Management of under nutrition

Is coeliac disease a cause of undernutrition?

Only 22% of people diagnosed with coeliac disease will have a BMI less than 20 (1). One study showed that 39% of people are in fact overweight (2).

Most people with coeliac disease gain weight following diagnosis as absorption increases. Others find it hard to regain any weight lost prior to diagnosis.

Management of under nutrition

The first step is to consider if nutrient requirements can be met via ordinary foods and drinks. It is only when this option does not meet requirements that other measures need to be considered (3).

In practice, nutritional support can be regarded as a graded process of increasing levels of intervention:

• improving energy and nutrient intake from ordinary foods
• fortifying the energy and nutrient intake from ordinary foods
• sip feed and other forms of supplementation
• enteral nutrition
• parenteral nutrition.

The type and level of nutritional support must be determined on an individual basis.

In the elderly, micronutrient deficiency is not uncommon and should be addressed. Adequate amounts of zinc are required to stimulate appetite.

Practical dietary advice for patients needing to gain weight

Each pound (0.45kg) of weight gain requires 3500 kcal, therefore a patient's energy intake should be increased by 500 kcal daily to promote a weight gain of 1lb (0.45kg) per week.

Choose foods with concentrated calories (energy dense) to reduce the volume of food: 

• make use of high calorie ingredients, such as sour cream or cheese on a baked potato, gluten-freeWhen a food has less than 20 parts per million (ppm) of gluten so it is safe for people with coeliac disease to eat. mayonnaise on a glutenA protein that is found in the cereals wheat, barley and rye. -free sandwich, cream and sugar on porridge (make sure they are pure uncontaminated oats). Garnish salads with olives, avocadoes, gluten-free dressings and cheese.
• try dried fruits or fruits canned in syrup instead of fresh fruit 
• fortify soups and casseroles with cream or sour cream 
• the protein and calorie value of milk can be increased by adding powdered milk
• try having nuts as a high calorie snack
• use food labels as a guide to choosing higher calorie food.

Focus on nutrient-rich foods and drinks. Do not fill up on low and no-calorie foods, such as diet drinks and plain tea or coffee. Instead have calorie containing drinks such as milky coffee, hot chocolate, fruit juice, milk, and milk shakes. Try to limit drinks at mealtimes.

If required, use a commercial supplement drink. Most supplement drinks, with the exception of those that contain added fibre, are suitable for people with coeliac disease.

Eat small, frequent meals and snacks and try having a snack before bedtime.

A patient may not have an appetite for various reasons. 

Below are suggestions to stimulate a patient's appetite:

• make food look attractive and colourful
• drink a small glass of alcohol before meals to stimulate appetite
• eat meals with company
• keep favourite foods on hand
• make mealtimes pleasant
• try eating meals away from the dining room.  A change in scenery may help to stimulate appetite
• exercise may stimulate appetite.

References

1 Dickey W & Bodkin S (1998) Prospective study of body mass index in patients with coeliac disease. British Medical Journal 317:1290. 

2 Dickey W & Kearney N (2006) Overweight in Celiac Disease: Prevalence, Clinical Characteristics, and Effect of a Gluten-Free Diet. American Journal of Gastroenterology. 101: 2356-2359.

3 Manual of Dietetic Practice (2007) Edited by Briony Thomas and Jacki Bishop in conjunction with The British Dietetic Association. Blackwell Science