Management of undernutrition

Is coeliac disease a cause of undernutrition?

Coeliac disease can result in severe symptoms of malabsorption such as steatorrhoea, abdominal discomfort and weight loss.  However, it is important to appreciate that while coeliac disease may be a cause of undernutrition, this 'classic' presentation' is not as common as previously thought.  Dickey and Bodin (1) found that only 22% of patients have a BMI less than 20. Most people with coeliac disease gain weight following diagnosis as absorption increases but others find it hard to regain any weight lost prior to diagnosis.

Management of undernutrition

The first step is always to consider whether nutrient needs can be met via ordinary foods and beverages.  It is only when this option is obviously inadequate or inappropriate that other measures need to be considered (2).

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

These measures are not mutually exclusive.  The type and level of nutritional support have to 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 to 1lb (0.45kg) per week.
• Choose foods with concentrated calories (energy dense) to reduce the volume of food.  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.  Make use of high calorie ingredients, such as sour cream or cheese on a baked potato, mayonnaise on a sandwich, cream and sugar on porridge etc.  Garnish salads with olives, avocadoes, dressings and cheese.
• Eat small, frequent meals and snacks.  Nuts and dried fruits makes a good snack.
• Limit beverages at mealtimes
• Focus on nutrient-rich foods and beverages.  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.
• Have a snack before bedtime.
• Use food labels as a guide to choosing higher calorie foods.
• 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.

A patient may not have an appetite for various reasons.  Below are suggestions to simulate 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. Prospective study of body mass index in patients with coeliac disease.  British Medical Journal 1998;317:1290. 

2 Manual of Dietetic Practice. Revised and edited by Briony Thomas in conjunction with The British Dietetic Association. Blackwell Science 2001.