-efficacy and personal responsibility in everyday nutrition.
Conclusion for practice
- Multifactorial causes require differentiated diagnosis and counselling: if symptoms persist despite initial indications of lactose intolerance, additional or alternative causes such as coeliac disease or FODMAP sensitivity should be considered.
- A change in diet must be based on a sound diagnosis and accompanied by professional guidance. Premature or incomplete elimination carries the risk of nutrient deficiencies and complicates or prevents diagnosis.
- Individual, symptom-oriented nutritional therapy, sound knowledge, practical guidance and the promotion of self-efficacy can enable a safe, symptom-free diet that provides all the necessary nutrients - and improve quality of life in the long term.
About the author
Birgit Blumenschein
Dietitian, certified medical educator
Specialist in occupational health management (IHK) Focus on gastroenterology
blumenschein ernährung beratung & therapie
Aalen / Germany
