guide-lines and the Nutrition Care Process for celiac disease have been recently developed by the American Dietetic Associa-tion.99 Major components of nutrition care services and the Nutrition Care Process are highlighted in Table 3.9. Moni-toring individuals for abnormalities in nutritional status that may impact reproductive outcomes is an important part of the Nutrition Care Process for celiac disease.
Table 3.9 Key features of the Nutrition Care Process for individuals with celiac disease99
A. Nutrition Assessment
1. Assessment of food/nutrition-related history Food and nutrient intake with focus on
•
vitamins and minerals listed in Table 3.5 Knowledge, skills, attitudes about celiac and
•
dietary change Access to food
•
2. Assessment of biochemical data and medical results
Severity of intestinal lining damage
•
Presence of anemia, osteoporosis, other
• diseases
B. Nutrition Intervention
1. Provide education and guidance on nutritionally adequate, gluten-free diet
2. Advise on the use of gluten-free multivitamin and mineral supplement as required
3. Provide resources and education on label reading, food cross-contamination, and support groups
C. Nutrition Monitoring and Evaluation
1. Monitor dietary intake, gluten intake from all sources, celiac antibody levels
2. Monitor persistent gastrointestinal symptoms not eliminated by a gluten-free diet, coordinate care 3. Monitor nutrition risks for poor pregnancy
outcomes Table 3.8 Example of one day’s diet and snack option for an adult with celiac disease
Breakfast Dinner
Gluten-free bagel with nut butter Sliced bananas in yogurt Tea
Lamb stew (thickened with potato starch) with carrots and lentils
Rice
Gluten-free cake Low-fat milk
Lunch Snack Options
Gluten-free pasta salad with chicken, broccoli, and tomatoes Oil and vinegar dressing
Gluten-free roll with margarine Fresh fruit
Low-fat milk
Popcorn
Spring rolls with rice paper Ice cream
Fruit
Dark chocolate Gluten-free cookies String cheese Rice cakes
amounts of essential fatty acids, does not appear to beat a placebo in relation to PMS relief.102
There are too few trials involving herbs and sup-plement use for the treatment of infertility to warrant solid recommendations, but chaste berry, antioxidants, and Fertility Blend (a proprietary supplement containing chaste berry, green tea extracts, L-arginine, vitamins, and minerals) have some preliminary support in terms of safety and effectiveness.100 Sperm concentrations, motility, and the percent of sperm with normal shape have been found
Illustration 3.2 The Gluten-Free Certification Organiza-tion tests and certifies products as gluten-free and awards qualifying products this mark.
to improve among infertile men given 200 mcg selenium plus 600 mg N-acetyl-cysteine (a derivative of the amino acid cysteine) daily for 6 months. Both selenium and
Courtesy of the Gluten-Free Certification Organization
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Illustration 3.3 Sections of the small intestine showing normal villi structures of a person without celiac disease (a) and the flattened villi that develop in people with untreated celiac disease (b).
In Focus Celiac Disease
Definition: Celiac disease is an autoimmune disease that occurs in people with a genetic susceptibility to the protein gliadin found in the gluten component of wheat, rye, and barley. Oats do not contain gluten, but commercial oats and oat products may be cross-contaminated by grains that do. Gluten-free oat products should be selected.96 Celiac disease is also called celiac sprue and nontropical sprue.
Diagnosis: Blood tests for celiac antibodies and genetic markers of celiac disease are used to help identify the pres-ence of celiac disease. The gold-standard diagnostic test for celiac disease, however, is small bowel biopsy and exami-nation of cells for signs of damage due to the disease. The test has to be undertaken while individuals are consum-ing their normal diet and not a gluten-free one. Removal of gluten from the diet corrects intestinal cell damage and may lead to an incorrect diagnosis.
Prevalence: Celiac disease occurs in one in every 133 peo-ple in the United States and is three times more common in women than men. The incidence of celiac disease appears to be increasing.96 Although awareness of, and screening for, celiac disease is increasing, far more individuals have the disease than have been diagnosed with it.97
Major physiological aspects and consequences: The presence of gliadin in the small intestine triggers an auto- immune re-sponse that causes an inflammatory reaction to occur in the inside lining of the small intestine. Over time, the inflamma-tion causes the lining of the small intestine to become flat-tened and to absorb nutrients poorly (Illustration 3.3). The damage produced by chronic inflammation in the small intestine may lead to a variety of vitamin and mineral defi-ciencies and other health consequences (Table 3.5).
Signs and symptoms of celiac disease range from very mild to severe and vary by age and sex. Diarrhea, nutrient malabsorption, bloating, weight loss, iron-deficiency ane-mia, infertility, fatigue, and growth failure in children often characterize the disease. Many cases of celiac disease are clinically silent—presenting no clear, related symptoms.96 Long-standing, untreated celiac disease predisposes indi-viduals to other autoimmune diseases. The only effective treatment is a lifelong gluten-free diet.
Risk factors: The primary risk factor for celiac disease is a genetic predisposition toward reacting to gliadin as a for-eign protein. Repeated exposure to certain types of infec-tious agents, such as rotavirus, may also trigger the onset of the disease in genetically susceptible people.98
N-acetyl-cysteine function as antioxidants and may help prevent oxidative damage to sperm.103 Coenzyme Q10 given at a dose of 200 mg Autoimmune Response Chemicals
released by the immune system that attack its own molecules, cells, and tissues.
Rotavirus A virus that is the most common cause of severe diarrhea among children.
Diarrhea caused by rotavirus generally lasts 2 days, and recovery is full in otherwise healthy children. The rotavirus is generally spread from an infected peron’s stools to food.
(a) (b)
per day for 6 months in males with poor sperm motility for unknown reasons increased sperm motility and pregnancy rates.104,105 Coenzyme Q10 acts as an antioxidant and is a coenzyme in energy formation. It may help protect sperm membranes from oxidation and facilitate energy formation
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Key Points
1. Dietary intake, supplement use, weight status, and exercise levels before conception affect fertility in women and men, and the course and outcome of pregnancy in women.
2. Symptoms of PMS can be modified in some females by specific changes in dietary intake and supplement use.
3. Obesity is related to a number of hormonal and metabolic changes that compromise fertility and health status in men and women.
4. Modest levels of weight loss in obese women and men, and weight gain in underweight individuals, improve fertility.
5. Rates of diseases and disorders associated with obesity such as metabolic syndrome, polycystic ovary syndrome, and type 2 and gestational dia-betes are increasing in the United States and other countries. Obesity-related health problems affecting fertility and the course and outcome of pregnancy are being seen increasingly in clinical practice.
6. Chronic inflammation is an important compo-nent of disorders such as infertility, metabolic syndrome, and polycystic ovary syndrome. Anti-oxidant nutrients and the omega-3 fatty acids EPA and DHA may play key roles in reducing adverse effects of chronic inflammation.
7. Insulin resistance is a key feature of obesity, type 2 and gestational diabetes, metabolic syndrome, and polycystic ovary syndrome.
8. Energy deficits in individuals with hypothalamic amenorrhea, eating disorders, and the female athlete triad are related to hormonal changes that reduce fertility.
9. Energy and estrogen deficits in women with the female athlete triad lead to reduced fertility and lower bone formation in young women.
10. PKU is a genetic disorder that causes blood pheny-lalanine levels to rise to toxic concentrations in un-treated individuals with the disorder. Unun-treated PKU can produce malformations, neurological disorders, and severe mental retardation in children and adults.
It is treated with a low-phenylalanine diet for life.
11. Untreated celiac disease is related to multiple vitamin and mineral deficiencies and infertility, early pregnancy, impaired fetal growth, and other poor pregnancy outcomes. Standard treatment for celiac disease is a gluten-free diet.
12. Some herbal remedies and other dietary supple-ments appear to reduce symptoms of premen-strual syndrome and may aid fertility. Due to limited knowledge of the safety of herbs and other dietary supplements taken before conception and during early pregnancy, they are best used under medical supervision.
by sperm. Coenzyme Q10 appears to be well tolerated.106 Bee propolis, which consists of plant resins collected by honeybees, appears to have anti- inflammatory activity and has been found to increase pregnancy rates in women with mild endometriosis. Use of the compound was not related to adverse side effects in one study.109
Women and men using herbs for fertility problems should inform their health care providers. They should avoid herbs and other dietary supplements that have not been demonstrated to be safe for use during early pregnancy.
Review Questions
Lois was diagnosed with type 2 diabetes 2 months before she planned to become pregnant. To get her blood glucose under control before pregnancy, Lois worked with a dietitian who specializes in diabetes, and together they developed a plan to reduce Lois’s blood glucose levels.
The following four questions refer to this case and appropriate components of the nutritional management of type 2 diabetes. Check true is the statement is correct and false if it is incorrect.
1. As part of the plan, Lois would have to exclude from her diet sugar and foods containing sugar.
True False
2. Assume Lois will attempt to consume 2000 calories a day. Based on that level of calorie intake, her fiber intake should total approximately 28 grams daily.
True False
3. Lois plans to perform aerobic exercise 25 minutes daily because it will help improve insulin resistance, lower blood glucose levels, and improve her blood lipid levels.
True False
4. Lois should take a chromium supplement to help lower her blood glucose levels.
True False
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5. High intake of caffeine or coffee has been found to increase the risk of premenstrual syndrome.
True False
6. Obesity is related to infertility and chronic inflam-mation in men only.
True False
7. Obesity is associated with inadequate vitamin D status.
True False
8. Health problems related to anorexia nervosa re-solve after the eating disorder is successfully treated.
True False
9. Weight loss of 7% or more of body weight and exercise in individuals with prediabetes reduce the risk of type 2 diabetes.
True False
10. Excess visceral fat and insulin resistance are shared characteristics among women with PCOS.
True False
11. Individuals with PKU can safely consume high-protein foods such as beef, chicken, or eggs once a day.
True False
12. Most individuals with celiac disease share the symptoms of abdominal pain, diarrhea, and bloating.
True False
Resources
Health Topics
High-quality information on eating disorders, PMS, and other conditions as presented in this chapter can be found here.
Website: www.healthfinder.gov PCOS Support
Chat rooms for women with PCOS include the following:
Website: www.obgyn.net/PCOS/PCOS.asp Website: www.PCOSupport.org
Celiac Disease Resources
Support journal articles, and other resources for people with celiac disease are available from the following:
Websites:
The Celiac Disease Foundation: www.celiac.org Celiac Sprue Association, USA: www.csaceliacs.org Gluten Intolerance Group: www.gluten.net Raising Our Celiac Kids: www.celiackids.com
Resource guide for gluten-free diets: www.glutenfreediet.ca Obtain a list of gluten-free foods at this site.
Website: www.celiac.com
Select a company’s name and get a list of the gluten-free prod-ucts it sells, or select a food type and receive a list of companies that sell the gluten-free version of the food.
Website: www.gfco.org/products.php Obesity and Weight-Control Resources
The Centers for Disease Control and Prevention provide up-dated obesity statistics.
Website: www.cdc.gov/obesity/data/trends.html
Read about small steps changes for weight loss and weight-loss maintenance.
Website: www.healthfinder.gov/prevention/ViewTopic.
aspx?topicID525
National Institute of Diabetes and Digestive and Kidney Dis-eases offers information on weight control.
Website: www.nlm.nih.gov/medlineplus/weightcontrol.html
NIH’s Weight Control Information network presents leading myths about weight control, weight-loss diets, food, and physi-cal activity.
Website: www.win.niddk.nih.gov/publications/myths.htm The FTC has developed and updates a site on bogus weight-loss advertisements and guides for industries that may pro-duce them.
Website: http://www.ftc.gov/redflag/
Diabetes Resources
Support and other resources related to diabetes are available from the following resources:
Websites:
American Diabetes Association: www.diabetes.org The National Institutes of Health: www.niddk.nih.gov Canadian Diabetes Association: www.diabetes.ca Physical Activity Resources
View a slide show on weight-training exercises produced by the Mayo Clinic staff.
Website: www.mayoclinic.com/health/weight-training/
SM00041&slide=1
Find strength-building exercise plans.
Website: http://www.healthfinder.gov/getactive NIH provides a list of physical activities for large people.
Website: win.niddk.nih.gov/publications/active.htm Obtain a copy of the 2008 Physical Activity Guidelines for Americans, the first such guidelines to be published by the federal government. The site contains information and tools for increasing physical activity based on individual preferences, and offers physical-activity recording forms.
Website: www.health.gov/paguidelines Healthful Diet Resources
MyPyramid.gov provides a wealth of resources related to diet and physical activity planning and evaluation.
Website: www.mypyramidtracker.gov
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