Case study: Difficulty concentrating – 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 medical nutrition therapy practice in fall 2023.
Case presentation
1. Medical history
A 20-year-old female patient, student, 5’8” tall, about 143 lbs., with years of recurring gastrointestinal complaints, requests an appointment for medical nutrition therapy. 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 celiac disease has not yet been ruled out.
The patient is specifically seeking medical nutrition therapy support to identify possible triggers and improve her quality of life. A detailed nutrition history, assessment, and evaluation reveal the following:
Current dietary habits
- 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 gluten)
Resources/risks
- Uncertainty/lack of knowledge about suitable foods
- Risk of nutrient deficiencies and further damage to the mucous membrane if potential celiac 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 through a symptom and food diary.
and
- Information on suspected celiac disease: significance, diagnosis, risks of a gluten-containing diet in celiac disease.
- Support on the path to diagnosis (referral to a physician).
- Continue eating gluten-containing foods—even if symptoms occur—for at least four to twelve weeks before testing, as recommended by clinical guidelines.
4. Course
- Medically confirmed diagnosis of lactose intolerance in November 2023
and
- Medically confirmed diagnosis of celiac disease in March 2024.
5. Further medical nutrition therapy
- Training on gluten-free nutrition after medically confirmed celiac 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 products.
- Planning for everyday challenges, for example, in the cafeteria or shared kitchen.
- Ensuring a needs-based diet that takes individual intolerances into account.
- 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 medical nutrition therapy (e.g., with regard to a possible secondary lactose intolerance, which would improve under a gluten-free diet in the course of mucosal regeneration).
- Building confidence in managing your diet and personal responsibility in everyday nutrition.
Conclusion for practice
- Multifactorial causes require differentiated diagnosis and medical nutrition therapy: If symptoms persist despite initial indications of lactose intolerance, additional or alternative causes such as celiac disease or FODMAP sensitivity should be considered.
- A change in diet must be based on a diagnosis and accompanied by professional guidance. Premature or incomplete elimination carries the risk of nutrient deficiencies and complicates or prevents diagnosis.
- Individual, symptom-oriented medical nutrition therapy, sound knowledge, practical guidance, and building self-efficacy can enable a safe, symptom-free diet that meets nutrition requirements-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 nutrition counseling & therapy
Aalen / Germany
