Case study: Nutritional Management of a Patient with Newly Diagnosed Celiac Disease
Brief description
The patient was a woman in her late 30s referred to an outpatient nutrition clinic following a new diagnosis of celiac disease. She had previously been well with no significant gastrointestinal history. Referral was made by the gastroenterology team after positive celiac disease serology and confirmatory biopsy. This patient had attended our group session on how to follow a gluten-free diet for celiac disease and was now scheduled for a one-to-one session with a registered dietitian to consolidate her knowledge and offer more tailored support to assist with the implementation of a strict gluten-free diet.
Case presentation
1. Presenting Complaint / History of Presenting Issue
The patient initially developed gastroenteritis while on vacation abroad. Although the acute infection resolved, she continued to experience persistent gastrointestinal symptoms. These included frequent loose stools, abdominal discomfort, and significant abdominal bloating. She also reported reduced appetite and unintentional weight loss.
Symptoms persisted for several weeks following the infection and began to impact her quality of life, including reduced dietary intake. Following an appointment with her primary care physician, she was referred to gastroenterology where she was diagnosed with celiac disease.
2. Medical History & Medications
The patient had no significant past medical history and was otherwise fit and well. Current diagnosis: Celiac disease Medications/Supplements: OTC Multivitamin and Vitamin D supplements.
3. Anthropometry
- Height: 1.6 m
- Pre-illness weight: 60 kg
- Weight at dietetic assessment: 55 kg
- BMI: 21.5 kg/m²
This represented an approximate 5 kg (8.3%) unintentional weight loss over three and a half months. The weight loss was likely related to malabsorption upon accidental gluten intake and reduced oral intake due to ongoing gastrointestinal symptoms.
4. Biochemistry
At diagnosis, investigations demonstrated:
- Positive tissue transglutaminase antibodies (tTG)
- Confirmatory duodenal biopsies.
- Low ferritin consistent with iron deficiency
- Borderline vitamin D levels
- Slightly reduced PTH levels.
These findings were consistent with active coeliac disease and associated micronutrient malabsorption.
5. Nutrition Assessment
A 24 hr dietary recall was taken during our consultation. At this point the patient had received some information of following a gluten-free diet from the group session.
The patient's 24 hr dietary recall:
- Breakfast - Homemade gluten-free granola with greek yogurt or oats.
- Lunch - Canned soup +/- a slice of gluten-free toast OR chicken and mayonnaise sandwich with Schar Artisan Baker 10 Grains & Seeds bread.
- Dinner - generally a protein source (meat/chicken) with a side of potatoes or rice and mixed vegetables - half portion.
- Snacks - rice crackers, gluten-free cookies.
- Fluids - x8 cups of tea with a splash of milk, water occasionally throughout the day ~2 cups/day.
The patient demonstrated some knowledge of gluten sources but was not aware of various possible cross-contamination risks. She was confident around food labels and safe food choices when dining out. Since diagnosis, she had started trialing gluten-free products and reported enjoying gluten-free alternatives.
6. Psychosocial Factors
The patient lived with her partner who was supportive of the dietary changes required. She reported having access to gluten-free foods via her local grocery stores but mentioned many of these food items came with a higher price tag compared to non-gluten-free food.
She was highly motivated to adhere to nutrition advice due to the clear link between gluten consumption and symptoms - she had already started to implement these dietary changes before our consultation.
7. Nutrition Intervention
Nutrition intervention focused on education and practical support for long-term adherence to a gluten-free diet. This was done via a virtual group session and via a one-on-one dietitian consultation.
Key areas covered included:
- Knowledge on foods containing gluten (wheat, barley, and rye) or foods that can be potentially contaminated (oats)
- Naturally gluten-free alternatives e.g., was unsure of polenta being naturally gluten free.
- Label reading and identifying hidden gluten sources e.g., was not aware that regular gravy could be a gluten source.
- Preventing cross-contamination in the home environment and when dining out. The patient was also provided with information regarding online/app resources to support their dining out while on vacation.
- Tips to ensure regular bowel movements and ensure proper hydration e.g., incorporating increased water intake during the day via cups of water, water-containing foods like cucumber or watermelon, etc.
Nutrition advice was also provided to address potential deficiencies, including increasing iron-rich foods alongside vitamin C sources and optimizing calcium intake (low intake as indicated by diet and PTH levels). Vitamin D supplementation was recommended. Educational resources were provided from the Academy of Nutrition and Dietetics, including information about support available through the Celiac Disease Foundation.
8. Outcome / Follow-Up Review
At six-month follow-up, the patient reported significant improvement. Gastrointestinal symptoms had completely resolved, with normal stool frequency and no further abdominal discomfort or bloating. The patient’s appetite had improved and her weight had begun to stabilize. She reported strong adherence to the gluten-free diet and increased confidence with food choices and label reading. Repeat blood tests for micronutrient status were planned through her primary care physician at a later stage to monitor improvement.
9. Reflection
This case highlighted the importance of combining group education with one-to-one support to address gaps in knowledge and promote long-term adherence to a gluten-free diet. It reinforced the need to consider both symptom management and micronutrient deficiencies. The positive outcome demonstrated the impact of personalized nutrition intervention on improving symptoms and patient confidence.
Author
Arafah Olusekun RD,
Band 5 Dietitian
Wythenshawe hospital, Manchester